Subungual Osteochondroma of the Great Toe: A Case Report.

Bony outgrowths of the distal phalanx of the great toe have been described in the literature but rarely. These subungual bony outgrowths can be caused by subungual exostosis or subungual osteochondromas. Both of these abnormalities are bony outgrowths with differences in the cartilage cap wherein the exostoses have fibrocartilage, and osteochondromas have hyaline cartilage. The subungual exostosis and osteochondroma that are protruding present symptoms of pain, redness, and deformed nail bed, whereas the nonprotruding osteochondromas have only a lump as the presenting symptom. In both conditions, excision of the lesion and curettage of the base helps prevent a recurrence. Curettage at the end of the excision of the bony outgrowth is required to avoid recurrence. After excision, the specimen should be sent for histopathologic examination to differentiate between the exostosis and osteochondromas, which are underreported in subungual locations, and to rule out malignant transformation. We present a 13-year-old girl with an isolated subungual nonprotruding exostosis of the great toe that was treated by excisional biopsy. The histopathologic examination confirmed it as osteochondroma, which is underreported.

Double row reconstruction of achilles tendon (speedbridge technique) for haglund syndrome results in early weight bearing.

Background: Reconstruction of tendoachilles (TA) tendon using double row reconstruction (speedbridge technique) following excision of haglund deformity is relatively newer technique. The purpose was to assess the clinical outcome and effects of early postoperative mobilization with speedbridge technique. Methods: This was a prospective observational study performed between January 2018 to February 2019. All the patients underwent open excision of haglund deformity after complete detachment of TA tendon. Reconstruction of TA tendon was done using fibretape and 4.75 mm biocomposite Swivelock [ArthrexAchilles SpeedBridge Convenience Pack (AR-8928 BC-CP)].Clinical evaluation was done using American Orthopedic Foot and Ankle Society (AOFAS) Hind Foot Score (HFS) and Visual Analogue Scale (VAS). Patients were followed at 6weeks, 6 months,12 months,18 months and 2 years. Results: 11 female and 2 male patients (16 feet) with mean age of 53.00 ± 4.93 years were analyzed. Full weight bearing mobilization was started on an average of 10 days postoperatively.The mean postoperative HFS, at 24 months of postoperative period, was 87.61 ± 4.69 compared to mean preoperative HFS of 53.07 ± 5.93. Conclusion: Haglund deformity excision and reconstruction of Tendoachilles using double row technique is an agile construct for early mobilization with an excellent clinical outcome.

The Role of Conservative Management in the Avascular Necrosis of the Femoral Head: A Review of Systematic Reviews.

Introduction/Background: Multiple medical and surgical treatments have been described in the early stages of Avascular Necrosis (AVN) of the femoral head which delay the disease progression. Similarly, multiple studies, trials, reviews, and systematic reviews exist for the various treatments described and their outcomes but with no consensus over which is superior. So in this study, we reviewed the systematic reviews of all the conservative therapies for AVN of the femoral head systematically to identify a single or a combination of non-surgical treatment choices in the initial stages of the disease. Methodology: A thorough literature search has been carried out in January 2022 through the use of Pubmed, EMBASE, and Cochrane electronic databases using PRISMA guidelines. The Mesh words and Keywords used were "femoral head AVN", "Conservative management", and "Systematic Reviews". The inclusion criteria used during the screening were, any systematic reviews which included patients with AVN either idiopathic or secondary, who are managed with conservative therapies like bisphosphonates, Hyper Baric Oxygen Therapy (HBOT), Shock wave therapies like Extracorporeal Shock Wave Therapy (ESWT), or electrical therapy like Pulsed Electro Magnetic Field (PEMF). The quality of the included systematic reviews was assessed using AMSTAR-2 criteria. Results: The initial search yielded 364 studies which on screening based on our inclusion criteria finally resulted in seven systematic reviews to be included in the present study. There were two systematic reviews for Hyper Baric Oxygen Therapy (HBOT), two for Extracorporeal Shock Wave Therapy (ESWT), one for electrical stimulation modalities like Pulsed Electro Magnetic Field (PEMF), and two for bisphosphonates. The follow-up of the patients in the included systematic reviews varied from 6 weeks to 10 years. The total number of patients varied from 77 to over 1000 across the systematic reviews. Almost all of the studies included a control group that either received the intended treatment with adjuncts or did not receive any treatment at all. Because of the heterogeneous nature of included articles in the systematic reviews, meta-analysis was performed in only three of the included systematic reviews. Conclusion: Of all the modalities of treatment described, bisphosphonates are easily available and cost-effective and do not require any hospital resources/machinery for delivering the treatment. So they can be used as an initial line of treatment for patients with early stages of AVN (Ficat and Arlet 1-3) and based on the hospital availability of resources could be supplemented with any of the biophysical modalities (ESWT/PEMF/HBOT) for maximum efficacy to delay the disease progression. Level of Clinical Evidence: Systematic review. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00818-5.

