Combining non-vascularized fibula and cancellous graft in the masquelet technique: A promising approach to distal femur compound fracture management with large defects.

INTRODUCTION: Compound fractures of the distal femur with large defects pose a significant challenge in management, with several options available, including external fixators, bone grafting, the Masquelet-induced membrane technique, and free vascularized fibular grafts. The Masquelet-induced membrane technique involves placing a cement spacer in the defect to create a biologically active membrane. In the second stage, the gold standard for filling the defect is an autologous cancellous bone graft of 1-2 mm in size. This study aims to examine the effects of using a non-vascularized fibula as a support combined with a cancellous graft in the Masquelet technique for treating compound fractures of the distal femur. METHODS: The study was conducted between December 2017 and December 2020 and included 11 patients who underwent the Masquelet technique. The procedure involved a lateral locked plate and an antibiotic-impregnated bone cement spacer, followed by a 20-30 mm longer ipsilateral fibula used as a strut graft. The remaining area was filled with cancellous bone from the iliac crest. The size of the defect, Time to the bony union, the average range of motion of the knee, and any complications are analysed. The final evaluation was done at 18 months using the Lower Extremity functional scale to assess functional outcomes. RESULTS: The study included 11 patients (8 male and 3 female) with a mean age of 45.8 years. The average time to bony union was 6.6 months, and the average range of motion of the knee was 2.2° to 93.3 ° (0-110 °). No complications such as infection, non-union, or implant failure were observed. CONCLUSION: The Masquelet Technique combined with a fibular strut graft is a feasible solution for complex distal femur fractures with bone loss. The non-vascularized fibula graft provides both structural support and reduces the amount of cancellous bone graft needed, which results in earlier weight bearing and improved functional outcomes.

Adoption of robotics in arthroplasty- a survey of perceptions, utilization and challenges with technology amongst Indian surgeons.

Introduction: Total joint replacement surgeries are standard procedures for managing end-stage hip or knee arthritis. Despite advances in technology, some patients experience dissatisfaction after total knee arthroplasty (TKA). Robotic technology has evolved significantly and has shown promise in improving component positioning, alignment, and surgical outcomes. However, the widespread adoption of robotics in arthroplasty faces challenges such as high costs, a steep learning curve, and limited evidence on long-term outcomes. Methods: This cross-sectional observational study used a structured self-administered online survey to assess the perceptions of Indian arthroplasty surgeons regarding robotic technology. The survey included questions about the surgeon's background, experience, perceptions of robotic joint replacement, and limiting factors for robotic usage. A total of 417 responses were collected from practising arthroplasty surgeons. Results: Most participants(78.1 %) expressed a willingness to adopt robotics in their arthroplasty practice if the cost of installation was reduced. Robotic users were more convinced about the benefits of robotics, including improved alignment, reduced pain, faster rehabilitation, and better outcomes. High-volume robotic surgeons demonstrated a greater belief in the broader potential of robotics beyond implant positioning and alignment. The major barriers to adoption were the high cost of installation and limited insurance coverage for robotic-assisted procedures. Lack of formal robotic training opportunities, resistance from corporate management, patient acceptance issues, and limited published literature supporting robotic advantages were also cited as limiting factors. Conclusion: Robotic technology is increasingly being adopted in India for TKA. The main obstacle to widespread adoption is the high cost of installation. As technology costs decrease, we can expect a rise in the number of installations across the country. Advocacy from national orthopaedic organizations may be needed to address insurance reimbursement challenges. Overall, this study provides valuable insights into the perceptions and challenges associated with the adoption of robotic technology in arthroplasty in India.

Relationship between femoral component placement and patient-specific anatomical rotational landmarks in robotic arm assisted total knee Arthroplasty- a multicentric study.

