Salvage Tibial-Talocalcaneal Arthrodesis with Retrograde Intramedullary Nail Fixation in Elderly with Posttraumatic Secondary Arthritis: Limb Salvage Reconstruction in Two Cases with Review of Literature.

Introduction: Posttraumatic secondary arthritis (SA) in the elderly with diabetes mellitus, osteoporosis, and neuromuscular affections has poor healing potential, leading to poor clinical and functional outcomes. Tibial talocalcaneal arthrodesis (TTCA) has been used to salvage for resultant hindfoot deformation. Retrograde intramedullary nailing (RIMN) has achieved reasonable fusion rates with improved functional outcomes. Case Report: We report two cases of failed ankle surgery with progressive SA managed with curved RIMN to achieve TTCA. The American Orthopaedic Foot and Ankle Society Hindfoot scale, visual analog scale, radiologic assessment, and clinical examination were used to assess outcome measures. We achieved good ankle scores with pain-free independent mobilization at 4 months. At minimum 1-year follow-up, all had good hindfoot alignment, good fusion, and no implant loosening or failure. Conclusion: Salvage TTCA with RIMN for a hindfoot SA can be a reliable technique to obtain good fusion, high satisfaction rate, and functional improvement following post-traumatic failed ankles in the elderly. The complex procedure has marked clinical improvement with the pain-free walking ability in an arthritic ankle, even with associated medical comorbidity.

Closed Negative Suction Drain Entrapment in Total Knee Arthroplasty: A Report on the Implications of a Broken Drain Based on the ChatGPT Outlook.

Total knee arthroplasty (TKA) has been the gold standard treatment for end stage arthritis of knee. The advancements in techniques have allowed successful outcomes. The use of closed negative suction drain in TKA has been controversial. Entrapment of a drain following TKA with a broken drain has been reported rarely though it has important implications.  An obese 65-year-old female presented with painful bilateral knees. A clinic-radiological assessment confirmed an advanced grade osteoarthritis (OA). A single stage bilateral TKA was done. The use of closed negative suction drain for both knees was done as a routine protocol. The left knee drain got entrapped and an inadvertent pull due to abnormal positioning in flexed knee impinged and broke the drain. The right knee removal of drain on the second post-operative day was uneventful. A radiological assessment confirmed the position of the broken drain in left knee. A mini arthrotomy ensued with removal of the drain piece. Subsequent post-operative period was uneventful. The knee function recovered with painless full range of motion. There was no evidence of infection or implant loosening noted at a two-year follow-up. The generative text model ChatGPT (OpenAI, USA) was used to identify the implication with the use of drains in TKA. The use of drains remains controversial with no clear consensus on its regular use. The breakage of drain poses an immediate concern with need for wound revision and removal of foreign body. The long-term observation for any knee infection, stiffness or poor knee function needs monitoring. The early identification can prevent late symptomatology.  The closed negative suction drain in our practice has become selective and presently has an infrequent use in TKA. An entrapment of a closed negative suction drain merits urgent measures. The remedial measures may ensure to preserve the knee joint function and maintain the ability to do activities of daily living.

Synovial Chondromatosis-Induced Monoarticular Knee Arthritis: Challenges With Arthroscopic Synovectomy on Late Presentation.

Unilateral painful swelling of the knee is one of the most common orthopedic presentations. Monoarticular synovitis of the knee may be present due to inflammation, trauma, age-related degeneration, or tumor pathology. Primary synovial chondromatosis (PSC) is an uncommon cause. A 40-year-old female presented with painful swelling of her left knee for around nine months. She had a flexion deformity of her left knee with minimal hydrops. The radiograph showed speckled calcifications and osteopenia with a reduction of medial joint space. MRI imaging confirmed synovitis with calcifications. She underwent an arthroscopic synovectomy for her management. Her biopsy was consistent with synovial chondromatosis. The initial progression was favorable to allowing independent, unsupported, pain-free activities of daily routine. At three months, however, there was disease progression, causing limitation of knee movements and the need for a walker for support. An uncommon cause of synovitis presents at a late stage with a delay in the early diagnosis and early recognition. PSC is considered a benign lesion with good functional outcomes after arthroscopic surgery. Recurrence and poor functional outcome possibly suggest aggressive disease. A delayed diagnosis and late presentation may be susceptible to recurrence and poor functional outcome, even after an adequate arthroscopic debridement and rigorous post-operative rehabilitation program.

