A Successful Arthroscopic Management of a Benign but Locally Aggressive Tenosynovial Giant Cell Tumour in the Shoulder.

Introduction Pigmented villonodular synovitis (PVNS) is a relatively rare disorder affecting the synovial membrane and tendon sheath of a joint. It rarely affects the shoulder joint. This prospective study aims to document the challenges encountered in achieving total synovectomy and assesses the clinical outcomes of arthroscopic synovectomy for PVNS in shoulder patients. Methods This is a prospective study conducted from April 2017 to September 2023. This monoarticular disease was observed among six patients (four females and two males). All patients underwent arthroscopic extensile synovectomy with biopsy and culture. The outcomes were measured using Constant score, American Shoulder and Elbow Surgeons (ASES), and University of California Los Angeles (UCLA) scores. All patients were followed up for a minimum of 36 months after arthroscopic synovectomy. Results All intraoperative findings were consistent with PVNS and confirmed with histopathological examination. All patients achieved a satisfactory, painless range of movements following surgery. The individual Constant score improved from a mean value of 64.83 to 94.50, the ASES score improved from a mean value of 81.15 to 99.73, and the UCLA score improved from a mean value of 23.16 to 34.83 post-arthroscopic intervention, proving its effectiveness. No recurrences were reported after 36 months of follow-up. Conclusion PVNS can be easily missed, and one must have a high index of suspicion to diagnose early. Delayed presentation of the disease had led to severe destruction of the joint. Early diagnosis and arthroscopic intervention prior to joint destruction are crucial for achieving a good functional outcome. Incomplete excision may lead to recurrence of the disease. Therefore, we propose extensile arthroscopic synovectomy of the shoulder, wherein by expecting and addressing the intraoperative challenges, complete excision can be achieved, thus preventing recurrence.

Bipartite Patella in an Elite Football Player - A Rare Cause of Anterior Knee Pain.

Introduction: Bipartite patella is usually an asymptomatic anatomical variant estimated to have a prevalence of 0.2-6% in an adult population. Case Report: A 28-year-old league-level football player presented with the left anterior knee pain of 6 months duration. Imaging studies revealed bilateral bipartite patella. Arthroscopic excision of the fragment was performed following which he returned to play 6 weeks after accelerated sports-specific rehabilitation. Atraumatic knee pain should raise suspicion of the bipartite patella. Surgical intervention plays a key role in patients with refractory pain after careful exclusion of other causes of anterior knee pain. Conclusion: Arthroscopic excision is preferred in the case of a high-demand athlete to accelerate recovery and fasten the return to sport duration.

Preoperative Templating of Bone-Patellar Tendon-Bone Graft for Anterior Cruciate Ligament Reconstruction: A Morphometry-Based Graft Harvest Method

Background@#Knowledge of anatomy and morphometry of the patella and patellar tendon is crucial for the selection of bonepatellar tendon-bone (BTB) graft for anterior cruciate ligament reconstruction. Graft tunnel mismatch in BTB graft especially in patients with patella alta or baja can result in compromised fixation for the bone-to-bone healing. This complication can be avoided by proper templating of graft using parameters measured from magnetic resonance imaging (MRI). The study aimed to derive morphometric data from MRI and predict the suitability of BTB graft preoperatively. @*Methods@#MRI of 1,002 knees was chosen from database after applying the eligibility criteria, which included individuals in the age group of 18–50 years (both sexes) with the intact patella and patellar tendon. Individuals with pathologies of the knee joint and associated structures such as patellar fracture/dislocations, fractures of the distal femur and proximal tibia, and avulsion of the quadriceps tendon or patellar tendon were excluded. For analysis, 1.5 Tesla, proton density, and fat-suppressed sequences of sagittal and axial sections of T2-weighted MRI images were used. @*Results@#Mean age of the 1,002 patients was 35.45 years and there were 290 women and 712 men. Respective measurements were as follows: patella length, width, and thickness, 40.3 mm, 40.2 mm, and 18.6 mm, respectively; patellar tendon length, width, and insertional thickness, 45.2 mm, 27.2 mm, and 5.7 mm, respectively; Insall-Salvati ratio, 1.13; overall graft length, 90.2 mm; and effective tendon length, 26.1 mm. @*Conclusions@#A simple MRI analysis can give us valuable inputs on BTB graft morphometry. The values can also help us with the near-perfect graft harvest. The intraoperative complication of graft tunnel mismatch can be avoided by predicting the overall graft length, effective tendon length, tibial tunnel length, and patellar position using the measured parameters on MRI.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons.

AIM: Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. MATERIALS AND METHODS: 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. RESULTS: Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. CONCLUSIONS: A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Plyometric-based Training for Isokinetic Knee Strength and Jump Performance in Cricket Fast Bowlers.

