Multimodality Imaging in Metabolic Syndrome: State-of-the-Art Review.

Metabolic syndrome comprises a set of risk factors that include abdominal obesity, impaired glucose tolerance, hypertriglyceridemia, low high-density lipoprotein levels, and high blood pressure, at least three of which must be fulfilled for diagnosis. Metabolic syndrome has been linked to an increased risk of cardiovascular disease and type 2 diabetes mellitus. Multimodality imaging plays an important role in metabolic syndrome, including diagnosis, risk stratification, and assessment of complications. CT and MRI are the primary tools for quantification of excess fat, including subcutaneous and visceral adipose tissue, as well as fat around organs, which are associated with increased cardiovascular risk. PET has been shown to detect signs of insulin resistance and may detect ectopic sites of brown fat. Cardiovascular disease is an important complication of metabolic syndrome, resulting in subclinical or symptomatic coronary artery disease, alterations in cardiac structure and function with potential progression to heart failure, and systemic vascular disease. CT angiography provides comprehensive evaluation of the coronary and systemic arteries, while cardiac MRI assesses cardiac structure, function, myocardial ischemia, and infarction. Liver damage results from a spectrum of nonalcoholic fatty liver disease ranging from steatosis to fibrosis and possible cirrhosis. US, CT, and MRI are useful in assessing steatosis and can be performed to detect and grade hepatic fibrosis, particularly using elastography techniques. Metabolic syndrome also has deleterious effects on the pancreas, kidney, gastrointestinal tract, and ovaries, including increased risk for several malignancies. Metabolic syndrome is associated with cerebral infarcts, best evaluated with MRI, and has been linked with cognitive decline. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Pickhardt in this issue.

Multisystem Imaging Manifestations of Kidney Failure.

Kidney failure (KF) refers to a progressive decline in glomerular filtration rate to below 15 ml/min per 1.73 m2, necessitating renal replacement therapy with dialysis or renal transplant. The hemodynamic and metabolic alterations in KF combined with a proinflammatory and coagulopathic state leads to complex multisystemic complications. The imaging hallmark of systemic manifestations of KF is bone resorption caused by secondary hyperparathyroidism. Other musculoskeletal complications include brown tumor, osteosclerosis, calcinosis, soft-tissue calcification, and amyloid arthropathy. Cardiovascular complications and infections are the leading causes of death in KF. Cardiovascular complications include accelerated atherosclerosis, cardiomyopathy, pericarditis, myocardial calcinosis, and venous thromboembolism. Neurologic complications such as encephalopathy, osmotic demyelination, cerebrovascular disease, and opportunistic infections are also frequently encountered. Pulmonary complications include edema and calcifications. Radiography and CT are used in assessing musculoskeletal and thoracic complications, while MRI plays a key role in assessing neurologic and cardiovascular complications. CT iodinated contrast material is generally avoided in patients with KF except in situations where the benefit of contrast-enhanced CT outweighs the risks and in patients already undergoing maintenance dialysis. At MRI, group II gadolinium-based contrast material can be safely administered in patients with KF. The authors discuss the extrarenal systemic manifestations of KF, the choice of imaging modality in their assessment, and imaging findings of complications. ©RSNA, 2024 Supplemental material is available for this article.

Effect of Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers on COVID-19 outcome: A Record Based Observational Study in West Bengal.

BACKGROUND: Since its first identification in December 2019, in WUHAN (CHINA), SARS-COV-2, causative agent of Corona virus pandemic, has affected millions of people worldwide, causing thousands of death. There is much speculation about the interplay between ACEI/ARB and Corona virus infection, as for internalization into host cell SARS-COV-2 binds through S spike protein to ACE-2, aided TMPRSS2. METHODS: A record based observational study has been conducted (data obtained from the clinics of fourteen physicians) in two worst affected districts of West Bengal, to find out the association of ACEI/ARB on patients, suffering from Corona virus infection. The study-protocol has already been approved by Clinical Research Ethics Committee of Calcutta School of Tropical Medicine. (IEC Ref. No: CREC-STM/2020-AS-37) Results: Increasing age, male sex and presence of co-morbidities (viz. Diabetes, COPD) are significantly associated with the occurrence of moderate and severe disease. Drugs (viz. ACEI/ARB), though are associated with less severe disease, have not achieved statistical significance, in the present study. CONCLUSION: Drugs, like ACEI/ARB, should be continued in patients suffering from COVID-19 infection, (if they are already on these drugs).

Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients.