A Comparison of Arc of Motion, Radiological Parameters of the Wrist and Patient Rated Wrist Evaluation between Adult Transfusion Dependent Thalassemics and Normal Subjects.

Background: Bony deformities and arthropathies have been noticed in thalassemia patients. The aim of this study is to compare the arc of motion and radiological parameters of the wrist and patient rated wrist evaluation (PRWE) between adult transfusion-dependent thalassemics and normal subjects. Methods: An observational cross-sectional study was done in the department of orthopaedics over a period of 2 years where a total of 30 skeletally mature thalassemia major patients (group A) were assessed. The data was then compared with the data of demographically matched 30 healthy adults (group B). Arc of motion of the dominant wrist that included flexion, extension, radial and ulnar deviation, pronation and supination was measured using a handheld goniometer for both groups. Radiographs of the dominant wrist were obtained in both groups and used to determine the radial height, radial articular angle and carpal slip. PRWE was used to assess the function of the wrist. A p-value of <0.05 was considered statistically significant. Results: Clinical abnormalities at the wrist joint were found in 80% of thalassaemia patients. There was a statistically significant increase in ulnar deviation, wrist extension and decrease in wrist flexion in group A compared to group B. Radiological abnormalities were found in 100% of thalassaemia patients. All the radiological parameters were significantly increased in group A compared to group B. There were no differences in PRWE scores between both groups. Conclusion: Clinical and radiological changes of wrist joint occur in skeletally mature thalassaemia major patients due to shortened ulna compared to healthy adults. This may be due to disease itself, bone marrow expansion, osteopenia, drug (chelating agent) or iron toxicity. Understanding the changes at the wrist in patients with thalassemia major is important to increasing the life expectancy of these patients. Level of Evidence: Level IV (Diagnostic).

Knee-Spine Syndrome: Management Dilemma When Knee Osteoarthritis Coexists With Spine Degeneration.

The elderly present with progressive degenerative osteoarthritis of the knee and lumbar spine degeneration (LSD). The coexistent conditions when presented concurrently become challenging for the clinicians and surgeons, as well as determining the predominant source of the underlying pain generation factor. The concurrent presentation of a significant knee and low back pain poses challenges in decision-making for treatment with management being normally individualized. The review narrates the different concepts used for the assessment of knee-spine syndrome. The prime factor for the pain needs to be ascertained by evaluating the deformity of the lumbar spine and the knees to address the causative factor appropriately. A thorough history, detailed examination, and supplemental diagnostic testing will differentiate the clinical entities and guide the treatment. However, a misdiagnosis may need a secondary site surgery and further treatment to alleviate the pain. Clinicians have been challenged while differentiating between the knee and spine pathology to target prime pain generator factors for adequate pain relief, improved functional outcomes, and substantial patient satisfaction. We present our strategy for the management of knee-spine syndrome. The protocols utilized to manage the clinical scenario have been reviewed and discussed. Clinical pearls to identify and treat the symptomatic concurrent knee-spine degeneration are presented. There is still a lack of consensus on the concurrent knee-spine degenerative pathology and its management strategy. The dilemma persists, and a case-based approach needs to be adopted by surgeons.

Isolated Posterior Malleolar Fracture: A Case Report of a Rare Presentation With Narrative Review of Literature.

The isolated posterior malleolar fracture is a rare case. An innocuous injury may have associated ligamentous disruption. The fracture classification and treatment protocol are not well-defined. A missed injury results in poor functional outcomes. A 28-year-old male sustained a twisting injury to his left ankle. The radiograph revealed an isolated posterior malleolar fracture. A computerized tomographic examination suggested talus lateralization and deltoid ligament injury. Surgical fixation with a syndesmotic screw was done. Post-operative delayed weight-bearing was allowed. At a one-year follow-up, there was painless weight-bearing and independent mobilization. The posterior malleolus significantly contributes to ankle stability. The estimation of fragment size may be an erroneous guiding factor for surgical fixation. Recent literature suggests that syndesmotic stability, residual talus subluxation, joint congruence, and fibular notch involvement are more significant factors for risk assessment and to guide the management of posterior malleolar fracture. The isolated posterior malleolar fracture presents rarely. They should be evaluated by tomographic evaluation and an unstable injury should be surgically managed.

MRI for an Acute Secondary Site Complication in Post-arthroplasty Management: Narrative Review of Safety Concerns for an Implanted Hip and Knee Joint.

