The Modified PROMT Score: A Better Prognosticative Tool to Assess Traumatic Meniscal Tear Reparability.

Background: Considering various factors that influence meniscal repairability, Ortho One PROMT score (OPS) was proposed in 2019. With an increased understanding of factors influencing meniscal repair and by analysis of OPS predictions and repair results, a modified PROMT score (MPS) has been formulated. The objective of this study is to assess the superiority of MPS over OPS. Methods: Age, chronicity, and pattern of tears were found to be important contributors to false-negative results of OPS. Considering these factors, MPS was designed. A prospective, double-blinded study was conducted between November 2020 and May 2021. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value, and accuracy of both scores were calculated. Receiver Operating Characteristic (ROC) curve was plotted. Results: Of 133 meniscal tears, 100 met the inclusion criteria. In predicting meniscal repairability, OPS demonstrated sensitivity and specificity of 90.32% and 83.33% medially and 64.71% and 79.41% laterally. MPS had sensitivity and specificity of 96.77% and 88.89% medially and 82.35% and 88.24% laterally. Both scores showed good statistical significance (p < 0.05) in predicting meniscal reparability. For medial meniscus repairability, area under the ROC curve was 0.868 for OPS and 0.928 for MPS. For lateral repairability, the area under the curve was 0.721 for OPS and 0.853 for MPS. Conclusion: MPS will serve as a simple and more effective tool for surgeons to predict meniscal repairability, thus enhancing their pre-surgical preparedness. This tool will also help surgeons to realistically counsel their patients and to achieve optimal patient.

A new scoring system for prediction of meniscal repair in traumatic meniscal tears.

PURPOSE: Traditionally, MRI has not been used to predict meniscus tear reparability. An attempt has been made in this study to predict meniscal reparability using MRI, and a new scoring system to help with the same has been developed and tested. METHODS: Thirty repaired menisci were compared with equal number of meniscectomy cases retrospectively. Various clinical and radiological (radiographs and MRI) characteristics like chronicity of tear, pattern of tear, etc, were tabulated. Based on their association with the outcome of repair or meniscectomy, odds ratio of each attribute were calculated. A scoring system-Ortho One PROMT Score (Prediction of Reparability of Meniscal Tears)-to predict meniscal repair was formulated. Using this score, meniscus surgery outcomes were prospectively predicted in 120 cases and results tabulated. RESULTS: The newly devised Ortho One PROMT score predicted medial meniscus repair with a sensitivity of 90.9% and a specificity of 93.2% and medial meniscectomy with a sensitivity of 93.2% and a specificity of 90.9%. It predicts lateral meniscus repair with a sensitivity of 69.2% of patients and lateral meniscectomy with a sensitivity of 78.8% of patients. CONCLUSION: Ortho One PROMT score is a useful scoring system to predict the outcomes of meniscus surgery preoperatively. It uses a combination of clinical and radiological (MRI and plain radiograph) characteristics. With this scoring system, both the surgeon and the patient are better prepared preoperatively regarding the outcome of a particular meniscus surgery. The scoring shall make day-to-day arthroscopic meniscus surgery less stressful. LEVEL OF EVIDENCE: III.

Arthroscopic Excision of Osteoid Osteoma of the Femoral Neck.

Osteoid osteoma (OO) is a benign, solitary bone tumor of the long bones of the lower limbs and accounts for 10% to 12% of all benign bone. However, an OO of the femoral neck is extremely rare and difficult to treat. Arthroscopic excision of OO of the femoral neck has many advantages. We report a 15-year-old patient with OO of the femoral neck which was treated with arthroscopic excision. The clinical and radiographic findings along with the surgical management of the lesion are presented. The pain disappeared immediately after the operation. At the 14 months' followup, the patient was pain free, and there was no evidence of recurrence.

Functional outcome of an early anterior cruciate ligament reconstruction in comparison to delayed: Are we waiting in vain?

BACKGROUND: Surgical techniques of ACL reconstruction (ACLR) have evolved over the past three decades along with debate regarding timing of reconstruction. It was a widespread belief that the timing of surgery was an important factor in determining the resulting stiffness after ACLR. Delayed rather than early reconstruction of the ACL is the current recommended treatment since it is thought to give a better functional outcome. However, there is no consensus in the literature regarding the optimal time of surgical intervention. The purpose of this study was to compare the range of motion and functional outcome in patients who underwent ACLR early with those that were delayed. MATERIALS AND METHODS: The patients were randomized into two groups; patients who underwent the procedure within three weeks were kept in Group I (Early) and those patients who were reconstructed after six weeks were categorized as Group II (Delayed). Hamstring grafts were used and a standard protocol of surgery and physiotherapy was followed. The range of motion, IKDC and Tegner scores were compared. RESULTS: A hundred and four patients underwent ACLR; fifty-three patients were grouped as Group I (Early) and fifty one as Group II (Delayed). The range of motion of both groups was comparable. The IKDC and Tegner scores were also comparable for early (Group I) ACLR and the patients who had their ACL reconstructed after a delay of at least 6 weeks (Group II). CONCLUSION: There are no clinical differences in terms of range of motion and functional results between early and delayed ACLR.

