Role of Triple Injection Platelet-Rich Plasma for Osteoarthritis Knees: A 2 Years Follow-Up Study.

PURPOSE: To assess the clinical outcomes of intra-articular Platelet-rich plasma (PRP) injection in knee osteoarthritis (OA) at 2 year follow-up. METHODS: This was a prospective interventional study. 68 cases (105 knees) with Kellgren-Lawrence (KL) grades I, II and III knee OA received 3 intra-articular injections of PRP 1 month apart. The cases were followed up for 2-years. Outcomes were measured using Western Ontario and McMaster Universities Arthritis Index (WOMAC) score and Visual analog scale (VAS) scores. RESULTS: The mean age was 51.7 years. 18 knees had KL grade I, 55 had grade II and 32 had grade III OA. The mean pre-treatment VAS score decreased significantly at 1 year (mean difference - 5.3, p = 0.003) and 2 year follow-up (mean difference - 6, p = 0.007). The mean pre-treatment WOMAC score decreased significantly at 1 year (mean difference - 45.9, p = 0.011) and at 2 year (mean difference - 52.4, p = 0.009). The WOMAC and VAS scores improved significantly from baseline to final follow-up across all KL grades (p = 0.001 and 0.001, 0.009 and 0.007, 0.021 and 0.017 for WOMAC and VAS across KL grade I, II and III, respectively). There was no significant differences in WOMAC and VAS scores between three KL grades at final follow-up (p = 0.17 and 0.09, respectively), although the baseline scores had significant difference (p = 0.001 for both VAS and WOMAC) with worse scores in higher KL grades. The variables like age, sex, BMI, KL grade, baseline VAS and baseline WOMAC did not predict the final VAS and WOMAC scores. CONCLUSION: Triple injection of intra-articular PRP given one month apart significantly relieves the symptoms of knee OA till 2 years in KL grade I, II and III. The improvement in symptoms at 2-year follow-up did not differ across different KL grades.

Impact of COVID-19 pandemic on clubfoot program at tertiary care institute.

PURPOSE: The COVID-19 pandemic had serious impact on health care sector. During reprioritisation of the services, elective and non-emergency procedures were suspended, with gradual resumption of services after lockdown was over. In this study we assessed the impact of pandemic on our clubfoot program at a tertiary care institute. Also, we discussed the future challenges and strategies to re-start our clubfoot program. METHODS: Data was collected retrospectively regarding registrations, demography and procedures done at our clubfoot centre. Study period was 25 March to 31 December 2020 and it was compared with same duration from previous years 2019 and 2018. After the data analysis, the findings were discussed on departmental committee meeting, future challenges were considered and strategies were charted out for re-establishing the clubfoot program at our Institute. RESULTS: When compared to previous year, we noted 46% decline in paediatric outpatient registrations and 60% decline in new clubfoot registrations at our centre. The clubfoot follow-up visits reduced by 30% in the pandemic year 2020. 80% of clubfoot registrations were local residents during pandemic year, which was 54%, 58% in year 2019 and 2018 respectively. The percentage of neglected cases remained stable, however, share of relapse cases increased during pandemic year. There was 80% decline in number of tenotomies and 90% decline in other clubfoot surgeries performed during pandemic year 2020 compared to year 2019. CONCLUSION: COVID-19 pandemic had definite disruptive impact on our clubfoot program. With decreased new registrations, follow-up visits and increased relapses, we anticipate a significant increase in clubfoot cases in need of casting & treatment. To deal with pent-up demand and an anticipated wave of relapse and neglected clubfoot cases, we have proposed strategies to re-establish clubfoot program in post-pandemic new-normal. We hope these will prepare us for any adversaries we face.

Tibial plateau fractures-Does non anatomic reduction lead to an adverse outcome? A 10-year follow-up.

PURPOSE: Assess the effect of residual intra-articular step and limb alignment on the outcomes of operated tibial plateau fractures. METHODS: After retrospectively enrolling 123 cases of operated tibial plateau fracture whole limb weight bearing X-rays of both knees and computed tomography scan was done to record the presence of knee osteoarthritis (OA), alignment and articular step. The Rasmussen functional score (RFS) and Visual Analogue scale (VAS) score was calculated. Depending on the articular step there were four groups, group A (no step), group B (<2 mm), group C (2 mm-5 mm) and group D (6 mm-10 mm). The patients were also divided into 3 groups based on knee alignment, group 1 (0-10° valgus angle), group 2 (varus angle upto 5°) and group 3 (varus angle of 5-15°). RESULTS: Group A had 53, group B 31, group C 23 and group D 16 cases. The mean follow up was 10.23 years. The difference in the RFS/VAS score and OA rate amongst the 4 groups based on articular step had a P>0.05. Based on knee alignment RFS and OA rate amongst three groups had a P<0.05 with better results in group 1. CONCLUSIONS: Mal-alignment is a more important predictor of outcome in operated tibial plateau fractures than articular step.

