Role of orthobiologics in managing patellar tendinopathy: A narrative review.

Patellar tendinopathy is a relatively common cause of anterior knee pain in athletes. It is predominantly seen in sports involving jumping, running, abrupt change in direction like basketball, volleyball, soccer, sprinting and jumping. The main pathophysiology is considered to be repetitive microtrauma at the inferior pole of patella along with a poor healing response. Although eccentric exercises have shown to be beneficial, the improvement is often slow and may result in a less than satisfactory outcome. There is a growing interest of orthobiologics, mainly platelet-rich plasma (PRP) in multiple chronic musculoskeletal pathologies. This narrative review aimed to analyse the current evidence on the role of orthobiologics in the management of recalcitrant patellar tendinopathy. Multiple studies have shown significant clinical improvement with negligible adverse effects on PRP injection for patellar tendinopathy. Most studies assessed report that the effects of PRP are sustained. However, among all studies evaluated, there is a considerable heterogeneity in terms of PRP composition, number of injections, dosage interval and postinjection rehabilitation protocol, pointing to the need for further research to enable standardisation of PRP therapy. Stem cells too have shown potential to be effective as a treatment modality for chronic patellar tendinopathy, but there is limited data to recommend its use outside of research setting or to enable a meaningful comparison to PRP. There is a promising role of orthobiologics in management of chronic patellar tendinopathy not responding to conventional treatment. Level of Evidence: Not applicable (narrative review).

Seasonal variation and Vitamin-D status in ostensibly healthy Indian population: An experience from a tertiary care institute.

Background: 25-hydroxy vitamin-D (25(OH)D) deficiency is prevalent worldwide including India. Earlier some cross-sectional studies have discussed 25(OH)D deficiency and its prevalence. The correlation of 25(OH)D with seasonal variation has been reported rarely in India. To determine the 25(OH)D levels and seasonal changes of 25(OH)D status at a tertiary care hospital in North-western India. Materials and methods: 25(OH)D assessments performed in laboratories between 2018 and 2020 was acquired using hospital records. A total of 11,428 assays of serum 25(OH)D were analyzed in the study. Subjects were divided into three groups based on the International Endocrine Society's recommendation for serum 25(OH)D level. The 25(OH)D deficiency <20 ng/ml, insufficiency 20-29 ng/mL and sufficiency ≥30 ng/mL was defined. The months have been separated into the following seasons to analyze seasonal trends: Summer/monsoon (April-September), and winter/spring (October-March). Results: The median 25(OH)D was 17.2 ng/mL. We observed the prevalence of 60 %, 24.1 % & 15.9 % of 25(OH)D deficiency, 25(OH)D insufficiency, and sufficiency respectively in the total number of individuals tested. 56 % male and 63 % females were 25(OH)D deficient. Notably, the lowest median 25(OH)D value was found in the 21-30 age group (14.8 ng/mL). A significant difference in 25(OH)D levels between the summer (18.7 ng/mL) and winter (15.8 ng/mL) seasons has been noticed. Discussion: Current study revealing that 25(OH)D deficiency is common in all age groups and genders, according to our findings. Surprisingly, the lowest levels were reported in young adults. Seasonal variation has an impact on 25(OH)D status, however in all seasons 25(OH)D levels are lower than reference intervals. These findings suggest that the criteria for determining the state of 25(OH)D insufficiency and deficiency in the Indian population should be reconsidered.

Short segment posterior fixation of unstable thoracolumbar vertebral fractures with fractured vertebra augmentation with intermediate pedicle screw - a clinicoradiological analysis.