Outcome of arthroscopic subscapularis tendon repair: Are the results improving with improved techniques and equipment?: A retrospective case series.

BACKGROUND: Rotator cuff tears are a common cause of shoulder pain and dysfunction. More recently, there has been a renewed interest in understanding the subscapularis tears. There are multiple articles in the literature showing the short term results of isolated subscapularis tendon repair. However, the midterm and long term outcome studies for arthroscopic subscapularis repair are few. This study evaluates the functional outcome after arthroscopic subscapularis repair. MATERIALS AND METHODS: The records of 35 patients who underwent an arthroscopic subscapularis repair between May 2008 and June 2012 were included in this retrospective study. The records of all patients were reviewed. There were 22 males and 13 female patients with mean age of 58.2 years (range 41-72 years). All patients had a complete history, physical examination, and radiographs of their shoulders. Visual analogue scale (VAS), range of movements, power of cuff muscles, and modified University of California at Los Angeles (UCLA) score were assessed. RESULTS: The mean followup was 2.8 years (range 2-4 year). Functional outcome after arthroscopic subscapularis repair has an excellent outcome as analysed by clinical outcome, VAS score and UCLA score. Results were analyzed and had statistically significant values. The VAS for pain improved significantly (P < 0.001), and the mean modified UCLA score improved significantly (P < 0.001) from 14.24 ± 4.72 preoperatively to 33.15 ± 2.29 at 2 years postoperative. According to the UCLA system, there were 22 excellent, 11 good, and 2 fair results. Around 95% of patients returned to their usual work after surgery. CONCLUSION: At a median followup of 2 years, 95% of patients had a good to excellent result after an arthroscopic subscapularis tendon repair. We conclude that the midterm results show that arthroscopic subscapularis repair remains a good option for the treatment of patients with subscapularis tendon repair.

Long-term follow up of single-stage anterior cruciate ligament reconstruction and high tibial osteotomy and its relation with posterior tibial slope.

BACKGROUND: Open-wedge high tibial osteotomy is considered to be an effective treatment for medial compartmental osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. Young patients with anterior cruciate ligament (ACL) deficiency along with medial compartment osteoarthritis need a combined procedure of ACL reconstruction along with high tibial osteotomy to regain physiological knee kinematics and to avoid chondral damage. MATERIALS AND METHODS: We retrospectively analysed data from 30 patients who underwent arthroscopic ACL reconstruction along with medial opening-wedge osteotomy from Jan 2004 to June 2012 with a minimum follow up of 2 years. The pre-operative and post-operative posterior tibial slopes were measured. Functional outcome was analysed using clinico-radiological criteria, IKDC scoring and Lysholm score. RESULTS: Post-operative patients improved both clinically and functionally. The patients who had posterior tibial slope >5° decrease, compared to patients who had less <5° decrease, had better functional scores (IKDC and Lysholm score), which was statistically significant (p < 0.05). CONCLUSION: Our study has shown that decreasing the tibial slope >5° compared to pre-operative value has functionally favourable effect on the reconstructed ACL graft and outcome. It is known that increasing slope causes an anterior shift in tibial resting position that is accentuated under axial loads. This suggests that decreasing tibial slope may be protective in an ACL deficient knee. Hence by placing the tricortical graft posterior to midline in the opening wedge reduces the posterior tibial slope and thereby reduces the stress on the graft leading to better functional outcome.

In vitro comparison of resistance to implant failure in unstable trochanteric fractures fixed with intramedullary single screw versus double screw device.

