Role of placental membrane in ACL graft healing - A series of 18 patients.

Introduction: ACL injuries are common and the standard treatment remains to be ACL reconstruction. Controversy still remains around graft ligamentisation and various methods have been experimented to augment this process. In this series we discuss the outcome of using dehydrated umbilical cord derived membrane in ACL reconstruction. Material and method: A prospective Level IV analysis of outcome in 30 consecutive patients of complete isolated ACL tear presenting to us between May 2022 to September 2022 was done. There was no age or sex restriction. Revision cases were excluded from this series. ACL reconstruction was done using standard all inside technique using the ipsilateral semitendinosus graft which was wrapped with dehydrated umbilical cord derived membrane (5*3 cm2) after soaking in normal saline (Cord Thick - Life Cell; LifeCell international private limited, Chennai, Tamil Nadu, India) and secured with Monocryl 3-0 sutures in a continuous manner. Results: 18 patients completed the one year follow up and were analysed for final results. Eleven of the patients followed up were females and seven males, with an average age of 30.3 years.The average VAS score at 6 weeks was 2.2. The mean KOOS score at the follow up visits were 72.3, 82.3, 90.7, 95.8. The mean SANE score reported at 6 weeks, 3 months, 6 months and 1 year were 68.8, 80, 87.5, 95.1.The follow up MRI's confirmed good ligamentisation of the graft even as early as 6 weeks with minimal fluid in the tunnel. Conclusion: The use of dehydrated umbilical cord derived membrane augmentation to potentiate graft integration in ACL reconstruction seems promising and helps improve patient outcomes.

Low-dose prophylaxis protocol for heterotopic ossification after hip preservation surgery in a sport participants cohort.

BACKGROUND: Heterotopic ossification (HO) is a well-known complication of arthroscopic and open surgical treatment of femoroacetabular impingement (FAI). Incidence of heterotopic ossification has been reported in the literature between 0% and 44% after hip arthroscopy and between 18.2% and 25% after anterior mini-open surgery. Currently, pharmacological prophylaxis with NSAIDs and selective COX-2 inhibitors are commonly used and their effectiveness is well documented in literature. HYPOTHESIS: We hypothesized that the low-dose prophylaxis protocol with selective cox-2 inhibitors decreases the risk of heterotopic ossification in open or arthroscopic hip preservation surgery in athletes. METHODS: This study is an analysis of prospectively gathered data on 98 sport participant patients who underwent arthroscopic or anterior mini-open treatment for FAI between April 2008 and April 2018. All the patients received postoperative oral prophylaxis with 60 mg etoricoxib once daily for two weeks. Post-operative X-rays were performed at 1, 3, and 12 months after surgery and reviewed by two orthopedic surgeons blinded to the type and side of surgery. HO were graded according to the Brooker classification. Descriptive statistics was used to analyze demographic data. Bivariate analysis was performed to analyze the association of HO with each of the following variables: type of surgery, physical activity, time of evolution of symptoms, age at surgery, and sex. Finally, a regression model analysis was performed to determine the presence of confounding effects between variables. RESULTS: The study cohort was composed of 54 patients in the arthroscopic treatment group and 44 patients in the anterior mini-open group. HO was identified in 6 (13.6%) patients in the mini-open group. No HO was identified in the arthroscopic group. In the bivariate analysis, "type of surgery" was the only variable that showed a statistically significant association with HO (p = 0.007). CONCLUSION: Results of this study suggest that anterior mini-open treatment was characterized by a higher risk of HO development compared to hip arthroscopy for femoroacetabular impingement treatment regardless of pharmacological prophylaxis. The treatment regimen of 60 mg etoricoxib daily for two weeks was an effective prophylaxis for HO formation in sport participant patients compared with data available in the literature.

Body fat content correlates with maximum aerobic capacity in healthy sedentary Indian males.

Background: Obesity is a multifactorial public health problem with varying effects on physical fitness determined by maximum aerobic capacity or VO2max. The relationship between body fat content and VO2max has shown varying results. The present study was planned as an experimental study to evaluate the relationship between body fat content and maximum aerobic capacity. Methods: 104 healthy Indian males [Age: 21 (4.87)years; Height: 171.4 (6.14)cm; Weight: 64.1 (8.57)kg] were evaluated for body fat content using body mass index (BMI), bioimpedance, skinfold thickness (SFT), body girth (BG) measurements, waist circumference (WC), and waist-hip ratio (WHR). Maximum aerobic capacity or VO2max for all subjects was determined indirectly from maximum heart rate achieved using an incremental treadmill protocol using Astrand and Astrand nomogram. Results: VO2max, when expressed in L/min, showed a statistically significant positive correlation with body fat irrespective of the method of estimation. VO2max, when expressed in ml/kg/min, showed negative correlation with five of the seven clinical parameters of fat estimation. Of these, a statistically significant negative correlation was seen with SFT. Conclusion: VO2max (L/min) shows a significant positive correlation with all methods of body fat estimation. VO2max (ml/kg/min) shows a significant negative correlation with skinfold thickness. Monitoring of body fat content using skinfold thickness could be studied further for its use in the early identification of young, healthy adult Indian males with low aerobic fitness.

