3D CT scan-based study of glenoid morphology in Indian population: Clinical relevance in design of reverse total shoulder arthroplasty.

BACKGROUND: The knowledge of normal anatomy of glenoid in a population has relevance in terms of comparison with other regional and national population. Furthermore, it could enable clinicians to judge whether the available sizes of reverse total shoulder arthroplasty (RTSA) prosthesis could provide optimal fit for the glenoid in Indian patients. METHODS: We evaluated consecutive 200 3-dimensional chest CT scans of 50 male and 50 female patients which included both shoulder joints and done for non-orthopaedic diseases at a tertiary care institute. The glenoid height, width, and version were measured using commercially available computer program. RESULTS: Mean age of the patents was 38.6 ± 13.8 years (range, 19-59 years). The mean glenoid height was 33.9 ± 3.1 mm and maximum glenoid width was 24.2 ± 2.1 mm. Mean glenoid version in the study population was a retroversion of 3.47 ± 4.7°. The maximum glenoid width of 45% female and 15% male patients was less than 25 mm which is the diameter of smallest available glenoid baseplate among the commonly used RTSA systems. CONCLUSIONS: The normal glenoid size of a large cohort of Indian population studied was smaller than that reported in cohorts from western countries. The glenoid width of substantial proportion of patients, especially female patients, was less than the diameter of smallest available glenoid baseplate. Clinical studies are needed in future in Indian patients undergoing RTSA to evaluate the glenoid bone-baseplate mismatch and ascertain the necessity of development of smaller size glenoid baseplate for optimal prosthesis fit in Indian patients.

Arthroscopic Anterior Cruciate Ligament Reconstruction in a Case of Multiple Osteochondromatosis: A Case Report.

INTRODUCTION: Osteochondroma is the most common benign bone tumor and usually occurs in the metaphyseal region of the long bones. Anterior cruciate ligament (ACL) tear is the most common ligament injury of the knee joint, and reconstruction of the ACL is the most commonly performed procedure in the knee joint nowadays. CASE PRESENTATION: A 26-year-old male with multiple osteochondromas around the knees, shoulders, and ankles presented with a chronic ACL injury. Reconstruction of ACL using quadrupled hamstring tendon grafts was done. Anterior drawer and Lachman tests were negative postoperatively. The Cincinnati score increased from 180 to 310 at 3-month follow-up. This is a novel case report to describe ACL injury in a case of osteochondromatosis managed by an arthroscopic ACL reconstruction. The problems faced are discussed. CONCLUSION: Our report highlights the fact that ACL tear may occur in a patient having osteochondromas around the knee. ACL reconstruction can be performed in routine fashion in such patients with particular attention to careful harvesting of grafts and tunnel placements.

Do autologous blood transfusion systems reduce allogeneic blood transfusion in total knee arthroplasty?

PURPOSE: To study whether autologus blood transfusion systems reduce the requirement of allogneic blood transfusion in patients undergoing total knee arthroplasty. METHODS: A comprehensive search of the published literature with PubMed, Scopus and Science direct database was performed. The following search terms were used: (total knee replacement) OR (total knee arthroplasty) OR (TKA) AND (blood transfusion) OR (autologous transfusion) OR (autologous transfusion system). Using search syntax, a total of 748 search results were obtained (79 from PubMed, 586 from Science direct and 83 from Scopus). Twenty-one randomized control trials were included for this meta-analysis. RESULTS: The allogenic transfusion rate in autologus blood transfusion (study) group was significantly lower than the control group (28.4 and 53.5 %, respectively) (p value 0.0001, Relative risk: 0.5). The median units of allogenic blood transfused in study control group and control group were 0.1 (0.1-3.0) and 1.3 (0.3-2.6), respectively. The median hospital stay in study group was 9 (6.7-15.6) days and control group was 8.7 (6.6-16.7) days. The median cost incurred for blood transfusion per patient in study and control groups was 175 (85.7-260) and 254.7 (235-300) euros, respectively. CONCLUSION: This meta-analysis demonstrates that the use of auto-transfusion systems is a cost-effective method to reduce the need for and quantity of allogenic transfusion in elective total knee arthroplasty. LEVEL OF EVIDENCE: Level I.

Minimally Invasive Treatment of a Complex Tibial Plateau Fracture with Diaphyseal Extension in a Patient with Uncontrolled Diabetes Mellitus: A Case Report and Review of Literature.