A Minimally Invasive Surgical Technique for Hallux Valgus Deformity Correction Using an Ultrasonic Bone Scalpel (All India Institute of Medical Sciences Technique).

Hallux valgus is a common forefoot deformity characterized by medial deviation of the first metatarsal and lateral deviation of the hallux. More than 150 procedures have been described for the hallux valgus deformity with no proven superiority of one over the other. The initial osteotomies are open, and with the advent of power and micro instruments, the osteotomies were manageable via mini incisions and percutaneous procedures. The minimally invasive procedures have been divided into three generations. The first-generation osteotomies involve wedge correction. The second and third-generation osteotomies are translational. The second generation is a simple osteotomy, and the third is a chevron-type osteotomy. In our technique, we have used a hybrid procedure of second and third-generation procedures. The technique uses an ultrasonic bone scalpel to create a transverse sub-capital osteotomy which is then fixed with screws for a stable construct.

Ramp Lesions in Chronic Anterior Cruciate Ligament Injuries.

BACKGROUND: Meniscus ramp lesions associated with anterior cruciate ligament (ACL) injuries are being increasingly reported in the literature. This study was carried out to know the incidence of ramp lesions in ACL injured patients and to study the characteristics of these patients in our population. METHODS: Seventy-five patients who underwent ACL reconstruction from January 2021 to December 2021 were prospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. All patients were examined clinically and all underwent MRI examinations. The findings of arthroscopy during ACL reconstruction were recorded and analyzed. RESULT: Seventeen patients had ramp lesions with an incidence of 22.67%. Eight were isolated ramp lesions, and nine had other meniscus injuries. Ramp lesions were identified with 41.18% sensitivity using preoperative MRI. Thirteen out of 17 patients with ramp lesions had increased mobility of the posterior horn of the medial meniscus on anterior probing. The duration from injury to surgery was significantly longer in patients with ramp lesions as compared to patients without ramp lesions. CONCLUSION: A ramp lesion is not an uncommon lesion in ACL injuries and can occur either as an isolated meniscus lesion or in association with other meniscus lesions.Ramp lesions can occur in road traffic accidents as well and are not just sports-related injuries. Ramp lesions are not visible through routine anterior portal diagnostic arthroscopy and their repair adds to the stability of the knee. The absence of ramp lesions on MRI does not rule out their presence; hence, one should always look for ramp lesions in the posteromedial compartment of the knee in all cases undergoing ACL reconstruction.

Is there evidence to recommend transcatheter arterial embolisation in adhesive capsulitis: A review of literature.

BACKGROUND: Hypervascularity of the rotator interval with increased expression of the vascular endothelial growth factor may be the causative factor of conventionally managed adhesive capsulitis. Hence, transcatheter arterial embolisation(TAE) has emerged as an alternative treatment option to occlude the target neovessels by infusing an embolic agent. The present study reviews the literature regarding the efficacy of the TAE for adhesive capsulitis. MATERIAL AND METHODS: The systematic review was performed following PRISMA guidelines. MEDLINE, Google Scholar, Scopus and Cochrane database of systemic reviews (CDSR) were searched for relevant publication (from 1960 to 2021). The search algorithm used was Transcatheter arterial embolisation and resistant adhesive capsulitis or refractory adhesive capsulitis or vascular adhesive capsulitis. The database search produced a total of 12026 publications. After exclusion of the non relevant titles, 113 abstracts were reviewed. From these abstracts, three full-text articles were obtained for final review. RESULTS: All the studies were analyzed in depth. Patients with no or minimal improvement with conservative treatment for at least 3 months underwent TAE. Pre and post embolisation visual analog score(VAS), shoulder range of motion(ROM) were noted. Any additional therapy was also taken into account. Significant improvement of the VAS score and shoulder ROM was noted immediately after surgery and maintained till final follow up at 24.5 months. CONCLUSION: Resistant cases of adhesive capsulitis can be managed successfully with TAE. But ample evidence is lacking regarding the appropriate patient selection and efficacy of TAE as a sole management option of resistant AC.

Accelerometer-based, hand-held navigation for improved knee alignment in total knee arthroplasty: An observational study.

