Pulsed lavage is associated with better quality of bone-cement-implant interface in knee arthroplasties (TKA/UKA) compared to syringe lavage in vitro; however, clinical data are missing: A systematic review.

Purpose: The purpose of this systematic review is to analyse the available literature to ascertain the optimal method of bone preparation to improve the quality of bone-cement-implant interface with either pulsed lavage or syringe lavage in both total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA). Methods: A comprehensive search was conducted across MEDLINE, Scopus and Embase databases until July 2023. Both inclusion and exclusion criteria were clearly stated and used to identify all the published studies. Subsequent screening throughout the title, abstract and full text was made, followed by complete critical appraisal and data extraction. This sequential process was performed by two reviewers independently and summarised following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines). A quality assessment of the systematic review was performed according to the Quality Appraisal for Cadaveric Studies scale (QUACS), reaching a quality level ranging from 69% to 85%. Results: A total of 10 articles, out of 47, nine biomechanical cadaveric studies and one human clinical study were analysed. A total of 196 UKA tibial components, 74 patellar components, 36 TKA tibial components and 24 UKA femoral components were retrieved, and a high level of heterogeneity resulted overall. The pulsed lavage group showed better cement penetration and higher pull-out force than the syringe lavage group; a higher interface temperature was also found in the pulsed lavage group. No differences were found regarding tension ligament forces between the groups. Conclusion: Our systematic review suggests that pulsed lavage is superior to syringe lavage in terms of the quality of bone-cement-implant interface in knee arthroplasties (TKA/UKA). However, translation of these results from cadaveric studies to individual clinical settings may be hazardous; therefore, clinical in vivo prospective studies are highly needed. PROSPERO CRD: PROSPERO CRD number CRD42023432399. Level of Evidence: Level III.

Revision ACL reconstruction in female athletes: current concepts.

The challenge of revision anterior cruciate ligament (ACL) reconstruction lies in its complexity, varied presentation, and technical intricacies. A successful ACL reconstruction should allow patients to safely return to preinjury activities. However, it is only sometimes simple, and many risk factors and concurrent pathologies come into play. Evaluating and analysing the cause of failure and associated conditions is paramount to addressing them effectively. Despite a plethora of research and improvements in knowledge and technology, e gaps exist in issues such as optimal techniques of revision surgery, graft options, fixation, concurrent procedures, rehabilitation and protocol for return to sports of high-level athletes. Female athletes need additional focus since they are at higher risk of re-injury, suboptimal clinical outcomes, and lower rates of return to sport following revision reconstruction. Our understanding about injury prevention and the protection of ACL grafts in female athletes needs to be improved. This review focuses on the current state of revision ACL surgery in female athletes and provides recommendations and future directions for optimising outcomes in this high-risk group.

Hamstring graft diameter above 7 mm has a lower risk of failure following anterior cruciate ligament reconstruction.

PURPOSE: Multi-stranded hamstring-tendon autografts have been widely used for anterior cruciate ligament reconstruction (ACLR) surgeries. Recently, smaller diameter hamstring autografts have been linked with the risk of failure or graft rupture. However, there is limited evidence concerning the optimal diameter of the hamstring autografts for ACLR. The current systematic review and meta-analysis analysed the association of ACLR failure with the diameter of hamstring autografts. METHODS: A systematic search of three major scientific databases (Pubmed, EMBASE, and Cochrane library) was conducted to identify studies that presented ACLR failure-related outcomes with different diameters of hamstring autografts. The pooled data from the included studies were analysed to investigate the association between ACLR failure and the cut-off diameters of 6, 7, 8, and 9 mm. Subgroup analyses based on the level of evidence and follow-up duration were also performed at each cut-off diameter. RESULTS: Of the 2282 studies screened, 16 reported failure rates with hamstring autografts of different diameters, 15 of which were included in the meta-analysis. A graft diameter ≥ 7 mm was associated with significantly lower ACLR failure rates than a graft diameter < 7 mm (p = 0.005), based on pooled data of 19,799 cases. Age < 20 years and higher physical activity were associated with significantly higher ACLR failure rates. CONCLUSION: The current systematic review suggests that the hamstring graft diameter for ACLR should be more than 7 mm considering the significantly higher failure rates with graft diameters less than 7 mm. LEVEL OF EVIDENCE: Level IV.

