Intrameniscal Cyst-Arthroscopic Open- and Closed-Door Repair Technique.

Meniscal cyst is rare and usually is associated with degenerative horizontal meniscus tears. These cysts are parameniscal in nature, as synovial fluid collects due to a check-valve mechanism. Most often, they are located on at the posteromedial aspect of the knee. Various repair techniques had been established in the literature to decompress and repair them. We describe an isolated intrameniscal cyst with an intact meniscus managed by arthroscopic open- and closed-door repair technique.

Modified Outside-in Repair Technique for Chronic Retracted, Unstable Bucket-Handle Anterior Horn Lateral Meniscal Tear.

The meniscus plays a very important role in normal functioning of the knee joint. It acts as a shock absorber, gives stability to the knee joint, delays the onset of osteoarthritis, provides load sharing, and so on. It is a well-known fact that after meniscectomy, there is a significant increase in joint reaction forces leading to early osteoarthritis. Hence, in the past decade, meniscal repair has gain enormous importance and various techniques have been developed to repair the meniscus. Conventionally, posterior-third meniscal tears are repaired with all-inside and outside-in techniques whereas middle-third meniscal tears are repaired with all 3 methods: inside out, outside in, and all inside. For tears of the anterior horn of the meniscus, only the outside-in method is used. We have developed a method for repair of chronic unreduced, retracted bucket-handle anterior horn lateral meniscal tears, in which we combined the use of both the outside-in and all-inside methods of repair. Hence, this method is called modified outside-in meniscal repair for chronic retracted bucket-handle anterior horn lateral meniscal tears.

Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts.

PURPOSE: There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic. METHODS: The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus. RESULTS: Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis. CONCLUSION: It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

To Evaluate the 'Real World' Clinical Performance of Bisoprolol in Post-Myocardial Infarction with Left Ventricular Dysfunction: Tenacity Study.

Beta-blockers are the cornerstone in management of heart failure and are well studied in Acute Coronary Syndromes (ACS). There is paucity of data of Bisoprolol in acute ICU setting in patients admitted with left ventricular systolic dysfunction (LVSD) with recent ACS, especially amongst Asian Indians. We evaluated the impact of Bisoprolol on Heart Rate (HR) and Left Ventricular Ejection Fraction (LVEF) along with metabolic indicators of HbA1C and lipid profile in post-ACS patients with LVSD at 1 year as compared to baseline. MATERIAL: This non-interventional, retrospective, single center, secondary data collection study captured demographics, comorbidities, hemodynamics, concomitant medications and assessed the effectiveness of oral Bisoprolol (1.25, 2.5 mg, 5 mg and 10mg) treatment over a 1-year follow up period, in post-ACS patients with LVSD (i.e., HFmrEF and HFrEF; LVEF <50%). Data-records of 400 patients hospitalized between August 1, 2016 to November 30, 2018 were evaluated for change in LVEF as primary endpoint and change in HR and Lipid profile, HBA1C and ST segment deviation of J point at 1 year as compared to baseline as secondary outcomes. OBSERVATION: The mean age of 400 patients was 55.28±7.9 years of which 29.75% were female. Significant improvement in LVEF (41.45±5.1% vs 48.73±5.5%) with significant reduction in heart rate (85.06±5.64 bpm vs 76.73±4.6 bpm) was observed at the end of 1-year treatment as compared to baseline (p=0.0001 and p=0.0001 respectively) on treatment with Bisoprolol (mean 4.15 + 1.4 mg). NYHA class improved from 1.6 + 0.5 to 1.11 + 0.31 at the end of 1 year. Bisoprolol along with GDMT was neutral for HbA1C (6.2±0.6 % vs 6.1±0.7%; p=0.64), while serum lipids (Total Cholesterol: 199.7 + 7.6 vs 127.6 + 4.85 mg% p=0.001; TG: 196.2 +12.1 vs 111.7 + 6.88 mg%, p=0.001; LDL: 126.9 + 9.1 vs 62.4 + 5.51 p=0.001; HDL: 33.7 + 3 vs 42.8 +1.9 p=0.001) improved at 1 year due to statins. Maximum ST deviation at J point in resting ECG was also lesser at 1 year as compared to baseline (0.29 + 1.5 mm vs 0.05 + 0.22 mm; p=0.0001). CONCLUSION: Bisoprolol administered along with GDMT to patients post-ACS with LVSD significantly improved LVEF with significant reduction in heart rate and ST segment deviation at J point at 1 year without adverse effect on lipid and HBA1C.

Single-Tunnel Double-Bundle-Like Effect With Footprint Enhancing Anterior Cruciate Ligament Reconstruction.

