Simultaneous ACL and Patellofemoral Instability: Surgical Management and Outcomes.

Introduction: The study discussed three patients who experienced both anterior cruciate ligament (ACL) injury and patellofemoral instability. This combination of injuries is rare and has a scarcity of published /literature. The study described the mechanism of injury, diagnostic modalities, and the decision-making process for surgical intervention. It emphasizes the importance of a comprehensive clinical evaluation and discusses surgical techniques for combined ACL and medial patellofemoral ligament (MPFL) reconstruction. The study suggests that with careful evaluation and meticulous surgical techniques, patients with concurrent ACL and MPFL injuries can achieve successful outcomes and return to normal activities. Case Report: The cases presented involve young patients who suffered twisting knee injuries, often resulting from accidents or sporting activities. The surgical technique involved the use of grafts for ACL and MPFL reconstruction. MPFL reconstruction was performed followed by ACL reconstruction. Post-operative rehabilitation included the use of a patellar stabilizing knee brace and gradual mobilization. Results: The patients experienced moderate pain initially but achieved a full range of motion and stability in the knee after several weeks. At the 1-year follow-up, both patients reported no symptoms of instability or pain. Conclusion: The article highlights the importance of MPFL reconstruction in preventing ACL reconstruction failures and emphasizes the need for aggressive rehabilitation to prevent knee stiffness. Overall, this study presented important information and added knowledge regarding the diagnosis, surgical management, and post-operative care of patients with concurrent ACL and patellofemoral instability.

Cemented bipolar hemiarthroplasty for unstable intertrochanteric fracture in elderly patients over 70 years: Boon or bane?

INTRODUCTION: The surgical management of intertrochanter femur fracture in elderly patient is still under debate. Various implants can be utilised but prosthetic replacement is gaining popularity. This study was performed to evaluate the functional and clinical outcomes of cemented bipolar arthroplasty as a primary treatment for unstable intertrochanteric fracture in elderly patients (> 70 years). MATERIALS AND METHODS: Thirty-seven patients with unstable intertrochanteric fracture in elderly patient (> 70 years) who underwent cemented bipolar hemiarthroplasty. Intra-operative and post-operative complications were noted; functional outcomes were assessed using Harris hip score (HHS). All patients were followed up for a minimum of 12 months. RESULTS: Overall 90% of patients has some minor or major intra or post-operative complication. One year mortality rate was 16% (6/37). Cardiopulmonary events were the most common life threatening incident. Mean fall in Haemoglobin was 1.6 gm/dL. The average time for full weight bearing mobilisation with the help of walker was 2.8 ± 1.2 days (1-8 days). The average duration of surgery was 58 ± 6 min (44-96 min) with an average blood loss of 126 ± 24 mL (90-380 mL). HHS at the end of 12 months was 77. CONCLUSIONS: The use of bipolar hemiarthroplasty in senile patient with unstable hemiarthroplasty gives an advantage of early weight bearing. However, it is associated with risk of significant intra or post-operative morbidity due to intra-operative trauma, surgical time and blood loss during the surgery. Although hemiarthroplasty can be a single-time solution to the complexities of intertrochanter fracture in elderly patients but should be performed in selected patients only.

Total hip arthroplasty in different types of advanced tubercular hip arthritis: is it justified.

PURPOSE: Total hip arthroplasty (THA) provides a good treatment option for the patients in late arthritis stage. We present our experience of THA in various spectrums of disease. METHODS: Retrospective study including 23 advanced tubercular hip arthritis patients over a period of 13 years. The patients with active discharging sinus were excluded from the study. The patients were divided into three groups: group 1 (healed TB), group 2 (active TB), and group 3 (intraoperative surprise). The preoperative and postoperative antitubercular treatment (ATT) was administered to all the patients as per the protocol for various duration. All patients underwent THA (cementless or hybrid) after investigations including MRI. The patients were followed up with clinic-radiological and laboratory investigations. RESULTS: The mean age of the patients was 58.2 years with 16 males and seven females. There were 14 healed TB hips, eight active TB hips, and one intraoperative TB hip patient. Preoperative ATT duration in group 1 varied from one to two weeks and in group 2 patient's average was 9.6 weeks (range: 6-12weeks). Postoperatively, ATT was given for a minimum of ten months extending to 16 months. Cementless THA was performed in 17 patients and hybrid THA (cemented stem) in six patients. Only one patient had aseptic loosening of the stem and revision arthroplasty was done. CONCLUSION: THA is a viable option and provides mobile, stable hip in tubercular hip arthritis even in active TB hip patients. ATT is important in the management and prevent the reactivation of the disease.

Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores.

PURPOSE: Chronic insertional Achilles tendinopathy is a common pathology in the over 50 years old population. Patients not relieved with conservative treatment had to undergo surgical intervention for the management. This study evaluates the clinical outcome of FHL transfer in such patients using validated ankle functional scores. METHOD: It is a retrospective study including 20 patients of either gender managed with debridement of the distal degenerative remnant Achilles tendon fibers either at the insertion site or the distal end of the torn tendon, resection of Haglund deformity with FHL transfer, and reattachment of Achilles tendon. The average age of the patients was 56.55 + 11 years (50-77 years) followed by over 35.6 months (Range 22-48months). The preoperative FAAM, FADI, SF 36, VAS, and AOFAS scores were calculated and followed every 6 months. The plantarflexion and dorsiflexion of the ankle were also recorded preoperatively and at follow-up visits. RESULTS: All the patients were operated on by a single surgeon (MS) with the same surgical technique, implant, and rehabilitation protocol. All the patients were followed for an average of 35.6 months (Range 22-48 months). All the ankle scores, FAAM, FADI, SF36, VAS, and AOFAS improved in follow-ups. The mean plantarflexion and dorsiflexion were 39.300+ 4.90 and 12.50+ 4.70 respectively. Three patients had minor wound complications. All the patients returned to activities of daily living. CONCLUSION: FHL transfer in elderly patients with insertional Achilles tendinopathy improves the validated ankle functional scores and decreases pain significantly. Furthermore, randomized studies with a larger study population and longer follow-ups may ascertain the beneficial effects.

Mesenchymal stromal cell therapy for patients with rheumatoid arthritis.

Management of relapses and refractory rheumatoid arthritis (RA) patients is complex and difficult. Even after the administration of new biological disease-modifying anti-rheumatic drugs (DMARDs), only a few patients achieve the complete remission phase. DMARDs help only in modifying the disease activity, which sooner or later fails. They do not manage the disease at the patho-etiological level. There are some serious side effects as well as drug interaction with DMARDs. There are few subsets of RA patients who do not respond to DMARDs, reasons unknown. Mesenchymal stem cells (MSCs) provide a promising alternative, especially in such cases. This review elaborates on the studies pertaining to the application of MSCs in rheumatoid arthritis over the last two decades. A total of 14 studies (one review article) including 447 patients were included in the study. Most of the studies administered MSCs in refractory RA patients through the intravenous route with varied dosages and frequency of administration. MSCs help in RA treatment via various mechanisms including paracrine effects. All the studies depicted a better clinical outcome with minimal adverse events. The functional scores including the VAS scores improved significantly in all studies irrespective of dosage and source of MSCs. The majority of the studies depicted no complications. Although the use of MSCs in RA is still in the early stages requiring further refinement in the source of MSCs, dosage, and frequency. The role of MSCs in the management of RA has a promising prospect. MSCs target the RA at the molecular level and has the potential to manage refractory RA cases not responding to conventional treatment. Multicentric, large sample populations, and long-term studies are required to ascertain efficacy and safety.

Midfoot tuberculosis: Clinical suspicion and early investigation is the key.

BACKGROUND: Tuberculosis affecting midfoot is not common, leading to delay in diagnosis further leading to deformity and difficult management. Tissue diagnosis is always not possible at such sites. MRI is the better imaging modality to diagnose earlier than conventional radiographs. The aim of the study is to have a clinical suspicion of tuberculosis in midfoot pain and a low threshold to perform MRI in these patients. METHODS: The data of 7 patients were collected prospectively over 3 years. Inclusion criteria included midfoot pain for more than 4 weeks in a skeletally mature patient with no radiographic findings. MRI and laboratory investigations were done in all the patients. All the patients were given Anti-tubercular therapy and followed up for 12 months. The patients were assessed at 3, 6- and 12-months duration with ESR, CRP, MRI, VAS and AOFAS Midfoot scores. RESULTS: There were 3 males and 4 females included in the study with a mean age of 55.5 years. The mean duration of symptoms was 5.2 weeks. The mean ESR and CRP at presentation were 46 and 12 respectively which progressively decreased over 12 months. The mean VAS and AOFAS midfoot score at presentation were 4 and 70 respectively. None of the patients had any complication from ATT drugs. Residual pain was present in 4 patients with no functional limitation of the foot. The follow-up MRI showed healed tuberculosis in all the patients. CONCLUSIONS: Tuberculosis can be a cause of vague midfoot pain in tuberculosis endemic countries. The MRI in such patients along with laboratory findings can lead to early diagnosis and the empirical institution of the ATT. The tissue diagnosis is not always possible in the early stages of the disease as there is no radiographic lesion or collection in the midfoot.