An Unexpected Intra-operative Encounter of Anterior Tibial Vessels Entrapment in the Fracture of Tibial Pilon: A Case Report and Literature Review.

We present a rare case of a comminuted tibial pilon fracture with entrapment of anterior tibial vessels in fracture site, which was unexpectedly discovered intra-operatively. Following safe extrication of vessels and fracture fixation through minimally invasive approach, the patient recovered uneventfully. Phenomenon of anterior neurovascular entrapment should be kept in mind while dealing with high-energy tibial pilon fractures. Astute clinical examination, judicious use of imaging modality, and strict intra-operative vigilance are key to successful outcome.

Modified radiographic views to prevent the anterosuperior and posterosuperior bony violation during screw fixation of femoral neck fractures.

INTRODUCTION: The standard anteroposterior and lateral fluoroscopic projections used during femoral neck fracture fixation provide a two-dimensional representation of the cephalocaudal and anteroposterior extents of the femoral neck. The radiographic representation differs from the actual extent of the femoral neck. The anterosuperior (AS) and posterosuperior (PS) surfaces of the femoral neck are at risk of bony breach by the fixation screws and that may get easily missed with standard fluoroscopic views. The current study aims at investigating the special fluoroscopy views, based on the orientation of the AS and PS surface of the femoral neck, that can help in the safe placement of screws near these surfaces without bony breach. METHOD: A computed tomography-based analysis of fifty intact proximal femora was performed. The longitudinal axis of the proximal femoral shaft and the center of the femoral head were aligned along a common horizontal plane. The cephalocaudally constricted zone of the femoral neck was identified along its axis. The surface inclinations of the AS surface and the PS surface at the constricted zone of the femoral neck were measured in relation to the horizontal plane. The mean, standard deviation, overall range, interquartile ranges and gender-based variation of each of the two surface inclinations were measured. RESULTS: The mean surface inclinations of the AS surface and the PS surface with reference to the horizontal plane were 55° ± 7.76° and 123.32° ± 7.88°, respectively. There were no significant side to side and male to female differences. CONCLUSIONS: The modified radiographic views based on the surface inclinations of the AS and the PS surfaces can help in the localization of the critical zones of these surfaces which are at risk of bony breach with screw placement close to the surface. A prior fluoroscopic evaluation of these surfaces before guidewire placement can help in preventing the surface violation.

An unusual pattern of posterior wall fracture of acetabulum.

BACKGROUND: This study aims to describe an uncommon presentation of posterior wall acetabular fracture-dislocation with displacement of fracture fragment anterior to femoral head with its management and clinico-radiological outcome. METHODS: This retrospective review was performed at a Level I trauma centre over a period of six years. Hospital records, radiological database, operative register and follow-up data identified 7 patients with anteriorly lying posterior wall fragment of acetabulum. Analysis was performed with 6 patients having complete follow-up ranging from 2 to 7 years. The patients were operated with standard Kocher-Langenbeck approach; modification of this approach with trochanteric flip osteotomy and safe surgical dislocation was performed based on the location of the anteriorly lying fragment. Final functional and radiographic outcome was analysed according to modified Merle D'Aubigné and Postel score, and Matta's grade, respectively. RESULTS: This uncommon presentation was observed in 11.11% of patients out of 63 patients with isolated posterior wall acetabular fractures managed during the study period. Anteriorly displaced posterior wall fragment was located in anterosuperior (n, 3), anterocentral (n, 2) and anteroinferior (n, 1) quadrants anterior to the femoral head. Final clinical and radiographic outcome revealed good-to-excellent outcome in 5 (83.33%) patients, and poor in one. One patient developed progressive arthrosis of hip which required total hip arthroplasty within 2 years. CONCLUSION: This unusual pattern of posterior wall fracture requires adequate pre-operative planning, careful handling of the fractured fragments along with its soft tissue attachments during surgery, and preferably a concomitant trochanteric flip osteotomy with/without surgical hip dislocation to achieve good results.

