Bilateral Floating Knee Injuries Managed by Intramedullary Nailing - An Unusual Injury.

Introduction: Floating knee injuries were first described in 1975 by McBryde as concurrent femur and tibial fractures in an ipsilateral limb. They usually occurred in a polytrauma setting and presented with poor functional outcomes with frequent post-operative complications. Management of this injury was based on patient and fracture characteristics and can be done by external fixators, plating, and nailing. Case Report: A 24-year-old female presented with bilateral floating knees. She was operated on for a left femoral fracture with retrograde nailing when she developed tachycardia and underwent external fixation of the remaining fractures. She later developed a fat embolism which was managed accordingly for the same. After adequate stabilization, her right femur and tibia fractures were fixed by intramedullary nailing through a single percutaneous approach along with nailing for the left tibial fracture. She has satisfactory clinical outcomes on follow-up. Conclusion: Bilateral floating knee injuries are extremely rare injuries and should be managed on an emergency basis. Intraoperative and post-operative complications should be anticipated and managed accordingly. Good functional outcomes can be obtained by intramedullary nailing.

Cervical sagittal alignment in Lenke 1 adolescent idiopathic scoliosis and assessment of its alteration with surgery: a retrospective, multi-centric study.

PURPOSE: To document baseline cervical sagittal characteristics in Lenke 1 adolescent idiopathic scoliosis (AIS) patients and assess the alteration in these parameters with surgery. METHODS: Pre-operative and 2-year postoperative radiographs of 82 Lenke 1 AIS patients recruited from five hospitals were analysed. Selected radiographic parameters capturing regional and global sagittal alignment were measured. Comparison was made between groups based on baseline thoracic kyphosis (TK: TK < 20°, TK ≥ 20°). Pre-operative and postoperative values were compared-the change in each radiographic parameter was correlated with the degree of sagittal and coronal correction. RESULTS: At baseline, TK was 29.8° ± 16°, cervical lordosis (CL) was - 1° ± 14°, lumbar lordosis (LL) was - 57.1° ± 21°, C2-C7 sagittal vertical axis (SVA) was 16 ± 14 mm and C7-S1 SVA was - 15 ± 28 mm; 44% of patients had cervical kyphosis. Patients with thoracic hypokyphosis had a significantly lower LL and more kyphotic cervical spine compared to those with thoracic normohyperkyphosis. The effect of surgery on TK depended on pre-operative thoracic sagittal alignment-TK increased in patients with thoracic hypokyphosis, but decreased in patients with thoracic normohyperkyphosis. Neither CL nor C2-C7 SVA changed significantly with surgery; 46% of patients still had cervical kyphosis postoperatively. CONCLUSION: There is a high incidence of cervical kyphosis at baseline in AIS patients-more so in those with pre-operative thoracic hypokyphosis. Unlike TK, CL is not significantly altered with surgery-improvement in CL correlates weakly with sagittal correction of the structural curve.

Which one restores in vivo knee kinematics effectively-medial or lateral pivot?

INTRODUCTION: Total knee arthroplasty (TKA) usually provides good pain relief and improved function but has generally been unable to fully restore normal knee kinematics. Does Medial or Lateral Pivot TKA designs guide us to native knee kinematics needs to be elucidated? METHODS: Kinematic assessment of 13 knees with Medial Pivot TKA and 13 knees with Lateral Pivot TKA was done. The subjects were asked to perform step-up and weight bearing deep knee bend exercise under fluoroscopy for kinematic assessment. Patellar Tendon Angle (PTA) was measured after correcting f luoroscopic images for distortion against Knee Flexion Angle (KFA). RESULTS: During the weight bearing deep knee bend, the average active maximum flexion achieved with Medial Pivot design was 113.8 ͦ as compared to 102.9 ͦ with Lateral Pivot design. There was no significant difference in PTA in step up and deep knee bend exercise between both the designs. CONCLUSION: The kinematic assessment of both the Medial and Lateral Pivot TKA designs revealed linear trend of PTA with increasing KFA as described for normal knee. Both the designs were able to achieve functional knee range of motion.

Freeman-Sheldon Syndrome with Stiff Knee Gait - A Case Report.

Introduction: Freeman-Sheldon syndrome (FSS), also known as the distal arthrogryposis (DA) type 2A, is a rare congenital anomaly. We report a unique case of the DA type 2A with mixed clinical features and the unusual presentation of bilateral congenital dislocation of the knee but had unassisted stiff knee gait. Case Report: A 5-year-old female child presented to the clinic with the complaint of inability to bend both knees since birth. She had an unassisted bipedal gait, but could not squat, cross-leg sit, run, and climb stairs without assistance. Her youngest brother had a similar presentation but succumbed to death at the age of 5 months due to respiratory distress. Clinical features were in the favor of FSS. Her serum creatinine kinase level was normal and the electromyography of bilateral tibialis anterior and abductor pollicis brevis was not suggestive of the myotonia. Radiograph of the skull showed cooper beaten skull appearance whereas bilateral pelvis with the hip showed following changes in the right hip; decrease femoral epiphysis height, horizontal proximal femoral physis, and the coxa brevia. She was initially managed conservatively by weekly stretching, manipulation, and casting. As a result, she could flex her knee up to 20°. Although the quadricepsplasty might be helpful for the persistent extension deformity, there was marked quadriceps weakness which could make it harder for the child to stand and walk. In addition, the abnormal muscle physiology in FSS may result in unfavorable outcomes after the surgery. Moreover, a consideration of the surgical aspect is not free of risks which include difficult endotracheal intubation, vein access, and malignant hyperthermia. Conclusion: FSS is a rare congenital anomaly that should be differentiated from another syndrome of the close resemblance, Sheldon Hall syndrome and Schwartz Jampel syndrome which are other rare autosomal recessive disorders characterized by myotonia and the chondrodysplasia. Conservative management has still a role in bilateral knee involvement especially if the patient is an independent walker.

Management of Neglected Peroneal Tendon Dislocation of Iatrogenic Etiology: A Case Report.

Introduction: Neglected peroneal tendon dislocation with iatrogenic etiology has been rarely reported in the literature and its management has not been fully understood to date. Case Report: We present a case of a 25-year-old male who presented with pain over the posterolateral aspect of his left ankle which was diagnosed to be a case of neglected peroneal tendon dislocation of iatrogenic etiology. Peroneal groove deepening with superior retinaculum repair was done in the patient along with loose body removal and osteophyte excision. Subsequent fibrosis augmented with the deepening of the groove maintained peroneal tendon position in the retromalleolar groove. On post-operative follow-up, the patient was completely satisfied with relief of pain and no complications. He also regained full range of motion and could walk without support. Conclusion: Surgical intervention of fibular groove deepening with superior peroneal retinaculum reconstruction results in an excellent outcome for neglected peroneal tendon dislocation.