Fractures of the proximal tibia comprise a huge spectrum of injuries with different fracture configurations. The combination of tibia plateau fracture with diaphyseal extension is a rare injury with sparse literature being available on treatment of the same. Various treatment modalities can be adopted with the aim of achieving a well-aligned, congruous, stable joint, which allows early motion and function. We report a case of a 40-year-old male who sustained a Schatzker type VI fracture of left tibial plateau with diaphyseal extension. On further investigations, the patient was diagnosed to have diabetes mellitus with grossly deranged blood sugar levels. The depressed tibial condyle was manipulated to lift its articular surface using K-wire as a joystick and stabilized with an additional K-wire. Distal tibial skeletal traction was maintained for three weeks followed by an above knee cast. At eight months of follow-up, X-rays revealed a well-consolidated fracture site, and the patient had attained a reasonably good range of motion with only terminal restriction of squatting. Tibial plateau fractures with diaphyseal extension in a patient with uncontrolled diabetes mellitus is certainly a challenging entity. After an extended search of literature, we could not find any reports highlighting a similar method of treatment for complex tibial plateau injuries in a patient with uncontrolled diabetes mellitus.

Extensive subcutaneous emphysema complicating a percutaneous Mumford procedure.

Subcutaneous emphysema may be a part of a life-threatening pneumomediastinum or pneumothorax and usually does not occur alone. A case of a 75-year-old lady who underwent a percutaneous Mumford procedure for acromioclavicular osteoarthrosis has been reported. She developed extensive subcutaneous emphysema of the neck, chest, bilateral shoulders, and upper arms, in the absence of pneumomediastinum or pneumothorax, during the procedure. Isolated subcutaneous emphysema as a complication of a percutaneous Mumford procedure has not been reported so far in the English literature. The possible mechanism of this complication is discussed. Understanding the mechanism is essential in avoiding this preventable complication.

Magnetic resonance appearance of bioabsorbable anchor screws for double row arthroscopic rotator cuff repairs.

BACKGROUND: Little is known about the bioabsorbable, anchor related postoperative changes in rotator cuff surgery, which has become more popular recently. The purpose of the present study was to use magnetic resonance imaging (MRI) to analyze the degradation of bioabsorbable anchors and to determine the incidences and characteristics of early postoperative reactions around the anchors and their mechanical failures. MATERIALS AND METHODS: Postoperative MRIs of 200 patients who underwent arthroscopic rotator cuff repair were retrospectively analyzed. The tissue reactions around the bioanchors included fluid accumulations around the anchor, granulation tissue formation and changes in the condition of the surrounding osseous structure. The condition of the bioanchor itself was also examined, including whether the bioanchor failed mechanically. In the case of mechanical failure, the location of the failure was noted. Serial MRIs of 18 patients were available for analysis. RESULTS: The total number of medial row bioanchors was 124, while that of the lateral row was 338. A low signal intensity rim suggestive of sclerosis surrounded all lateral row bioanchors. Ninety three lateral row bioanchors (27%) showed a rim with signal intensity similar to or less than that of surrounding bone, which was granulation tissue or foreign body reaction (FBR). Similar signal intensity was seen around nine medial row bioanchors (7%). Fluid accumulation was seen around 4 lateral row bioanchors (1%) and around 14 medial row bioanchors (11%). Five lateral row bioanchors showed the breakage, while there was none in the medial row bioanchors. There were nine cases with a cuff re-tear (4.5%). There was no evidence of affection of glenohumeral articular surfaces or of osteolysis around any bioanchor. In serial MRI, there was no change in appearance of the bioanchors, but the granulation tissue or FBR around four bioanchors and the fluid around one bioanchor showed a decrease in successive MRI. CONCLUSION: This study highlights the normal and adverse reactions to Bioabsorbable anchors that surgeons can expect to see on MRI after rotator cuff repairs.

Acromioclavicular joint dislocations.

Acromioclavicular (AC) dislocation is a common injury especially among sportsmen. There is still a lack of consensus on whether to conserve or operate type III AC joint dislocations. Even among surgeons inclined to operate AC joint dislocations there is no unanimity on which surgical technique. There are a plethora of choices between mechanical fixation or synthetic materials or biologic anatomic reconstructions. Even among surgeons, there is a choice between open repairs and the latest-arthroscopic reconstructions. This review of AC joint dislocations intends to analyze the available surgical options, a critical analysis of existing literature, actual technique of anatomic repair, and also accompanying complications.

Fracture dislocation of the proximal humerus with ipsilateral shaft fracture: a report of two cases.

We report two cases of ipsilateral proximal humerus fracture dislocation and shaft fracture in young adults. Fractures were treated with prosthetic replacement for the proximal humerus and open reduction and internal fixation for the shaft fracture due to the extent and complexity of the injury.