Radiographic Quantification of Safe Zones for Screw Placement in the Femoral Neck: A Computed Tomography-Based Analysis.

OBJECTIVES: The purpose of this study is to design a radiographic map of the femoral neck showing proportion-based locations of the safe zones for screw placement with widest bony extents in anteroposterior and lateral radiographs using normal computed tomography-based data. METHODS: We analyzed computed tomography-based studies of 50 intact normal proximal femora equally from male and female subjects. Using software-developed radiographs, the proportionate locations of the maximal anteroposterior and cephalocaudal extents in both constricted zones were measured. The width of the femoral neck in the measurement zone was taken as the reference for calculation of proportions. RESULTS: For anteroposterior radiographs, the anteroposterior safe zones in the femoral neck are located at the gradients of 34.21% and 34.33% from the superior border in midcervical and basicervical regions, respectively. In lateral radiographs, they correlate with the visible anterior extent of femoral neck and lie at a gradient of 7.16% and 11.79% from the visible posterior border in midcervical and basicervical regions, respectively. In lateral radiographs, the calcar-based cephalocaudal safe zone was located at the gradients of 43.49% and 39.53% from the visible posterior border in midcervical and basicervical regions, respectively. In anteroposterior radiographs, cephalic limit of the calcar-based safe zone is located at the gradients of 9.63% and 17.82% from the superior border in midcervical and basicervical regions, respectively. CONCLUSIONS: Radiographic margins cannot be reliably trusted for screw fixation of femoral neck fractures. The proportionate locations of the anteroposterior and calcar-based cephalocaudal safe zones with widest bone stock in anteroposterior and lateral fluoroscopic projections can help in the safe placement of screws for fixation of femoral neck fractures.

Is mini-open intramedullary nailing an effective intervention for adult femoral diaphyseal fractures in odd hours? A prospective case-control functional outcome and radiation safety study.

BACKGROUND: Closed intramedullary (IM) nailing among various modalities is one of the commonest sought out procedure in current practice for management of femoral-diaphyseal fractures (FDF) following trauma. However, it has some limitations like prolonged procedural duration, high radiation exposure and a steep learning curve. Therefore, with limited resources in odd hours and at a high patient turnover center where closed reduction can be a challenge, we adopted a modified mini-open technique which can overcome the limitations of closed reduction technique. PURPOSE: To compare the closed IM nailing and mini-open technique in FDF in terms of radiation exposure, surgical duration, radiological and functional outcome. PATIENTS AND METHODS: A total of 100 patients (118 femurs) with FDF (AO 32A1-B2) operated in odd-hours (20:00-06:00 hrs. GMT +5.30) with closed (Group I, n=62) or mini-open (Group II, n=56) IM nailing technique between September 2018 to December 2019 with a minimum follow up of 12 months were included in this study. The functional outcomes were measured using Thoresen scoring system and statistical analysis were performed using paired t-test and χ2 -test. RESULTS: The overall mean patient age was 33.5 years (18-74 years). The mean surgical duration, c-arm shoots for reduction and radiological union time were 71.5 minutes, 21 shoots and 16 weeks, respectively for group I and 47.5 minutes, 9.4 shoots and 18 weeks for group II. There was significant difference between the two groups in mean surgical duration (p<0.05) and c-arm shoots (p<0.05). However, there was no statistical significant difference between time for union, rate of union, functional results and incidence of superficial or deep infection between the two groups. CONCLUSION: In conclusion, mini-open technique is a safer alternative in patients with FDF at high-volume centers and in odd-hours when the available resources are limited.

Prospective Evaluation of Outcome of Acetabular Fractures Managed by Anterior Intrapelvic Approach.