The anterior cruciate ligament (ACL) consists of an anteromedial bundle and a posterolateral bundle giving anteroposterior and rotational stability. It's one of the most commonly injured ligaments and also one of the most commonly performed arthroscopic procedures. Management of ACL injuries is one of the most frequently studied subjects in the literature. Surgical management of ACL injuries varies from extraarticular tenodesis to arthroscopic transtibial reconstruction to double-bundle reconstruction to anatomic single-bundle reconstruction. Although double-bundle ACL reconstruction gives more rotational stability than anatomic single-bundle, functional outcome of both are the same, but the complication rates are much higher for double-bundle reconstruction. Hence, anatomic single-bundle ACL reconstruction has gained popularity. The femoral and tibial footprint of the ACL varies in shape and size; it can be oval, elliptical, rectangular, C-shape, and more. But all available ACL reconstruction techniques prepare a circular tunnel; hence, the footprint coverage of the native ACL is maximum after double-bundle reconstruction and less after anatomic single-bundle reconstruction. So, to have the benefit of double-bundle reconstruction with a single tunnel, we propose our technique of a single-tunnel double-bundle-like effect, with the footprint enhancing ACL reconstruction using our newly designed tunnel dilators.

Single-Row Repair in Chronic Medial Collateral Ligament Insufficiency.

ABSTRACT: Medial collateral ligament (MCL) is the most commonly injured ligament of the knee. Acute Grade III MCL injuries can be managed conservatively except bony avulsion, intra-articular entrapment and Stener lesion, which requires surgical treatment by repair with or without augmentation. Chronic MCL injuries are treated surgically with various reconstruction techniques that are well established in the literature, which requires use of autograft or allograft and multiple tunnel placement with multiple implants for graft fixation. These techniques possess higher chances of tunnel convergence and hardware-related complications, further increasing surgery cost, especially for multi ligament injuries. Finally, all these MCL reconstruction surgeries are technically challenging. Here, we propose our technique of single-row repair in cases of chronic femoral side MCL insufficiency with grade III valgus laxity. This technique reattaches the torn ligament at its near anatomical attachment site using a single, double-loaded 5.5-mm suture anchor. This technique preserves and uses the native MCL, requiring no separate graft and no tunnel preparation. Hence, no graft site morbidity and tunnel-related complications, along with maintenance of proprioception. It is a cost-effective, reproducible, and technically simple procedure with good functional outcome. LEVEL I: knee. LEVEL II: collateral ligaments.

Assessment of Limb Alignment and Component Placement After All Burr Robotic-Assisted TKA.

BACKGROUND: All burr robotic-assisted total knee arthroplasty (R-TKA) is the new way of doing TKA without conventional jigs and saw. The aim of this study is to assess the accuracy of limb alignment and component placement after R-TKA. METHODS AND MATERIALS: This is the prospective study of 63 patients who underwent R-TKA between March and October 2019. Standing scanogram and AP/lateral radiograph were done on day of discharge, 5th day after surgery to calculate limb alignment and component placement angles in coronal and sagittal plane. Deformity correction Bone Ninja software had been used to calculate all this angles. RESULTS: Mean difference between robotic achieved and postoperative limb alignment was 1.24°. Mean difference between planned and achieved component placement in coronal and sagittal plane for tibia was 0.33° and 0.66° and for femur was 0.62° and 0.30°, respectively. Posterior condylar offset difference was 0.03. As per planned by Navio software, R-TKA had reduced the overall outlier of coronal limb alignment from 3° to less than 1.2° and component placement malposition to less than 1° in coronal and sagittal plane. CONCLUSION: R-TKA provides near perfect limb alignment and near accurate femoral/tibial component placement as planned in both coronal and sagittal plane. Posterior condylar offset was also perfectly maintained. R-TKA had reduced the overall outlier of coronal limb alignment from 3° to less than 1.2° and component placement malposition to less than 1° in coronal and sagittal plane.

Echocardiographic assessment of cardiac dysfunction in patients of end stage renal disease on haemodialysis.