Current Role of Intra-Articular Injections of Platelet-Rich Plasma in Adhesive Capsulitis of Shoulder: A Systematic Review.

Adhesive capsulitis shoulder is a common problem of patients presenting with shoulder pain and disability. The approach to such patients includes a variety of modalities. This systematic review evaluates the efficacy of intra-articular injections of platelet-rich plasma (PRP) in the treatment. A literature search was performed between January 2010 and 30 May 2022. MeSH terms used were 'Platelet-rich plasma' OR 'PRP' AND 'Frozen shoulder' OR 'Adhesive capsulitis shoulder' OR 'Periarthritis shoulder'. The search included published articles in the English language involving human subjects. Studies evaluating other types of shoulder disorders, in vitro studies, review articles, animal-model studies, and pre-clinical trials were excluded. The data regarding study characteristics, efficacy, and safety outcomes were analyzed. A total of 11 studies with 347 patients over 10 years were finally included in this review. Most publications were in 2019 and 2020, mostly from India. This review included seven comparative studies, three case series, and one case report. In seven studies, a single intra-articular PRP injection was administered, whereas in the rest of the studies two or multiple injections were given. Only one study demonstrated an equivocal efficacy of PRP and steroid intra-articular injection. The rest all depicted better clinical and functional outcomes with the PRP injection. Only one study compared the outcomes of hydro-dissection treatment in adhesive capsulitis with the intra-articular PRP injection. The rest all either examined PRP alone or compared it with the steroid intra-articular injection. None of the studies showed any major side effects. The intra-articular injections of PRP in the management of adhesive capsulitis of the shoulder provide a new treatment approach. Further studies are required to ascertain the efficacy and safety of the PRP intraarticular injection as a management alternative in adhesive capsulitis.

Surgical Management of Non-Union Patella Fracture: A Case Series and Review of the Literature.

BACKGROUND: The neglected patella fracture leading to non-union of the fracture in long term. Non-union patella is the rare entity with incidence of 2.4-12.5%. The fractured proximal fragment of the patella is retracted proximally leading to fracture gap of various centimetres. Various surgical modalities are described to manage such fracture morphologies. METHODS: Ten neglected patella fracture morphology were included in the study. Five patients with transverse fracture was treated with ORIF with TBW. Two patients with communited fracture was treated with ORIF with TBW (K wires) and cerclage wire. Three patients with inferior pole patella was managed by open reduction and Krachow suture using fibre wire. The results were assessed in terms of time of union, knee range of motion, extension lag, quadriceps power, fracture gap, Knee society score, Kujala knee score and any complications. Follow-up with radiographs was done at 2, 4, 6 and 12 months. RESULTS: All patients presented with a mean duration of 9.3 months (7-13months) after the trauma with mean gap between the fracture fragments of 5.2cm (3.8-6.6cm) in maximum flexion and 2.6cm (2.0- 3.0cm) in full passive extension. The mean duration of the radiological union was 5months (3-6months). The average range of motion achieved at the end of 12 months ranges from 10o to 110o. The quadriceps power in all patients were 4+ or 5 at 6 and 12months. The mean Knee Society Score was 75 (Range 72-82) and mean Kujala knee score was 73 (Range 70- 82) at the end of 12 months. CONCLUSION: We conclude that in cases of non-union patella ORIF using TBW has the best result. V-Y plasty is rarely required for fracture reduction. The need for bone grafting can be assessed on case to case basis. Partial/total patellectomy should be avoided and Krackow suture technique is helpful in management of inferior pole patella fractures.

