Unveiling foot tuberculosis as an under-recognized source of foot pain.

PURPOSE: Foot tuberculosis is a rare form of osteoarticular tuberculosis, accounting for less than 1% of cases. It presents unique diagnostic challenges due to its nonspecific clinical features and overlapping symptoms with other conditions. This study aimed to investigate the clinical presentation, radiographic findings, and prognosis of foot tuberculosis, with the goal of improving early recognition and appropriate intervention. METHODS: A prospective study was conducted between November 2016 and July 2021, involving 39 patients diagnosed with foot tuberculosis. Clinical examinations, laboratory tests, X-rays, and MRI evaluations were performed to aid in the diagnosis. Biopsy was conducted on patients with radiological lesions. Patients were treated with an 18-month course of antitubercular therapy (ATT). Foot Function Index (FFI) scores were recorded before and after treatment. Statistical analysis was conducted to assess factors impacting prognosis. RESULTS: Unilateral foot involvement was observed in all patients, with a male predominance (61.5%) and a mean age of 31.3 years. The most common symptoms were pain and edema, with sinus tracts present in 17.9% of patients. Radiographic findings showed cystic and sclerotic lesions, with the "spina ventosa" appearance primarily affecting the metatarsal bones. MRI played a valuable role in early detection. Histopathological examination confirmed tuberculosis in all cases, and acid-fast bacilli were found in 23% of patients. Most patients (79.4%) responded well to ATT without requiring surgery. Factors such as high initial ESR, delayed ATT initiation, multiple lesions, and tarsal involvement were associated with unfavourable outcomes. CONCLUSION: Foot tuberculosis presents with nonspecific symptoms, leading to misdiagnosis and delays in appropriate treatment. Clinical examination, radiographic evaluation, and biopsy are essential for accurate diagnosis. Early initiation of ATT is crucial for favourable outcomes. Factors such as high initial ESR, delayed treatment initiation, multiple lesions, and tarsal involvement negatively impact prognosis. This study highlights the importance of recognizing foot tuberculosis and provides insights into its clinical presentation, radiographic features, and treatment outcomes, facilitating timely intervention and improved patient management.

Time to Look for Ergonomically Viable Designs of Radiation Protection Aprons and Thyroid Shields in Orthopedic Surgery: A Survey of 416 Orthopedic Surgeons.

Introduction The advent of minimally invasive surgery has increased the use of C-arm among orthopedic surgeons. Their views on the ergonomicity of radiation protection aprons and thyroid shields need elucidation. To investigate, we deliberated a question-based survey. The primary aim of the survey was to find out the percentage of those not using these devices, the prevalence of back pain, and its relationship with the type of radiation protection aprons. Materials and methods This was a cross-sectional survey. A five-section Google Forms survey (Google, Inc., Mountain View, CA) was filled out, and responses from 416 orthopedic surgeons were included. Analysis was carried out using Statistical Package for the Social Sciences (SPSS) version 14.0 (SPSS Inc., Chicago, IL). Results Of the total number of orthopedic surgeons, 36.8% felt that apart from radiation exposure, wearing a radiation protection apron was the biggest problem in C-arm usage. Furthermore, 20.4% wore thyroid shields the majority of the time. The 31-40 years age group was the most comfortable wearing these devices, wore them more often, and suffered more often from back pain (all p<0.01). Conclusion The study concluded that the majority of orthopedic surgeons were not comfortable with the current designs of radiation protection aprons and thyroid shields. Thyroid shields are worn less than aprons. Lead apron weight and thyroid shield ergonomicity were the number one reason for being bare-bodied. Among those who regularly wore aprons, a large proportion suffered from back pain.

Clinical Outcome of Neer Type II Lateral End Clavicle Fractures With Coracoclavicular Ligament Disruption Treated With Pre-Contoured Locking Plate and Endobutton.

