Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons.

AIM: Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. MATERIALS AND METHODS: 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. RESULTS: Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. CONCLUSIONS: A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Comparison of Clinico-radiological Outcomes of Monolateral Fixator in Infected Non-union of Tibia Based on Bone Gap Quantification.

INTRODUCTION: Monolateral rail fixators are more comfortable to the patients and have a lesser learning curve compared to ring fixators. Guidelines are still lacking for rational use of monolateral fixator for bone transport. This retrospective study aimed to analyze and compare the clinico-radiological outcomes of monolateral fixator in infected non union of tibia based on bone gap quantification. MATERIALS AND METHODS: This retrospective study included 35 patients of post traumatic infected osteocutaneous defects of tibia operated from May 2013 to May 2016. Group I having bone gap of 6 cm or less (n = 20) and group II with > 6 cm bone gap (n = 15). The mean age was 29.56 (range 18-62) years in group I and 29.67 (range 20-65) years in group II. The mean bone gap was 4.62 (2-6 cm) in group I and 7.6 cm (6.5-10 cm) in group II (P < 0.00001, Mann-Whitney test). The results were assessed by Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. RESULTS: Union was achieved primarily in 90% (n = 18) cases in group I and 73.34% (n = 11) cases in group II. The bone result was excellent, good, fair/poor in 14, 5, 1 in group I; and in 4, 6, 5 in group II, respectively (P = 0.020, Chi-square test). The functional results were excellent, good, fair/poor in 15, 4, 1 in group I; and 5, 8, 2 in group II, respectively (P = 0.0479, Chi-square test). CONCLUSION: We recommend use of monolateral fixator in patients with infected diaphyseal non union of tibia with bone gap ≤ 6 cm. Use of monolateral fixator in patients with bone gap > 6 cm is associated with higher incidence of residual problems and complications.

Demographic Study of Orthopedic Trauma among Patients Attending the Accident and Emergency Department in a Tertiary Care Hospital.

BACKGROUND: Trauma causes a major burden on the health system and economy of the country. A better understanding of the epidemiology of trauma can be of great help in planning preventive and curative strategies. MATERIALS AND METHODS: A total of 4834 patients of trauma presenting during 1 year were included in this observational study. Demographic profile and other related criteria were noted, and data were statistically analyzed. RESULTS: Male to female ratio was 5:1; most affected age group was 25-44 years in males and 45-64 years in females; 23.2% were illiterate; and professionals and students were most commonly affected. Road traffic accident (RTA), fall, and assault were the three most common causes; two wheelers were the most common accident causing vehicle. Nearly 17.7% were below poverty line and 67.6% reached hospital within 12 h. Medicolegal cases were 29.7%; only 29.3% reached hospital by ambulance and 3.72% were hemodynamically unstable. Only 3.6% received prehospital care and 16.23% were under alcohol influence. About 23.18% of RTA victims were pedestrians; city roads were the most common accident site. Head injury (25.85%) was the most common associated injury. Fractures were most common in hand (9.72%). The injury severity score (ISS) and New ISS were worse in the patients who were not using seat belt/helmet or were under influence of alcohol. The rate of death and associated injuries was also higher in this group. CONCLUSION: Trauma is a major preventable cause of mortality and morbidity mainly affecting the productive age group of the society.

Prospective randomized comparison of quality of regenerate in distraction osteogenesis of ring versus monolateral fixator in patients with infected nonunion of the tibia using digital radiographs and CT.

AIMS: In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia. PATIENTS AND METHODS: Both groups were comparable in demographic and injury characteristics. A phantom (aluminium step wedge of increasing thickness) was designed to compare the density of regenerate on radiographs. A CT scan was performed at three and six months postoperatively to assess regenerate density. A total of 30 patients (29 male, one female; mean age 32.54 years (18 to 60)) with an infected nonunion of a tibial fracture presenting to our tertiary institute between June 2011 and April 2016 were included in the study. RESULTS: The regenerate mineralization on radiographs was comparable in both groups at two, four, six, and ten months' follow-up but the rail fixator group had statistically significant higher grades of mineralization when compared with the circular frame group at eight and 12 months' follow-up. The regenerate mineralization was also higher in the rail fixator group than in the circular frame group on CT at three and six months, although this difference was not statistically significant. CONCLUSION: Overall, the regenerate mineralization was higher in the monolateral than the circular frame group. A monolateral fixator may be preferred in patients with infected nonunion of the tibia with bone defects up to 7 cm. Cite this article: Bone Joint J 2019;101-B:1416-1422.