Eliminating Visual Acuity and Dilated Fundus Examinations Improves Cost Efficiency of Performing Optical Coherence Tomogrpahy-Guided Intravitreal Injections.

PURPOSE: The clinic efficiency and cost savings achieved by eliminating formal visual acuity (VA) and dilated fundus examinations (DFEs) were assessed for established patients receiving optical coherence tomography (OCT)-guided intravitreal injections. DESIGN: Comparative cost analysis. METHODS: Two different treatment models were evaluated. The first model included patients undergoing routine VA assessment, DFEs, OCT imaging, and intravitreal injections. The second model eliminated the routine VA assessment and DFE while using OCT imaging through an undilated pupil followed by the intravitreal injection. The 2 models incorporated both bevacizumab and aflibercept. The number of patients per clinic day, the cost per visit, and the daily revenues were compared between the 2 models. RESULTS: Optimized schedules with and without VA assessments and DFEs allowed for 48 and 96 patients to be injected per day, respectively. Excluding drug costs, the cost per encounter for the visits with and without a DFE were $39.33 and $22.63, respectively. Including the drug costs, the costs per encounter for the visits with and without a DFE were $85.55 and $68.85 for bevacizumab and $1787.58 and $17770.88 for aflibercept, respectively. Once the reimbursements for each visit type were included, the clinics that eliminated the VA and DFEs were more cost efficient. CONCLUSION: Eliminating both VA assessments and DFEs for patients undergoing OCT-guided retreatment with intravitreal injections resulted in decreased exposure times between patients and clinic staff, decreased cost per encounter, and increased patient volumes per clinic day, resulting in improved clinic efficiency and safety while seeing more patients in a clinic day.

Cephalomedullary blade cut-ins: a poorly understood phenomenon.

OBJECTIVES: Proximal femoral nail antirotation (PFNA) cut-in is a unique phenomenon seen in pertrochanteric hip fractures treated with the PFNA. Cut-in refers to the superomedial migration of the proximal femoral blade into the femoral head and hip joint. We recognize that cut-in is a completely separate entity from the well-described cut-out failure. This study assesses relevant radiological and patient risks factors for cut-in. DESIGN: Retrospective multicenter study looking at patients with pertrochanteric hip fractures managed with the Synthes PFNA SETTING: Four tertiary hospitals over 7 years. PATIENTS: Patients with cut-ins were identified. OUTCOME MEASUREMENT: The radiological appearance of this mode of failure was assessed and compared to cut-outs. Patient demographics, fracture configuration, time to implant failure (cut-in), bone mineral density, tip-apex distance, neck-shaft angle and position of the tip of the helical blade in the femoral head were collected. RESULTS: There was a total of 1027 patients across 4 institutions with 23 patients with cut-in. Average neck-shaft angle was 133 degrees. 16 out of 19 patients had severe osteoporosis with BMD < - 2.5. 14 of 23 patients had poor placement of the blade. 13 of 23 had a tip-apex distance of more than 20 mm. CONCLUSION: We propose a standardized nomenclature of "cut-in" for the phenomenon of superomedial migration of the proximal femoral blade. An anatomical neck-shaft reduction, accurate blade placement and increased surveillance for patients with severe osteoporosis are required to reduce the incidence and morbidity of cut-in.

Coccidioidomycosis Chorioretinitis.

Coccidioidomycosis is an invasive fungus found primarily in the soil of Southwestern United States, Mexico, and Central America. Primary disease mostly presents as a pulmonary disease although multiple organ systems can be affected through lymphohematogenous dissemination, with ocular seeding extremely rare. When present, the anterior segment structures are most commonly affected. Isolated choroid and/or vitreal disease has been reported infrequently. This is a case of chorioretinitis with vitreal involvement.

Ventilatory parameters at rest after months of stay at 3300 m: A comparison between acclimatized lowlanders and natives at Leh.