Introduction: Osteoarthritis of the knee is a common problem in the elderly, leading to severe morbidity. Total Knee Arthroplasty (TKA) is a widely validated surgery to provide a remarkable extent of knee function and simultaneously alleviates pain for knee osteoarthritis (OA). It is clearly understood that precision of the rotational alignment and accuracy of the technique in the placement of the femoral component is a prerequisite for excellent and successful outcomes of TKA. Advanced technology has now allowed surgeons to understand patient-specific variabilities in anatomical reference landmarks and the relationship of component positioning in relation to the reference landmarks to achieve accurate gap balancing with minimal soft tissue release.14 Robotic Arm Assisted-Total Knee Arthroplasty (RAA-TKA) is a semi-automated system that enables us in replicating the same. Using this technology, the bony resections, component positions, probable component sizing and gap balancing can be tentatively planned preoperatively with CT Scan Analysis and executed intraoperatively. Hence this study was undertaken to estimate the relationship between femoral component placement to normal rotational landmarks such as the Posterior Condylar Axis (PCA) and to quantitatively evaluate coronal and sagittal plane correction obtained. Also, we aimed to use the data to detect any anatomical variations in the study population and evaluate the accuracy of predicted component sizing, including gender-based evaluation. Materials and methods: A Prospective Observational Study of 1073 knees of patients of either sex above 50 years of age with Kellgren Lawrence Grade 4 Osteoarthritis of the knee which were confirmed with X-Ray undergoing RAA-TKA using MAKO Robotic System using Stryker Triathlon (Cruciate Substituting) CS Knee was conducted during the period between 2022 and 2023 in two South Indian hospitals specializing in joint replacement surgeries. Results: We found a statistically significant difference between the native Posterior Condylar Axis (PCA) (4.82 ± 2.15°) and final femoral component external rotation (3.24 ± 1.29°) with a p-value of <0.001 at 95% confidence interval. The accuracy of component size prediction was 99.8%. Also, analysis in our study has shown the most common implant sizes to be 4 in males and 2 in females. We also found no statistically significant difference based on age, size, laterality, or primary varus deformity. Conclusions: RAA-TKA provides patient-specific alignment/restricted kinematic alignment which might further enhance the outcome for the patient. Reliable deformity correction in coronal and sagittal planes can be achieved. Accurate flexion and extension gap balancing can be done through component placement and with minimal soft tissue dissection. Irrespective of all the advantages noted in RAA-TKA, further follow-up and long-term outcome studies are required to properly gauge and analyze this new technology.

Corrigendum to "Relative frequency of avascular necrosis of the hip as indication for primary Total Hip Arthroplasty in the USA vs. India" [J. Orthop. 36C (2023) 1-6].

[This corrects the article DOI: 10.1016/j.jor.2022.12.002.].

Is it worth the risk? Frailty transition and complications following robotic total knee arthroplasty: A retrospective observational study.

BACKGROUND: Frailty is an underutilized prognostic parameter in the geriatric population. Our study aimed to analyse the frailty incidence, its transition over 1 year and its influence on complication rate in patients undergoing elective robotic-assisted total knee arthroplasty (TKA). METHODS: This was a retrospective study wherein an accumulation of deficits model was used to evaluate frailty of 435 consecutive patients undergoing primary unilateral Mako-assisted cemented TKA between January 2020 and July 2021. Based upon the preoperative values, participants were divided into three groups; non-frail (FI < 0.11), vulnerable (0.11-0.20) and frail (FI > 0.20) states and were followed up for 1 year for change in frailty class, complications, re-admissions and mortality. RESULTS: A total of 435 patients were divided into three groups, non-frail (178), vulnerable (208) and frail (49). Improvement in mean frailty scores was seen in all three groups (P < 0.0001); 21.63% of the vulnerable and 48.97% of the frail participants improved by one frailty class. Multivariate analysis showed the co-relation of change in frailty index (ΔFI) with preoperative FI (r = 0.083) and Knee Society Score (KSS) (r = 0.742). The frail group had a significantly higher re-admission rate over 1 year. When compared with the vulnerable group, the frail group had a higher hazard ratio for readmission (3.12 vs. 0.96) and complications (1.62 vs. 1.26). CONCLUSION: Although frail individuals are at a higher risk for readmissions and perioperative complications, TKA significantly improves the mobility and frailty status of elderly individuals. With explained higher risk of complications, surgeons should not refrain from offering TKA to elderly frail individuals disabled with knee pain.

Partial versus total knee arthroplasty for isolated antero-medial osteoarthritis - An analysis of PROMs and satisfaction.