Proximal Tibiofibular Joint: A Forgotten Entity in Multi-Ligament Injuries of the Knee.

PURPOSE: The proximal tibiofibular joint (PTJF) can be injured with the structures in the lateral aspect of the knee in a multi-ligament knee injury (MLKI) patient. Such injuries are scarce but require attention in the management of the complex MLKIs. The assessment and management of such injuries are not well described in the English literature. This study describes the frequency of PTFJ injuries, clinical assessment and functional outcomes of such injuries in MLKI patients. METHODOLOGY: The data were collected retrospectively from the cohort from 2013 to 2018. The 84 MLKI were included in the study, out of which 9 patients had associated PTFJ injury. All the PTFJ injuries were operated by one single surgeon (D.S) which involves stabilization with K-wires (Kirschner wire) and fixation with 4 mm cancellous cannulated screw along with reconstruction surgery for MLKI in single stage. RESULTS: The frequency of PTFJ injury in our patient cohort is 10.71%. Three patients out of the nine patients received Larson procedure apart from the fixation of PTFJ. At a mean follow-up of 13 months, the Lysholm score was 77.4 (range: 69-86) and mean modified Cincinnati score was 62 (range: 52-72). There was grade I posterior laxity present in one patient with PCL and PLC injury, one patient with ACL, PCL and PLC injury, and one patient with ACL, PCL, MCL and PLC injury at final follow-up. Terminal flexion of 15° or more restriction was noted in six patients. All patients were satisfied with the outcome. CONCLUSION: Evaluation of PTFJ should be an integral part of preoperative as well as an intraoperative examination of MLKI patients. The fixation of this joint is of utmost importance for the reconstructive ligament procedures on the lateral aspect of the knee. The dial test used for the assessment of the integrity of PLC injury should have a prerequisite of proximal tibiofibular joint stability, otherwise, it can lead to erroneous assessment. LEVEL OF EVIDENCE: IV.

Unusual aetiology of foot pain in the elderly: A case report & review of literature.

The osteochondroma of metatarsal is a rare clinical entity. It generally occurs in the first or second decade of life. The osteochondroma should be investigated to rule out any malignant changes before embarking any surgical intervention. We report an osteochondroma of 5th metatarsal in a 65 years old female as an unusual aetiology of foot pain. We propose the scalloping effect of the osteochondroma on adjacent metatarsal as one of the mechanisms of causing pain in the foot. After ruling out the malignant transformation with the help of MRI, excision of the tumour was done with a curvilinear incision on the dorsum of the foot. There was no recurrence in 1 year follow up. This case report depicts the occurrence of osteochondroma in geriatric patient as an unusual cause of foot pain. The scalloping effect on the adjacent bone and tissues can be the aetiology of the pain.

Epidemiology of Trauma Patients Admitted to a Trauma Center in New Delhi, India.

INTRODUCTION: The rapid economic and automobile growth in India leads to a rapid increase in road traffic accidents (RTAs) and factors affecting it. This study evaluates the epidemiology of trauma patients' reports to the major trauma center in New Delhi, India. MATERIALS AND METHODS: The 1,583 patients over 6 months reporting to the casualty of the trauma center attached to Lok Nayak Hospital, New Delhi were included in the study. The patients reporting to the outpatient department as follow-up visits were not included in the study. The data were collected with the help of a structured pro forma. RESULTS: The data depicted the RTAs as the most common cause affecting adults between 20 years and 40 years. The study reports other risk factors like alcohol intoxication and motorcycle riders. Mostly, the patients present in a semiconscious and disoriented state requiring fluid resuscitation. Abrasions and bruises in the extremities stand out as the most common injury pattern. The fractures suffered were the most common injury suffered by the patients. CONCLUSION: Our study shows that RTAs and workplace injuries are the predominant causes of trauma affecting mostly the adults. This study defines the correlation of various parameters with causation and distribution of the trauma in the sample population. This study was performed to improve the understanding of the mode of trauma, severity of injuries, and outcome in our hospital, so that effective prevention and comprehensive management strategies could be made. CLINICAL SIGNIFICANCE: This study signifies the fundamental study for the occurrence, distribution, and prevention of trauma in the society. The acquisition of knowledge of different patterns of trauma patients along with other descriptive factors helps to understand the causation of this disease as well as development of preventive measures. This can form the basis of hospital and regional trauma management strategies. HOW TO CITE THIS ARTICLE: Harna B, Arya S, Bahl A. Epidemiology of Trauma Patients Admitted to a Trauma Center in New Delhi, India. Indian J Crit Care Med 2020;24(12):1193-1197.

