Malunited Right and Ununited Left Fracture Neck Femur in Autism with Seizures Treated with Valgus Osteotomy: A Case Report.

CASE: An 18-year-old autistic boy with seizure disorder had a 4-month-old hip injury with a similar right hip injury 6 months earlier. X-rays revealed an ununited fracture neck femur on the left and a malunited fracture neck femur on the right hip. Magnetic resonance imaging indicated preserved head vascularity. Valgus osteotomy and double-angle plate fixation of both hips were performed at an interval of 2 months. CONCLUSION: Delayed presentation bilateral neck fractures are rare. X-rays showed healed fractures with no avascular necrosis in both hips at 2-year 6-month follow-up. Valgus osteotomy is ideal and relevant for osteosynthesis in selected ununited femur neck fractures.

Decreased femur tunnel widening after augmented suspensory fixation compared to suspensory fixation for single bundle hamstring ACL reconstruction.

Background: Tunnel widening after Anterior cruciate ligament (ACL) reconstruction using a hamstring graft is known to occur at follow-up. Our study aimed to investigate the effect of suspensory fixation augmentation using an interference screw on tunnel widening in single-bundle hamstring ACL reconstruction. Methods: 48 patients who had single bundle ACL reconstruction with femoral fixed loop fixation technique in 15 knees, and, fixed loop with augmented aperture (bio screw) fixation in 33 knees were analyzed. The width of the tunnel was measured using radiographs immediate post-op and at follow-up within 1 year. Computerized Tomogram (CT) measurements of the tunnels and functional scores were also done with overall follow-up for the fixed loop group being 21.33 months (Standard Deviation (SD)11.14) and the Augmentation group 9.12 months (SD 3.83). Results: Midpoint femur tunnel widening was reduced in the augmentation group, with measurements of 0.74 (SD 1.05) mm Antero Posterior (AP) and 1.01 (SD 1.04) mm in the Lateral view, compared to 1.54 (SD 1.48) mm AP and 1.79 (SD1.47 mm) in the Lateral for the fixed button group. The radiological widening was considerably less in the augmentation group with a p-value of 0.07. AP aperture widening in the augmentation group was 1.25(SD 1.10 mm), and 1.09(SD0.98) mm in the lateral view. The fixed button-only group measured 1.53 (SD1.30) mm in the AP, and 1.65 (SD 1.29) mm in the lateral view, both of which were not statistically significant. The follow-up Lysholm and International Knee Documentation Committee (IKDC) scores were similar for the 2 groups. Conclusion: Femoral tunnel midpoint and aperture widening were reduced with the fixed loop with aperture (bio screw) augmentation technique for hamstring grafts in single bundle ACL fixation within 1 year with comparable functional scores. Level of evidence: 4.

Functional and clinical outcome with modified lateral approach total hip arthroplasty in stiff hips with ankylosing spondylitis.