INTRODUCTION: Unstable thoracolumbar burst fractures are routinely encountered in orthopedic practice. Recently, short-segment fixation with pedicle screw augmentation of the fractured vertebra for unstable thoracolumbar burst fractures has gained popularity. Nonetheless, the maintenance of the kyphotic correction during the follow-up period remains controversial. This study aimed to examine the clinical-radiological outcomes, complications, and functional outcomes of fractured vertebrae augmentation with intermediate pedicle screws in short-segment instrumentation in acute thoracolumbar spine fractures. METHODS: This retrospective study was conducted in the Department of Orthopedics, All India Institute of Medical Sciences, Jodhpur, using medical records from January 2021 to October 2022. Parameters such as local kyphosis correction, loss of kyphotic correction at final follow-up, anterior body height correction (%), and loss of correction (%) at final follow-up were measured as primary outcomes. Various other parameters such as operative time, blood loss, length of hospital stay, and visual analog scale were measured as secondary outcomes. RESULTS: The mean correction obtained via surgery in the immediate postoperative period was 13.7±2.3 degrees. The mean loss of correction at the final follow-up was 4.1±2.0 degrees, and the mean final local kyphotic angle was 7.2±2.4 degrees (P<0.05). The mean correction obtained via surgery in the immediate postoperative period was 37.2%±9.0%. The mean loss of correction at the final follow-up was 10.5%±5.3%, and the mean final anterior vertebral body height maintained was 72%±11.0% (P<0.05). CONCLUSION: Short-segment posterior fixation with pedicle screw augmentation achieves good correction of local kyphotic angle and anterior vertebral height in the immediate postoperative period, but some loss of correction at final follow-up is common. In our study, the loss of correction corresponded directly to the load-sharing score.

Perception of telemedicine among orthopedic surgeons and patients and an analysis of the factors governing its overall efficacy: Results from the COVID-19 pandemic.

Background: Providing health-care services through telemedicine for musculoskeletal ailments after the first wave of COVID-19 may help reduce the burden on the already-strained health-care system. Objectives: The objectives of this study were (1) to assess the satisfaction levels of orthopedic surgeons and patients with respect to telemedicine and (2) to determine the factors governing the overall efficacy of telemedicine consultations. Materials and Methods: A cross-sectional study was conducted to ascertain the perception of telemedicine (both doctors and patients) under the following domains - (1) information provided and ease of usage; (2) doctor-patient communication; (3) ease of prescribing and understanding treatment; and (4) audio-video quality of the consultation. The influence of these factors on overall satisfaction was determined using multinomial logistic regression analysis. Results: Of the 204 patients and 27 surgeons who completed the questionnaire, 77% (patients) and 89% (surgeons) were satisfied with the overall efficacy of telemedicine. Maximum satisfaction was noted with the ease of obtaining a telemedicine appointment (168/204). 68.6% of patients further stated they would prefer future visits virtually. While all four factors were found to have a significant correlation (P < 0.001) with the overall efficacy of teleconsultation services, the quality of the telephone call (odds ratio [OR] =90.15) and good doctor-patient communication (OR = 15.5) were found to be the most important of the lot. Conclusion: Our study not only demonstrates the high degree of satisfaction with telehealth services but is also able to pinpoint the areas where improvement is needed to enhance the overall experience with this technology.

Evaluation of spinopelvic parameters in patients with lumbosacral transitional vertebra: a cross sectional and comparative study.

INTRODUCTION: Lumbosacral transitional vertebra (LSTV) is the most common congenital anomaly of the lumbosacral junction and is a frequent cause of back pain in young patients with a prevalence of 4.6% to 36% in different regions. OBJECTIVE: The objective of this study was to evaluate spinopelvic parameters in patients with lumbosacral transitional vertebra and to compare them with the same parameters of low back ache patients without lumbosacral transitional vertebra. METHODS: This was a cross-sectional and comparative study conducted among low back ache patients presenting to our tertiary care center. Low back ache patients presenting to the outpatient department of AIIMS Jodhpur were screened for LSTV using radiographs. The spinopelvic parameters of those with LSTV were measured using Surgimap software and compared with the parameters of low back ache patients without LSTV. An Independent sample t-test was done and p-values were calculated. RESULTS: The spinopelvic parameters, pelvic incidence, pelvic tilt and lumbar lordosis differed significantly in the patients with LSTV. Pelvic incidence was higher in the group with LSTV (58.5+9.3) when compared to the group without LSTV (50+8.8) with a p-value (<0.001). Pelvic tilt was higher in the group with LSTV (19.4+8.8) when compared to the group without LSTV (13.6+7.8) with a p-value (0.001). Lumbar lordosis was significantly higher in the group with LSTV (57.6+13.2) when compared to the group without LSTV (50.7+12.2) with a p-value (0.007). No significant differences were obtained in sacral slope and Pelvic-incidence and lumbar lordosis mismatch. CONCLUSION: LSTV alters the spinopelvic parameters. Altered spinopelvic parameters predispose to spondylolisthesis, degenerative disc disease, and facet joint arthritis and are important in preoperative planning in spine and pelvic surgeries.