Factors affecting the functional outcome of surgically managed displaced acetabular fractures.

PURPOSE OF STUDY: To evaluate the impact of various factors on functional outcome of surgically managed displaced acetabular fractures. METHODS: In this prospective study 50 cases of surgically managed displaced acetabular fractures were followed up to a mean of 28.6±4 months (18-48 months). The effect of age, associated injuries, fracture pattern (elementary/associated type), time to surgery (<2 weeks/>2 weeks), accuracy of reduction (anatomical/imperfect/poor), gender and associated hip dislocation on the clinical outcome was evaluated using Harris hip score and modified Postel Merle d'Aubigné score. RESULTS: The mean age was 36.6±11.9 years (range 19-67 years). There were 76% (n=38) males and 24% (n=12) females. 82% (n=41) patients sustained fracture due to motor vehicle accident. 60% of the cases had associated injuries. The mean Harris hip score at final follow-up was 80.96±8.9 and mean modified Merle d'Aubigné and Postel score was 15.1±2.4. The Harris Hip score and modified Postel Merle d'Aubigné score was significantly affected by presence of associated injuries (P=0.0025 and 0.0037 respectively), time to surgery (P=0.0087 and 0.0093 respectively), fracture pattern (P=0.015 and 0.023 respectively), associated hip dislocation (P=0.011 and 0.008 respectively), accuracy of reduction (P<0.05) and age (P<0.05), but gender (P=0.78 and 0.93 respectively) didn't have any significant effect on the clinical outcome. CONCLUSION: The presence of associated injuries, concomitant hip dislocation, associated type of fracture patterns, elderly age (more than 60 years), sub optimal fracture reduction and delay in surgery beyond 2 weeks are factors that lead to statistically significant suboptimal functional scores.

Osteosynthesis of pediatric femoral shaft fractures with flexible intramedullary nailing-experience from developing world.

BACKGROUND: Flexible intramedullary nailing (FIN) has become the standard treatment for pediatric femoral fractures in the 6-14 years age group. The other treatment options include traction plus spica casting and external fixation. In spite of excellent results described, there is disunity in the orthopedic fraternity regarding its usefulness and nail material. The aim of our study is to determine the outcome of pediatric femur fractures treated with Stainless steel FIN. METHODOLOGY: Between 2014 to 2018, 45 children within the age group of 6-12 years with femoral shaft fractures were included in the study. Two Stainless steel nails of predetermined size were inserted in a retrograde fashion under fluoroscopy. Patients were followed up at regular intervals to assess clinical and radiological parameters. Final results were evaluated using Flynn's clinical criteria. RESULTS: There were 29 boys and 16 girls with an average age of 10.2 years. Fracture patterns included transverse (n=8), oblique (n=20), spiral (n=12) and comminuted (n=5). Open injuries were present in two cases and five patients had associated injuries. The mean injury to surgery interval was 2.9 days, mean hospital stay was 4.8 days and mean time to union was nine weeks. Complications included deep infection with delayed union in one case, superficial infection in two cases, malunion in three cases, limb length discrepancy of >10 mm in one patient and skin irritation from prominent nail tips in five patients. Results were excellent in 36 patients, satisfactory in eight patients and poor in one patient. CONCLUSION: FIN is safe, reliable and efficacious method of fixation because of its simplicity, minimal invasiveness, ease of insertion and removal with better cosmesis, rapid union with short rehabilitation, less psychosocial stress to the patient and family.

Proximal Fibular Osteotomy for Medial Compartment Knee Osteoarthritis: Is It Worth?

