Treatment of chronic and complex meniscal tears with arthroscopic meniscus repair augmented with collagen matrix wrapping: failure rate and functional outcomes.

PURPOSE: Meniscal wrapping is a fully arthroscopic technique that involves enhanced meniscal repair with a tissue-engineered collagen matrix wrapping. This study aims to investigate the feasibility of using the meniscal wrapping technique for the treatment of chronic or complex meniscal tears. The primary objective is to assess its failure rate. The secondary objectives are to analyse complication rate, functional outcomes and overall patient satisfaction. METHODS: This retrospective case series study included patients who sustained chronic and complex tears undergoing meniscal wrapping with autologous liquid bone marrow injection. Failure rate was considered if the patient underwent partial or complete meniscectomy or knee replacement during the follow-up, while other unexpected knee reoperations were considered as complications. Clinical outcomes were evaluated through the IKDC score, Tegner Activity Score and Short Assessment of Patient Satisfaction. RESULTS: Twenty-one patients were included (15 non-acute bucket-handle tears, three non-acute horizontal tears and three non-acute complex injuries). The failure rate was 9.5% at 33 months. The rate of other unplanned reoperations was 14.3%, but none of these complications were apparently directly related to the wrapping technique. The average postoperative IKDC was 73.3/100. No statistically significant difference was encountered between preinjury and postoperative Tegner Activity Score. The mean overall patient satisfaction was 88.3/100. CONCLUSIONS: Meniscal wrapping can be safely used as an adjunctive technique to meniscal repair in such difficult-to-treat cases to preserve the meniscus. The technique achieves a low failure rate and promising results of knee function, and patient satisfaction.

Are cardiac surgical patients at increased risk of difficult intubation?

BACKGROUND AND AIMS: Safe airway management is the cornerstone of contemporary anaesthesia practice, and difficult intubation (DI) remains a major cause of anaesthetic morbidity and mortality. The surgical category, particularly cardiac surgery as a risk factor for DI has not been studied extensively. The aim of this study was to test the hypothesis whether cardiac surgical patients are at increased risk of DI. METHODS: During the study, 627 patients (329 cardiac and 298 non-cardiac surgical) were enrolled. Pre-operative demographic and other variables associated with DI were assessed. Patients with Cormack Lehane grade III and IV or use of bougie in Cormack grade II were defined as DI. The incidence of anticipated and unanticipated DI was assessed. Factors associated with DI were described using univariate and multivariate logistic regression models. RESULTS: The overall incidence of DI was 122/627 (19.46%). The incidence of DI was higher in cardiac surgery patients (24%) as compared to non-cardiac surgery patients (14.4% P = 0.002). On multivariate analysis, factors independently associated with DI were greater age, male sex, higher Mallampati grade, and anticipated DI, but not cardiac surgery. The incidence of unanticipated DI was 48.1% and 53.4% in cardiac and non-cardiac surgery patients, respectively. CONCLUSION: Although there was a higher incidence of DI in cardiac surgical patients, cardiac surgery is not an independent risk factor for DI. Rather, other factors play more important role. About half of the DI both in cardiac and non-cardiac surgeries were unanticipated.

Revision anterior cruciate ligament reconstruction using tibial or hamstring tendon allografts.

