Symptomatic ACL mucoid degeneration in middle-age athletes.

Background: Mucoid degeneration of the anterior cruciate ligament (ACL) is an uncommon non-traumatic cause of knee pain and motion restriction, typically seen in a middle-aged population. Primarily, the management consists of partial arthroscopic debridement and notchplasty, which has proven satisfactory clinical and functional outcomes. Study objectives: This review aims to highlight key clinical, radiological and arthroscopic findings of mucoid ACL degeneration, and also to provide an approach to manage a symptomatic middle-aged athlete. Rationale: Due to the paucity of literature on ACL mucoid degeneration, symptomatic presentation in a middle-aged athlete can be challenging to manage. Diffuse central pain, motion restriction in extension or flexion, absence of trauma, and an intact enlarged ACL on Magnetic resonance imaging (MRI) should raise suspicion for mucoid degeneration in middle-aged athletes. Specific radiological and arthroscopic findings can help to confirm the diagnosis. In this review article, we have also described a new clinical test to mimic the pain due to anterior impingement in the presence of an enlarged ACL. Conclusion: In symptomatic middle-aged athletes, knowledge of characteristic findings can help in the timely diagnosis of mucoid degeneration of ACL. Treatment options include arthroscopic debridement, notchplasty, ACL augmentation, and ACL reconstruction. The presence of associated injuries can influence return-to-sports prognosis.

A Rare Cause of Ankle Pain - Chondrosarcoma of the Talus: A Case Report and Literature Review.

Introduction: Chondrosarcoma of the talus is one of the rare causes of ankle pain. Often this pain is neglected by the patients. Hence, the presentation is late. A rare occurrence, lack of clinical familiarity, and resemblance to enchondroma make the diagnosis of chondrosarcoma difficult. Case Report: We present a case of chondrosarcoma of talus in a 42-year-old female, which is an uncommon site of occurrence. In the presence of non-classical radiologic and histologic findings, the patient was treated with below-knee amputation. At present, the patient is disease-free and walking with a prosthesis. Conclusion: Talus is an infrequent site for chondrosarcoma. When affected, it presents as vague ankle pain. A patient can be underdiagnosed as there are no clear radiological and histological guidelines to differentiate between benign and low-grade cartilaginous tumors such as enchondroma and low-grade chondrosarcoma. Histologically proven benign lesions must be followed for a long time in suspicion of malignancy. The treatment of chondrosarcoma of the talus can vary from local wide excision to below-knee amputation, depending on the grade of malignancy.

Anatomic Considerations of Anterior Transarticular Screw Fixation for Atlantoaxial Instability.

STUDY DESIGN: Cadaveric, observational study. PURPOSE: Atlantoaxial instability (AAI) is characterized by excessive movement at the C1-C2 junction between the atlas and axis. An anterior surgical approach to expose the upper cervical spine for internal fixation and bone grafting has been developed to fix AAI. Currently, no anatomic information exists on the anterior transarticular atlantoaxial screw or screw and plate fixation between C1 and C2 in the Indian population. The objective of this study is to assess the anatomic landmarks of C1-C2 vertebrae: entry point, trajectory, screw length, and safety of the procedure. OVERVIEW OF LITERATURE: Methods outlined by Magerl and Harms are the optimal approaches among the dorsal techniques. Contraindications for these techniques include aberrant location of vertebral arteries, fractures of C1-C2 posterior structures. In these cases, anterior transarticular fixation is an alternative. Several available screw insertion trajectories have been reported. Biomechanical studies have demonstrated that adequate rigidity of this fixation is comparable with posterior fusion techniques. METHODS: Direct measurements using Vernier calipers and a goniometer were recorded from 30 embalmed human cadavers. The primary parameters measured were the minimum and maximum lateral and posterior angulations of the screw in the sagittal and coronal planes, respectively, and optimum screw length, if it was placed accurately. RESULTS: The posterior and lateral angles of screw placement in the coronal and sagittal planes ranged from 16° to 30° (mean±standard deviation [SD], 23.93°±3.93°) and 8° to 17° (mean±SD, 13.3°±2.26°), respectively. The optimum screw length was 25-38 mm (mean±SD, 28.76±3.69 mm). CONCLUSIONS: If the screw was inserted without lateral angulation, the spinal canal or cord could be violated. If a longer screw was inserted with greater posterior angulation, the vertebral artery at the posterior or posterolateral aspect of the C1 superior facet could be violated. Thus, 26° and 30° of lateral and posterior angulations, respectively, are the maximum angles permissible to avoid injury of the vertebral artery and violations of the spinal canal or atlanto-occipital joint.

A proposed radiological classification system of Hoffa's fracture based on fracture configuration and consequent optimal treatment strategy along with the review of literature.