Arthroscopy and COVID-19: Impact of the pandemic on our surgical practices.

The aim of this article is to study systematically current evidence on status of arthroscopic surgeries during the COVID-19 pandemic. We aim to study (1) changes in global arthroscopic practices, (2) recommendations on reducing risk to patients and health care workers (HCW), (3) changes in follow-up protocols of these patients. Systematic search was carried out by two different reviewers using three different online databases for all studies published in the English language before April 2020. The total number of abstracts screened initially was 314. After screening of these abstracts, a total of 13 studies were included for the systematic review. Numbers of orthopaedic injuries have seen a sharp fall during this time. Most elective surgical facilities were also closed at this time. Most studies have recommended telemedicine as an essential medium of providing continued care to patients during COVID-19. Studies have recommended that a conservative approach should be preferred for most patients with ligament injuries, and alternative procedures that have less requirement for an operating room should be explored. Common recommendation in all studies is that procedures of more elective nature should be postponed to a safer time frame when the transmission of COVID-19 virus in the population has declined. When surgeries are resumed, there is a need for triage of arthroscopy procedures from more important or urgent to less important ones. Elective surgical procedures should preferably be started with patients with no co-morbidities and lesser risk of peri-operative complications. All patients undergoing surgery and health care personnels should have some screening for disease. Attempts should be made to have shortest hospital stay. Choice of anaesthetic procedure should emphasize on minimal aerosolization of the virus. Regional anaesthesia is the preferred choice as far as possible. Most guidelines have recommended that patient follow up should be made telephonically or on video-conferencing.

A Rare Case of Complex Carpal Injury: Divergent Trapezium-Trapezoid Fracture Dislocation.

Background Divergent trapezium-trapezoid fracture dislocation is a rare and complex injury. The authors present an unusual case of dislocation of the trapezium-trapezoid complex with scaphoid fracture. Case Description A 25-year-old man suffered a road traffic accident leading to complex carpal injury due to axial and rotation forces (steer wheel injury) on the left wrist. X-rays and computed tomographic (CT) scan were done showing trapezium-trapezoid dissociation with fracture of distal pole of scaphoid and ulna styloid. The second metacarpal base was fractured with many ligamentous injuries in the wrist. Methods Volar flexor carpi radialis (FCR) approach was used to reduce and fix scaphoid fracture with 2.7-mm cannulated screw. Dorsal approach was used to fix fracture of second metacarpal base and perform reduction in trapezium-trapezoid complex with help of 0.8-mm K-wires, and suspension wiring of first to second and second to third metacarpal was done using 1.5-mm K-wires. The transverse flexor retinaculum (TFR) in this case was avulsed. Discussion The divergent trapezium-trapezoid joint with scaphoid fracture is not described in the literature yet. The authors implicate steering wheel injury pattern for such complex carpal fracture dislocations. CT scan is imperative to diagnose and plan treatment of such fracture morphology. Early fracture reduction and stabilization of carpal dislocations are essential for proper functioning of wrist.

Bicondylar conjoint Hoffa's fracture with patella entrapped in the fracture: A rare case report.

Bicondylar Hoffa fracture involving both the femoral condyles is a rare injury. Conjoint variety with intact bone bridge between condyles in intercondylar notch area is even rare. We report a conjoint variety of bicondylar open grade III A Hoffa's fracture with patella entrapped in the fracture with quadriceps rupture in an adult which was surgically treated with initial debridement and later open reduction with fixation and quadriceps repair. The final outcome at 1 year post injury is satisfactory. To the best of our knowledge, no such case has been reported till date in English literature.

Pediatric conjoint Hoffa's fracture: An uncommon injury and review of literature.

Coronal plane fracture of femoral condyles was first elaborated by Hoffa. These are difficult articular injuries, often described in adult skeleton and very rarely in pediatric age group. Conjoint variety with intact bone bridge between condyles in intercondylar notch area is rare. We report a conjoint variety of bicondylar Hoffa's fracture in a child which was surgically treated using headless compression screws along with a brief review of literature about fracture entity and complexities associated with it.