AIM: This study aimed to compare the patient-reported functional outcomes and patient satisfaction after medial Unicompartmental Knee Arthroplasty (UKA) versus Total Knee Arthroplasty (TKA), performed for anteromedial osteoarthritis (AMOA) of the knee in patients from an Indian population, at a minimum 3-year follow-up. METHODS: This is a prospective matched cohort study (1:2 ratio). One hundred and one UKA cases were matched to 206 TKA cases by propensity score matching for age, body mass index (BMI), gender distribution, and the Charlson Comorbidity Index (CCI). The primary outcome (Oxford knee score, OKS) was assessed at a 3-year follow-up, along with secondary outcomes (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] Score, Forgotten Joint Score (FJS), Anterior Knee Pain (Kujala) score, patient satisfaction, and revision rate at the final follow-up). RESULTS: The UKA group was superior to the TKA group in patient-reported functional outcomes based on the OKS (p = 0.004). Using the FJS score, UKA was more likely to be a forgotten joint compared to TKA (p < 0.001). However, differences in the OKS and FJS did not meet the reported minimal clinically important difference (MCID) thresholds. Quality of life (EuroQol-5D VAS scale) was found to be significantly higher in the UKA group (p < 0.001). Patients in the UKA group were more likely to be very satisfied (75.2%) versus the TKA group (62.1%, p = 0.023). CONCLUSION: For AMOA, UKA was associated with improved patient satisfaction compared to TKA. Although patient-reported outcome measures were statistically in favour of UKA over TKA, the differences were not clinically significant. Multicenter and randomized studies comparing the two procedures are warranted. EVIDENCE: Level-II Therapeutic.

Relative frequency of avascular necrosis of the hip as indication for primary Total Hip Arthroplasty in the USA vs. India.

Introduction: Background: Primary total hip arthroplasty (THA) is performed for a variety of pathologies. Osteoarthritis (OA) is the most common indication for THA in the United States of America (USA). The study aims to establish the incidence of indications for THA in the USA as compared to India and to assess whether Avascular Necrosis (AVN) of the Hip is a more frequent indication for THA in India than in the USA. Methods: The National Inpatient Sample database (USA) and two Indian databases (one national and one regional) were analyzed to identify all patients who underwent primary THA within the databases. The relative frequencies of each indication for THA were determined. The patients' demographics and risk factors for AVN of the hip were recorded and assessed. The data were then compared across the patients in the USA and the patients in India. Results: 225,061 primary THA patients were identified in the USA database and 20,288 in the Indian database. The proportion of primary THA performed for AVN in the American database (5.97%) was significantly lower than the proportion of THA performed for AVN in the Indian database (51.8%). Conclusion: The relative frequency of AVN as an indication for THA is significantly higher in India than in the USA. It is important to recognize the differences in relative indications for THA between world populations, as outcomes after THA among Eastern populations of the world may not be equivalent to ones seen in their Western counterparts.

Pre-operative planning and templating with 3-D printed models for complex primary and revision total hip arthroplasty.

Background: Complex primary and revision THR requires comprehensive understanding of abnormal bony anatomy. Evaluation and classification of acetabular bone defects is essential to manage them appropriately. It is difficult to appreciate complex defects using conventional 2-Dimensional radiological modalities. 3D printed models can provide both visual and tactile reproduction of the bony anatomy, with potential for better pre-operative planning and making these complex surgeries more precise and accurate. Materials and methods: Anatomical 3D models of pelvis and femur were made based on CT scans of 27 patients undergoing complex primary THR/Revision THR by FDM (Fusion Deposition Modeling) technology using Flash Forge-Dreamer 3D printer with ABS (plastic) material. Models were used for pre-operative planning and simulation of surgery. Aims of the study were to study the accuracy of 3D models in predicting the implant sizes, accuracy in evaluation of acetabular bone defects and validating the utility of 3 D models through surgeon feedback. Results: The acetabular cup size and placement was accurate in 25 (92.6%) patients. Preoperative acetabular bone defect was accurately estimated in all the patients. There were no neurovascular complications at early and 1-year follow-up in this case series. Model realism and reliability survey response from five surgeons was graded, with average overall usefulness of 3D models of 4.86/5, average model realism was 4.9/5, average usefulness for planning was 4.74/5 and usefulness for teaching was 5/5. Conclusion: 3D models are accurate and help in assessing acetabular bone deficiencies reliably in complex and revision THR. Anatomical models help in surgical planning and simulation, enabling surgeons in predicting the correct implant sizes and importantly placement of acetabular cup and for management of bone defects. The safe trajectory of acetabular screws can be simulated and determined, thereby avoiding penetration into pelvis and neuro-vascular injuries.

