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.

Our experience with liver and spleen elastography in the prediction of oesophageal varices.

Background: Variceal bleeding is an important cause of mortality in patients with chronic liver disease (CLD). The gold standard for detection and grading of oesophageal varices (EV) is upper gastrointestinal endoscopy. However, it is expensive, time-consuming and invasive. Objectives: This study aimed to find any association between splenic shear wave velocity (SWV) measured by acoustic radiation force imaging (ARFI) and the presence of EV. Method: The quasi-experimental study included 50 patients with CLD and 50 subjects without CLD as the control group. Both underwent upper abdominal ultrasonography followed by elastographic assessment on a Siemens Acuson S2000TM ultrasound system. A comparison of the findings was made between the control and patient groups. Results: Both groups had similar hepatic size while patients with CLD had larger splenic size and area (p < 0.05). The CLD patients had higher mean hepatic and splenic SWV compared with the control group (p < 0.05). The mean splenic size and splenic SWV were higher in patients with varices than in those without varices (p < 0.05). Conclusion: Chronic liver disease causes significant increase in liver and splenic stiffness with splenic SWV values being higher for patients with varices emphasising the role of elastography as a non-invasive predictor for the presence of EVs. Splenic SWV had the highest sensitivity and specificity, which was augmented by a combination of hepatic and splenic SWV. Thus, splenic SWV alone or in combination with hepatic SWV is a useful technique for prediction of the presence of EVs. Contribution: This study aims to find an alternative non-invasive and cost-effective technique for screening of EV.

Rare Intra-Aortic Migration of Temporary Epicardial Pacing Wire.

Temporary epicardial pacing wires are used routinely in the postoperative period to prevent brady-arrythmias and maintain hemodynamic condition. Their safety and efficacy have been widely accepted with a low incidence of complications. Complications associated with temporary epicardial pacing wires may occur during removal or may be related to retained wires. Migration is one of the well-established but rare complications of retained epicardial pacing wire. Though migrations to various organs have been well documented in the literature, there are only few reports on intra-aortic migration of pacing wires in the postoperative period. Further, it is important for radiologists to know and identify these epicardial pacing wires as they may be associated with complications like superadded infection, migration to surrounding or distant areas, and injury to the heart and vessels.

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.

Congenital Aural Atresia: What the Radiologist Needs to Know?

Congenital aural atresia (CAA) is characterized by hypoplasia or aplasia of external auditory canal associated with auricular deformity. It also embodies a spectrum of temporal bone abnormalities including anomalies of middle ear, ossicles, facial nerve, oval window, round window, mastoid pneumatization, temporomandibular joint and occasionally inner ear and vascular anomalies. The management in such patients is variable and consists of rehabilitative hearing aids or surgical correction depending on various patient factors like associated temporal bone abnormalities, degree of hearing impairment and laterality. Surgical management if planned, depends on the extent of associated temporal bone anomalies and hence necessitates comprehensive knowledge about the normal and abnormal anatomy of these structures. High resolution computed tomography (HRCT) is the optimal investigation which provides required anatomical information and plays a pivotal role in deciding the management strategy. This pictorial review aims to review the spectrum of anomalies involving critical structures in CAA on HRCT along with their clinical significance.

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.

Imaging in congenital inner ear malformations-An algorithmic approach.

Malformations of the inner ear are an important cause of congenital deaf-mutism. Arrest in embryologic development of inner ear during various stages gives rise to the variety of malformations encountered. Current treatment options include hearing aids, cochlear implants, and auditory brainstem implants (ABI). With the advent of cochlear implant surgery and ABI, decent functional outcomes can be obtained provided such cases are diagnosed correctly and timely. To that end, high-resolution computed tomography (HRCT) has a fundamental role in the assessment of these conditions, ably supplemented by magnetic resonance imaging (MRI). The purpose of this pictorial essay is to illustrate the imaging features of inner ear anomalies in children with congenital deaf-mutism as per the latest terminology and classification and provide an algorithmic approach for their diagnosis.

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.