Introduction Many surgical techniques have been described for the treatment of Neer type II lateral end clavicle fractures like open reduction and internal fixation with hook plate, tension band wiring, coracoclavicular screw fixation, and distal clavicle locking plate. However, most of these operative procedures are associated with high perioperative complications ranging from hardware prominence, hardware failure, screw and plate pull-out, and infection. As the lateral end clavicle fractures has both vertical and horizontal stress forces, any technique counteracting both the forces should result in a better clinical outcome. Therefore, this study was conducted to assess the functional and radiological outcome of type II lateral end clavicle fracture treated using pre-contoured locking plate along with coracoclavicular reconstruction with endobutton and fiberwire. Methods Thirty-two consecutive patients with Neer type II fractures of the lateral end of clavicle were treated surgically using pre-contoured locking plate and coracoclavicular reconstruction with endobutton and fiberwire between May 2014 and December 2016. Clinical outcome was assessed using the University of California Los Angeles (UCLA) shoulder score and Constant Murley score. The coracoclavicular distance was also recorded. These were compared to the unaffected side at one-year follow-up. Results The bony union was achieved in all cases. There were no major complications in any of the patients. All the patients were able to return to their preinjury level of activity. The UCLA score, the Constant Murley score, and coracoclavicular distance did not vary significantly at a one-year interval when compared to the normal shoulder. Conclusion Open reduction and internal fixation of Neer type II lateral end clavicle fractures using pre-contoured locking distal clavicle plate along with coracoclavicular reconstruction with endobutton and No. 2 fiberwire provide an excellent functional and radiological outcome.

Sternoclavicular tuberculosis: an atypical imitator of refractory shoulder pain.

INTRODUCTION: Sternoclavicular joint tuberculosis is rare and has been presented in literature with few sporadic case reports or small case series. Rarity of the condition, nonspecific symptoms, difficulty to visualise the area on X-rays, and minimal clinical signs make diagnosis of sternoclavicular tuberculosis extremely difficult. Delay in diagnosis is therefore the common feature of all presented reports in literature. We here present our experience of treating 19 cases of sternoclavicular tuberculosis at our centre. MATERIALS AND METHOD: This is an observational study from 2010 to 2017 in a tertiary care referral hospital. All patients with clinical tenderness of sternoclavicular joint and shoulder joint pain of over three week duration were subjected to MRI. Patients who showed radiological lesions (radiography/MRI) were subjected to core biopsy under image guidance. A total of 26 patients had biopsy confirmed sternoclavicular tuberculosis (TB) during this period. RESULTS: All patients had improvement in shoulder function after treatment completion. Mean CSS pre-treatment was 29 which improved to mean of 8 after 18 months of ATT. Eight patients had excellent results, seven good, three fair, and one patient poor result. High initial ESR, late commencement of ATT from initial symptoms, and surgery of the involved joint were considered poor prognostic factors. DISCUSSION: Sternoclavicular tuberculosis is a rare disease with controversial etiology. Both haematogenous spread through suprascapular artery and contiguous spread through latent disease in apical lungs has been postulated. Delay in diagnosis is common to most reports in literature. Early MRI is useful in diagnosis of the lesion. The treatment for sternoclavicular joint in literature is controversial with proponents of both surgery and conservative management. CONCLUSION: Primary sternoclavicular tuberculosis is rare condition and requires a high index of suspicion for an early diagnosis. A focused sternoclavicular MRI and early biopsy may help in timely diagnosis. Early commencement of ATT has overall good clinical and functional results.

Experience of valgus osteotomy for neglected and failed osteosynthesis in fractures neck of femur.

PURPOSE: There is vast literature supporting valgus osteotomy in fracture neck of femur. However, little or no distinction has ever been made to evaluate the success of the procedure in these two different scenarios-non-unions due to failed osteosynthesis and neglected fractures neck of femur. The aim of our study was to compare the results of valgus osteotomy in neglected neck femur fractures and non-union fractures of neck of femur. METHODS: This is a single tertiary centre-based retrospective study. The records of all patients aged less than 45 years who underwent valgus osteotomy for neck of femur fractures from 2012 to 2017 were evaluated. Patients with fracture neck of femur of over one month's duration, where no previous surgical intervention was undertaken were placed in neglected fracture group. Patients with failed primary osteosynthesis surgery, either cannulated cancellous screw or dynamic hip screw, were placed in fixation failure group. There were 23 patients in neglected group and 17 patients in fixation failure group. Demographical details, fracture patterns, and preoperative radiograph, surgery time, blood loss, post-operative complications, union time, and non-unions were studied in both groups. RESULTS: Osteotomy site united in mean time of 11 weeks in fixation failure group and 11.3 weeks in neglected group (p = .434). Time to radiological union of fracture was 16 weeks (12-23 weeks) for neglected fracture group compared to 25 weeks (20-32 weeks) for fixation failure group which was statistically significant (p = .02). Seven out of 17 fractures did not unite in fixation failure group compared to one non-union out of 23 patients in neglected group. (p = .004) There were two loss of fixation with implant failure in fixation failure group compared to none in neglected group (p = .174). Neither of the groups had any surgical site infection. CONCLUSION: Valgus osteotomy results in excellent union rates for neglected fractures of neck of femur. However, the union rates of valgus osteotomy are lower in neck femur fractures with failed implants compared to neglected fractures and the procedure should be cautiously used in such circumstances.