Continuous adductor canal block is superior to adductor canal block alone or adductor canal block combined with IPACK block (interspace between the popliteal artery and the posterior capsule of knee) in postoperative analgesia and ambulation following total knee arthroplasty: randomized control trial.

BACKGROUND: ACB is given as single injection or as continuous block or combined with IPACK block (interspace between the popliteal artery and the posterior capsule of knee) to reduce postoperative knee pain after total knee arthroplasty. The aim of this study is to evaluate the technique of ACB that is superior in controlling postoperative pain, decrease opioid consumption and facilitate ambulation in the immediate postoperative period. METHODS: A total of 171 patients were analyzed from a group of 180 patients who were randomized into three groups: (1) ACB alone, (2) continuous ACB infusion via catheter (CACB) and (3) ACB combined with IPACK. The primary outcome was pain at rest and after ambulation measured by VAS scale every 8 h till 48 h after surgery. The secondary outcome measures were opioid consumption in morphine equivalents, ambulation distance measured in feet on postoperative day 2, timed up and go test, 30 s chair stand test, sitting active extension lag test and maximal knee flexion at discharge. RESULTS: VAS score at rest and after ambulation, opioid consumption was significantly lower (p < 0.05%) in CACB group compared to other study groups. Similarly, patients in CACB showed significantly (p < 0.05%) better results in the secondary outcome measures. There were no significant differences in the outcomes between ACB and ACB combined with IPACK. CONCLUSION: CACB allows better pain control and less opioid consumption in the immediate postoperative period after TKA compared to ACB alone or ACB with IPACK resulting in better ambulation and rehabilitation. Clinical Trial Registration Number CTRI/2019/03/018239 registered on March 25, 2019.

A comparative study evaluating the role of adductor canal block catheter versus intraarticular analgesic infusion on knee pain and range of motion in the immediate postoperative period: a prospective multicenter trial.

Postoperative pain after total knee arthroplasty (TKA) is an important determinant of hospital stay and rehabilitation and thereby functional outcome. Adductor canal block (ACB) and intraarticular analgesic infiltration through catheters (IAC) are techniques of multimodal analgesia which have shown to control postoperative pain satisfactorily. The aim of this study is to evaluate the efficacy of ACB versus IAC in reducing immediate postoperative pain and thereby allow early rehabilitation. A multicenter quasi-experimental study was conducted on 511 patients undergoing unilateral primary TKA from March 2016 to April 2017 who either received ACB with catheter (Group I, n = 350 patients) or IAC (Group II, n = 172 patients) for postoperative pain control. All the patients were assessed for severity of pain by Visual Analogue Scale at 8, 24, 48, 72 h postoperatively and knee range of motion (ROM) on the day of discharge. There was no significant difference in pain scores on postoperative day (POD) 0 (1.09 ± 0.30 vs. 0.98 ± 0.46, p = 0.45) and POD 1 (1.21 ± 0.45 vs. 1.00 ± 0.00, p = 0.11) and in mean ROM on the day of discharge between ACB and IAC (88.40° ± 7.96° vs. 88.34° ± 5.74°; p = 0.93) groups. This study shows that both ACB and IAC provide satisfactory postoperative analgesia with sparing of quadriceps function and good knee ROM leading to early rehabilitation and reduced hospital with no advantage of one technique over another.

When can I go home after my knee replacement? Factors affecting the duration of in-hospital stay after knee replacement.