BACKGROUND: Osteoarthritis of knee is one of the important causes of knee pain in elderly patients and is a debilitating disease. It often leads to varus deformity of knee. Many treatment options are available for this progressive knee joint disorder. Proximal fibular osteotomy (PFO) is a novel yet simple procedure used to alleviate the symptoms of medial compartment knee osteoarthritis. The present study was undertaken to evaluate whether this procedure improves the symptoms, functions and limb alignment in patients with medial compartment knee osteoarthritis. METHODS: Following approval by the Institutional Review Board, this prospective study included 42 cases (56 knees) with Kellgren-Lawrence grade II and III medial compartment knee osteoarthritis and underwent proximal fibular osteotomy. Clinical assessment was done by visual analogue scale (VAS) score and The Western Ontario and McMaster universities osteoarthritis Index (WOMAC) score pre-operatively and at 3, 6 and 12 months follow-up for pain and functional improvement. Radiological assessment was done by measuring femoro-tibial angles (FTA) pre-operatively and at 1 year follow-up. RESULTS: The mean age was 58.30 years. There were 30 females and 12 males. The preoperative mean WOMAC score was 87.3, at 3 months follow-up it was 29.4 this was significantly better (p < 0.05) but the improvement was not significant at subsequent follow-up visits. Similarly the VAS scores also showed significant improvement at 3 months, but not at 6 and 12 months follow-up. There was no significant improvement in the femoro-tibial angle (FTA) at 1 year follow-up. CONCLUSION: The study highlights that both the VAS scores and WOMAC scores were significantly better at 3 months after surgery. However these did not show any significant improvement at 6 and 12 months. It does not change the alignment of knee at one year follow-up. The authors conclude that proximal fibular osteotomy provides only short-term relief in patients of medial compartment knee osteo-arthritis.

How Much has COVID-19 Pandemic Affected Indian Orthopaedic Practice? Results of an Online Survey.

BACKGROUD: Coronavirus Disease 2019 (COVID-19) has spread globally affecting all strata of people including the orthopaedic surgeons of India. We have witnessed a drastic fall in the number of patients. The aim of study was to assess the extent to which the Indian orthopaedic practice has been affected by the pandemic. METHODS: We conducted an online survey amongst currently practicing Indian orthopaedic surgeons. Those currently not in practice or under training or having left clinical practice before the onset of pandemic were excluded. A total of 533 orthopaedic surgeons took part in the study amongst which, complete responses were obtained from 407 individuals. Statistical analysis was done to see the association between demographic profile of study participants and various variables of orthopaedic practice. RESULTS: There was drastic fall in all the parameters of orthopaedic practice. Over half of the practicing surgeons witnessed fall in out-patients over 90%. Most had stopped elective surgeries (64%) and even emergency ones (21%) altogether. More than 50% of doctors had their earnings reduced by > 75%. We found a statistically highly significant association of reduction in earnings with the sector, type of set-up and duration of practice. (p-value < 0.001). CONCLUSION: This study suggests that orthopaedic surgeons across all sectors in different kinds of set-ups have been affected in their out-patient and operative numbers. With regards to earnings, those working in private and running their own (individual) hospitals & clinics have been most severely affected while those in government sector and medical colleges have been affected the least.

Paediatric conjoint bicondylar Hoffa fracture with patellar tendon injury: An unusual pattern of injury.

Epiphyseal injuries of distal femur are rare with an incidence of 1%-6% among all physeal injuries. Prompt diagnosis and appropriate surgical treatment is crucial to achieve satisfactory functional outcomes. A conjoint bicondylar coronal split (Hoffa) fracture with complete transaction of ipsilateral patellar tendon has been reported in a 12 year old child. The injury was managed by open reduction and internal fixation and bone to tendon repair. This case emphasizes the need of accurate intraepiphyseal fixation for the management of these fractures in skeletally immature patients.

An Unexpected Complication of Residual Fibular Strut Graft While Performing A Press fit Hemiarthroplasty for A Secondary Nonunion Fracture Neck of the Femur.

INTRODUCTION: Perioperative complications are well known during partial and total hip arthroplasty. One of the common categories of these complications is an intraoperative fractures of the proximal femur. Here we discuss a case of perforation of posteromedial cortex of the proximal femur, while doing a press fit modular bipolar hemiarthroplasty, in a young adult with secondary nonunion of the femoral neck fracture. The cause of this proximal femur perforation was residual fibular strut graft that, redirected the femoral stem into undesirable direction. This complication of residual fibular strut graft has not been disscussed much in the orthopedic literature previously. CASE REPORT: A press fit modular bipolar hiparthroplasty was performed in a young adult male with nonunion fracture neck of the femur secondary to initial fixation using 6.5mm cannulated hip screws and nonvascularized free fibular strut grafting. Failure to completely remove the fibular strut from the proximal femur lead to difficult negotiation of the femoral stem into the femoral canal and ultimately a perforation in the proximal femur at the level of the lesser trochanter. A revision procedure was done to completely remove the residual fibular graft, and then a fresh press fit modular bipolar hemiarthroplasty was done. CONCLUSION: Complete removal of fibular strut graft should be done, while performing hip arthroplasty in patients with failed fibular grafting for fracture neck of the femur.