Arthroplasty in the elderly may present with acute or late-onset complications unrelated to an implanted arthroplasty joint. Magnetic resonance imaging (MRI) evaluation of an acute onset complication in the immediate post-arthroplasty scenario presents safety concerns. An arthroplasty surgeon's dilemma relates to the loosening, heating, or migration of implanted hip or knee joints. We present a representational case scenario for discussion. A hip arthroplasty patient presenting with hemiplegia in the immediate postoperative period necessitated an MRI evaluation for the brain with an additional angiogram. A knee arthroplasty patient presenting with lower limb weakness in the immediate postoperative period necessitated an MRI evaluation of the brain. Loosening of surgical metallic clips used for wound closure and the instability or loosening of recently implanted hip and knee joints pose significant safety concerns for the arthroplasty surgeon. The confirmatory diagnosis of the secondary site complication in the acute post-arthroplasty perioperative period, however, allowed the allied super-specialist to plan the management protocol. A review of the literature suggests that the use of nonferromagnetic elements in implanted joints with the use of cement or the press-fit method of implantation during arthroplasty has high safety margins. The staples used for wound closure have significant strength to hold the wound without any disruption or dehiscence during the MRI imaging. The metallic artifacts associated with an implanted joint do not interfere in the evaluation of the secondary site MRI. MRI can be safely done in a well-fixed joint of non-ferromagnetic elements. The review of literature also suggests that MRI can be done even in the presence of skin staples for the assessment of an acute secondary site complication in a post-arthroplasty patient. The risk-to-benefit ratio though needs to be applied for imaging a secondary site.

Evaluation of an asymptomatic COVID-19 patient post-surgery with chest radiography: A surgeon's dilemma.

Routine chest radiography is not a requirement in post-surgery cardiac bypass patients. However, the safety of abandoning routine chest radiographs in critically ill patients remains uncertain. Surgery in an asymptomatic coronavirus disease 2019 (COVID-19) patient presents additional challenges in postoperative management. Chest radiography remains a valuable tool for assessment of all patients, even a stable one. Management of surgical patients as an emergency in an asymptomatic COVID-19 case remains a surgeon's dilemma.

Bilateral Periprosthetic Knee Fracture with the Right Floating Total Knee and Left Periprosthetic Patella Fracture Management Strategy: A Case Report.

INTRODUCTION: Periprosthetic fractures (PPFs) in total knee replacement are an uncommon condition. The floating knee injury around total knee arthroplasty (TKA) is even rare and poses challenges in management. Incidence is increasing due to growing primary joint arthroplasties and revision procedures. We report a case of bilateral PPF with a floating total knee. CASE REPORT: A 74-year-old female involved in a violent car accident sustained bilateral knee injuries, facial, and hand injury. In the emergency room, the initial resuscitation and trauma protocol stabilization were done and she was provisionally immobilized for her limb injuries. She presented with the right-sided floating total knee involving periprosthetic periarticular comminuted distal femur fracture and midshaft comminuted fracture tibia fibula. The patient also had left knee lower pole periprosthetic patellar fracture. The patient had a history of bilateral TKA around 2 years back. She underwent surgical management of the right floating total knee by stabilization of distal femur fracture and tibial shaft fracture fixation with locking plates. She underwent primary autologous bone grafting for both fracture sites. The left knee patellar fracture was managed conservatively in a brace. At 8 months follow-up, the patient was pain free and had consolidation of fractures. The patient walked without any walking aids. At 18 months, she had regained her pre-injury functional status. CONCLUSION: Each fracture in a floating total knee injury is unique and treatment should be decided based on individual analysis and the extent of soft-tissue injuries. An uncommon occurrence highlights the complex injury patterns involving PPF requiring individualized case specific management strategy.

Physiotherapeutic assistance verse home care assistance in the early rehabilitation of total knee arthroplasty during COVID-19 lockdown.

BACKGROUND: The aim of this retrospective comparison study was to assess early functional recovery of total knee arthroplasty with home care assistance during COVID-19 lockdown. METHODS: A total of 16 patients (27 knees involved) were divided into a pre-lockdown group (10 patients; 17 knees) and a post-lockdown group (6 patients, 10 knees) in terms of the time of surgeries performed before and after lockdown, respectively, due to COVID-19 pandemic. Patients of pre-lockdown group underwent rehabilitation under the guidance of trained physiotherapists for at-home sessions and under assisted physiotherapy. Patients of post-lockdown group followed the rehabilitation protocol of at-home sessions and under home-care assistance during COVID-19 lockdown. Functional recovery of the knee was assessed against the Knee Injury and Osteoarthritis Outcome Score, Junior. A p < 0.05 was considered statistically significant. RESULTS: The pre- and postoperative mean KOOS Junior of pre-lockdown group were 48.73 ± 2.64 and 64.91 ± 2.74, respectively (p < 0.001). The pre- and postoperative scores of post-lockdown group were 48.83 ± 2.83 and 67.84 ± 4.31 (p < 0.001), respectively. Intergroup comparison between pre- and postoperative KOOS Jr. revealed no significant differences (p > 0.05). CONCLUSION: Although the COVID-19 lockdown affected the routine postoperative rehabilitation after total knee arthroplasty, the coordination among the surgeon, therapists, and home caregivers can provide sustained assistance in rehabilitation. The guidelines for practitioners and physiotherapists can benefit functional recovery of the knee.