Effect of platelet-rich plasma on healing of autologous graft after anterior cruciate ligament reconstruction: a randomized control trial.

Aim: This study aimed to assess the effect of platelet-rich plasma (PRP) on anterior cruciate ligament (ACL) graft healing at graft tunnel interface and ACL graft 6 months post-reconstruction. Material & methods: A randomized trial involving 87 patients was conducted, dividing them into PRP and non-PRP groups. Magnetic resonance imaging (MRI) and functional outcome measures were used to evaluate graft healing. Results: Out of the 87 patients, 80 were analyzed. The PRP group exhibited superior clinical and radiological outcomes compared with the non-PRP group, as indicated by Figueroas score, Lysholm score and knee range of motion. Conclusion: These findings demonstrate that PRP can be used as an adjunct therapy for ACL reconstruction, enhancing graft healing and improving patient outcomes. CTRI approval (Reg. No - CTRI/2018/11/016263).

This study investigated the effects of platelet-rich plasma (PRP) on the healing of the anterior cruciate ligament (ACL) after knee reconstruction surgery. The ACL is an important ligament for knee stability, and its tear is a common sports injury. PRP, a substance found in blood, has been used to speed up healing in various surgeries. In this study, 80 patients who underwent ACL reconstruction were randomly assigned to receive either PRP or standard treatment. After 6 months, the group treated with PRP showed improved healing and better knee function compared with the non-PRP group. These findings suggest that PRP can help accelerate ACL healing and improve outcomes for patients.

Mucoid degeneration of the anterior cruciate ligament: can platelet-rich plasma combined with reductionplasty provide better results?

Introduction: Mucoid degeneration of the anterior cruciate ligament (ACL) is commonly treated with arthroscopic debridement of the ACL. But many studies have reported the weakening and laxity of ACL postoperatively and on follow-up. Platelet-rich plasma (PRP) is known to influence musculoskeletal healing through multiple growth factors. Methodology: Five patients who were diagnosed as a case of mucoid degeneration of the ACL based on MRI, over a period of 1 year (December 2018-2019), were included in the study. Autologous PRP, prepared by double spin protocol, was injected into the remaining ACL after partial debridement was done. Results: Visual analogue scale and Lysholm scores improved compared with preoperative scores, along with strength (anterior drawer test and Lachman test). Conclusion: PRP can be used to improve the healing and strength of a weakened ACL after partial debridement, but further research is needed to demonstrate its efficacy.

Mucoid degeneration of the anterior cruciate ligament (ACL) of the knee can cause knee pain and other symptoms. For treatment of this, partial removing of bulky ACL is generally done, which causes weakness of the ACL. Nowadays, orthobiologics such as platelet-rich plasma (PRP) are increasingly used in ligament surgeries to improve healing. This study used PRP to augment the weakened ACL and followed patients for 1 year to assess outcomes. The results found improved functional scores and pain scores compared with preoperative levels. As this improvement might not be entirely due to PRP, high-end comparative studies are needed to confirm its efficacy.

Bibliometric Analysis of Top 100 Systematic Reviews and Meta-analyses in Orthopaedic Literature.

Aim: We performed a bibliometric analysis of top 100 systematic reviews (SR) and meta-analyses (MA) in orthopaedic literature and also evaluated articles with maximum average citation per year, which were unable to make up in the present top 100 cited list, but may have a promising future in the world of citations. Methods: This bibliometric study was performed by searching Web of Science database according to a specific search strategy by two independent authors according to eligibility criteria of the studies. Articles with more than 100 citations were eligible for analysis and were evaluated for following parameters: number of citations, journal name, publication date and year, first author, the total number of authors, average citations per year, methodological design of the study, geographic origin and institute associated. Inter-rater reliability was evaluated using Kappa coefficient. Results: The number of citations ranged from 1073 to 198 with a total citation count of 30,589. Inter-rater reliability came to out in the good agreement (Kappa value-0.8). There was visible up-gradation of the research from the 2000 year till today. Spine journal had the maximum articles (26) followed by Journal of Bone and Joint Surgery-America (12 articles). The topics "Spine" and "Sports Medicine" were the most frequently cited topics with 41 and 20 articles, respectively. USA has the maximum articles in the top 100 cited SR and MA. Based on the maximum average citations per year, 34 old articles were replaced in the list with the latest articles that have a bright future ahead and can be predicted to be in the top 100 cited SR and MA of Orthopaedics soon. Conclusion: This study recognizes those articles that have contributed significantly to the growth of knowledge and influenced clinical practices in orthopaedics. We believe that this will facilitate and encourage researchers and clinicians in their future research. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-022-00604-9.