BACKGROUND: Malalignment in total knee arthroplasty has been associated with poor implant longevity and clinical outcomes. The aim of this study was to investigate the accuracy of accelerometer-based navigation in restoring the mechanical axis. METHODS: 106 primary total knee arthroplasties performed during February 2016 to September 2017 at a tertiary care centre in India were enrolled in this observational study. We noted the intra-op tourniquet time. Two separate blinded observers measured the preoperative mechanical axis and the post operative radiological results (mechanical axis, coronal and sagittal alignment of femoral and tibial components) and the mean value was taken as final data. Interclass correlation was done to look for variability between the two observers. RESULTS: The mean pre operative mechanical axis was 13.74 ± 10.44. The mean tourniquet time was 53.14 ± 7.42 min 91.5% (96/106) knees were within ±3° of neutral mechanical axis with a mean of 1.00° ± 2.68°. The femoral and tibial components with coronal alignment within ±3° perpendicular to the mechanical axis were 93.39% (99/106) and 89.62% (95/106) respectively. In the sagittal plane 89.62% of the femoral components and 87.73% of the tibial components were within ±3° perpendicular to the axis of tibia. CONCLUSION: The Accelerometer based portable navigation system effectively reduces the coronal and sagittal alignment outliers in total knee arthroplasty and has no role in rotational alignment of components.

Intraosseous Lipoma of the Calcaneum.

Lipomas are benign lesions of adipose tissue, which commonly affect the soft tissues but are rarely found in the musculoskeletal system. Intraosseous lipomas are rare benign tumors and even rarer in calcaneum, only to be found incidentally in the majority of cases. We report a case of a 45-year-old male patient who presented to the outpatient department with complaints of bilateral heel pain, which was initially treated conservatively as the presentation was similar to plantar fasciitis. On further follow-up, a plain radiograph of the ankles was taken, which showed a lytic lesion of the calcaneum with mild sclerotic margins on the right side with normal left foot radiographs. On magnetic resonance imaging, the lytic lesion demonstrated hyperintense signals on T1-weighted sagittal images, characteristic of fatty tissue, which helped us in arriving at the diagnosis of an intraosseous lipoma. The patient was treated by conservative means with physiotherapy, which relieved the pain, and on serial follow-ups, the lesion was found non-progressive on successive radiological evaluation. The differential diagnosis of such an entity includes plantar fasciitis, tumors such as an aneurysmal bone cyst, bone infarct, etc. With the increasing use of magnetic resonance imaging and computed tomography scans, physicians should be aware of the possibility of an intraosseous lipoma of the calcaneum, which should be ruled out during evaluation. Although possible, malignant pathology or aggressive transformation of such lesions is very rare; however, the lesion should be evaluated adequately and managed by surgical means in cases non-responsive to various conservative modalities.

Posterior hip dislocation associated with concomitant ipsilateral femoral head and shaft fractures: an unusual combination of injuries.

The combination of posterior hip dislocation with an ipsilateral femoral head and shaft fractures is unusual. While cases of concomitant fractures of femoral head and shaft have been previously reported, the treatment of such injuries is challenging. Presence of an associated hip dislocation further complicates the matter. A timely diagnosis and treatment are crucial to have a good outcome.We are presenting the case of a 20-year-old man who sustained a traumatic posterior hip dislocation with ipsilateral femoral shaft and femur head fractures. After reducing the hip, we fixed the femoral shaft with a retrograde femur nail and the femoral head by the trochanteric flip approach in the same sitting. The patient returned to his pre-injury occupation after 4 months. He has been doing well until his last follow-up, 1 year after the surgery, thus emphasising the utility of following basic principles of trauma management in the management of unusual injuries.

Neglected medial swivel talonavicular dislocation treated with arthrodesis: A case report and literature review.

Talonavicular dislocation is a rare injury. It usually occurs in conjunction with a variety of midfoot and hindfoot injuries. Isolated medial or lateral talonavicular dislocations without disruption of subtalar joint are known as medial or lateral swivel dislocations respectively, both being extremely rare. We describe a case of neglected medial swivel dislocation with articular impaction injury of talar head, which was managed with open reduction and arthrodesis with two 4 mm cannulated cancellous screws. At 6 months follow-up, patient was pain free and walking full weight bearing. All movements were painless and there was no footwear related problems. Radiographs showed sound arthrodesis of talonavicular joint. Although a rare injury, good results can be obtained by prompt recognition and treatment. In neglected cases, arthrodesis of the talonavicular joint is a viable option, especially if articular injury is present.

Arthroscopic Repair of a "U" Shaped Rotator Cuff Tear: Modified Margin Convergence with a Single Triple-loaded Suture Anchor.