BACKGROUND: Despite a sevenfold decline in the number of postoperative nights (21-3) after a total knee arthroplasty (TKA) over the last four decades, predictors of length of stay (LOS) are not fully understood. We attempted to ascertain these factors by analyzing a large cohort of patients. METHODS: Prospectively collected data between January 2016 and March 2017 were retrospectively analyzed at our institute. Charts of 1663 consecutive, simple primary unilateral and bilateral TKAs were reviewed for the LOS excluding staggered bilateral, complex primary and revision knees. STATISTICAL ANALYSIS: Preoperative variables [demographics, cash/credit status, historical, clinical, laboratory findings, Knee Society Function Scores and Oxford Knee Scores (OKSs)] were scrutinized by multivariate regression to identify significant factors affecting LOS and formulate model equations for patients and health caregivers. Results were incorporated into an iOS application, which was tested for accuracy. RESULTS: Among 1524 unilateral and 139 bilateral TKAs, mean LOS was 4.4 and 5.2 days, respectively. Five factors, namely insurance, flexion/hyperextension deformity, preoperative OKS and a rheumatoid etiology, were significantly associated with prolonged LOS in unilateral knees. The impact of these independent variables on LOS could be calculated by: [Formula: see text]For bilateral cases, the only significant variable extending LOS was a low preoperative OKS and the equation is given as follows: [Formula: see text]The iOS-app-predicted LOS and actual LOS were similar (p > 0.05) for 115 prospectively operated knees. CONCLUSION: Poor preoperative OKS, rheumatoid etiology, flexion and hyperextension deformity and delays in insurance affected unilateral TKR LOS, while poor preoperative OKS alone affected LOS in bilateral cases.

Clinical outcomes in periarticular knee fractures with flexible fixation using far cortical locking screws in locking plate: a prospective study.

PURPOSE: Periarticular fractures around the knee joint are treated traditionally by locking plates which provide excellent stability but suppress callus formation. Far cortical locking (FCL) screws allow axial motion and enhance uniform callus formation. Our study aims to evaluate the outcomes of FCL screws in traditional locking plate in periarticular fractures of the knee. METHODS: Thirty patients with periarticular fractures of the knee joint were operated with locking plate using FCL screws. All patients were evaluated clinically and radiographically using X-rays at 6, 12, 24 weeks, 1 year and with CT scan at 12-weeks follow-up. RESULTS: The average time for complete union was 20 weeks in tibial fractures and 24 weeks in femur fractures. Average time to full weight bearing ambulation was 4.8 ± 0.93 weeks. One patient had delayed union in which union was complete after 9 months. CONCLUSION: This study shows that FCL screws in locking plates allow uniform callus formation and fracture union with minimal complication rates.

Efficiency of dual siRNA-mediated gene therapy for intervertebral disc degeneration (IVDD).