Perioperative morbidity and mortality of total hip replacement in liver transplant recipients: a 7-year single-center experience.

OBJECTIVE: This study aims to evaluate perioperative mortality and morbidity after total hip replacement in liver transplant recipients and suggesting safety guidelines. BACKGROUND: Hip replacement surgery is one of the most common elective surgeries even for organ transplant recipients. However, there is a paucity of literature addressing the morbidity and complications of hip replacement surgery for liver transplant recipients. MATERIALS AND METHODS: We analyzed retrospectively 33 arthroplasty cases in 20 liver transplant recipients carried out in a single center from 2005 to 2011. All perioperative clinical and laboratory data were evaluated together with early and late morbidity and mortality. RESULT: Of 2253 liver transplant recipients, 20 (0.9%) patients underwent 33 total hip arthroplasties. Thirty-two arthroplasties were performed for avascular necrosis of the femoral head, whereas only one was performed for osteoarthritis. There was no death, liver failure, or infection within 30 days after surgery. Three patients showed elevated liver enzyme more than 5 times the normal value, but it eventually decreased to normal within 1 week. Of 33 cases of arthroplasty, postoperative blood transfusion was needed in 14 cases with 1 case receiving more than 4 U. On long-term follow-up, no patients have developed periprosthetic fracture, implant loosening, or liver failure. All patients showed good to excellent postoperative Harris hip score. CONCLUSION: In this series, we can infer that hip replacement surgery in liver transplantation patients is safe and gives a reliably good result. Some preoperative conditions should be obtained to reduce postoperative morbidity.

Locking plate for proximal humeral fracture in the elderly population: serial change of neck shaft angle.

BACKGROUND: We conducted this radiographic study in the elderly population with proximal humeral fracture aiming to evaluate 1) the serial changes of neck-shaft angle after locking plate fixation and 2) find relationship between change in neck shaft angle and various factors such as age, fracture pattern, severity of osteoporosis, medial support and initial reduction angle. METHODS: Twenty-five patients who underwent surgical treatment for proximal humeral fracture with locking plate between September 2008 and August 2010 are included. True anteroposterior and axillary lateral radiographs were made postoperatively and at each follow-up visit. Measurement of neck shaft angle was done at immediate postoperative, 3 months postoperative and a final follow-up (average, 11 months; range, 8 to 17 months). Severity of osteoporosis was assessed using cortical thickness suggested by Tingart et al. RESULTS: The mean neck shaft angles were 133.6° (range, 100° to 116°) at immediate postoperative, 129.8° (range, 99° to 150°) at 3 months postoperative and 128.4° (range, 97° to 145°) at final follow-up. The mean loss in the neck-shaft angle in the first 3 months was 3.8° as compared to 1.3° in the period between 3 months and final follow-up. This was statistically significant (p = 0.002), indicating that most of the fall in neck shaft angle occurs in the first three months after surgery. Relationship between neck shaft angle change and age (p = 0.29), fracture pattern (p = 0.41), cortical thickness (p = 0.21), medial support (p = 0.63) and initial reduction accuracy (p = 0.65) are not statistically significant. CONCLUSIONS: The proximal humerus locking plate maintains reliable radiographic results even in the elderly population with proximal humerus fracture.

Penetration depth and size of the nonarthritic glenoid: implications for glenoid replacement.

Shoulder arthroplasty is technically demanding and relies heavily on precise surgical technique and preoperative planning. Proper glenoid component sizing plays a crucial role for successful shoulder arthroplasty. In this study, we measured the glenoid size together with penetration depth using three-dimensional computed tomography (3D-CT). From January 2010 to January 2011, 38 patients, including males and females, without evidence of a pathological glenoid, were enrolled for this study. CT images were taken and subsequently reconstructed in 3D images. The height of the glenoid was measured and the width was measured at five different levels (H1-H5). Axial images were taken at each level, with the anteroposterior (AP) glenoid diameter divided into eight areas (W1-W7). The penetration depth between the near and far cortices (thickness) at points W1-W7 was also measured. The overall mean height of the glenoid was 37.67 ± 4.09 mm. The width of the glenoid was the greatest at the distal 4/5th point and it was the least at the proximal 1/5th point. The penetration depth of the glenoid increased as the reference point progressed in the posterior direction, which was at the 5/7th point from the anterior margin. The measurement was greatest at the W4 point at the H1 level, but the W5 point was greatest at all other levels. On the basis of this study, the posterior and inferior parts of the glenoid are thinner than the anterior and superior parts. Thus, caution must be taken when inserting screws into the posteroinferior parts, where the glenoid is thinner than 15 mm, especially in females, to avoid penetration of the far cortex.