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip and total knee arthroplasty in Indian patients?

Both apixaban and enoxaparin are Food and Drug Administration-approved standard therapy for prophylaxis of deep-vein thrombosis; however, the superiority of one over the other is still controversial. With an objective to observe efficacy and safety outcomes of apixaban and enoxaparin in patients undergoing total hip (THA) and knee (TKA) arthroplasty, 96 patients undergoing THA/TKA (October 2018 to August 2019) were randomly allocated into 2 groups; (n = 48) apixaban; and (n = 48) enoxaparin. Efficacy outcomes and safety outcomes were recorded at 2 and 5 weeks post-TKA/THA. Follow-up functional scoring was done at 6 months postoperatively. Apixaban and enoxaparin were found to be equally efficacious in preventing venous thromboembolism; however, apixaban had a better safety profile. The apixaban group had nonsignificant higher tendency for wound discharge, atrial fibrillation and transient ischaemic attack. Enoxaparin had nonsignificant greater tendency for bleeding, wound dehiscence and pulmonary complications. Apixaban is a safe alternative to conventionally used enoxaparin for chemoprophylaxis in patients undergoing THA or TKA.

Reappraisal of Limited Duration Tourniquet in Total Knee Arthroplasty: A Double-Blinded RCT.

BACKGROUND: The majority of arthroplasty surgeons use a full duration of tourniquet while doing total knee arthroplasty. Recent literature suggests clinical dilemma about superior function with limited duration use of a tourniquet. The purpose of this study is to evaluate the time-dependent effects and clinical outcome of tourniquet in patients undergoing total knee arthroplasty (TKA) and to assess the incidence of adverse vascular events of the limb in TKA. This study is the first of its kind to evaluate all the serious vascular events prospectively. METHODS: Sixty participants who underwent TKA in the duration of 1.5 years at a large single tertiary care centre were recruited and randomly allocated in two groups: Full duration tourniquet (n = 30) and tourniquet only during cementation (n = 30). All patients underwent preoperative and postoperative arterial and venous Doppler to evaluate the presence of thrombosis. The operative duration, blood loss, and clinical outcome (visual analogue scale, active knee range of motion, Knee Society score, and duration of stay) were recorded. RESULTS: The incidence of vascular complications was not statistically significant in either group (P = 0.99). Tourniquet during cementation only group exhibited decreased postoperative pain on days 1, 2, and 3 (P < 0.01). But postoperative knee active range of motion was the same between the two groups with no significant postoperative complications. CONCLUSION: Tourniquet use only during cementation could result in faster recovery and less pain during the early rehabilitation period with no influence over the incidence of serious vascular events. TRIAL REGISTRY NUMBER: AIIMS/IEC/2018/475. This study was approved by the Research Ethics Committee at All India Institute of Medical Sciences, Jodhpur and was carried out at AIIMS (Jodhpur), India.

Primary pelvic echinococcosis though uncommon but not rare.

Echinococcosis is caused by larva of Echinococcus granulosus. Liver being most commonly involved, other organs/body parts such as bone involvement is not so uncommon, especially in cattle-raising countries such as India. Primary osseous echinococcosis remains undiagnosed until complications have developed. We report a case of complicated pelvic echinococcosis presented with left gluteal mass, acetabulum and femoral head destruction, and reduced hip mobility. Pre- and postoperative chemotherapy with albendazole and en bloc surgical removal of the cyst were advocated as the preferred option of treatment. Primary osseous echinococcosis must be kept in mind when encountering a case of chronic bony mass not responding to antitubercular therapy, and hydatid serology should be performed along with other imaging and histopathological examinations to support or confirm the diagnosis to prevent long-term complications.