BACKGROUND: Ankylosing spondylitis at total hip arthroplasty (THA) has significant hip stiffness with flexion deformity, restricted mobility, and function. Range of movement (ROM) improvement with good functional outcome is seen following THA in these hips. The modified Hardinge approach without abductor compromise is helpful in these stiff hips with associated flexion deformity. AIM: To assess improvement in ROM and functional outcomes with a modified lateral approach THA in ankylosing spondylitis with stiff hips. METHODS: A total of 69 hips that underwent THA with a modified Hardinge approach in 40 patients were evaluated at a mean follow-up of 38.33 mo. All individuals ambulated with weight-bearing as tolerated and ROM exercises from the 1st postoperative day. Modified Harris hip score and ROM were assessed during follow-up. Quality of life assessments using the 36-item and 12-item short form health surveys were done along with clinical and functional outcomes at follow-up. SPSS 22.0 was used for statistical analysis. The correlation of ROM and functional score change was performed using Pearson's correlation coefficient. RESULTS: Sixty-nine hips with a significant decrease in ROM preoperatively with 32 clinically fused hips showed significant improvement in flexion range. The mean flexion in 69 hips improved from 29.35 ± 31.38 degrees to 102.17 ± 10.48 degrees. The mean difference of 72.82 with a P value < 0.0001 was significant. In total, 45 out of 69 hips had flexion deformity, with 13 hips having a deformity above 30 degrees. The flexion during the follow-up was below 90 degrees in 3 hips. Eleven hips had flexion of 90 degrees at follow-up, while the remaining 55 hips had flexion above 100 degrees. Modified Harris hip score improved from 17.03 ± 6.02 to 90.66 ± 7.23 (P value < 0.0001). The 36-item short form health survey at the follow-up indicated health status in 40 patients as excellent in 11, very good in 20, good in 5, fair in 3, and poor in 1. The mean mental health score was 84.10 ± 11.58. Pain relief was good in all 69 hips. Altogether, 28/40 patients (70%) had no pain, 9 patients (22%) had occasional pain, and 3 patients (8%) had mild to moderate pain with unusual activity. Heterotopic ossification was seen in 21 hips with Brooker class 1 in 14 hips. CONCLUSION: Modified Hardinge approach THA in ankylosing spondylitis with stiff hips with flexion deformity significantly improved ROM, Harris hip score, and quality of life indicated by the 36-item and 12-item short form health surveys.

Spinopelvic Mobility Pattern and Acetabular Anteversion in Stiff Hips With Ankylosing Spondylitis After Total Hip Arthroplasty.

Background: Fused hips with spine stiffness in ankylosing spondylitis (AS) reduce spinopelvic mobility. We aimed to assess spinopelvic mobility pattern and acetabular anteversion in AS after total hip arthroplasty (THA). Material and methods: Ninety-four stiff hips in 58 AS individuals (mean age: 37.05) who underwent THA between 2012 and 2018 with a modified lateral approach were included. Twenty-three hips were fused, and 71 hips had mean flexion of 37.67°. Pelvic tilt, pelvic inclination, sacral slope (SS), and lumbar lordosis were correlated with THA, and functional outcomes were assessed at 34.6-month mean follow-up. Results: Thirty-seven had a stuck sitting pattern with stuck standing seen in 4 individuals. SS standing before and after THA were 25.08° and 27.30°. SS sitting was 8.99° compared to 16.80°. SS from sitting to standing was reduced (17.7°) in 17 individuals. Spine stiffness in extension was seen in 4 out of 37. Mean acetabular inclination after THA was 42.67°, and acetabular anteversion was 17.48°. Flexion after THA improved to mean 98.47°. Changes in SS from sitting to standing were correlated with THA (r-value: 0.93, P-value: .0001). The Harris Hip Score improved from 25.31 to 82.39 (P-value <.05), and the mean 12-item Short Form Survey at review was 52.18 and 59.55 (physical and mental components). The mean Western Ontario and Mc Master Universities Arthritis Index score was 17.56. Conclusions: Spinopelvic mobility change was <10° after THA in AS, stuck sitting was seen in 37 of 58 (63.8%), and stuck standing was seen in 4 of 58 (6.9%), including spine stiffness in flexion or extension. Acetabular anteversion assessed was 17.48° (standard deviation: 4.41), with significant functional improvement. Level of Evidence: Level 4.

Does hip structural analysis confer additional benefit to routine BMD assessment in postmenopausal women with hip fracture? A study from a tertiary center in southern India.