BACKGROUND CONTEXT: One of the common causes of low back pain is intervertebral disc degeneration. The pathophysiology of disc degeneration involves apoptosis of nucleus pulposes cells and degradation of extra cellular matrix (ECM). Caspase 3 plays a central role in apoptosis and the ADAMTS5 (A Disintegrin and Metalloproteinase with Thrombospondin motifs 5) gene plays a critical role in ECM degradation. Hence, we hypothesized that if one can silence these two genes, both apoptosis and ECM degradation can be prevented, thereby preventing the progression and even reverse disc degeneration. PURPOSE: The purpose of this study is to demonstrate the regenerative potential of small interfering RNA (siRNA) designed against Caspase 3 and ADAMTS5 genes in an in vitro and animal model of disc degeneration. STUDY DESIGN: In vitro study followed by in vivo study in a rabbit model. METHODS: In vitro studies were done using the human hepatocellular carcinoma (Hep G2) cell line for validating the efficacy of liposomal siRNA in controlling the expression of genes (Caspase 3 and ADAMTS5). Later, siRNA's validation was done in a rabbit annular punctured model by administering siRNA's individually (Caspase 3 and ADAMTS5) and in combination Caspase3-ADAMTS5) for assessing their synergistic effect in down regulating the gene expression in the degenerative discs. Annular punctured intervertebral discs of the rabbit were injected with siRNA formulations (single and dual) and phosphate buffer saline, one week after initial puncture. Magnetic resonance imaging (MRI) scans were done before and after siRNA treatment (1, 4 and 8 weeks) for assessing the progression of disc degeneration. The histopathology and real time polymerase chain reaction (RT-PCR) studies were done for evaluating their efficacy. We did not receive any funding for conducting the study, and we do not have a conflict of interest with any researchers or scientific groups. RESULTS: The observations made from both in vitro and in vivo studies indicate the beneficial effects of siRNA formulation in down regulating the expression of Caspase 3 and ADAMTS5 genes. The MRI and histopathological evaluation showed that the disc degeneration was progressive in phosphate buffer saline and AT5-siRNA injected discs but the discs that received Caspase 3-siRNA and dual siRNA (Cas3-AT5-siRNA) formulation showed signs of recovery and regeneration 4 and 8 weeks after injection. The efficacy of siRNA designed against Cas3 and AT5 was also assessed in both in vitro and in vivo experiments by using RT-PCR analysis and the results showed downregulation of Caspase 3 gene in Caspase 3-siRNA group, but there was no significant downregulation of ADAMTS5 gene in ADAMTS5-siRNA group (ie, indicated by fold change). Synergistic effect was observed in the group that received dual siRNA (Cas3-AT5 siRNA) formulation. CONCLUSIONS: This experiment suggests that intervention by siRNA treatment significantly reduced the extent of apoptosis in the discs. CLINICAL SIGNIFICANCE: Delivery of siRNA directly into spinal discs has a potential in treating disc degeneration nonsurgically.

Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block alone after total knee arthroplasty: a prospective control trial on pain and knee function in immediate postoperative period.

BACKGROUND: Adductor canal block (ACB) is a peripheral nerve blockade technique that provides good pain control in patients undergoing total knee arthroplasty which however does not relieve posterior knee pain. The recent technique of an ultrasound-guided local anesthetic infiltration of the interspace between popliteal artery and the capsule of posterior knee (IPACK) has shown promising results in providing significant posterior knee analgesia without affecting the motor nerves. MATERIALS AND METHODS: A prospective study was conducted from September 2016 to March 2017 in a total of 120 patients undergoing unilateral total knee arthroplasty. The initial 60 consecutive patients received ACB + IPACK (Group 1, n = 60), and the subsequent 60 patients received ACB alone (Group 2, n = 60). All patients were evaluated with VAS score for pain recorded at 8 h, postoperative day (POD) 1 and POD 2 after the surgery. The secondary outcome measures assessed were the range of movement (ROM) and ambulation distance. RESULTS: VAS score showed significantly (p < 0.005) better values in ACB + IPACK group compared to the ACB group. The mean ROM of knee and ambulation distance also showed significantly better values in ACB + IPACK group compared to the ACB group. CONCLUSION: ACB + IPACK is a promising technique that offers improved pain management in the immediate postoperative period without affecting the motor function around the knee joint resulting in better ROM and ambulation compared to ACB alone.

Error Analysis: How Precise is Fused Deposition Modeling in Fabrication of Bone Models in Comparison to the Parent Bones?

BACKGROUND: Rapid prototyping (RP) is used widely in dental and faciomaxillary surgery with anecdotal uses in orthopedics. The purview of RP in orthopedics is vast. However, there is no error analysis reported in the literature on bone models generated using office-based RP. This study evaluates the accuracy of fused deposition modeling (FDM) using standard tessellation language (STL) files and errors generated during the fabrication of bone models. MATERIALS AND METHODS: Nine dry bones were selected and were computed tomography (CT) scanned. STL files were procured from the CT scans and three-dimensional (3D) models of the bones were printed using our in-house FDM based 3D printer using Acrylonitrile Butadiene Styrene (ABS) filament. Measurements were made on the bone and 3D models according to data collection procedures for forensic skeletal material. Statistical analysis was performed to establish interobserver co-relation for measurements on dry bones and the 3D bone models. Statistical analysis was performed using SPSS version 13.0 software to analyze the collected data. RESULTS: The inter-observer reliability was established using intra-class coefficient for both the dry bones and the 3D models. The mean of absolute difference is 0.4 that is very minimal. The 3D models are comparable to the dry bones. CONCLUSIONS: STL file dependent FDM using ABS material produces near-anatomical 3D models. The high 3D accuracy hold a promise in the clinical scenario for preoperative planning, mock surgery, and choice of implants and prostheses, especially in complicated acetabular trauma and complex hip surgeries.