Acute Kidney Injury Secondary to Rhabdomyolysis: A Rare Complication of Low-Energy Trauma.

INTRODUCTION: Crush syndrome refers to the systemic manifestation of muscle cell injury following release of myocyte contents into the blood circulation. It is seen most commonly in patients sustaining high-energy trauma. Acute kidney injury is one of the most serious complications of crush syndrome and is an important cause of mortality in these patients. In contrast, the occurrence of rhabdomyolysis in patients sustaining low-energy trauma is sparsely reported in the literature. The authors report one such rare case. CASE REPORT: The patient was a 77-year-old hypertensive male who presented to the emergency following an episode of slip and fall at home. After prompt resuscitation, he was sent for radiological evaluation which revealed fractures of the left inter-trochanteric femur and left proximal humerus. Meanwhile, laboratory investigations showed grossly deranged renal parameters, along with elevated serum creatinine phosphokinase levels (more than 5 times the baseline). A diagnosis of acute kidney injury secondary to traumatic rhabdomyolysis was made. Medical management included adequate intravenous fluid administration combined with strict input-output monitoring. Subsequently, the patient underwent closed reduction and internal fixation of the inter-trochanteric femur fracture with a proximal femoral nail. However, fracture of the proximal humerus was managed non-operatively with sling immobilization as patient refused to give consent for a second surgery. CONCLUSION: Although rare, acute kidney injury secondary to rhabdomyolysis can occur in patients with low-energy trauma. It is important not to confuse it with chronic renal insufficiency, especially in geriatrics many of whom are long-standing hypertensives.

Arthroscopic Subtalar Arthrodesis as a Treatment Strategy for Subtalar Arthritis: A Systematic Review.

Arthroscopic subtalar arthrodesis is a relatively new technique which is increasingly being used by foot and ankle surgeons as an alternative to open surgery. However, there is still a lack of consensus with respect to the efficacy of the procedure. The purpose of this review was to ascertain (1) whether arthroscopic subtalar arthrodesis improves the functional outcome of treated patients and (2) how do the 2 techniques of subtalar arthroscopy (posterior and lateral) compare with each other. MEDLINE and Cochrane Library databases were accessed by 2 independent reviewers. Inclusion/exclusion criteria were predefined. National Institute of Health risk of bias assessment tool was used to determine the methodological quality of the included studies. A total of ten studies with 234 patients (240 feet) were included. The most common indication for arthroscopic subtalar fusion was posttraumatic subtalar arthritis. Weighted pre- and postoperative American Orthopaedic Foot and Ankle Society scores were 47 and 80.7, respectively. Average time to fusion was 10.2 weeks and weighted mean fusion rate was 95%. Pain secondary to prominent hardware and nonunion were the most common complications. Although improvement in functional scores was higher and complication rate lower with the posterior group, a better fusion rate was seen with the lateral approach. Arthroscopic fusion techniques have shown to be an effective alternative to open surgery. While there was a trend for better functional outcome with the posterior approach, randomized control trials comparing the 2 techniques are needed to better assess their respective outcomes.

Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines.

BACKGROUND: Articular cartilage lesions are becoming increasingly common. Optimum diagnosis and management of chondral defects cause a lot of dilemma. A number of surgical methods have been reported in the literature for treating focal cartilage defects. There is a lack of consensus on the most effective management strategy, with newer surgical and cell-based treatments being advocated regularly. STUDY DESIGN AND METHODS: A clinical review is constructed by appraising the published literature about clinical evaluation and diagnostic modalities for articular cartilage defects and subsequent surgical procedures, management strategies employed for such lesions. Prominent available databases (PUBMED, EMBASE, Cochrane) were also searched for trials comparing functional outcomes following cartilage procedures. Synthesis of a practical management guideline is then attempted based on the evidence assessed. RESULTS: Systematic examination and optimal use of diagnostic imaging are an important facet of cartilage defect management. Patient and lesion factors greatly influence the outcome of cartilage procedures and must be considered while planning management. Smaller lesions < 2 cm2 respond well to all treatment modalities. Autologous osteochondral transplants (OATs) are effective in high activity individuals with intermediate lesions. For larger lesions > 4 cm2, newer generation autologous chondrocyte implantation (ACI) has shown promising and durable results. Stem cells with scaffolds may provide an alternate option. Orthobiologics are a useful adjunct to the surgical procedures, but need further evaluation. CONCLUSIONS: Most treatment modalities have their role in appropriate cases and management needs to be individualized for patients. The search for the perfect cartilage restoration procedure continues.