A diagnostic dilema in benign lytic lesions of clavicle - our experience of 37 patients.

INTRODUCTION: The studies on benign lytic lesion of clavicle are sparse. Asymptomatic nature of lesions, rare occurrence, the difficulty in interpretation of the X-rays because of the surrounding structures and striking similarities in various lesions further make the diagnosis of such atraumatic lytic lesions difficult. MATERIAL AND METHODS: Prompted by the rarity of lesion and scarcity of data regarding presentation and management, we performed a prospective study of benign lytic lesions of clavicle. The results of the lesions are categorised in infective, metabolic and neoplastic conditions. RESULTS: Infective lesions were most common cause of symptomatic painful benign lytic lesions. Metabolic lesions, like rickets, were the most common cause of painless swelling in clavicle. Neoplastic conditions although rare were an important differential. CONCLUSION: It is important to differentiate and diagnose lytic lesions of clavicle. Early MRI and Biopsy of the lesion helps in preventing an undue delay in diagnosis. Most lesions when diagnosed in time have excellent results.

Factors Affecting Tibial Tuberosity-Trochlear Groove Distance in Recurrent Patellar Dislocation.

BACKGROUND: The tibial tuberosity-trochlear groove (TT-TG) distance is used to determine the necessity of tibial tubercle osteotomy. We conducted this study to determine the extent to which each of the tibial tuberosity lateralization, trochlear groove medialization, and knee rotation angle affects the TT-TG distance in both normal and patella dislocated patients and thereby scrutinize the rationale for tuberosity transfer based on the TT-TG distance. METHODS: Retrospective analysis of rotational profile computed tomography was done for patella dislocated and control group patients. Femoral anteversion, tibial torsion, knee rotation angle, tuberosity lateralization, and trochlear groove medialization were assessed in all patients. Relationship of these parameters with the TT-TG distance was investigated to evaluate their effects on the TT-TG distance. RESULTS: We observed that the patellar dislocation group, compared to the control group, had increased TT-TG distance (mean, 19.05 mm vs. 9.02 mm) and greater tuberosity lateralization (mean, 64.1% vs. 60.7%) and tibial external rotation in relation to the femur (mean, 7.9° vs. -0.81°). CONCLUSIONS: Tuberosity lateralization and knee rotation were factors affecting patellar dislocation. These factors should be considered in addition to the TT-TG distance to determine the need for tibial tubercle osteotomy in patients with patellar dislocation.

Is Combined Administration of Tranexamic Acid Better than Both Intravenous and Topical Regimes for Total Loss, Hidden Loss and Post-operative Swelling? A Randomized Control Trial.

BACKGROUND: Bleeding is one of the unavoidable complications of total knee arthroplasty (TKA). Tranexamic acid (TXA) in last decade has emerged as an effective and safe way to decrease postoperative bleeding and transfusion rates. Although there is little doubt on the efficacy of the drug, the debate on ideal mode is more recent. We undertook this study to find out the most effective and yet safest way of TXA administration. MATERIALS AND METHODS: A single institution - two hospital-based, double-blinded, prospective, randomized control trial was conducted from January 2015 to December 2015. One hundred and fifty patients were randomly divided in one of the three groups using computer-generated tables - intravenous (IV), intraarticular and combined. Evident loss through drain, total loss based on gross method and hemoglobin balance method, hidden blood losses, hemoglobin, and hematocrit drop, all possible complications related to TXA were evaluated and compared among groups. The analysis of variance and Tukey's post hoc were used for continuous outcome variables and Chi-square test for binary outcome variables. RESULTS: Evident loss in combined group was 574.25 ± 209.8 ml, significantly less than IV (685.4 ± 289.9 ml) and intraarticular group (724.3 ± 246.8 ml). Total loss was similarly least for combined group (930.1 ± 262.2 ml) compared to IV (1208.3 ± 368.8 ml) and intraarticular group (1198.1 ± 356.8 ml). There were no transfusions in combined group compared to five in IV and four in intraarticular group. Combined group also had least hidden losses after surgery. No patients in any group developed symptomatic deep venous thrombosis. CONCLUSION: Combined administration of drug is most effective way to decrease postoperative bleeding and requirement of transfusion in unilateral TKA without increasing any risk of complications.