This study from southern India showed that proximal hip geometry was significantly impaired in postmenopausal women with femoral neck fracture. The trabecular bone score (TBS), which is reflective of bone microarchitecture, was also significantly impaired in patients with fracture. INTRODUCTION: There is limited information with regard to comprehensive bone health in Indian postmenopausal women with neck of femur fracture. We studied the bone mineral density (BMD), trabecular bone score (TBS), proximal hip geometry, and bone mineral biochemistry in postmenopausal women with and without femoral neck fractures. METHODS: This was a cross-sectional study conducted at a tertiary care center in South India. BMD, TBS, and hip structural analysis (HSA) were assessed using a dual-energy X-ray absorptiometry (DXA) scanner. Bone mineral biochemical profiles were also studied. RESULTS: A total of 90 postmenopausal women with acute femoral neck fracture with mean (SD) age of 63.2 (6.1) years and 90 age-matched controls were included. The prevalence of osteoporosis was higher among cases as compared to controls (83.3% vs 47.8%; P < 0.001). Degraded bone microarchitecture (TBS value < 1.200) was more frequent among women with hip fracture as compared to controls (46.7% vs 31.1%; P = 0.032). Cross-sectional moment of inertia (CSMI) was significantly lower at the narrow neck (NN) and inter-trochanteric (IT) region in cases (P < 0.05) and buckling ratio (BR) was significantly higher at all three sites in postmenopausal women with femoral neck fracture as compared controls. Multivariate logistic regression analysis showed that femoral neck osteoporosis, low CSMI at NN and high BR at NN and femoral shaft emerged as factors significantly associated with femoral neck fractures. CONCLUSION: This study highlights that impaired parameters of proximal hip geometry and a low trabecular bone score may be significantly associated with femoral neck fractures in postmenopausal women.

Total hip arthroplasty in fused hips with spine stiffness in ankylosing spondylitis.

Ankylosing spondylitis (AS) is characterized by involvement of the spine and hip joints with progressive stiffness and loss of function. Functional impairment is significant, with spine and hip involvement, and is predominantly seen in the younger age group. Total hip arthroplasty (THA) for fused hips with stiff spines in AS results in considerable improvement of mobility and function. Spine stiffness associated with AS needs evaluation before THA. Preoperative assessment with lateral spine radiographs shows loss of lumbar lordosis. Spinopelvic mobility is reduced with change in sacral slope from sitting to standing less than 10 degrees conforming to the stiff pattern. Care should be taken to reduce acetabular component anteversion at THA in these fused hips, as the posterior pelvic tilt would increase the risk of posterior impingement and anterior dislocation. Fused hips require femoral neck osteotomy, true acetabular floor identification and restoration of the hip center with horizontal and vertical offset to achieve a good functional outcome. Cementless and cemented fixation have shown comparable long-term results with the choice dependent on bone stock at THA. Risks at THA in AS include intraoperative fractures, dislocation, heterotopic ossification, among others. There is significant improvement of functional scores and quality of life following THA in these deserving young individuals with fused hips and spine stiffness.

Microbiological profile of septic arthritis in adults: Lessons learnt and treatment strategies.

Objective: The aim of this study is to characterise the clinical and microbiological profile of adult patients treated at our orthopaedic unit with septic arthritic between 2006 and 2017. Materials and Methods: A total of 70 patients who were admitted with a diagnosis of septic arthritis between 2006 and 2017 were included in the study. The patients' clinical and epidemiological characteristics were surveyed; microbiological profile and the complications relating to the patients' treatment were identified. Results: Septic arthritis was more common among males (83%). About 75% of the patients presented with a history of fever. The knee was the most commonly affected joint (71%), followed by the hip. While C-reactive protein was found to be consistently >75, total blood white blood cell (WBC) counts were found not to be reflective of the presence of infection with a mean WBC count of only 13,561/cu.mm, and Gram stain examination had a poor sensitivity of 47%. Among the co-morbidities, the most prevalent association was with diabetes mellitus. The infectious agent most frequently isolated was Staphylococcus aureus(42.85%). The antibiotic sensitivity pattern has evolved since the early years, with resistant strains becoming increasingly prevalent. Unusually, high incidence of streptococci was noted (30%), contrary to the published literature. One-third of the patients had multi-resistant organisms. Septic arthritis left 70% of the patients with a significant residual disability at 6 months follow-up and had 4.25% mortality. Conclusion: Changing sensitivity patterns of microbes in septic arthritis point to a need for reconsidering empirical antibiotic therapy. Joint damage following infection can lead to significant disability.