Competitive cricket demands a high level of performance from fast bowlers. Ground reaction forces during the landing phase pose a risk for lower limb and lumbar spine injury. Good dynamic knee strength allows the knee to flex to absorb these forces and extend prior to ball release for maximum efficiency. Plyometric training has been shown to improve dynamic strength. There is a lack of literature on this subject for cricket. This study evaluated the effect of a combined plyometric and strength training program on isokinetic knee strength of fast bowlers. Forty-two professional fast bowlers were randomly assigned to a training group (n=21) and a control group (n=21). Both groups underwent isokinetic knee strength and vertical and standing broad-jump testing. Quadriceps and hamstring concentric and eccentric peak torques, bilateral strength asymmetries (BSAs), and dynamic control ratios (DCRs) were evaluated by isokinetic testing. The study group underwent 12 weeks of plyometric training, whereas the control group continued with their own training methods. The study group showed a significant improvement (p<0.05) in jump performance and eccentric strength. There was a reduction in the proportion of bowlers with poor BSA and DCR. Improving dynamic knee strength through plyometric training reduces injury risk and improves performance in cricket fast bowlers.

Proteases, proteolysis and inflammatory molecules in the tears of people with keratoconus.

PURPOSE: To investigate the expression of proteases, proteolytic activity and cytokines in the tear film of people with keratoconus. METHODS: Basal tears from people with keratoconus, from individuals who had undergone corneal collagen cross-linking for the treatment of keratoconus, and from normal controls were collected using a capillary tube. Corneal curvature of each subject was mapped. The total protein in tears was estimated. Levels and activity of proteases in the tears were analysed using specific antibody arrays and activity assays. RESULTS: The total tear protein level was significantly reduced in keratoconus (4.1 ± 0.9 mg/ml) compared with normals (6.7 ± 1.4 mg/ml) (p < 0.0001) or subjects who had undergone corneal collagen cross-linking (5.7 ± 2.3 mg/ml) (p < 0.005). Significantly (p < 0.05) increased tear expression of matrix metalloproteinases (MMP) -1, -3, -7, -13, interleukins (IL) -4, -5, -6, -8 and tumour necrosis factor (TNF) -α, -ß were evident in keratoconus. Tear IL-6 was the only cytokine significantly (p < 0.05) increased in tears of keratoconus subjects compared with the collagen cross-linked group. No significant difference in tear proteases were observed between the normal and the cross-linked groups, although the expression of TNF-α was significantly (p < 0.05) increased in the cross-linked group compared with the controls. Elevated gelatinolytic (87.5 ± 33.6 versus 45.8 ± 24.6 FIU, p < 0.0001) and collagenolytic (6.1 ± 3.2 versus 3.6 ± 2.0 FIU, p < 0.05) activities were observed in tears from keratoconus compared with normal subjects. The activity of tear gelatinases (69.6 ± 22.2 FIU) and collagenases (5.7 ± 3.3 FIU) in the collagen cross-linked group was not significantly different compared with either keratoconus or normals. CONCLUSION: Tears of people with keratoconus had 1.9 times higher levels of proteolytic activity and over expression of several MMPs and cytokines compared with tears from controls. Further investigations are required to study the possible implications of these changes and whether they can be used to monitor disease progression or determine the success of corneal collagen cross-linking.

Levels of lactoferrin, secretory IgA and serum albumin in the tear film of people with keratoconus.

Keratoconus is a degenerating disease of the eye which causes an irregularly shaped cornea leading to severe impairment of vision. Tear proteomics in keratoconus has been a topic of substantial discussion and speculation over many years. This study was designed to examine the levels of total protein, lactoferrin, secretory IgA and serum albumin in the tear film of people with keratoconus. Basal tears were collected using a capillary tube and corneal curvature was mapped using a topographer. Total protein in tears was estimated. The amount of regulated protein lactoferrin, constitutive protein sIgA and serum protein albumin was measured using specific ELISAs. The changes in protein concentrations in tears were correlated to the degree of corneal asphericity. There was a two-fold (p<0.0001) decrease in total protein levels between keratoconus (3.86 ± 1.62 mg/ml) and normal (7.00 ± 1.58 mg/ml) tears. The amount of lactoferrin (0.67 ± 0.28 vs. 1.13 ± 0.29 mg/ml) and secretory IgA (0.78 ± 0.36 vs. 1.70 ± 0.66 mg/ml) were significantly (p<0.0001) reduced in keratoconus tears. Variation in serum albumin levels between keratoconus (8.18 ± 4.72 µg/ml) and normal tears (11.66 ± 8.20 µg/ml) were not significant. The differences in total protein, lactoferrin and secretory IgA were not associated with contact lens wear, age, gender or atopy of subjects. The keratometry reading was negatively correlated to tear levels of total protein (r = -0.59, p < 0.01) lactoferrin (r = -0.40, p < 0.05) and secretory IgA (r = -0.34, p < 0.05). The tears of keratoconus subjects appear to have an altered protein profile, and one that might change with the severity of the disease. These findings may lead the way to understanding or monitoring disease progression.