Modified Ponseti technique for management of neglected clubfeet.

Achieving adequate dorsiflexion in neglected clubfoot cases remains challenging. On a close observation of the Ponseti method, we have now made certain modifications from the standard Ponseti protocol. This has helped us improve functional results, as well as reduce the number of casts in this walking-age group. From March 2011 onward, we managed 62 neglected clubfeet in 41 patients with the modified protocol. All these patients were treated with serial weekly above-knee casts. The feet were assessed by Dimeglio and Pirani scorings, which were done every week. These children were closely monitored and followed up at regular intervals for any signs of relapses. The mean age group was 3.1 years (1.1-12 years). The mean follow-up period for these feet was 3 years (1.2-4 years). Mean Dimeglio score before treatment was 15.9, and after treatment it was 0.52. Mean Pirani score before treatment was 4.21 and after treatment it was 0.03. The average number of casts before tenotomy with our modified method was 6.9. Percutaneous tenotomy was done in all the cases. The mean dorsiflexion achieved at the end of treatment was 21.3° (15°-40°). Our modified Ponseti technique is a very effective and reproducible method for correction of neglected clubfeet. We feel that an extensive soft tissue surgery may not be required for neglected clubfeet even up to the age of 10 years.

Open reduction versus in-situ fixation of neglected lateral condyle fractures: a comparative study.

The management of neglected fracture of the lateral condyle of the humerus is controversial. Careful neglect and conservative management with early ulnar nerve transposition and ostetomy, in-situ surgical fixation and accurate open reduction and internal fixation are all recommended as treatment options. However, an overgrowth of fractured condyle, highly distorted anatomy, contracted soft tissue and almost unrecognizable fracture ends make open reduction a challenging task. As the functional loss is not severe, in-situ fixation of the fragment provides a good alternative. There have been proponents of both surgeries with very limited data on comparison on both procedures. Here, we present our experience of 45 patients, 22 treated with anatomical reduction and 23 treated with in-situ fixation with no attempts of anatomical restoration, and attempted to evaluate the results of two surgeries with a follow-up of at least 2 years. Neglected fractures of the lateral condyle were surgically treated with two different techniques. In all, 22 patients were treated with open reduction and fixation whereas 23 patients were treated with in-situ fixation to render the elbow stable. Patients were followed for a minimum of 2 years. These patients were studied in terms of functional scores and radiological union. Radiological union was better in the anatomical reduction group with one nonunion compared with five in the in-situ group. However, functional results and elbow range were better in the in-situ fixation group. The surgical time was 57 min in in-situ fixation compared with 73 min in the anatomical reduction group. Complication rates were found to be high in the open reduction group. In-situ fixation of neglected lateral condyle fractures is an effective technique for the treatment of these difficult fractures presenting late compared with anatomical fixation. Radiological union, although less successful compared with open anatomical reduction, leads to better functional outcome, with decreased surgical time and postoperative complications.

High tibial osteotomy accelerates lateral compartment osteoarthritis in discoid meniscus patients.

PURPOSE: The valgus high tibial osteotomy (HTO) in patients with medial osteoarthritis and discoid lateral meniscus can result in increased load on the lateral compartment and hence a higher chances of tear. This may accelerate the progression of osteoarthritis on lateral compartment. We, therefore, carried out the case control study with a hypothesis that an HTO would accelerate the progression of osteoarthritis (OA) on lateral compartment in patients with complete discoid meniscus. METHODS: The records of all patients with open wedge HTO from 2008 to 2012 were evaluated for complete lateral discoid meniscus. The patient who had a valgus HTO with or without partial meniscectomy for medial compartmental OA was included for this study. Cases to control were chosen to match age, body mass index (BMI), pre-operative osteoarthritis grade, and deformity angles in ratio 1:2. Patient's records were studied for demographic data, clinical examination records, and pre-operative knee functional scores and radiological scores and were compared with post-operative data. RESULTS: Thirty-six patients out of 674 patients, who underwent an HTO, consisted of discoid meniscus group. 72 patients were chosen as control group. Four patients showed progression of OA on the lateral compartment in discoid group compared to none in control group. Although control groups showed a little bit better functional outcomes, there were no statistical differences between two groups (n.s.). CONCLUSION: The high tibial osteotomy could result in accelerated lateral compartment osteoarthritis in patients with complete discoid meniscus, and the procedure should be used with caution in such patients. LEVEL OF EVIDENCE: IV.