Implantless patellar fixation in medial patellofemoral ligament reconstruction.

PURPOSE: The medial patellofemoral ligament (MPFL) acts as primary restraint to lateral patellar dislocation and its rupture has been reported in almost all cases of acute patellar dislocation. Various surgical techniques have been described for MPFL reconstruction, using many femoral and patellar fixation techniques and different grafts. This article details our technique for MPFL reconstruction using semitendinosus graft which avoids the use of implant at patellar end. METHODS: Twenty patients (8 males and 12 females) with complaints regarding acute and chronic lateral patellar instability were evaluated and treated by MPFL reconstruction procedure. The mean age of patients was 21 years (range 17-34 years). MPFL reconstruction was performed using semitendinosus graft passing through two parallel, obliquely directed tunnels created in patella. Fixation of graft was done with an interference screw only at the femoral end. Mean follow-up period after intervention was 26.4 months (range 23-30 months). Results were evaluated using Kujala score. RESULTS: All patients gained adequate patellar stability and full arc of motion. No incidence of patella fracture was noted. There were no postoperative complications related to the procedure. There was no recurrence of instability in patella at final follow-up. CONCLUSION: Passing the graft through the tunnels in patella without use of any implant has given excellent functional outcome and moreover has the advantages of less implant-related complications and cost-effectiveness.

Comparative analysis of arthroscopic debridement in osseous versus soft tissue anterior ankle impingement.

BACKGROUND: Arthroscopic debridement has been a gold standard procedure for anterior ankle impingement, both in cases of osseous and soft tissue impingement. There is sparse literature on comparative outcome with respect to functional results between the two types of impingement post-arthroscopic debridement. METHODS: Our study included 14 patients diagnosed as cases of anterior ankle impingement on the basis of clinical and radiological examination. They were segregated into two groups (on the basis of cause of impingement (osseous versus soft tissue)). Both groups were treated by arthroscopic debridement. Primary outcome was patient satisfaction, which was assessed by Likert scale and clinical outcomes were measured using AOFAS ankle-hind foot scale, VAS score, range of motion and time to return to pre-injury activity level in both groups. RESULTS: Mean follow-up was of 15 months where eleven patients reported an excellent recovery, two patients had good recovery while one patient reported poor outcome. Mean AOFAS ankle hind foot scale improved from 50.5 preoperatively to 85.71 postoperatively (statistically significant; p value - 0.0001). Mean Likert scale value post-operative was 4.21. VAS score showed significant improvement in patients of both the groups. Range of motion was slightly better in soft tissue impingement type with a relatively shorter time to return to sports or preinjury activity level as compared to osseous impingement group. CONCLUSIONS: The patients in both the groups had comparable outcomes with no statistically significant difference with regard to patient satisfaction and clinical outcome.

A prospective study to evaluate the clinico-radiological outcomes of arthroscopic single bundle versus double bundle anterior cruciate ligament reconstruction.

INTRODUCTION: The aim of the study was to compare clinical and radiological outcomes of arthroscopic single-bundle versus double-bundle anterior cruciate ligament (ACL) reconstruction. PATIENT AND METHODS: 60 patients with isolated ACL injury were divided into single bundle (SB) (n = 30) and double bundle (DB) reconstruction groups (n = 30) and operated between July 2009 and July 2012. Outcome evaluation was performed using GNRB arthrometer, International Knee Documentation Committee & Lysholm scale. Rotational stability was determined by lateral pivot-shift test. Magnetic resonance imaging (MRI) was performed postoperatively to compare the reconstructed ACL graft orientation. RESULTS: Average follow-up was 34.8 months in SB and 36.2 months in DB group. At final follow-up, mean Lysholm score was 94.13 ± 2.67 in SB and 93.13 ± 3.31 in DB group (P value = 0.202, statistically non-significant). All patients in both groups were in grade A or B according to objective IKDC scores. Mean differential anterior tibial translation was 1.45 ± 0.6 mm in SB and 1.17 ± 0.8 mm in DB group (P value = 0.105, NS). All had negative pivot shift test in DB group while 2 patients had positive pivot shift in SB group. MRI of operated knees showed that values of mean sagittal ACL graft-tibial angle and mean coronal ACL graft-tibial angle were comparable in both groups (P value > 0.05, NS). CONCLUSIONS: There was no statistically significant difference concerning knee stability, knee scores, subjective evaluations, and MRI evaluation of graft inclination angles between single- and double-bundle ACL reconstruction groups at an average of 35 months of follow-up.