How effective is periarticular drug infiltration in providing pain relief and early functional outcome following total hip arthroplasty?

The aim of the study was to compare the efficacy of periarticular injection of a cocktail of analgesic drugs (PIC) with epidural infiltration (EA), in providing postoperative pain relief and early functional improvement following Total Hip Arthroplasty (THA). METHODS: 50 patients undergoing unilateral THA were randomized to receive either EA or PIC for postoperative pain control. Postoperative pain relief, as determined by the visual analogue scale (VAS), functional recovery and side effects related to EA and PIC were assessed. RESULTS: PIC resulted in significantly lower VAS scores [0.48(0.71) vs 3.04(2.07)] in the first 24 h after surgery [mean (SD)], when compared to EA. The pain relief continued to be significantly lower even on the 10th postoperative day. Functional recovery was significantly better in the PIC group, with patients being able to walk longer distances and climb steps more quickly following THA. EA, unlike PIC was associated with side effects like nausea, vomiting, motor weakness, back pain and urinary retention. The overall satisfaction rate with treatment was significantly better in PIC group (9.04/10) than those who received EA (7.76/10). CONCLUSION: PIC provides significantly better pain control and functional recovery in the early postoperative period, with less side effects when compared with EA. PIC should be the choice for pain control following THA.

Hypovitaminosis D and Other Risk Factors of Femoral Neck Fracture in South Indian Postmenopausal Women: A Pilot Study.

BACKGROUND: Non-communicable diseases like hip fractures are a significant problem in a developing country like India. The risk factors for hip fractures vary according to local practices and the availability of preventive health care delivery systems. There is paucity of data on risk factors for hip fracture in the south Indian population. AIM: This study was undertaken to assess risk factors associated with femoral neck (FN) fracture in South Indian postmenopausal women along with subsequent one year mortality. MATERIALS AND METHODS: One hundred four postmenopausal women with FN fracture and 104 age and BMI matched controls were included. Sedative use, visual impairment and other relevant risk factors were assessed. Bone biochemistry and Bone Mineral Density (BMD) were evaluated. A telephonic interview was done at the end of one year to ascertain the well-being. RESULTS: Sedative use, visual impairment, low FN BMD and vitamin-D deficiency (<20 ng/ml) were seen more in fracture subjects compared to controls (p≤0.05). At the end of one year, 20% of the fracture subjects and 5% of the controls had died (p=0.001). CONCLUSION: Risk factors identified in our study are potentially correctable, and needs special attention in an Indian context to prevent hip fractures.

Fate of bone grafting for acetabular defects in total hip replacement.

BACKGROUND: The use of allografts and autografts in the management of acetabular defects have been reported with varying results. Trabecular metal is an expensive option in the management of these defects. This study aims to assess the fate and efficacy of bone grafting for acetabular bone defects in total hip arthroplasty. MATERIALS AND METHODS: A total of 30 hips in 28 patients with acetabular deficiencies were treated with bone grafting and total hip replacement (THR). Seventeen hips had American Academy of Orthopedic Surgeons (AAOS) type 2 (Paprosky type 2c) deficiency and 13 had AAOS type 3 (Paprosky type 3a) defects of the acetabulum. Allografts were used in 15 patients and autografts were used in the remaining 13. Cemented total hip arthroplasty was done in 18 hips and uncemented THR in 12. Seven patients underwent the procedure for, acetabular erosion and symptoms following hemiarthroplasty (4 out of 7), or, acetabular revision for failure (3 out of 7) following total hip arthroplasty. Acetabular deficiencies in other patients were due to posttraumatic causes, advanced primary hip arthritis and second stage treatment of postinfective arthritis. A mesh was used in 6 hips and screws were used in 13 hips for graft fixation. RESULTS: Patients were followed up clinicoradiologically for a period of 10 months to 4 years (mean 23.4 months). One patient required staged revision due to infection. Two patients had early asymptomatic cup migration. One patient had graft lysis and change in cup inclination with persistent pain. He was not keen on further intervention at last followup. Other patients were pain free at the time of followup with radiographs showing maintenance of graft and implant position. CONCLUSION: Bone grafting is a suitable option in the management of acetabular defects in total hip arthroplasty, especially in resource challenged countries.

