Is performing joint arthroplasty surgery during the COVID-19 pandemic safe?: A retrospective, cohort analysis from a tertiary centre in NCR, Delhi, India.

PURPOSE: Resuming joint replacement arthroplasty amidst the COVID-19 pandemic and lockdown has come with various challenges that had to be dealt with utmost caution. Patients with severe arthritis experiencing a state of intolerable pain, could not be left unaddressed. Guidelines published by surgical associations, collaborative surgical author groups including public health organisations had to be modified to suit the Indian scenario and obtain optimal functional outcomes in these patients. METHODS: A retrospective cohort analysis of 147 patients who underwent arthroplasty during the pandemic (March 2020 to April 2021), for either primary or secondary arthritis, was performed. We assess the efficacy and safety of the newly established Institutional surgical peri-operative protocol at our tertiary care centre in the National Capital Region, India in response to COVID-19 guidelines. The primary outcome measures appraised was 30-day mortality and the secondary outcome measures included length of stay, peri-operative complications and COVID-19 infection. RESULT: The most common indication for arthroplasty during the pandemic was neglected trauma. One patient died, due to myocardial infarction during the follow-up period. About 67% of patients were discharged to their usual residence within 7 days of admission. Two patients tested positive for COVID-19 postoperatively, but none required Intensive Care Unit admission. CONCLUSION: Joint replacement arthroplasty can be undertaken safely with diligent patient selection, application of a stringent COVID appropriate behaviour and a 'ring-fenced' peri-operative pathway.

Postoperative clinical outcome between lateral retraction and eversion of patella following simultaneous bilateral total knee arthroplasty.

AIMS AND OBJECTIVE: Among the various exposure technique used in total knee arthroplasty (TKA); the midline medial parapatellar knee approach is most commonly performed; which require mobilisation of patella for adequate surgical exposure. In this study, we compare the effect of patellar eversion with lateral retraction in simultaneous bilateral TKA to find out difference in postoperative clinical outcome between the two patellar mobilisation techniques. METHODS: We enrolled 41 patients who underwent bilateral simultaneous TKR (82 knees) from Nov 2016 to Dec 2018. During surgery patellar eversion was done in one knee and lateral retraction was done in other knee selecting them randomly to reduce the bias. During the follow up period achieving unassisted active straight leg raise (SLR), 90 flexion and complications were recorded. Measurement of Oxford knee society score (OKSS), American knee society score (AKSS), Visual Analogue Scale (VAS) score, and quadriceps strength (measured by handheld dynamometer) was done daily up to one week, 1 month, 3 months, 6 months, and 1 year postoperatively. RESULTS: The time of achieving active SLR and 90∗ flexion postoperatively was quicker in the lateral retraction group with a statistically significant difference. VAS pain score at 1 week and 1 month along with quadriceps strength in 1-month had statistically significant favourable outcomes in the lateral retraction group. Throughout the follow up lateral retraction group had better Oxford and American knee score but the difference being statistically insignificant. No significant difference was found on the complication rate. CONCLUSION: In comparison to lateral retraction, patellar eversion has an adverse effect in early knee functional recovery after TKA; it delays achieving active SLR, 90∗ flexion and has unfavourable outcome in functional scores, quadriceps strength, and postoperative pain relief. However it has minimal effects on long term functional outcomes.

Is in-vivo 80 N tensioned quadrupled hamstring graft better than conventional unmeasured pull for arthroscopic ACL reconstruction.

PURPOSE: To find clinical outcome of in-vivo standard 80 N tensioning of quadrupled hamstring graft during arthroscopic single bundle ACL reconstruction in comparison to traditional graft tensioning. METHODS: Sixty cases of isolated ACL tears were included in this study. All cases underwent Arthroscopic ACL reconstruction with Tibial attachment sparing quadrupled hamstring graft. Cases were divided into group I and group II (30 cases each). Graft Tensioning in group 1 was conventional one-handed unmeasured pull and in group II it was measured tension of 80 N with tensionometer during graft fixation. Pre-operative and post-operative (12 months) Anterior tibial translation (ATT) was measured with KT-1000 arthrometer. Clinical outcome was measured using Lysholm knee scoring system at 6weeks, 3months, 6months, 12 months and compared statistically among both groups. RESULTS: The mean pre-op ATT of 10.6 ± 2.04 mm (group I) & 10.83 ± 2 mm (group II) improved to 3.63 ± 1.16 mm (group I) & 3.63 ± 0.92 (group II) respectively at one year without significant difference (p value 1). The mean pre-op Lysholm score was 46.73 ± 6.77 (group I) and 45.97 ± 8.68 (group II). The mean Lysholm score at 6 weeks was 91.5 ± 2.78 (group I) and 93.43 ± 3.02 (group II) with significant difference (p value 0.014). At 3 months it was 95.4 ± 2.99 (group I) and 97.07 ± 2.07 (group II) with significant difference (p value 0.025). At 6 months it was 95.53 ± 2.46 (group I) and 97.5 ± 1.2 (group II) with significant difference (p value 0.0002). At 1 year it was 95.73 ± 2.22 (group I) and 97.8 ± 0.979 (group II) with significance (p value 0.0001). CONCLUSION: The clinical score of ACL reconstruction is better when in-vivo 80 N tension is applied using tensionometer during graft fixation in comparison to conventional manual tensioning but there is no difference in ATT.