Outcome of distraction osteogenesis by ring fixator in infected, large bone defects of tibia.

BACKGROUND: Salvage of large, infected bone defects in tibia poses a formidable problem. The present prospective study aimed to evaluate radiologic and functional outcome of ring fixator in infected, large (≥6 cm) bone defects of tibia treated with distraction osteogenesis. MATERIALS AND METHODS: The study included 35 patients (30 males and 5 females) who had minimum of 6 cm gap after radical resection of necrotic bone and presence or history of active infection. Mean age was 36.1 years. Mean bone gap was 7.27 cm. Mean follow-up period was 25.4 months. RESULTS: Fracture united primarily in 17 cases and after fixator adjustment with freshening of fracture margins in 15 cases. Fixator adjustment with bone grafting was done in one patient to achieve union. One patient had nonunion and another had amputation. The bone result was excellent, good, and poor in 19, 13, and 3 patients, respectively. The functional results were excellent, good, fair and failure in 14, 19, 1, and one patient, respectively. 24 patients had superficial pin tract infection and 18 patients had ankle stiffness. CONCLUSION: Ring fixator systems reliably achieve union in infected, large bone defects of tibia and help in treating infection, shortening, bone and soft tissue loss simultaneously. We advocate early freshening of fracture ends and removal of interposed soft tissue at docking sites to achieve union. Superficial pin tract infection and ankle stiffness are common problems in managing large tibial defects. But good to excellent functional outcomes can be achieved in majority of patients.

Tubercular Tenosynovitis of Hand: A Rare Presentation.

INTRODUCTION: Tuberculosis tenosynovitis of the wrist and hand is an unusual condition. It mimics a number of other clinical conditions such as ganglion, De quervan's disease, carpal tunnel syndrome, granulomatous gout, neurofibroma, and haemangioma. CASE REPORT: We present case of 58-year-old male patient with swelling over thenar region of left hand where the initial fine needle aspiration cytology (FNAC) report suggested diagnosis of ganglion/synovial cyst, but the patient did not improve with conservative treatment. FNAC was repeated which showed granulomatous inflammation consistent with the clinical diagnosis of tuberculosis and antitubercular therapy for 9 months was given. Swelling disappeared and normal range of movements was attained in adjacent joints at final follow-up of 12 months from initiation of antitubercular treatment (ATT). CONCLUSION: The literature on the management of tubercular tenosynovitis has mostly incorporated surgical method as one of the first-line treatments. We report an unusual case, where the tenosynovitis of wrist completely responded within 12 months of ATT without any need of surgical treatment.

Arthroscopic anatomical double bundle anterior cruciate ligament reconstruction: A prospective longitudinal study.

BACKGROUND: Single bundle anterior cruciate ligament (ACL) reconstruction has been the current standard of treatment for ACL deficiency. However, a significant subset of patients continue to report residual symptoms of instability with a poor pivot control. Cadaveric biomechanical studies have shown double bundle (DB) ACL reconstructions to restore the knee kinematics better. This study evaluates the outcome of DB ACL reconstruction. MATERIALS AND METHODS: 30 consecutive patients who underwent anatomic DB ACL reconstruction were included in this prospective longitudinal study. There were all males with a mean age of 25 ± 7.45 years. All patients were prospectively evaluated using GeNouRoB (GNRB) arthrometer, functional knee scores (International Knee Documentation Committee [IKDC] and Lysholm) and postoperative magnetic resonance imaging (MRI) for comparing the graft orientation and footprint of the reconstructed ACL with that of the normal knee. RESULTS: The average followup was 36.2 months. At the time of final followup the mean Lysholm score was 93.13 ± 3.31. As per the objective IKDC score, 26 patients (86.6%) were in Group A while 4 patients (13.3%) were in Group B. The mean differential anterior tibial translation by GNRB, arthrometer was 1.07 ± 0.8 mm (range 0.1-2.3 mm). All cases had a negative pivot shift test. MRI scans of operated and the contralateral normal knee showed the mean sagittal ACL tibial angle coronal ACL tibial angle and tibial ACL footprint to be in accordance with the values of the contralateral, normal knee. CONCLUSION: The study demonstrates that DB ACL reconstruction restores the ACL anatomically in terms of size and angle of orientation. However, long term studies are needed to further substantiate its role in decreasing the incidence of early osteoarthritic changes compared to the conventional single bundle reconstructions.

Contralateral reversed distal femoral locking plate for fixation of subtrochanteric femoral fractures.