INTRODUCTION: Anterior Intrapelvic (AIP) approach has emerged, in the last two decades, as a promising approach for fixation of anterior acetabular fractures. This prospective study was conducted to analyze our results with this approach and suggest the indications for its rationale usages in a developing country. MATERIALS AND METHODS: All patients with acetabular fractures, which required anterior fixation, were operated by AIP approach and prospectively evaluated between October 2013 and January 2018. Mechanism of injury, fracture type, operative time, blood loss, complications, radiographic, and functional outcomes were analyzed in all patients. Modified Merle D'Aubigne system was used for clinical grading, while Matta's grading was utilized for radiographic outcome. RESULTS: Fifty eight [90.62%] patients out of the total 64 patients had good to excellent outcome on functional and radiographic results. About 93.75% patients were able to resume pre-injury activities including socially demanding tasks like ability to sit cross legged and squat. Patients operated early had better articular reductions as compared to those operated late. CONCLUSIONS: This approach can be considered as a safe, effective and feasible alternative to traditional ilioinguinal approach for acetabulum fractures which require anterior approach. Cases which present late may have difficulty through this approach as scarring or granulation tissue may lead to inadequate visualization.

Effect of Time Lag from Injury to Surgery on the Temporal Expression of Growth Factors After Intramedullary Nailing of Isolated Fracture of Femur Shaft.

BACKGROUND: Growth factors are considered to play an important role in the process of bone healing. This study assessed serum levels of transforming growth factor-ß1 (TGF-ß1) and vascular endothelial growth factor (VEGF) in patients undergoing intramedullary nailing for isolated fracture of femur shaft operated at various time lag from injury. PATIENTS AND METHODS: All patients between 18 and 60 years of age group operated for isolated femoral shaft fractures (AO/OTA32 A, B, C) were included. The serum levels of VEGF and TGF-ß1 were compared at various intervals amongst the study group divided into two groups based on the time lag between injury and surgery along with a health control cohort. RESULTS: 31 patients were operated within the first 48 h while 28 patients were operated within 2-12 days after injury. Highest VEGF levels were observed on postop day 3, followed by a subsequent decline thereafter. TGF-ß1 level also showed increasing trend after surgery, but the levels reached dual peaks after 2 weeks and 12 weeks after surgery. Both groups revealed similar trends of temporal expression of serum VEGF and TGF-ß1. There was no statistical difference between the two groups at any point of time during the observation period. There was also no statistical difference in clinico-radiological healing of fractures among the groups. CONCLUSION: There is a definite and specific trend of serum levels of growth factors in the fracture healing process. There is no effect of time lag from injury to surgery on the healing outcome of isolated femoral shaft fractures both at the molecular level and also at the clinical level.

Reliability of relation between greater trochanter and center of rotation of femoral head in Indian population.

PURPOSE: Accurate limb length restoration forms an important aspect of reconstructive surgeries around the hip joint. Among the various intraoperative methods for accurate limb length restoration, the relation between the greater trochanter and the center of the femoral head has been conventionally used owing to its simplicity and replicability. The current study aims to study the normal relation between the greater trochanter and the center of rotation of the femoral head, its population-based variation and its gender-based and contralateral differences in the Indian population. METHODS: Standard anteroposterior radiographs of normal hip joints with the proximal femur, performed over a one year period were studied. A software-based analysis was conducted to measure the difference between the levels of the greater trochanteric tip and the center of the femoral head along the longitudinal axis of the femur. The measurements among the male and female cases and the contralateral sides were compared. RESULTS: The greater trochanteric tip lies at a higher level than the center of rotation of the femoral head by a mean difference of 9.20 ± 5.30 mm. No significant differences were observed among male and female groups and between the contralateral hip joints. Intraobserver and Interobserver reliability were high. CONCLUSIONS: The tip of the greater trochanter and the center of the femoral head do not lie at the same level. This differential relation should be considered during the reconstructive surgeries around the hip joint to prevent an inadvertent limb length discrepancy. Considering the wide interindividual variations, this difference cannot be generalized for all the patients and restoring it to the contralateral normal hip would be more appropriate.

Overt metabolic bone failure as the initial manifestation of neglected primary hyperparathyroidism: An unusual presentation and review of current practice guidelines.