OBJECTIVE: To assess the prevalence of systolic and diastolic dysfunction in patients of end stage renal disease (ESRD) on haemodialysis. METHODS: Seventy patients with ESRD were subjected to two-dimensional and M mode echocardiography for determination of systolic and diastolic dysfunction. All patients were evaluated clinically, biochemically and radiologically and were diagnosed as chronic kidney disease (CKD). The left ventricular ejection fraction (LVEF) and fractional shortening (FS) were taken as measures of left ventricular (LV) systolic function. Diastolic function was determined by measuring E/A ratio by spectral doppler LV inflow velocity. Echocardiographic findings of hypertensive and normotensive patients were compared. RESULTS: Out of 70 patients studied, there were 53 males (75.7%) and 17 females (24.3%). Hypertension (37.1%) was leading cause of ESRD. Echocardiography showed that left ventricular hypertrophy (LVH) was present in 74.3%. Systolic dysfunction as measured by reduced fractional shortening (<25%) and decreased LVEF (< 50%) was present in 8.6% and 24.3% respectively. Diastolic dysfunction as denoted by E/A ratio of less than 0.75 or more than 1.8 was present in 61.4% of patients. Regional wall motion abnormality (RWMA) was present in 12.9%. Pericardial effusion was noted in 14.3% of patients. Valvular calcification was noted in 7.1% of ESRD patients. Mean left ventricular internal diameter in diastole was 45.55 +/- 6.03 mm. Mean Interventricular septum diameters in systole was 12.2 +/- 1.71 mm. Mean left atrium diameter was 33.01 +/- 4.11 mm. Normotensive group was compared to hypertensive group. Statistically significant difference was noted in LVH and E/A ratio in hypertensive group as compared to normotensive group. CONCLUSION: Patients with hypertensive ESRD had higher prevalence of diastolic and systolic dysfunction as compared to normotensive counterparts.

Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively?

BACKGROUND: Some studies have shown that rotator cuff tendon (RCT) retears occur early after surgery and ultimate failure strength is reached at between 3 and 6 months. However, few clinical studies have been reported to support their theory. The purpose of this study was to determine whether the RCT integrity after repair showed any difference at 6 months and at 19 months postoperatively. METHODS: Thirty-one patients who underwent complete repair for full-thickness RCT tears that were medium-sized tears or larger and had 2 postoperative follow-up magnetic resonance imaging (MRI) scans were included in this study. Retear, fatty degeneration, and muscle atrophy were evaluated during the first and second MRI sessions. Clinical assessment was performed by use of the American Shoulder and Elbow Surgeons score, Constant score, and pain visual analog scale preoperatively and at the time of the first and second MRI scans. RESULTS: The mean time for the two consecutive MRI scans was 5.9 months (range, 3.1-8.3 months) and 19.7 months (range, 10.1-24.3 months). On the first MRI scans, 24 patients had no retear, 5 had partial retears, and 2 had full-thickness retears. In terms of rotator cuff retears, the 2 sets of MRI scans showed exactly the same statuses. The only statistically significant improvement was a reduction in tendinosis on the second MRI scans. In addition, significant improvements in clinical status were observed between the 2 periods. CONCLUSION: Our study shows that the structural status of RCTs after arthroscopic repair can be assessed at 6 months after surgery. Furthermore, although functional status improved with time after 6 months, the structural status of repaired cuffs remained unchanged.

A magnetic resonance imaging study of 100 cases of arthroscopic acromioplasty.

BACKGROUND: A hooked-type acromion has been suspected to correlate with higher rotator cuff tear or impingement syndrome. However, correlation of acromial shape after acromioplasty with the rotator cuff retears and clinical results has not been studied before. PURPOSE: To assess the shape of the acromion after arthroscopic acromioplasty and to see if there is any relation with the rotator cuff retears and clinical results. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: One hundred consecutive patients who underwent acromioplasty using a posterior cutting block technique accompanied by rotator cuff repair were included in this study. The decision was made to perform acromioplasty intraoperatively after confirmation of external impingement. Postoperative acromial shape was evaluated according to whether the acromion was flat, curved, or hooked on coronal and sagittal planes on magnetic resonance imaging (MRI) at a mean 13.4 months after surgery. Retear rates and clinical scores were compared between the hooked acromion and the others on postoperative MRI. RESULTS: Preoperatively, only 29 patients had a hooked acromion on either coronal or sagittal plane MRI. After acromioplasty of those 100 patients, 23 still showed a hooked acromion. Twenty-six of 29 preoperatively hooked acromions were changed to nonhooked acromions, and 20 of 23 postoperatively hooked acromions had been nonhooked acromions preoperatively. No difference was found in the retear rate with respect to the postoperative acromial shape. Clinically, the American Shoulder and Elbow Surgeons (ASES) score was not different between the hooked acromion and the other group (82 vs 85, P = .099). However, the Constant score of the hooked acromion group was lower than that of the other group (74 vs 85, P = .036). Ninety-four of 100 patients were contacted again for the evaluation of the ASES score at a mean 36.5 months (range, 29-45 months) and showed no difference between the hooked acromion and the other group (87 vs 87, P = .903). CONCLUSION: Even with a standard posterior cutting block technique during acromioplasty, 23% of patients still showed a hooked acromion after arthroscopic acromioplasty. Using the signs of coracoacromial ligament impingement as an indication for acromioplasty might lead to hooked acromions postoperatively, which were nonhooked acromions preoperatively. However, the retear rate showed no difference according to the postoperative acromial shape.