PURPOSE: Subtrochanteric fractures of the femur are being managed successfully with various intramedullary and extramedulary implants with reasonable success. However, these implants require precise placement under image intensifier guidance, which exposes the surgeon to substantial amount of radiation. It also restricts the management of these fractures at peripheral centers where facility of image intensifiers is not available. Keeping this in mind we designed this study to identify if contralateral reversed distal femoral locking plate can be used successfully without the use of image intensifier. METHODS: Twenty-four consecutive patients (18 men and 6 women) with a mean age of 28 years (range 19-47 years) suffering subtrochanteric fractures of the femur underwent open reduction and internal fixation with reversed contralateral distal femoral locking plate. The outcome was assessed at the mean follow-up period of 3.2 years (range 2-4.6 years) using the Harris hip score. RESULTS: Twenty-one fractures united with the primary procedure, with a mean time of consolidation being 11 weeks (range, 9-16 weeks). One patient developed superficial suture line infection, which resolved with oral antibiotics. Another patient had a fall 3 weeks after surgery and broke the plate. Repeat surgery with reversed distal femoral locking compression plate was performed along with bone grafting and the fracture united. Two cases had nonunion, which went in for union after bone grafting. The mean Harris hip score at the time of final follow-up was 90.63 (range 82-97). CONCLUSION: The reversed contralateral distal femoral plate is a biomechanically sound implant, which when used for fixation of the subtrochanteric fractures with minimal soft tissue stripping shows results comparable to those achieved by using other extramedullary implants as well as intramedullary devices. The added advantage of this implant is its usability in the absence of an image intensifier.

Congenital pseudoarthrosis of the clavicle with bifurcation.

Congenital pseudoarthrosis of clavicle is a rare clinical entity. It usually presents as a swelling in the clavicular region at birth or soon after birth. Fitzwilliam's original description of 60 subtypes of congenital pseudoarthrosis of clavicle have addressed several anatomical variants, e.g. association with cervical rib and abnormally vertical and elevated upper ribs. However, congenital pseudoarthrosis of clavicle associated with bifurcation is an atypical anatomic variant. To the best of our knowledge, this variant has never been mentioned in the literature. In the present report, we have described this subtype of symptomatic congenital pseudoarthrosis of the clavicle with bifurcation and its possible management.

Ossicle in anterior cruciate ligament: a rare occurrence.

The occurrence of an intra-articular ossicle is not rare in the knee, with reports suggesting the existence of meniscal osscile. There are also reports describing the attachment of the posterolateral bundle of the anterior cruciate ligament (ACL) to an accessory ossicle. However, despite an extensive search of the English literature we did not find much written about an intrasubstance ossicle in the ACL. We present the case of a 13-year-old male with an intrasubstance ossicle in the anteromedial bundle of the ACL of his right knee.

Fixation of delayed union or non-union posterior cruciate ligament avulsion fractures.

PURPOSE: To report the outcome of fixation for delayed union or non-union posterior cruciate ligament (PCL) avulsion fractures. METHODS: Seven men and 4 women aged 24 to 35 (mean, 28) years underwent lag screw or suture fixation for non-union or delayed union of avulsion fracture of PCL tibial attachment after a mean delay of 8.6 (range, 4-14) months. Patient satisfaction was assessed using a visual analogue scale (VAS). Functional outcome was evaluated using the Lysholm scale. RESULTS: The mean follow-up period was 17 (range, 8-36) months. The mean Lysholm score improved from 82 preoperatively to 92 at the final follow-up (p=0.34), the mean range of knee motion improved from 82º to 87º (p=0.008), and the mean VAS score for patient satisfaction improved from 4.3 to 7.4 (p=0.0004). All patients but one achieved bone union after a mean of 7.5 (range, 7-9) weeks. Functional outcome was excellent for 6 patients, good for 4, and fair for one. Posterior drawer test was positive (grade I laxity) in 3 patients whose outcome was good for 2 and fair for one. The latter had non-union after Ethibond suture repair for a communited fracture. There were no instances of wound complications or implant loosening. CONCLUSION: Fixation with lag screw or suture combined with bone grafting for delayed union or non-union of PCL avulsion fractures achieves acceptable functional outcome.

Pseudoarthrosis of medial tibial plateau fracture----role of alignment procedure.

Nonunion in tibial plateau fractures is very rare. Limited literature is available on Pubmed search on intraarticular tibial nonunion. Most of the cases reported have been following failed surgical treatment and none was neglected fractures. Three patients of isolated and neglected medial tibial plateau nonunion with almost similar demographic profile are reported in this paper. All the three patients were managed by minimally invasive compression fixation using lag screws supplemented with limb realignment procedure of high tibial osteotomy. We discussed the injury mechanism, management and rehabilitation in such cases and reviewed the available literature regarding such a presentation.