A retrospective analysis of risk factors for meniscal co-morbidities in anterior cruciate ligament injuries.

BACKGROUND: The association of meniscal cartilage injury with anterior cruciate ligament (ACL) injury is well documented in literature. The aim of this study was to examine the relative risk factors for meniscal pathology at the time of arthroscopic ACL reconstruction. MATERIALS AND METHODS: A review of the case records including both in-patient and out-patient charts of all patients who underwent arthroscopic ACL reconstruction during the preceding 3 years was performed by either of the authors. The relative incidences of associated meniscal pathologies were analyzed in correlation with age, side of injury, time to surgery, mode of injury, and gender as the risk factors. Statistical analysis was performed to obtain individual data correlation. RESULTS: A total of 192 patients underwent ACL reconstruction during the 3-year time frame. Of these, complete data sets were available for 129 patients. Analysis revealed that the only factor that was statistically significant in raising the risk of meniscal pathology was the time to surgery (P = 0.001). There was a significant increase in medial, lateral, and both meniscal tears noted in cases operated beyond 24 weeks. Further, the incidence of medial meniscal tears as well as lateral meniscal tears increased with delay in presentation for surgery (P = 0.004). Mode of injury, age at presentation, sex, and side were not significantly associated with an increased incidence of meniscal pathology. CONCLUSION: The single factor that significantly affects incidence of meniscal co-morbidity in ACL injury is the delay in presentation (i.e. the time to surgery). The incidence of lateral meniscal tears as well as medial meniscal tears increased with delay in surgery. This should guide us toward recommending all patients irrespective of age, gender, or mode of injury to undergo early reconstruction, thereby reducing the likelihood of developing meniscal pathology.

Excision arthroplasty: an effective method in the management of plantar ulcers with metatarsophalangeal joint infection in anaesthetic feet.

The cases of 30 patients with septic arthritis of the metatarsophalangeal (MTP) joints as a complication of plantar ulceration in leprosy who underwent excision arthroplasty and primary closure of the plantar ulcer were reviewed. Twenty-two of these patients were male. The commonest site of MTP joint involvement was the first MTP joint. The average longitudinal diameter of ulcers was 2cm, and most ulcers were oval in shape. Diagnosis was made on the basis of signs of infection over the MTP joint, discharge from the ulcer and examination with a probe. Infection in the joint ranged from simple synovial discharge to seropurient or purulent discharge. Treatment involved excision arthroplasty of the MTP joint, excision of the ulcer with primary closure of the plantar incision and dorsal or lateral drainage depending upon the direction in which the infection extended. In two patients, the plantar wound could not be closed as it was too large. Healing of the plantar incision took 2 weeks in 12 patients and 3 weeks in 14 patients. In four patients, healing did not occur by primary intention. In a follow up of 1-2 years, there was no recurrence in 24 patients, while four patients had recurrent simple ulceration. Two patients were lost to follow up. Review of the results of this procedure dealing with septic arthritis of MTP joints secondary to plantar ulceration shows that primary healing of the plantar incision could be achieved in 3 weeks. With regard to recurrence, even though only four out of 28 ulcers treated by this procedure recurred, other contributing factors should be considered in a prospective control study to support the view that this procedure has contributed to non-recurrence.