Experience of supracondylar cheveron osteotomy for genu valgum in 115 adolescent knees.

PURPOSE: Medial close wedge Coventry type osteotomy is commonly performed procedure for adoloscent Genu valgum. However this osteotomy has some inherent problems, a wedge resection causes shortening of affected site. An additional plate for stabilization causes increase in soft tissue dissection and surgical time. A cheveron osteotomy is an alternative procedure, not requiring any internal fixation due to its inherent stability. We started this study with aim to analyze the results of Cheveron osteotomy, to see if the osteotomy was stable enough without implants, time required for healing of osteotomy, post-operative range of motion, limb length discrepancy and to evaluate any other complication. METHODS: This study was conducted to evaluate the efficacy of cheveron osteotomy in cases with genu valgum in our department from 2005 to 2012. 75 children with 115 knee deformities were included in the study. Patients were followed upto minimum 3 years post surgery. Clinical and radiological assessment was done on all subsequent visits. RESULTS: Preoperative mean valgus angle was 21° (12-30°) and mean inter malleolar distance was 12.3 cm(11-21 cm). The mean post-operative angle was 6.5° and mean intermalleolar distance was 5.6 cm. The difference was statistically significant. The mean tourniquet time was 26 min and mean surgical time including plaster cast application was 38 min. Mean blood loss was 75 ml. The mean time to union was 10.3 weeks. CONCLUSION: Supracondylar cheveron osteotomy is simple, stable, low cost osteotomy for surgical correction of genu valgum. The osteotomy provides excellent clinical, radiological and functional results in short surgical time and has an added advantage of omitting the need of second surgery.

A randomized control trial to evaluate the effectiveness of intravenous, intra-articular and topical wash regimes of tranexamic acid in primary total knee arthroplasty.

BACKGROUND: The efficacy of tranexamic acid to decrease post-operative blood loss and blood transfusion is well established in literature. However, the ideal mode of administration is debatable. Limited literature has compared all the available modes of administration including intravenous (IV), topical irrigation and retrograde through drain. We hypothesized that no difference would be present in either form of administration of tranexamic acid. METHODS: Fifty patients in four groups were enrolled for study. Group 1 received drug intravenously, group 2 had topical washing with drug before closure, group 3 received drug after closure through drain and group 4 was control that received no tranexamic acid. Post-operative blood loss, calculated blood loss, haemoglobin drop, transfusion requirements and complications were studied for all four groups. RESULTS: Tranexamic acid results in lower bleeding irrespective of the mode of administration compared to control group. Total loss at end of 5 days is similar in all tranexamic acid groups irrespective of method used to deliver the drug. Calculated blood loss and haemoglobin drop was minimum for IV and in patients who were administered drug retrograde through drain. Requirement for blood transfusion was found to be lower in all tranexamic acid patients compared to non-tranexamic acid group. The requirement was highest in topical wash group among all tranexamic acid groups. CONCLUSION: We conclude that intra-articular administration through drain and IV administration are equally effective and superior to topical wash method in reducing blood loss, haemoglobin fall and transfusion requirements.

Is surgery always indicated in rachitic coronal knee deformities? Our experience in 198 knees.

INTRODUCTION: Defective mineralization of osteoid matrix prior to physeal closure causes rickets. Poor calcification of the cartilage matrix in the zone of provisional calcification causes flattened skull, rachitic rosary, bowed legs, coxa vara and brittle bones. The recent literature has seen an increase in the incidence of the disease in both developing and developed nations. We evaluated behaviour of lower limb deformities due to nutritional rickets in 117 patients. MATERIALS AND METHODS: A prospective study was conducted from January 2009 to December 2011 for clinical and radiological evaluation of knee deformities in nutritional rickets. A total of 117 patients with 198 coronal plane knee deformities between 2 years and 12 years age of rickets were enrolled in this study. RESULTS: In our study, there were 65 genu varum and 133 genu valgum deformities. Seven genu varum (10.7%) and 37 genu valgum (28%) deformities were regarded as failure. Fifty eight genu varum got corrected completely obtaining an average of 5° of valgum in an average of 6.3 months. The average rate of spontaneous correction was 1.9° a month. Ninety six valgum got corrected obtaining an average of 4.7 valgum in an average of 13.3 months. The average rate of spontaneous correction was 0.92° a month. CONCLUSION: Most of the rachitic deformities get corrected with age. Genu varum is having better chances and a faster rate of correction as compared with genu valgum. Early surgery may be indicated in late presenting cases. We believe varum above 4 years and 18° of valgum above 9 years usually do not correct and may require surgical intervention.