Early quadriceps tendon rupture after primary total knee arthroplasty.

BACKGROUND: Extensor mechanism disruption following total knee arthroplasty (TKA) is a rare complication and results in significant morbidity and severe functional limitations. Quadriceps tendon rupture in the early postoperative period after TKA is one limitation about which there is a significant paucity of available information. METHODS: In this retrospective study of 2404 patients who underwent primary TKA between June 2015 to May 2016, there were 10 quadriceps tendon ruptures in seven patients (three bilateral, four unilateral) presented within 3 months after surgery. The rupture was due to a sudden fall while walking or getting up from a chair. All seven patients presented with haematoma formation around the knee, inability to get up and inability to walk. Diagnosis was confirmed by ultrasonography and managed by exploration and end-to-end tendon repair by suturing. RESULTS: In our study, incidence of quadriceps tendon tear in the early postoperative period (within 3 months) after TKA is 0.29% (seven of 2404). All patients had rupture within 90days of primary TKA; early primary repair was performed in all cases. All patients achieved preoperative range of motion without extension lag or restriction in range of movement within 6 months of repair of the quadriceps tendon. CONCLUSION: Early identification and prompt treatment of quadriceps tendon injury followed by controlled postoperative rehabilitation results in excellent short-term and mid-term outcomes.

The comparative efficacy and safety of topical and intravenous tranexamic acid for reducing perioperative blood loss in Total knee arthroplasty- A randomized controlled non-inferiority trial.

BACKGROUND: Total Knee Arthroplasty (TKA) can be associated with significant perioperative blood loss and blood transfusions. This is a prospective randomised non-inferiority trial comparing intraarticular (IA) and intravenous (IV) routes of administering Tranexamic acid (TXA) with regard to efficacy and safety. METHODS: A total of 113 patients who underwent primary unilateral TKA from January to June 2017 randomly received either 1.5g TXA in 100mL normal saline solution (IA group, n=58) or 10mg/kg TXA (IV group, n=55) at 10min before the tourniquet inflation and at tourniquet release. Haemoglobin (Hb) drop on third day (primary outcome), visible blood loss (VBL), hidden blood loss (HBL), total blood loss (TBL), transfusion requirement, incidence of deep vein thrombosis (DVT), wound complications and renal function derangement (secondary outcomes) were recorded. RESULTS: The mean difference in haemoglobin drop between both groups was 0.25g/dL with 90% CI of -0.07 to 0.58. Since the lower bound of 90% CI was above equivalence margin of -0.35, IA group was found to be non-inferior to IV group in terms of Hb drop. The mean difference between both groups of VBL, HBL and TBL were 0.85mL (p value 0.90), -7.9mL (p value 0.90) and -6.2mL (p value 0.93) respectively. Transfusions and wound complications were statistically insignificant. None of the patients had DVT or renal function derangement. CONCLUSION: IA TXA is not inferior to IV TXA with regard to efficacy and safety and may be preferred considering ease of administration and lack of systemic absorption.

Comparison between Multisite Infiltration Analgesia versus Adductor Canal Block for Pain Management in Total Knee Arthroplasty: A Prospective Study.