Introduction Repair of a "U" shaped rotator cuff tear tends to create extreme tensile forces at the central part of the rotator cuff margin, causing tensile overload and may result in subsequent failure. We describe our technique of repairing the "U" shaped tear in which margin convergence is done using Ethibond (Ethicon Inc., New Jersey) and a single triple-loaded suture anchor. It results in the reduction of the strain and also allows the repair of seemingly irreparable tears. Patients and method We included 10 patients having a "U" shaped degenerative rotator cuff tear. All patients were assessed preoperatively. The University of California at Los Angeles Shoulder score (UCLA shoulder score) recorded preoperatively and at final follow-up was used to assess functional outcome. Result Out of 10 patients, six were males and four were females. The mean age was 60 years (range 50-70 years). The average follow-up was for 31 months (range 24 - 48 months). The UCLA score increased from an average of 9 preoperatively (range 8 - 12) to an average of 29.6 (range 27 - 31) at the terminal follow-up. The UCLA increased in the postoperative period and was statistically significant (unpaired t-test; p < 0.0001). All patients had good/excellent outcomes (UCLA score > 27). Abduction increased from average 27 degree preoperatively (range 20 degree - 35 degree) to an average 131 degree (range 125 degree - 140 degree) at final follow-up (unpaired t-test; p < 0.0001). Conclusion Our technique of modified margin convergence achieves low tension repair and anatomical footprint reconstruction with good clinical outcomes using a single triple-loaded anchor.

A prospective randomized study comparing navigation versus conventional total knee arthroplasty.

BACKGROUND: Navigation is associated with improved accuracy in alignment. However, its influence on clinical outcome is inconclusive. The aim of this study was to compare the component alignment and functional outcome in patients undergoing navigation-assisted and conventional total knee replacement (TKR). MATERIALS AND METHOD: A prospective randomized study consisting of two groups (group A and group B) was carried out. Group A consisted of patients undergoing TKR using conventional jig-based method, whereas group B consisted of patients undergoing TKR using computer navigation-assisted method. We measured and compared the coronal and sagittal plane alignment in X-ray and rotational alignment in computed tomography scan between both groups. Functional outcome was analysed using Knee Society Score (KSS) and Western Ontario and McMaster University scale (WOMAC) score. RESULTS: A total of 50 patients were randomized into two groups A and B each with 25 patients. Navigation was associated with more accuracy in mechanical axis alignment ( p = 0.011) and femoral component rotation ( p = 0.033). The mean follow-up was 4.6 years (range 48-62 months). There was no statistically significant difference between the groups with respect to KSS and WOMAC score at the minimum follow-up of 4 years. CONCLUSION: We concluded that even though navigation-assisted system is associated with better accuracy, there was no difference in clinical outcome at an average follow-up of 4.6 years.

Effect of preservation methods on tensile properties of human femur-ACL-tibial complex (FATC) - a cadaveric study on male subjects.

PURPOSE: Deep freezing and storing in formalin are some of the common techniques of human tissue preservation. However, the preservation modes affect the biomechanical properties of the tissues. In this work, the effects of the above-stated preservation tech- niques are compared with that of fresh cadaveric samples. METHODS: FATC samples from male cadavers of age between 60 and 70 years were tested under tensile loading at a strain rate of 0.8 s-1. Fourteen FATC samples from soft embalmed cadavers were preserved for 3 weeks by two methods: (a) 10% formalin and (b) deep freezing at -20 ° C followed by thawing. Seven FATC samples from fresh ca- davers were experimented as control samples. The results were evaluated by a two-stage statistical process of Kruskal-Wallis H test and Mann-Whitney U-test. RESULTS: It was observed that the failure force of fresh cadavers was the highest while that of preserved samples were approximately half the value. Failure elongation of frozen samples exceeded fresh samples while formalin samples failed at lesser elongations. Higher incidence of tibial insertion point or mid-section failures were observed in fresh samples while the higher incidence of ruptures at femoral insertion point was observed in the two preservation methods. CONCLUSION: Tensile properties of fresh tissues vary significantly from that of formalin preserved or frozen preserved samples.

Tensile type of stress fracture neck of femur: role of teriparatide in the process of healing in a high risk patient for impaired healing of fracture.

Neck of femur stress fractures, whilst representing only around 8% of stress fractures is associated with a high morbidity. Radiographically, stress fractures of neck of femur are classified into compression and tensile type. Tensile type is notorious for displacement and hence prophylactic surgery is indicated, unlike stable compression fracture. Currently recombinant Parathyroid Hormone (PTH) is used in the treatment of osteoporosis. More recently, many animal studies suggest that the recombinant PTH is helpful to achieve fracture union in normal model and in impaired fracture healing model. We achieved union in a 62-year-old postmenopausal female with tensile type of fracture neck of femur, who had multiple comorbidities for impaired healing of fracture, without any surgical intervention using systemic recombinant PTH.