PURPOSE: To report outcomes of revision anterior cruciate ligament (ACL) reconstruction using tibial or hamstring tendon allografts and to compare with another study using non-irradiated fresh-frozen bone-patellar tendon-bone allografts. METHODS: Records of 12 men and 7 women aged 18 to 53 (mean, 33) years who underwent revision ACL reconstructions using tibial tendon (n=17) or hamstring tendon (n=2) allografts were retrospectively reviewed. At the time of primary ACL reconstruction, hamstring autografts (n=8) and bonepatellar tendon-bone allografts (n=11) were used. The mean time interval between surgeries was 93 (range, 11-225) months. The causes of failure were traumatic injury (n=7) and technical or biological reasons (n=12). The physical activity level was high in 2 patients, medium in 10, and low in 7. For clinical assessment, the Lysholm test, International Knee Documentation Committee (IKDC) scale, and visual analogue scale (VAS) for pain were used. Patient satisfaction was also assessed. RESULTS: Four of the patients had laxity and were dissatisfied or very dissatisfied with the outcome; the failure rate was 21%. The mean IKDC score was 63% (range, 25-100%), and the mean Lysholm score was 74% (range, 30-100%). Comparing our patients with those in another study using bone-patellar-bone allografts, there was no significant difference in terms of the VAS for pain, IKDC score, and Lysholm score. Comparing our patients with and without chondral and/or meniscal lesions, there was significant difference in terms of the Lysholm score only (86±11 vs. 57±28, p=0.043). Comparing patients who had used hamstring tendon autografts at the primary ACL reconstruction with those who had used bonepatellar tendon-bone autografts, there was significant difference in terms of the VAS for pain only (4.4±3.1 vs. 1.6±1.0, p=0.020). CONCLUSION: Revision ACL reconstruction using tibial or hamstring tendon allografts provided acceptable results, similar to those using the bone-patellar tendon-bone allografts.

Combined uphill and downhill varices as a consequence of rheumatic heart disease: a unique presentation.

Hemorrhage from downhill varices is a rare manifestation. The etiology of downhill varices is due to superior vena cava obstruction while uphill varices are secondary to portal hypertension. We report a rare case of 55-year-old female with bleeding downhill varices not associated with obstruction or compression of superior vena cava, but was due to severe pulmonary artery hypertension secondary to chronic rheumatic heart disease.

Medium-term outcome of mosaicplasty for grade III-IV cartilage defects of the knee.

PURPOSE: To evaluate the medium-term outcome of mosaicplasty for full-thickness cartilage defects of the knee joint in 17 patients. METHODS: Records of 12 men and 5 women aged 16 to 57 (mean, 35) years who underwent mosaicplasty for grade III/IV osteochondral defects in the lateral (n=14) or medial (n=3) femoral condyle were reviewed. 12 of the patients had undergone knee surgeries. The mean size of the defects was 3.4 (range, 1-4) cm(2). Three patients had defects of >2 cm(2). All operations were performed by a single surgeon using mini-arthrotomy. The lateral edge of the trochlea was the donor site. Graft integration and the presence of any abnormality at the articular surface were assessed using magnetic resonance imaging (MRI). In addition, patients were evaluated using the International Knee Documentation Committee (IKDC) rating scale, the SF-36 health questionnaire, visual analogue scale (VAS) score for pain. RESULTS: Two of the 17 patients developed necrosis and cystic degeneration of the grafts and underwent conversion to unicompartmental knee arthroplasty within 2 years. They were older than 45 years and had defects of >2 cm(2). Respectively in years 4 and 7, one and 4 patients were lost to follow-up, the mean IKDC score was 75% and 88%, the SF-36 score was 83% and 90%, and the VAS score was ≤3 in 13 of 14 patients at year 4 and in all 11 patients at year 7. At the 7-year follow-up, patient satisfaction with mosaicplasty was excellent in 8 patients, good in 3, and poor in 2 (who underwent unicompartmental knee arthroplasty). At year 4, MRI showed integration of the cartilage repair tissue and incorporation of the osseous portion of the graft into the bone in 13 of the 14 patients. The remaining patient had osteoarthritis at the graft donor site. At year 7, MRI showed good integration of the implant in all 11 available patients, but fissures were seen on the cartilage surface in 3 patients. CONCLUSION: The medium-term outcome of autologous mosaicplasty for symptomatic osteochondral defects in the femoral condyle is good. Longer follow-up is needed to determine the structural and functional integrity of the graft over time.

Hepatitis B and/or C co-infection in HIV infected patients: a study in a tertiary care centre from South India.