BACKGROUND: Severe acute postoperative pain after total knee arthroplasty (TKA) may cause significant morbidity to patients. Recent techniques such as peripheral nerve blocks have shown promising hope in providing appropriate pain control without systemic side effects. Adductor canal block (ACB) and multisite infiltration analgesia (MIA) are two techniques that are proven to be effective individually. AIM: This study aims to compare the efficacy of ACB versus MIA in postoperative analgesia and functional recovery after unilateral knee arthroplasty. SETTINGS AND DESIGN: A prospective study was conducted between July 2016 and December 2016 involving 200 patients undergoing unilateral TKA. MATERIALS AND METHODS: Patients were either administered MIA (Group I, n = 100 patients) or ACB (Group II, n = 100 patients). All the patients were assessed for severity of pain by visual analog scale (VAS) at 8, 24, and 48 h postoperatively and knee range of motion (ROM) at 48 h after surgery. STATISTICAL ANALYSIS: The Statistical Package for the Social Sciences (SPSS 19.0, SPSS Inc., Chicago, IL, USA) was used for descriptive and inferential analysis. RESULTS: Patients who received MIA showed significantly better VAS scores 8, 24, and 48 h after surgery. Furthermore, this subset of patients showed a marginally better ROM postoperatively. However, there was no difference number of patients requiring rescue analgesia for breakthrough pain or technique-related problems between both groups. CONCLUSION: This study demonstrates that MIA is a safe technique that provides effective analgesia at 8, 24, and 48 h postoperatively. This leads to faster rehabilitation compared to ACB in patients undergoing TKA.

Validating the Role of Steroid in Analgesic Cocktail Preparation for Local Infiltration in Total Knee Arthroplasty: A Comparative Study.

BACKGROUND: Pain control after total knee arthroplasty (TKA) through local analgesic cocktail preparation has gained widespread popularity in recent times. Local steroids have potent anti-inflammatory effect leading to reduced postoperative swelling and pain which might increase the efficacy and duration of local infiltration analgesia. AIM: The aim is to evaluate whether the addition of local steroid to an injectable analgesic cocktail for periarticular infiltration leads to better pain control and knee range of motion (ROM) in the immediate postoperative period compared to patients who do not receive steroid in their cocktail. SETTINGS AND DESIGNS: A prospective study was conducted in a group of 140 patients undergoing unilateral TKA between June 2017 and December 2017. MATERIALS AND METHODS: All the patients in the study group received either periarticular infiltration with an analgesic cocktail (Group I, n = 70) or analgesic cocktail with 100 mg methylprednisolone (Group II, n = 70) for postoperative pain with ultrasound-guided adductor canal block (ACB). Patients were evaluated with visual analog scale (VAS) for pain at 8, 24, and 48 h postoperatively and ROM at 48 h after surgery. STATISTICAL ANALYSIS: The SPSS 19.0 software (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Student t-test has been used to find the pairwise significance. RESULTS: Group II had a statistically significant decrease in VAS scores at 8 h (P = 0.096), first postoperative day (P = 0.0001) and second postoperative day (P = 0.0001) as compared to Group I. However, there was no statistically significant difference seen with early ROM in both the groups at 48 h (P < 0.361). CONCLUSION: Patients who received steroid cocktail infiltration plus ACB had an improved and better postoperative analgesia in an early postoperative period of 24-48 h; however, there was no significant difference in clinical ROM and functional outcome when compared to the study group.

A comparative analysis of the role of Tranexamic acid as an independent variable in reducing intraoperative blood loss in patients undergoing conventional total knee arthroplasty versus computer-assisted total knee arthroplasty.

BACKGROUND: Blood loss in total knee arthroplasty (TKA) is an area of significant concern as it has an effect on patient morbidity and hospital stay. Among many different modalities to reduce blood loss, the use of Tranexamic acid has become a standard procedure nowadays. The aim of our study was to determine if Tranexamic acid alone decreases blood loss as an independent variable irrespective of other blood loss preserving measures. METHOD: This prospective non-randomized study included patients undergoing unilateral TKA by conventional method (Group 1) and computer-assisted TKA (Group 2). All the patients in both groups received Tranexamic acid in a dose of 10 mg/kg body weight prior to inflation of tourniquet. Blood loss in both the groups was calculated using Nadler's formula, and haemoglobin (Hb) level was calculated on day one and day three after surgery. RESULTS: The mean drop of Hb in Group 1 was 1.608 and 1.56 g/dl in Group 2 which was statistically significant (p < 0.001); however, none of the patients in either of the groups actually required any blood transfusion postoperatively. Although there was a significant drop in haemoglobin and haematocrit in both the groups, on comparison, there was no significant difference in blood loss and fall in Hb levels between the groups (p > 0.001). CONCLUSION: Tranexamic acid decreases blood loss in patients undergoing TKA independent of all the other blood conserving procedures.