Osteoarticular tuberculosis-a three years' retrospective study.

INTRODUCTION: Extra pulmonary TB can be encountered in various organ systems, like lymph nodes, serous cavities, genitourinary tract, skeletal. Musculoskeletal TB can cause significant functional impairment. The clinical symptoms are variable, pain and swelling being common symptomatology. Investigations for suspected cases include radiological imaging, histopathological examination, bacteriological examination, and polymerase chain reaction. The mainstay of treatment is multidrug antitubercular chemotherapy. AIM: To study the cases of osteoarticular TB diagnosed on biopsy, to analyse the various microscopic patterns, results of microbiological investigations, correlate the clinical and radiological features and the response to ATT. Setting and Designs: A teaching tertiary medical institute in North India in catchment area, where prevalence of tuberculosis is high. A retrospective study of cases with a biopsy diagnosis of bone and/joint TB, retrieved from Histopathology section of Department of Pathology of the tertiary institute. MATERIAL AND METHODS: The study was retrospective and the data was collected for the preceding 3 years. The cases were retrieved from the records of the department of Pathology. A total of 16 cases were diagnosed as/suspected to be tuberculosis of bones and/joints. The clinical information were noted from the case files. Results of laboratory investigations along with relevant microbiologic investigations were noted. The biopsy samples were processed according to protocol. Ziehl-Neelsen stain to detect tubercle bacilli and PAS stain to rule out fungal infection were done. Microscopic features were noted. RESULTS AND CONCLUSION: Sixteen cases with a diagnosis of bone and/joint tuberculosis were found. The average age was 23.6 years. The most common presentation was pain and swelling. Knee joint was most commonly involved (7 cases) followed by spine and ankle (3 each). All the cases showed epithelioid granulomas which was necrotising in 11. AFB positivity was found only in 4 cases. ATT was started in 12 cases with a good response. It is important to suspect osteoarticular TB clinically and investigate accordingly. In resource poor setting, study of biopsy material can aid in diagnosis, further guiding the management.

Giant cell reaction of a metatarsal bone: a case report.

A rare, non-neoplastic lesion involving the 1st metatarsal bone in a 5-year-old female is described. Radiographically it presented as a cystic lesion of the whole of the metatarsal. Fine needle aspiration cytology showed it to be a benign giant cell lesion. The tumour was excised en bloc and the metatarsal replaced by a free fibular graft of adequate length. Histopathological examination confirmed the diagnosis as giant cell reaction of bone. The lesion is said to arise as a local tissue response to bleeding as evidenced by the clustering of giant cells in areas of haemorrhage. The entity should be differentiated from aneurismal bone cyst, brown tumours of hyperparathyroidism giant cell tumour, chondroblastoma, non-ossifying fibroma etc. Treatment usually consists of curettage or excision of the involved bone with or without bone grafting. Recurrences are common in curetted lesions.

Management of type C intercondylar fractures of lower end humerus in adults: A clinical study.

Thirty-six patients of type C intercondylar fractures of lower end of humerus who visited JN Medical College, Aligarh between January, 2001 and January, 2003 were included in the study. All patients were treated surgically by open reduction and internal fixation with 4mm cancellous screws, reconstruction plates, one-third tubular plates. Early physiotherapy was started and the results graded using Krishnamoorthy criteria.

Comparison of the results of sinus track culture and sequestrum culture in chronic osteomyelitis.

A prospective observational study was conducted at J. N. Medical College, Aligarh Muslim University, to compare the bacterial flora obtained from sequestrum culture and sinus track culture and to evaluate their antibiotic sensitivity. A total of 62 patients with chronic osteomyelitis were enrolled (38 males and 24 females). Sinus track cultures were done taking all aseptic precautions and the results were compared. Thirty three patients out of 62 showed a discrepancy between the bacterial flora grown from sinus track and sequestrum cultures.