Varied symptomatology exists in hyperparathyroidism. The current approaches and evaluation of altered calcium homeostasis have led to the practice of early identification and subsequent management of the adenomas. Hence, bony manifestations (deformities, lesions, and fractures) termed to be end stage of bone metabolism failure, have rarely been encountered in the last two decades. We report this infrequent presentation in a 47-year-old female, who visited the emergency department following a trivial fall. Her background history recorded left superior parathyroidectomy three months prior to fall. The clinical and radiological evaluations were suggestive of insufficiency fractures of right proximal humerus and right shaft of femur, multiple lytic lesions and other bony manifestations pathognomonic of hyperparathyroidism. Metabolic profile revealed a primary cause despite prior adenectomy, and targeted scintigraphy demonstrated a hyper-functioning right inferior parathyroid gland. The high resolution ultrasound used before the prior surgery failed to localise additional hyper-functioning glands. Post-parathyroidectomy, the hungry bone disease was adequately managed. The femur fracture required surgical stabilization. In conclusion, bony manifestations of hyperparathyroidism can be disabling and difficult to treat. Although a rare clinical presentation, the severity of bony manifestations arise from a preventable cause and that the initial evaluation of hyperparathyroidism should also include parathyroid scintigraphy, and not limited to screening of the neck with ultrasonography, for its combined additive information and improved diagnostic value.

Misery of Orthopaedic Surgeon: Delayed Diagnosis of Pseudoaneurysm of Profunda Femoris Artery Following Fixation of Intertrochanteric Femoral Fracture: A Case Report and Review of Literature.

INTRODUCTION: Pseudoaneurysm of profunda femoris artery is an uncommonly reported vascular mishap after orthopedic procedures around proximal femur. Diagnostic dilemma and resulting delay are quite common due to varied clinical presentations. CASE PRESENTATION: Herein, we report a case of a 65-year-old lady who was diagnosed in our institution with pseudoaneurysm of profunda femoris artery 3 months after getting operated for intertrochanteric fracture of right femur in a private hospital. She started having gradually enlarging painful thigh swelling of the involved limb 1 month after operation. She also developed concurrent weakness, anemia, and received multiple blood transfusions before being referred to our institution. Diagnosis was clinched with duplex ultrasound imaging and subsequent digital subtraction angiography with coil embolization was performed. She made an uneventful and speedy recovery, and doing well till the last follow-up. CONCLUSION: Timely diagnosis is paramount to avoid limb- and life-threatening sequelae; surgeons should keep strong vigil to administer the timely intervention. Various preventive strategies during fixation of intertrochanteric fracture should be deployed to keep this untoward entity in abeyance.

Orthopedic Surgeons' Nightmare: Rare Case of Retained Gauze Piece after Wrist Surgery Masquerading as Soft-Tissue Tumor.

INTRODUCTION: Retention of cotton-based gauze or sponge in surgical field, variously called as gauzoma, gossypiboma, textiloma, and muslinoma, is an unexpected and untoward human error that carries sinister consequences for patients and surgeons. Although reported at various surgical sites, no such case has been reported so far in upper limb after wrist surgery. CASE REPORT: Here, we present a case of gauzoma in a 24-year-old male who was operated for his right side distal radius fracture at a private hospital. He noticed gradually increasing swelling in his forearm 6 months after operation which persisted after the removal of implant. Initial cytological evaluation suspected soft-tissue tumor and he was referred to our hospital for further management. Plain radiographic, sonographic, and magnetic resonance imaging findings could not ascertain the pathology conclusively. Surgical exploration revealed retained gauze piece surrounded by granulation tissues and membrane. Histopathological examination confirmed gauze piece with necrosis and surrounding inflammation. The patient recovered uneventfully and has had no recurrence till final follow-up. CONCLUSION: Despite uncommon condition at uncommon site, one should always have a strong suspicion of this entity at previous surgical site since it has a varied clinical and radiologic presentation. Strong vigil, strict adherence to surgical safety protocol is paramount to evade this orthopedic surgeons' nightmare.