Postmenopausal Bleeding as a Late Sequela of Pelvic Fracture.

Postmenopausal bleeding is one of the common presenting complaints in the gynecological outpatient department. The common causes of which are atrophic endometritis, vaginitis, estrogen therapy, cancer endometrium, and cancer cervix. Hereby, we present a rare case of a 65-year-old female presented with postmenopausal bleeding who had history of trauma 1 year back with pelvic bone fracture. The cause of postmenopausal bleeding, in this case, is abnormal bony protrusion secondary to malunited pelvic fracture causing laceration of the right lateral vaginal wall. The case was managed by local osteotomy and vaginal wall repair.

Does a staged treatment of high energy tibial plateau fractures affect functional results and bony union? A case series.

PURPOSE: Tibial plateau fracture (TPF) is a devastating injury as it shatters lower articular surface of the largest joint. Apart from bony injury, TPF can lead to great soft tissue envelope compromise which affects the treatment plan and outcome. In the present study, clinical results were assessed in cases of high energy TPFs treated in staged manner. METHODS: Twenty-three (20 males and 3 females) patients of high energy communited TPFs (Schatzker type V and VI) were consecutively treated.1 All the patient had compromise of overlying skin conditions. They were all successively scheduled for staged treatment plan which comprised of application of bridging knee external fixator on the first day of admission and definitive internal fixation after skin and soft tissue overlying the fracture were healed. Schatzker type I, II, III and IV were excluded from the study. Primary survey was done and patient who had head injury, chest and abdominal injury, pelvic injury and contralateral limb injury and open fractures were excluded from the study. The patients were also evaluated in terms of wound complications, axial and rotary alignment of limb, fixation failure, articular congruity and range of motion of the knees and post injury employment. Statistical analysis was done using SPSS software. RESULTS: Maximum follow-up period was 13 months. All the fractures were united at final follow-up. Clinical evaluation was done with the Tegner Lysholm knee scoring scale.2 Excellent results were found in 78% cases and good and fair results in 22% cases. There was significant correlation between range of motion and the Tegner Lysholm knee score (p < 0.001, Pearson correlation coefficient = 0.741). The correlation between the score and the radiographical union duration was significant (p = 0.006, Pearson correlation coefficient = -0.554). CONCLUSION: A staged treatment plan allows healing of soft tissue envelope, with avoidance of dreadful complications such as compartment syndrome and chronic infection. In addition, a staged treatment strategy does not hamper the fracture reduction, bony union and the functional results.

Pelvic echinococcosis presenting as a mass in the gluteal region: a case report.

Hydatid disease of the skeletal system is a rare entity. We present one such case of pelvic echinococcosis in a 62-year-old male who presented with the chief complaints of pain and swelling in the left gluteal region for the past twelve years. The patient was planned for and underwent en-bloc excision of the lesion. Albendazole was used pre- and post-operatively to reduce parasitic load. At the last follow-up, the patient was disease-free and able to carry out his daily activities without much difficulty. We would conclude that, although uncommon, echinococcosis should always be ruled out, especially when dealing with other indolent pathologies of the hip joint.

Neglected Monteggia fracture dislocations in children: a systematic review.

Monteggia fractures are uncommon and frequently missed injuries in children. This article aims to study, in a systematic manner, the surgical management and complications of treatment of chronic radial head dislocations. After screening of relevant abstracts, a total of 28 studies were included in the systematic review. A narrative synthesis of various treatment modalities has been discussed. This article concludes that open reduction should be attempted unless dysmorphism of the radial head restricts it. Open reduction with ulnar osteotomy with or without annular ligament reconstruction is the most commonly performed procedure and is expected to result in reduced pain and elbow deformity.