Anterior Cruciate Ligament Reconstruction with Tibial Attachment Preserving Hamstring Graft without Implant on Tibial Side.

BACKGROUND: Tibial attachment preserving hamstring graft could prevent potential problems of free graft in anterior cruciate ligament (ACL) reconstruction such as pull out before graft-tunnel healing or rupture before ligamentization. Different implants have been reportedly used for tibial side fixation with this technique. We investigated short-term outcome of ACL reconstruction (ACLR) with tibial attachment sparing hamstring graft without implant on the tibial side by outside in technique. MATERIALS AND METHODS: Seventy nine consecutive cases of ACL tear having age of 25.7 ± 6.8 years were included after Institutional Board Approval. All subjects were male. The mean time interval from injury to surgery was of 7.5 ± 6.4 months. Hamstring tendons were harvested with open tendon stripper leaving the tibial insertion intact. The free ends of the tendons were whip stitched, quadrupled, and whip stitched again over the insertion site of hamstring with fiber wire (Arthrex). Single bundle ACLR was done by outside in technique and the femoral tunnel was created with cannulated reamer. The graft was pulled up to the external aperture of femoral tunnel and fixed with interference screw (Arthrex). The scoring was done by Lysholm, Tegner, and KT 1000 by independent observers. All cases were followed up for 2 years. RESULTS: The mean length of quadrupled graft attached to tibia was 127.65 ± 7.5 mm, and the mean width was 7.52 ± 0.78 mm. The mean preoperative Lysholm score of 47.15 ± 9.6, improved to 96.8 ± 2.4 at 1 year. All cases except two returned to the previous level of activity after ACLR. There was no significant difference statistically between preinjury (5.89 ± 0.68) and postoperative (5.87 ± 0.67) Tegner score. The anterior tibial translation (ATT) (KT 1000) improved from 11.44 ± 1.93 mm to 3.59 ± 0.89 mm. The ATT of operated knee returned to nearly the similar value as of the opposite knee (3.47 ± 1.16 mm). The Pivot shift test was negative in all cases. None had a failure of graft till final followup. CONCLUSION: Attachment sparing hamstring graft without a tibial implant is a simple, cost-effective technique that provides a consistently satisfactory outcome.

Comparative study of multiple cancellous screws versus sliding hip screws in femoral neck fractures of young adults.

PURPOSE: Both cannulated cancellous screw (CCS) and sliding hip screw (SHS) are used in femoral neck fracture fixations, but which is superior is yet to be determined. This study was aimed to compare the clinicoradiological outcome of femoral neck fracture treated with SHS or CCS in young adults. METHODS: Adults (16e60 years) with femoral neck fracture were divided into Group 1 fixed with SHS and Group 2 fixed with three CCS after closed reduction. Pain relief, functional recovery and postoperative radiographs at 6 weeks, 3 months, 6 months and then yearly for upto 4 years were analyzed. RESULTS: Group 1 (n=40) achieved radiological union at mean of 7.6 months, with the union rate of 87.5% (n=35), avascular necrosis (AVN) rate of 7.5% (n=3) and mean Harris Hip Score (HHS) of 86.15 at the end of 4 years. In Group 2 (n=45) these parameters were union at 7.1 months, union rate of 82.22% (n=37), AVN rate of 6.67% (n=3) and HHS of 88.65. Comparative results were statistically insignificant. CONCLUSION: There is no significant difference in clinicoradiological outcome between the two implants.

Tubercular osteomyelitis of the first metatarsal bone as a cause of forefoot pain.