BACKGROUND: The purpose of this study was to compare the resistance of intramedullary single screw device (Gamma nail) and double screw device proximal femoral nail (PFN) in unstable trochanteric fractures in terms of the number of cycles sustained, subsidence and implant failure in an axial loading test in cadaveric femora. MATERIALS AND METHODS: The study was conducted on 18 dry cadaveric femoral specimens, 9 of these were implanted with a Gamma nail and 9 with PFN. There was no significant difference found in average dual energy X-ray absorptiometry value between both groups. The construct was made unstable (AO type 31A3.3) by removing a standard sized posteromedial wedge. These were tested on a cyclic physiological loading machine at 1 cycle/s with a load of 200 kg. The test was observed for 50,000 loading cycles or until implant failure, whichever occurred earlier. Peak displacements were measured and analysis was done to determine construct stiffness and gap micromotion in axial loading. RESULT: It was observed that there was statistically significant difference in terms of displacement at the fracture gap and overall construct stiffness of specimens of both groups. PFN construct group showed a mean subsidence of 1.02 mm and Gamma nail construct group showed mean subsidence of 2.36 mm after cycling. The average stiffness of Gamma nail group was 62.8 ± 8.4 N/mm which was significantly lower than average stiffness of the PFN group (80.4 ± 5.9 N/mm) (P = 0.03). In fatigue testing, 1 out of 9 PFN bone construct failed, while 5 of 9 Gamma nail bone construct failed. CONCLUSION: When considering micromotion (subsidence) and incidence of implant/screw failure, double screw device (PFN) had statistically significant lower micromotion across the fracture gap with axial compression and lower incidence of implant failure. Hence, double screw device (PFN) construct had higher stability compared to single screw device (GN) in an unstable trochanteric fracture femur model.

Outcomes and complications of fractures of distal radius (AO type B and C): volar plating versus nonoperative treatment.

OBJECTIVES: Management of AO type B and C fractures of the distal radius is controversial. This study compares outcomes and complications of AO type B and C fractures of the distal radius treated with volar locked plating and nonoperative methods. MATERIALS AND METHODS: Sixty-four patients with fractures of the distal radius (AO type B and C) were included in this study, according to inclusion criteria, and were allocated to the volar plating group or nonoperative group by alternate randomization: 32 patients with odd numbers went into the nonoperative group and the other 32 with even numbers went into the volar plating group. Patients in the nonoperative group were managed with closed reduction of the fracture and plaster cast application under an image intensifier. Those in the volar plating group were managed by open reduction and fixation with a volar locked plate. Preoperative and postoperative serial clinico-radiological follow-up was done. The range of movement, grip strength, functional outcome scores and radiological parameters were compared. Student's t-test was used for statistical analysis with significance at p < 0.05. RESULTS: Range of movement and functional scores were significantly (p < 0.001) better in the volar plating group, but the difference in ulnar variance and radial and ulnar deviation was insignificant as compared to the nonoperative group. At 24 months follow-up, the nonoperative group had significantly more cases with malunion, articular incongruity and osteoarthritis. CONCLUSION: In cases of AO type B or C fractures of the distal radius, volar locked plating provides anatomical stable fixation and early mobilization with better clinico-radiological outcome as compared to conservative treatment.

Role of tricalcium phosphate implant in bridging the large osteoperiosteal gaps in rabbits.

Treatment options for large osteoperiosteal defects are limited and that which are available are not ideal. Osteoperiosteal defect were created in ulnae of both forelimbs of rabbits and tricalcium phosphate implant was used to bridge the gap. Amongst the 35 implanted ulnae, one implant got dislodged. Rest of the implants showed good adherence to host bone until the final follow up. Five control rabbit limbs (in which no implants were put) showed persistent bone gap. Histological and Electron microscopic examination revealed bone tissues covering the surface of the implant and bridging the gap. New bone was formed in the pores also. Tricalcium phosphate implants showed new bone formation due to osteoconductive properties. They are biodegradable. It is suggested that tricalcium phosphate implants are viable treatment alternatives in management of large osteoperiosteal defects with minimal to no adverse effects.

Role of autologous chondrocyte transplantation in articular cartilage defects: An experimental study.

INTRODUCTION: Injuries of articular cartilage (AC) have very limited potential to heal, because they are avascular and this may subsequently lead to secondary arthrosis. Autologous cultured chondrocytes transplantation is can be used to create hyaline or hyaline-like repair in a cartilage defect area. The purpose of this study was to repair artificially created full-thickness AC defects in 20 rabbit knee joints with autologous cultured chondrocytes. MATERIALS AND METHODS: An AC defect of 3 mm was created on the lateral condyle of both tibiae. The defect was filled with autologous chondrocytes cultured in vitro and fixed with fibrin, at a later stage on the left side. The right knee acted as a control. The rabbits were sacrificed after 3, 6, and 12 weeks of transplantation and the reparative tissues were analyzed macroscopically and histologically. RESULTS: Histological scores of the cultured autologous chondrocyte transplanted knees were significantly better than the control knees at 3, 6, and 12 weeks following the transplantation. Integration of repaired tissue with adjacent cartilage, hyaline characteristics of repaired tissue, maturity of cartilage, and cellularity increases with duration and is significant in chondrocytes-transplanted defects compared to control. The histological scores also become better with increasing duration of followup. CONCLUSION: Transplantation of autologous chondrocytes cultured in vitro and fixed with fibrin is effective in repairing AC defects.