Dorsally comminuted fractures of the distal end of the radius: osteosynthesis with volar fixed angle locking plates.

Background. Dorsally comminuted distal radius fractures are unstable fractures and represent a treatment challenge. The objective of this study was to evaluate the functional and radiological outcome of dorsally comminuted fractures of the distal radius fixed with a volar locking plate. Patients and Methods. Thirty-three consecutive patients with dorsally comminuted fractures of the distal end of the radius were treated by open reduction and internal fixation with AO 2.4 mm (n = 19)/3.5 mm (n = 14) volar locking distal radius plate (Synthes, Switzerland, marketed by Synthes India Pvt. Ltd.). There were 7 type A3, 8 type C2, and 18 type C3 fractures. The patients were followed up at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Subjective assessment was done as per Disabilities Arm, Shoulder, and Hand (DASH) questionnaire. Functional evaluation was done by measuring grip strength and range of motion around the wrist; the radiological determinants were radial angle, radial length, volar angle, and ulnar variance. The final assessment was done as per Demerit point system of Saito. Results. There were 23 males and 10 females with an average age of 44.12 ± 18.63 years (18-61 years). Clinicoradiological consolidation of the fracture was observed in all cases at a mean of 9.6 weeks (range 7-12 weeks). The average final extension was 58.15° ± 7.83°, flexion was 54.62° ± 11.23°, supination was 84.23° ± 6.02°, and pronation was 80.92° ± 5.54°. Demerit point system of Saito yielded excellent results in 79% (n = 26), good in 18% (n = 6), and fair in 3% (n = 1) patients. Three patients had loss of reduction but none of the patients had tendon irritation or ruptures, implant failure, or nonunion at the end of an one-year followup. Conclusion. Volar locking plate fixation for dorsally comminuted distal radius fractures results in good to excellent functional outcomes despite a high incidence of loss of reduction and fracture collapse.

Missed ulnar nerve injury and closed forearm fracture in a child / 中华创伤杂志(英文版)

Ulnar nerve injury in closed fracture of forearm in children is uncommon.Commonly, neurapraxia is the reason for this palsy but other severe injuries or nerve entrapment has been reported in some cases. The importance of diagnosis concerning the types of the nerve injury lies in the fact that they have totally different management.We present a case of ulnar nerve deficit in a child following a closed fracture of the forearm bones. It is imperative to diagnose exact cause of palsy as it forms the basis for treatment. MRI scan can help diagnosis and accordingly guide the management. Simple nerve contusion should be treated conservatively, and exploration with fixation of the fracture should be done in lacerations and entrapments of the nerve. Surgery is not the treatment of choice in cases that could be managed conservatively.

Locked intramedullary femoral nailing without fracture table or image intensifier.

The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18-70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist-Hansen types I and II) diaphyseal fractures of the femur.

Simultaneous use of cannulated reamer and schanz screw for closed intramedullary femoral nailing.

Introduction. Closed reduction is a critical component of the intramedullary nailing and at times can be difficult and technically challenging resulting in increased operative time. Fluoroscopy is used extensively to achieve closed reduction which increases the intra-operative radiation exposure. Materials and Methods. Sixty patients with femoral diaphyseal fractures treated by locked intramedullary nailing were randomized in two groups. In group I, fracture reduction was performed under fluoroscopy with a cannulated reamer in the proximal fragment or with simultaneous use of a cannulated reamer in the proximal fragment and a Schanz screw in the distal fragment. Patients in group II had fracture reduction under fluoroscopy alone. Results. Closed reduction was achieved in 29 patients in group I and 25 patients in group II. The guide wire insertion time, time for nail insertion and its distal locking, total operative time, and total fluoroscopic time were 26.57, 27.93, 68.03, and 0.19 minutes in group I, compared with 30.87, 27.83, 69.93, and 0.24 minutes in group II, respectively. The average number of images taken to achieve guide wire insertion, for nail insertion and its locking and for the complete procedure in group I, respectively, was 12.33, 25.27, and 37.6 compared with 22.1, 26.17, and 48.27, respectively, in group II. Conclusion. The use of cannulated reamer in proximal fragment as intramedullary joystick and Schanz screw and in the distal fragment as percutaneous joystick facilitates closed reduction of the fracture during closed intramedullary femoral nailing with statistically significant reduction in guide wire insertion time and radiation exposure.