BACKGROUND: Increased pulmonary ventilation helps lowlanders and natives to maintain arterial oxygenation at high altitudes. Natives of Ladakh have been shown to have similar ventilatory parameters as Tibetans at 3300 m. But there is limited literature comparing these parameters in Ladakhi natives with acclimatized lowland sojourners. METHODS: End-tidal carbon dioxide partial pressure (EtCO2), blood oxygen saturation (SpO2) and hemoglobin concentration (Hb) were measured in 276 participants, 126 native highlanders (NHL - 40 females, 86 males) and 150 acclimatized lowlanders (ALL - 60 females, 90 males). RESULTS: EtCO2 was greater in the NHL compared to the ALL, (33.8 ± 3.3 vs 31 ± 2.5 mmHg) although SpO2 was lower (90.9 ± 2.4 vs 91.7 ± 2.3%). When grouped by sex, NHL males had significantly greater EtCO2 than NHL females, ALL males and ALL females. Hb and calculated arterial oxygen content was similar in Ladakhis and acclimatized lowlanders, although greater in males compared to females. Systemic blood pressure, heart rate and the proportion of hypertensives was significantly greater in the ALL. CONCLUSION: Native Ladakhis, have a significantly greater resting EtCO2 (especially in males) and lower SpO2 than acclimatized lowlanders. Blood Hb concentration and oxygen content is, however, similar in natives and acclimatized lowlanders of the same sex.

Fractures in patients with osteopetrosis, insights from a single institution.

PURPOSE: Osteopetrosis is a hereditary skeletal disorder in which defective osteoclast function leads to abnormally hard and brittle bones. This study aims to describe the pattern of fractures occurring in this group of patients, possible complications, and strategies to avoid them. METHODS: This is a case series of six osteopetrotic patients with a total of 12 fractures managed in our institution over a period of nine years. Patient records were also reviewed for complications both intra- and post-operatively. RESULTS: The majority of the fractures involved the femur, with three of these being peri-implant in nature. Other bones involved include the tibia, humerus, patella, fifth metatarsal, and proximal phalanx of the toe. There was a high rate of complications while managing these patients: three patients had peri-implant stress fractures, three with retained broken screws, and one case each of delayed union, non-union, and surgical site infection. CONCLUSION: Osteopetrosis fractures present a unique challenge to the orthopedic surgeon. Careful pre-operative planning should be undertaken before proceeding with surgery in these cases.

Rewriting the tip apex distance for the proximal femoral nail anti-rotation.

INTRODUCTION: The proximal femur nail anti-rotation (PFNA-II) (Synthes GmbH, Oberdorf, Switzerland) is the most commonly used implant for intramedullary nailing of unstable intertrochanteric fractures in our centre. However, mechanical failure of the bone with respect to the implant is a cause of concern due to its significant morbidity especially in the elderly. To date, factors for fixation failures are not well defined in the literature. This study aims to evaluate the factors that predispose to cut out of the PFNA implant and to provide a guide for surgical fixation. PATIENTS AND METHODS: This study was a retrospective analysis of 340 patients who underwent PFNA-II insertion from 2011 to 2013 in our centre. Intraoperative image intensifier images were used for calculation of tip apex distance, neck shaft angles, determination of Cleveland zones. Demographic data was collected on patients age and gender. The fractures were classified based on AO-OTA classification (Marsh et al., 2007) [1]. Patients were followed up for a minimum of 4 months and union of the fracture or until a complication occurred. Risk ratio for cut out was also compared with each statistically significant variable to determine the cut-off point. RESULTS: The incidence of cut out was 6.7% Tip apex distance, neck shaft angles and female gender were statistically significant for cut out. The study found that tip apex distance beyond 27mm increased the risk of cut out. Neck shaft angles less than 128° also increased the risk of cut out. Posterior and superior blade position in the femoral head and AO 31A3 fractures trended towards significance for cut out but were not statistically significant. CONCLUSION: To avoid cut out, one should aim for a tip apex distance of not more than 27mm and preserve a neck shaft angle of more than 128°. Risk stratification of the patient allows the surgeon to take greater caution in the post-operative period to detect early cut out.

Objective criteria for diagnosing high altitude pulmonary edema in acclimatized patients at altitudes between 2700 m and 3500 m.