BACKGROUND & OBJECTIVES: Co-infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) in human immunodeficiency virus (HIV) infected individuals results in increased hepatic complications. We undertook this study to evaluate the presence of HBV and HCV in HIV infected individuals attending a tertiary care centre in southern India. METHODS: A total of 120 cases with HIV infection and 120 healthy adult control subjects were included in the study. Samples were tested for hepatitis B surface antigen (HBsAg) and anti-HCV antibodies by enzyme linked immunosorbent assay (ELISA) method. HBsAg and anti-HCV positive serum samples were further tested for the presence of hepatitis B e antigen (HBeAg), anti-HBe antibodies, HBV-DNA and HCV-RNA. RESULTS: The most common mode of transmission was sexual promiscuity (79%), followed by spouse positivity (15%) and history of blood transfusion (6%). HBsAg and anti-HCV were positive in 18 (15%) and 10 (8.3%) HIV infected patients; the corresponding figures in healthy controls being 2 (1.6%) 0 (0%) (P<0.0001). Among HIV infected patients, presence of HBeAg and anti-HBe antibodies was seen in 33.3 and 55.5 per cent, respectively; both HBeAg and anti-HBe antibodies were negative in 11.1 per cent. HBV DNA and HCV RNA were positive in 10 of 18 and in all anti-HCV positive samples. Triple infection with HBV, HCV and HIV was seen in three patients. CD4+ T-lymphocyte count less than 200/µl was seen in 22 of 28 co-infected cases. INTERPRETATION & CONCLUSIONS: The findings of our study showed presence of HBV (15%) and HCV (8.3%) co-infections in HIV positive patients which was higher than that seen in HIV negative controls. Co-infection with HBV and HCV is a common problem in HIV infected patients in India. Hence, all HIV patients need to be routinely tested for markers of HBV and HCV infection.

Synthetic resorbable scaffolds for the treatment of isolated patellofemoral cartilage defects in young patients: magnetic resonance imaging and clinical evaluation.

BACKGROUND: Surgical management of patellar cartilage defects remains controversial. The ideal technique to regenerate hyaline cartilage is not yet defined. However, a synthetic resorbable osteochondral scaffold plug (TruFit CB) seems to offer a treatment option with good results at short-term follow-up, at least in the condylar setting. HYPOTHESIS: A synthetic implant provides a simple and efficacious means of treating the cartilage defects of the patellofemoral joint in young patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A study was designed to evaluate prospectively short- and medium-term results in patients with osteochondral patellar defects treated with synthetic reabsorbable scaffolds. Patient outcome scores (Short Form 36 [SF-36] and Knee injury and Osteoarthritis Outcome Score [KOOS]), demographics, prior surgeries, and data from a physical examination were collected at baseline (before implantation) and at 6, 12, and 24 months after surgery. Defect characteristics were collected during implantation. Diagnosis and monitoring were performed by magnetic resonance imaging. RESULTS: Ten patients with a mean age of 33.3 years (range, 16-49 years) were evaluated prospectively at 24 months' follow-up. The number of plugs used for each patient ranged from 1 to 4. At 1-year follow-up, the results were satisfactory in 8 of 10 patients, and poor in 2, according to clinical assessment (KOOS, visual analog scale, and SF-36). At 18 months of follow-up, all patients except one complained of pain and knee swelling. Reoperation rate for implant failure at final follow-up was 70%. Magnetic resonance imaging at final follow-up showed a cylindrical cavity of fibrous tissue instead of subchondral bone restoration. CONCLUSION: A synthetic implant can improve symptoms and joint function, especially for small lesions, only for a short period of time. However, 2 years of monitoring has shown its failure in restoring the subchondral bone despite the formation of predominant hyaline cartilage from synthetic resorbable scaffolds. Under current conditions and according to our experience, we do not recommend TruFit synthetic implants for osteochondral patellar defects in active patients.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.

Primary hydatid cyst of skeletal muscle affecting the knee: a case report.

Hydatid disease is a parasitic infection generally occurring in specific geographical areas. Exclusive involvement of the muscles is extremely uncommon, because implantation at this site would require passage through the filters of the liver and lung. We describe a patient with a mass in the popliteal fossa of the knee for 7 years who was seen for pain and was found to have hydatid disease.