Bilateral Femoral Neck Stress Fracture in an Obese Middle-Aged Female With Osteomalacia and Coxa-Vara Managed by Simultaneous Bilateral Total Hip Arthroplasty.

Femoral neck stress fractures in middle-aged individuals are usually associated with underlying metabolic bone disease. There is increased abnormal loading on femoral neck with associated coxa-vara and obesity in a female. Bilateral presentation of such fractures is rarely reported. Their management poses significant challenges. We present a case of bilateral femoral neck stress fracture in a 58-year-old obese housewife with compression type of the left hip fracture and tension type of the right hip fracture with non-union following an operated femoral neck stress fracture. She presented two months from the onset of symptoms and was treated with simultaneous bilateral total hip replacement for the management of her painful hips. Follow-up at 18 months revealed excellent outcome and return to independent painless daily routine activity. This report highlights the importance of early recognition of femoral neck stress fracture and challenges in the management of their late presentation. Total hip arthroplasty allows early mobilization with a favorable functional outcome.

Wrist Joint Skeletal Changes in Children With Transfusion-dependent Thalassemia.

BACKGROUND: Arthropathies and bone deformities are well known to occur in patients with thalassemia major and have been attributed to the disease or to its therapy. Before the advent of chelation therapy, these children developed widened diploic space and "hair-on-end" pattern in skull, "cobweb" pattern in the pelvis, and the lack of the normal concave outline in the long bones because of extensive marrow proliferation. After the introduction of iron-chelation therapy, these patients were noted to develop metaphyseal abnormalities and vertebral changes resembling spondylo-metaphyseal dysplasia. Only one study has shown some association of deferiprone (chelating agent) use with distal ulnar changes in these children. Our study was done to describe the skeletal changes and deformities in wrist joints of children with transfusion-dependent thalassemia and correlate them with age, mean pretransfusion hemoglobin level, mean serum ferritin level, and type and duration of chelation therapy in these children. METHODS: A total of 60 children with transfusion-dependent thalassemia from the thalassemia daycare center were examined. These children were divided into 3 groups on the basis of their age (group A: 2 to 6 y, group B: 6 to 10 y, and group C: 10 to 14 y). Detailed history, including treatment history, number of blood transfusions received over the last 1 year, clinical examination, and radiologic assessment of both forearm with wrists were done. RESULTS: The clinical and radiologic differences in radial and ulnar lengths increased significantly with the increasing age of these patients, the ulna being short. There was some correlation between increasing negative ulnar variance and distal radial articular angle with deferiprone consumption. CONCLUSION: Chelation therapy, particularly with deferiprone, may cause distal ulnar growth arrest causing ulnar shortening and progressive radial bowing in these children. LEVEL OF EVIDENCE: Level IV-case series.

Peri-prosthetic trans-patellar fractures after Total knee Arthroplasty: a case series and review of literature.

Peri-prosthetic patella fracture is the second most common peri-prosthetic fracture after total knee arthroplasty. This report presented the treatment results in 6 patients with peri-prosthetic patella fractures. From January 2015 to February 2019, six patients with peri-prosthetic patella fractures were treated. The mean age at surgery was 64 years (range, 48-72 years). Four patients with displaced fractures were treated surgically, and two patients with non-displaced fractures were treated non-surgically. Outcomes were assessed in terms of motion, functional knee score, and Knee Society score. The mean follow-up period lasted 16 months (range: 12-20 months). The average arc of motion was 110° (range: 80°-130°). The mean functional knee score was 77 (range: 70-87). The mean Knee Society score was 84 (range: 75-89). The non-surgical treatment may be a good choice for non-displaced peri-prosthetic patella fractures. For displaced fractures, surgical treatments yielded good functional outcomes. LEVEL OF EVIDENCE: IVa.