The reporting of isolated metatarsal tuberculosis in the available literature is sparse, herein we report a case of 26-year-old female who presented with insidious onset pain and swelling in her forefoot. Radiograph showed osteolysis of the first metatarsal. Magnetic resonance imaging showed osseous erosion with marrow oedema. Diagnosis was ascertained by fine needle aspiration cytology of the lesion. The patient received anti-tubercular therapy and showed good clinical outcome. This case is reported because of its rarity of involving isolated metatarsal bone as a cause of forefoot pain.

Contiguous multiple cervicothoracic spinous process fractures in an adult: A case report.

Fracture of isolated spinous processes at multiple levels is a rare injury. Herein, we present a 45-year-old male with cervical pain and swelling following a road traffic accident. Computerized tomography and magnetic resonance imaging revealed fractures of spinous process from C7 to D6 vertebra. The patient was managed with rest, analgesics and immobilization. At the 1-year follow-up, the patient is doing well without any neurological problem.

Neglected Thorn Injury Mimicking Soft Tissue Mass in a Child: A Case Report.

Thorn injuries are common especially in rural areas. The diagnosis of such in children is always missed. An untreated retained thorn may cause late soft tissue and osseous complications. Herein, we report a case of neglected thorn injury mimicking soft tissue mass in an 11-year-old male child. The presence of the thorn was confirmed with ultrasound scan and computerized tomography. The child was successfully managed with removal of thorn with excision of foreign body granuloma.

Osteochondroma of Upper Dorsal Spine Causing Spastic Paraparesis in Hereditary Multiple Exostosis: A Case Report.

Osteochondroma of the spine is rare. It may present in solitary or multiple form (hereditary multiple exostoses). Herein, we report a case of an 18-year-old male who was diagnosed with thoracic osteochondroma, originating from the D4 vertebra with intraspinal extension and spinal cord compression in hereditary multiple exostosis. The patient was managed with surgery. Complete tumour excision was done to relieve cord compression and recurrence. Postoperatively the patient's symptoms were improved. At 2.5 year follow-up patient is doing well without any recurrence.

Isolated calcaneocuboid joint tuberculosis: a rare case report.

Tubercular arthritis affecting the foot is uncommon. Isolated calcaneocuboid joint tuberculosis has never been reported in the literature. Herein we report a case of 43-year-old male who presented with insidious onset pain in hindfoot of 4 months duration. Radiograph revealed destruction of calcaneocuboid joint along with cuboid. Computed Tomography scan further consolidated the findings. Diagnosis was confirmed from aspiration from joint with culture of mycobacterium tuberculosis. Anti-tubercular chemotherapy was started and good clinical response was noted. We reported this case because of its rarity to involve calcaneocuboid joint and the excellent outcome with medical treatment.

Tuberculosis of bilateral first costotransverse joints.

Involvement of posterior spine constitutes to 1-6% of the cases of spinal tuberculosis (TB). To the best of our knowledge, TB of costotransverse joints has only been reported once in the literature. The purpose of this study is to describe a case of TB arthritis of costotransverse joints. A 22-year-old immunocompetent patient presented with a 3-month history of pain in the neck and upper back along with a swelling on the left side of the base of the neck. On performing an MRI of the cervicodorsal spine, there was evidence of destructive collections at the bilateral first and right-sided second costotransverse joints. The patient was diagnosed as a case of tubercular pathology and was managed successfully with antitubercular chemotherapy.

Diagnosing the SAPHO syndrome: a report of three cases and review of literature.

SAPHO, an acronym for synovitis, acne, pustulosis, hyperostosis and osteitis, is a heterogeneous entity with myriad presentations and features overlapping with other entities. It is a differential in patients presenting with skin and bone symptoms, either singly or in combination. Often misdiagnosed radiologically as a malignancy or infection, the diagnosis is seldom thought of. We present three cases referred to us for evaluation of findings unrelated to the presenting symptoms. After evaluation, a (99)Tc bone scan was ordered, which showed the 'bull's head sign' in all the three cases, confirming the diagnosis. We review the literature for SAPHO. It has a few features which point to its diagnosis and can help us to distinguish it from other seronegative arthritis. The clinician should be aware of this entity and should not hesitate to order a (99)Tc bone scan. We conclude that SAPHO is not rare, but rather, it is underdiagnosed. High index of suspicion is necessary for diagnosis. A (99)Tc bone scan is diagnostic and should be ordered in patients having any of the presenting features of the syndrome. We put forward the suggestion of using (99)Tc bone scintigraphy to define a 'pre-MRI' stage of ankylosing spondylitis.