Is there a place for rotating-hinge arthroplasty in knee revision surgery for aseptic loosening?

We reviewed the results of 78 revision total knee arthroplasties using a rotating-hinge device, performed from 1993 through 2002. The average follow-up was 7.83 years. Only patients requiring revision arthroplasty due to aseptic loosening were included. Reasons for revision were malalignment with or without polyethylene wear (47), instability (24), extensor mechanism failure (3), and periprosthetic fracture (4). The mean preoperative scores according to the American Knee Society rating scale was 37.5 points for knee score and 32.8 points for function score. Postoperatively, the knee score improved to 85.7 points and the function score improved to 61.4 points. Nineteen patients had complications related to the design prostheses (mostly minor complications). Fifty-seven patients (73%) had excellent results, with a range of motion of 104 degrees in flexion and complete extension. For extreme circumstances, such as gross instability of the medial collateral ligament, massive bone loss, comminuted fracture, and chronic dysfunction of the extensor mechanism, there is a place for hinged revision implant surgery with good clinical results and quality of life.

Primary sacral hydatid cyst. A case report.

This case report highlights an unusual osseous spinal presentation of a well described disease, hydatidosis. A 59-year-old woman presented with increasing back pain and bilateral radiculopathy. Examination disclosed symptoms of spinal stenosis and urinary incontinence. Radiographs showed an expansive lytic lesion affecting the pelvic bones with destruction of the bone cortex. Laboratory analyses were performed and the patient underwent CT and MRI studies. Serology for Echinococcus was positive. When assessing sciatica, low back pain or lower limb weakness the pelvic cavity should be examined for hidden disease that might explain the neurological symptoms. Hydatid disease of bone should be considered in the differential diagnosis of any bone mass discovered in the human body. Diagnosis was delayed in this case because the pelvic cavity was not studied when radiculopathy symptoms started and there was no coexisting visceral involvement.

Stress fracture of the femoral neck as a complication of total knee arthroplasty.

Stress fracture of the hip is a rare complication of total knee arthroplasty that occurs most often in patients in whom a significant deformity of the knee has been corrected, particularly those with poor mobility before surgery. We report 4 cases of ipsilateral fracture of the femoral neck after total knee arthroplasty.

Clinical and aetiological profile of hepatoma at a tertiary care centre.

Hepatocellular carcinoma (HCC) is one of the most common cancers in the world. Infection with the hepatitis B virus (HBV) is one of the high-risk factors for the development of HCC, particularly in Asia and Africa. Other risk factors include hepatitis C virus (HCV) infection and, to a certain extent, exposure to a liver-specific carcinogen such as aflatoxin B, and alcohol consumption. In the present retrospective study, we analysed the clinical profile and aetiological role of HBV and HCV in HCC. A total of 40 cases of HCC (33 males and 7 females, age range 22-80 years) were seen from January 1999 to June 2001 at our institute. A detailed history of age, sex, past history of liver disease, clinical symptoms and presenting complaints was recorded. The most common presenting complaints were abdominal distention, pedal oedema and pain abdomen. Underlying cirrhosis of the liver was seen in 30 cases (75%), Child's A in 6, Child's B in 11 and Child's C in 13 cases. A history of alcoholism was present in 6 patients. All the patients were tested for HBsAg and anti-HCV by ELISA. HBsAg and anti-HCV was positive in 19 (47.5%) and 8 patients (20%), respectively. The diagnosis in the majority of cases was derived by FNAC and in a few by imaging techniques plus alfa-fetoprotein (AFP) evaluation. The diagnosis was confirmed by FNAC in 34, CT scan and AFP in 2, and ultrasound abdomen and AFP in 4 cases. We conclude that viral infection (HBV > HCV) is still a major aetiological factor and the incidence of HCV infection appears to be increasing. The majority of the cases of HCC studied had a cirrhotic background.