BACKGROUND: Coronal fractures of distal end femur, referred as Hoffa's fracture are not uncommon, yet easily missed injuries lacking proper classification system and consensus for ideal treatment. While most trauma surgeons adopt different strategies based on the fracture configuration and their own experience, there are no set ways to classify these based on the most appropriate treatment strategy. METHODS: Thirty cases of Hoffa fracture from tertiary care centres were studied for the fracture pattern, fragment size, comminution and possible variations to formulate a radiological classification and treatment guidelines. Additionally, a literature search was used to analyze 77 case studies based on Hoffa fracture to find out the common fracture patterns and treatment modalities adopted for varying fracture patterns in these studies. Six independent observers participated in testing the inter-observer reliability of the proposed classification. RESULTS: A new proposed radiological classification for Hoffa fracture consists of four main types. Type 1 is with fracture fragment >2.5 cm, Type 2 with fragment <2.5 cm, Type 3 is comminuted fracture, Type 4 are subdivided as Type 4a - Anterior, Type 4b - Bicondylar, Type 4c - Osteochondral type and Type 4d - With supracondylar extension. Optimum treatment modality depends on the type of Hoffa's fracture and has been suggested in the study. Interobserver reliability demonstrated that overall agreement was 0.907692 with a fixed marginal Kappa of 0.881067 and free Marginal Kappa at 0.892308. Intra-observer reliability test for the classification system showed a strong Kappa value of +1.0. CONCLUSION: The new suggested classification helps identify different types of Hoffa's fracture. This is likely to help decide optimal surgical treatment depending on the nature of the injury. The classification system has high inter and intra-observer reliability that enables its universal applicability.

Prevalence of Radiographic Morphology of Femoroacetabular Impingement in Indian Population: A Multicenter Study.

BACKGROUND: Femoroacetabular impingement (FAI) is an overlooked entity in India, as primary osteoarthritis of hip is uncommon in Indian population. The purpose of this study is to find out the prevalence of radiographic morphology of FAI in young asymptomatic population in India. METHODS: This is a multicenter, cross-sectional study. Radiographs of 500 young asymptomatic volunteers were taken from 10 centers across India. Suboptimal imaging lead to exclusion of 48 radiographs. Crossover sign, ischial spine sign, and posterior wall sign were included in "acetabular rotation abnormalities (R)," lateral center-edge angle and acetabular index were included in "acetabular overcoverage abnormalities (O)" while pistol grip deformity and alpha angle in "femoral abnormalities (F)." Furthermore, all the hips were divided into 4 types: normal hips (N); type I hip with single abnormality (R/O/F); type II with combination of any 2 (RO/RF/OF), and type III with all 3 abnormalities. RESULTS: Sixty-eight percent of 904 hips had at least 1 type of abnormality with 47.5% hips having signs of pincer impingement, 7.9% with signs of cam impingement, and 10.8% with mixed signs. Type I.R hips (32%) were the most common hips followed by type I.O hips (18%) and type I.F (8%). Males had higher percentage of abnormalities (1.5 times) compared to females. Interobserver reliability was 0.55 to 0.81 for all the parameters. Power of study was 0.98. CONCLUSION: Radiographic morphology of FAI exists with high prevalence in young asymptomatic Indian population similar to other ethnicities except for low prevalence of cam morphology. Long-term follow-up of this cohort will reveal the natural history of these morphologies.

Cross Pinning Versus Lateral Pinning in the Management of Type III Supracondylar Humerus Fractures in Children.

INTRODUCTION: Closed reduction of supracondylar humerus fractures with K-wires has become the standard line of management with different opinions regarding the technique that is utilized. AIM: To compare the functional and radiological outcomes of lateral and cross pinning technique in supracondylar fractures of humerus in children. MATERIALS AND METHODS: A prospective study with 57 cases of displaced fracture supracondylar humerus, treated by lateral (Group A n=28) and cross pinning (Group B n=29), was conducted between May 2013 and May 2015. Independent sample student's t-test was done to assess the parameters like age, follow-up and duration of surgery. The results were expressed as mean with standard deviation and p<0.05 was considered as statistically significant. RESULTS: As per the Gartland classification system, 46 (80.7%) patients had Type IIIA and 11 (19.2%) patients had Type IIIB fracture. The average surgical time was 28.3±1.6 minutes in Group A and 30±3.6 minutes in Group B (p=0.02). About, 3.5% patients in Group A had pin loosening. As per the Flynn criteria, 78.6% in Group A and 79.3% in Group B had excellent results. CONCLUSION: No significant difference in terms of functional and radiological outcome was observed between both the techniques. Thus, both the techniques have equal results.