How Much Does the Anatomical Tibial Component Improve the Bony Coverage in Total Knee Arthroplasty?

BACKGROUND: Recently, anatomical designs in total knee arthroplasty are introduced to address asymmetry of the resected tibia cutting surface. It is still not well known how much improvement would be achieved in total knee arthroplasty, especially in Asian knees. METHODS: We evaluated the bony coverage of 4 commercially available posterior-stabilized tibial designs (3 symmetrical: NexGen, Attune, and Vega; 1 anatomical: Persona) by measuring uncovered areas over 3 different regions: lateroposterior (LP), medioposterior (MP), and mediolateral (ML) areas. The implant size was chosen based on lateral anteroposterior dimension of the implant that most closely matched the corresponding surface of tibia. The knee with over coverage <1 mm and under coverage <2 mm was regarded as having optimal fit. RESULTS: The optimal fit of anatomical design in LP dimension was achieved in 76% of the cases, which was not significantly different from other symmetrical designs (P > .05). The anatomical tibial implant had a more optimal fit in MP and ML dimensions (48% and 42%, respectively) compared to all symmetric designs (P < .05). All symmetrical tibial designs had significant absolute underhang in MP (62%-78%) and ML (24%-34%) areas without difference. The anatomical tibial design had significant improvement for posteromedial coverage by about 69.8%-74.3% compared with the symmetrical designs. CONCLUSION: Recently introduced anatomical tibial design improves surface coverage at the medioposterior dimension in Asian knees. Moreover, there is small improvement in ML fit compared with the symmetrical designs.

Hand and wrist tuberculosis in paediatric patients - our experience in 44 patients.

Skeletal tuberculosis (TB) of the hand and wrist is rare, accounting for less than 1% of all osteoarticular TB. Although rare, TB of the hand and wrist is a cause of major morbidity. A common feature among all available reports on TB of the hand and wrist was a delay in diagnosis, causing residual stiffness and pain after treatment. Minimal initial symptoms, rarity of the lesion and ability of wrist TB to mimic more common pathologies account for the delay. Skeletal TB may behave differently in this age compared with the adult population. Further, the disease may affect the growing bone, causing residual deformities. The paucity of studies from different countries, coupled with a difficulty in diagnosis resulting in major morbidity, led us to carry out a study on this topic. A total of 44 patients with skeletal lesions in the hand and wrist were studied. The diagnosis was confirmed by biopsy. Patients were started on multidrug antitubercular treatment (ATT). Those not responding were scheduled for debridement. All patients were assessed using the Green O'Brian scoring system. All these patients were studied separately for clinical presentation, nutritional status (Rainey-Mcdonald nutritional index), time from onset of symptoms to presentation, treatment required, prognosis and complications. The proximal phalanx of the fourth digit and the metacarpal of the fifth digit were the most commonly involved bones in our series, with five cases of each. The capitate was the most common carpal bone, followed by the lunate. The duration of symptoms ranged from 5 weeks to 24 weeks (mean: 7.6 weeks). Most of these patients presented with complaints of pain, followed by swelling. 13 patients did not respond favourably to ATT over an 8-week period and were scheduled for surgery. Three of these patients had multidrug resistance. There was one case of a pathological fracture in our series and seven cases of arthritis/residual significant pain at the end of follow-up. For all the other patients, the results were excellent. A very high index of suspicion, MRI and early biopsy are required for a timely diagnosis of skeletal TB of the hand and wrist. Early commencement of ATT was the most important factor for good results. The possibility of multidrug resistance should be kept in mind for patients not responding to treatment.

Combined Administration of IV and Topical Tranexamic Acid is Not Superior to Either Individually in Primary Navigated TKA.