BACKGROUND: The criteria used for diagnosing high altitude illnesses are largely based on Western literature. This study was undertaken to define objective, simple and reliable diagnostic criteria for high altitude pulmonary edema (HAPE) in Indian soldiers at altitudes between 2700 m and 3500 m. METHODS: Clinical data of 235 cases of HAPE that occurred between 2700 m and 3500 m were analysed. Receiver operator characteristic (ROC) curve analysis was used to select simple clinical parameters suitable for the diagnosis of HAPE at peripheral medical facilities. Cut-off values and their reliability for the diagnosis of HAPE were defined. RESULTS: HAPE occurred 2.8 ± 2.2 days after arrival at altitudes between 2700 m and 3500 m. Breathlessness, cough, chest discomfort and headache were the commonest symptoms. Low pulse oximetry (SPO2) values than normal for this altitude were seen in 89% of patients. ROC analysis of clinical parameters identified a heart rate more than 95 beats per minute (bpm), respiratory rate more than 21 per minute and SPO2 less than 86% while breathing ambient air at this altitude as diagnostic of HAPE. The sensitivity and specificity of these cut-offs was 0.66, 0.83 and 0.82 and 0.94, 0.95 and 0.93 respectively. CONCLUSION: A heart rate of more than 95 bpm, respiratory rate more than 21 per minute and SPO2 less than 86% breathing room air in individuals complaining of breathlessness, cough, chest discomfort or headache within the first 5 days of arrival at altitudes between 2700 m and 3500 m is highly suggestive of HAPE.

Design, development, and optimization of polymeric based-colonic drug delivery system of naproxen.

The aim of present investigation deals with the development of time-dependent and pH sensitive press-coated tablets for colon specific drug delivery of naproxen. The core tablets were prepared by wet granulation method then press coated with hydroxypropyl cellulose (HPC) or Eudragit RSPO : RLPO mixture and further coated with Eudragit S-100 by dip immerse method. The in vitro drug release study was conducted in different dissolution media such as pH 1.2, 6.8, and 7.4 with or without rat caecal content to simulate GIT conditions. Surface morphology and cross-sectional view of the tablets were visualized by scanning electron microscopy (SEM). All prepared batches were in compliance with the pharmacopoeial standards. The tablets which are compression coated with HPC followed by Eudragit S-100 coated showed highest in vitro drug release of 98.10% in presence of rat caecal content. The SEM of tablets suggested that the number of pores got increased in pH 7.4 medium followed by dissolution of coating layer. The tablets coat erosion study suggested that the lag time depends upon the coating concentrations of polymers. A time-dependent hydrophilic polymer and pH sensitive polymer based press-coated tablets of naproxen were promising delivery for colon targeting.

Formulation and in vitro evaluation of Eudragit S-100 coated naproxen matrix tablets for colon-targeted drug delivery system.

The purpose of the present investigation was to prepare matrix tablets of naproxen using a hydrophobic polymer, i.e., Eudragit RLPO, RSPO, and combination of both, by wet granulation method. The tablets were further coated with different concentrations of Eudragit S-100, a pH-sensitive polymer, by dip immerse method. In vitro drug release studies of tablets were carried out in different dissolution media, i.e., 0.1 N HCl (pH 1.2), phosphate buffers pH 6.8 and 7.4, with or without rat cecal content. The swelling studies of the optimized formulation were carried out. The physicochemical parameters of all the formulations were found to be in compliance with the pharmacopoeial standards. The effect of dissolution medium on the surface of matrix tablet was determined by using Scanning Electron Microscopy technique. The stability studies of all formulations were performed as per ICH guidelines. The results demonstrated that the tablets coated with Eudragit S-100 (2% w/v) showed a sustained release of 94.67% for 24 h, but drug release increased to about 98.60% for 24 h in the presence of rat cecal content while the uncoated tablets released the drug within 5 h. With regard to release kinetics, the data were best fitted with the Higuchi model with non-Fickian drug release kinetics mechanism. The stability studies of tablets showed less degradation during accelerated and room temperature storage conditions for 6 months. The enteric-coated Eudragit S-100 coated matrix tablets of naproxen showed promising site-specific drug delivery in the colon region.

Novel drug delivery approaches on antiviral and antiretroviral agents.

Viruses have the property to replicate very fast in host cell. It can attack any part of host cell. Therefore, the clinical efficacy of antiviral drugs and its bioavailability is more important concern taken into account to treat viral infections. The oral and parenteral routes of drug administration have several shortcomings, however, which could lead to the search for formulating better delivery systems. Now, a day's novel drug delivery systems (NDDS) proved to be a better approach to enhance the effectiveness of the antivirals and improve the patient compliance and decrease the adverse effect. The NDDS have reduced the dosing frequency and shorten the duration of treatment, thus, which could lead the treatment more cost-effective. The development of NDDS for antiviral and antiretroviral therapy aims to deliver the drug devoid of toxicity, with high compatibility and biodegradability, targeting the drug to specific sites for viral infection and in some instances it also avoid the first pass metabolism effect. This article aims to discuss the usefulness of novel delivery approaches of antiviral agents such as niosomes, microspheres, microemulsions, nanoparticles that are used in the treatment of various Herpes viruses and in human immunodeficiency virus (HIV) infections.