Basic research: Issues with animal experimentations.

In vivo studies using the animals are helpful in developing the treatment strategies as they are important link between the successful in vitro testing and safe human use. Various research projects in the field of fixation of fractures, development of newer biomaterials, chemotherapeutic drugs, use of stem cells in nonunion of fractures and cartilage defects etc., have hugely depended on animal experimentation. The employment of animals in experiments is both scientific and ethical issue. There must be reasonable reasons to show that it will significantly advance the present knowledge and lead to improvement in care. The regulatory bodies exist for humane use and care of animals used for experiments e.g., International Council for Laboratory Animal Science, Council for International Organizations of Medical Sciences, International Union of Biological Sciences, International Committee on Laboratory Animals. In India, Indian National Science Academy, Indian Council of Medical Research, National Centre for Laboratory Animal Sciences promote high standards of laboratory animal quality, care and health. The Committee for the Purpose of Control and Supervision on Experiments on Animals guidelines are well defined and is a must read document for any one interested to carry out research with animal facilities.

Evaluation of role of anterior debridement and decompression of spinal cord and instrumentation in treatment of tubercular spondylitis.

STUDY DESIGN: Prospective study with simple randomization. PURPOSE: To evaluate the results of anterior spinal instrumentation, debridement and decompression of cord and compare it with results of a similar procedure done without the use of anterior instrumentation. OVERVIEW OF LITERATURE: Use of anterior spinal instrumentation in treatment of tubercular spondylitis is still an infrequently followed modality of treatment and data regarding its usefulness are still emerging. METHODS: Thirty-two patients of tubercular paraplegia with involvement of dorsal and dorso-lumbar vertebrae were operated with anterior spinal cord decompression, autofibular strut grafting with anterior instrumentation in 18 patients and no implant in 14 patients. Results were compared on the basis of improvement in Frankel grade, correction of local kyphosis, decrease in canal compromise and further progression of kyphosis. RESULTS: The mean local kyphosis correction in the immediate postoperative period was 24.1° in the instrumented group and was 6.1° in the non instrumented group. The mean late loss of correction of local kyphosis at 3 years follow-up was 1.7° in the instrumented and 6.7° in the non instrumented group. The mean improvement in canal compression was 39.5% in the instrumented group and 34.8% in the non instrumented group. CONCLUSIONS: In treatment of tubercular spondylitis by anterior debridement and decompression of the spinal cord and autofibular strut grafting, the use of instrumentation has no relation with the improvement in neurological status, however the correction of local kyphosis and prevention of further progression of local kyphosis was better with the use anterior spinal instrumentation.

Bicentric bipolar hip prosthesis: A radiological study of movement at the interprosthetic joint.

BACKGROUND: The bipolar hip prostheses after some time functions as a unipolar device. There is a need to change the design of bipolar hip prostheses to make it function as a bipolar device over a prolonged period of time. A bicentric bipolar hip prosthesis was used as an implant for various conditions of the hip. We evaluated the movement of this newly developed prosthesis at the interprosthetic joint radiologically at periodic intervals. MATERIALS AND METHODS: Fifty two cases were operarted with the Bicentric bipolar prosthesis for indications like fracture neck of femur and various other diseases of the hip and were followed up with serial radiographs at periodic intervals to evaluate, what fraction of the total abduction at the hip was occurring at the interprosthetic joint. RESULTS: In cases of intracapsular fracture neck of femur, the percentage of total abduction occurring at the interprosthetic joint at 3 months follow-up was 33.74% (mean value of all the patients), which fell to 25.66% at 1.5 years. In indications for bipolar hemireplacement other than fracture neck of femur, the percentage of total abduction occurring at the interprosthetic joint at 3 months follow-up was 71.71% (mean value) and at 1.5 years it was 67.52%. CONCLUSION: This study shows the relative preservation of inner bearing movement in the bipolar hip prosthesis with time probably due its refined design. Further refinements are needed to make the prosthesis work better in patients of intracapsular fracture neck femur.

Multicentric tuberculosis at two rare sites in an immunocompetent adult.

The case of a 20-year-old female who presented with refractory coccydynia and sternal pain is described. She was immunocompetent, and had no systemic features. She was diagnosed with tuberculosis of the sternal and coccygeal regions based on magnetic resonance imaging and histopathology of biopsy specimens. Conservative management with oral multidrug antituberculous therapy completely cured the patient, and she had not suffered any recurrence after three years of follow-up. This case highlights the possibility of the multicentric presentation of tuberculosis at two rare sites in the same immunocompetent patient, even though the differential diagnosis was coccydynia.