BACKGROUND: In this study, we tried to assess if combined method (intravenous [IV] and topical) of tranexamic acid (TXA) administration, which has been shown to be superior in conventional arthroplasty, has similar effect in navigational arthroplasty compared to administration of drug either individually. METHODS: In present randomized control trial, 200 patients were randomly divided in one of the 4 groups using computer-generated tables-control, IV, intraarticular, and combined. We studied evident loss through drain, total loss based on Gross method and hemoglobin balance method, hidden losses, hemoglobin and hematocrit drop, functional scores, and all possible complications related to TXA. RESULTS: Evident loss in combined group was 535.55 mL, not significantly less than IV (585 mL, P = .15) and intraarticular group (514 mL, P = .74). However, these were significantly less than control group (696 mL, P = .000). Functional scores and recovery rates were, however, comparable in all 4 groups. No patients in any group developed symptomatic deep vein thrombosis. CONCLUSION: Tranexamic use decreases blood loss in navigation-assisted arthroplasty, however, less than that observed for conventional arthroplasty in literature. Further, combined group has no added advantage over other methods of drug administration. We believe that additional amount of TXA administered in combined regimen may not be clinically useful. Further TXA group did not have any advantage in terms of functional recovery over control group.

Comparison of Radiological Parameters between Normal and Patellar Dislocation Groups in Korean Population: A Rotational Profile CT-Based Study.

PURPOSE: Patellofemoral instability is a common cause of anterior knee pain in adolescents and young adults. Most normal and pathological values for diagnosing patellofemoral instability are based on Western literature. We conducted this radiological study to determine normal values for different patellofemoral parameters in a Korean population and to evaluate their usefulness in diagnosis. MATERIALS AND METHODS: We retrospectively reviewed the rotational profile computerized tomography (CT) scans of the patellar dislocation and control groups. Trochlear, patellar, rotational profile, and trochleo-patellar alignment parameters were compared between the groups. Receiver operating characteristic curves were drawn for significant parameters, and sensitivity and specificity were calculated for the cut-off values. RESULTS: There were 48 patients in the patellar dislocation group and 87 patients in the control group. In the control group and patellar dislocation group, the mean sulcus angle was 132.5° and 143.3°, respectively, trochlear depth was 6.04 mm and 3.6 mm, bisect offset was 56.4% and 99.9%, lateral patellar tilting was 9.8° and 19.2°, patellar facet asymmetry was 63.5% and 45.16%, and the tibial tuberosity-trochlear groove (TT-TG) distance was 10.91 mm and 27.16 mm, respectively. CONCLUSIONS: The trochlear depth, bisect offset, patella tilting, and TT-TG distance were parameters that significantly contributed to patellar instability. Rotational profile CT can be considered a good diagnostic tool to assess all these parameters that help to identify anatomical aberration resulting in patellofemoral instability, thereby helping in formulating the most effective treatment plan.

Evaluation of Ponseti method in neglected clubfoot.

BACKGROUND: Gentle passive manipulation and casting by the Ponseti method have become the preferred method of treatment of clubfoot presenting at an early age. However, very few studies are available in literature on the use of Ponseti method in older children. We conducted this study to find the efficacy of Ponseti method in treating neglected clubfoot, which is a major disabler of children in developing countries. MATERIALS AND METHODS: 41 clubfeet in 30 patients, presenting after the walking age were evaluated to determine whether the Ponseti method is effective in treating neglected clubfoot. This is a prospective study. Pirani and Dimeglio scoring were done for all the feet before each casting to monitor the correction of deformity. Quantitative variables were expressed as mean ± standard deviation and compared between preoperative and postoperative followup using the paired t-test. Also, the relation between the Pirani and Dimeglio score, and age at presentation with the number of casts required was evaluated using Pearson's correlation coefficient. No improvement in Dimeglio or Ponseti score after 3 successive cast was regarded as failure of conservative management in our study. RESULTS: The mean age at presentation was 3.02 years (range 1.1 - 10.3 years). The mean followup was 2.6 years (range 2-3.9 years). The mean number of casts applied to achieve final correction were 12.8 casts (range 8 - 18 casts). The mean time of immobilization in cast was 3.6 months. The mean Dimeglio score before treatment was 15.9 and after treatment were 2.07. The mean Pirani score was 5.41 before treatment and 0.12 after treatment. All feet (100%) achieved painless plantigrade feet without any extensive soft tissue surgery. 7 feet (17%) recurred in our average followup of 2.6 years. CONCLUSIONS: Painless, supple, plantigrade, and cosmetically acceptable feet were achieved in neglected clubfeet without any extensive surgery. A fair trial of conservative Ponseti method should be tried before resorting to extensive soft tissue procedure.