BACKGROUND: Fracture of the capitellum is an often missed or inadequately treated serious elbow injury. Anatomic reduction and proper stabilization are essential to obtain articular congruity so that late-onset arthritis can be avoided. The main areas of interest in this intriguing fracture are the choice of implant and the surgical approach. We describe the use of anterolateral approach and headless double-threaded compression screws for the fixation of this fracture. MATERIALS AND METHODS: This prospective study included 16 capitellar fractures. A computed tomography scan was done for delineating the fracture line and planning the fixation technique. All fractures were treated with headless double-threaded compression screws using an anterolateral approach, over a period of 3 years, with a mean follow-up of 2.3 years (range, 1.5-4 years). RESULTS: The average time to bony union was 3.5 months (range, 2.5-5 months) with no malunion or nonunion. The mean range of flexion was 132° (range, 125°-135°). The average extensor lag was 10° (range, 0°-25°), but the range of motion remained functional in all patients. On the final follow-up, no evidence of osteonecrosis, post-traumatic osteoarthritis, or heterotrophic ossification was seen. The outcome was excellent in 10 patients, and 6 patients had a good result. CONCLUSIONS: The success of management of a capitellar fracture depends on an early diagnosis by keeping a high index of suspicion and timely management. Adequate exposure of the fracture is of paramount importance to achieve accurate reduction. This can be satisfactorily achieved by an anterolateral approach to the elbow. An adequate fixation of the fractured fragments can be achieved by the use of headless double-threaded compression screws.

Reversed distal femoral locking plate for failed proximal femoral nail with non-union of proximal femoral fractures.

INTRODUCTION: Failure of proximal femoral fracture managed by proximal femoral nail (PFN) leads to a very difficult situation to handle with conventional techniques, and reversed distal femoral locking compression plate (DF-LCP) is of great benefit in these selective cases. METHODS: Twelve patients with ununited proximal femoral fractures including subtrochanteric fractures with a failed PFN implant were included in the study. All patients with periprosthetic fractures and fractures treated by implants other than PFN were excluded from this study. RESULT: All fractures went into union in an average time of nine months and 15 days with no implant failures. The mean time of re-osteosynthesis after the primary index surgery of PFN was one year eight months. Mean surgical time of re-osteosynthesis was 110 minutes, and average blood loss during surgery was 550 ml. DISCUSSION: The PFM is one of the most commonly used implant for unstable proximal femur fractures. The use of PFN is technically demanding and is associated with high failure rates. Although dynamic compression screw (DCS), proximal femoral locking plate (PF-LCP) and other implants can be used in these failed situations, they are associated with a high complication rate. The reversed DF-LCP is a rescue implant for these complex situations. Apart from anatomical and biomechanical advantages, there are several other clinical benefits of using DF-LCP. CONCLUSION: We conclude that DF-LCP is a potential and safe implant of choice for the management of nonunion associated with failed PFN. It may be considered an implant of choice as rescue from such a complex situation. It offers several anatomical, biomechanical and clinical advantages over other available conventional implants.

Bilateral segmental pelvic and femoral fractures in a young female: A rare case report.

The management of multiple complicated injured patients remains a great challenge despite advance- ments in modern medical care. We present a rare case of bilateral unstable pelvic fractures associated with bilateral segmental femoral shaft fractures.We have proposed a mechanism of such complex injury pattern and discussed the plan of management. We believe that a timely and aggressive surgical intervention to fix all the major fractures soon after medically stabilizing the patient helped our patient to overcome these serious and lethal injuries. It is necessary to establish an optimal protocol for management of such complex fractures by conducting prospective and multicentric studies in the future.

Outcome of patients on second line antiretroviral therapy under programmatic condition in India.

BACKGROUND: The National AIDS Control Organization of India has been providing free second line antiretroviral therapy (ART) since 2008. This observational study reports the survival and virologic suppression of patients on second-line ART under programmatic condition and type of mutations acquired by those failing therapy. METHODS: 170 patients initiated on second-line therapy between 2008 and 2012 were followed up till 2013. Viral Load (VL) was repeated at 6 months for all patients and at 12 months for those with VL >400 copies/ml at 6 months. Adequate virological response was defined as plasma HIV-1 VL <400 copies/ml and virological failure was defined as VL >1000 copies/ml. Genotyping was done in 16 patients with virological failure. RESULTS: Out of 170 patients, 110 (64.7 %) were alive and on therapy and 35 (20.5 %) expired. In the first year the occurrence of death was 13.7 /100 person years while between 1 and 5 year it was 3.88 /100 person years. In the first year, duration of immunological failure >12 months, weight <45 kg, WHO clinical stage 3 and 4 and WHO criteria CD4 count less than pretherapy baseline [hazard ratio HR 4.2. 15.8, 11.9 & 4.1 respectively] and beyond first year poor first and second line adherence and first line CD4 count < 200/µL [HR 5.2,15.8, 3.3 respectively] had high risk of death. 119/152 (78.2 %) had adequate virological response and 27/152 (17.7 %) had virological failure. High viral load at baseline and poor second line adherence (Odds Ratio 3.4 & 2.8 respectively) had increased risk of virological failure. Among those genotyped, 50 % had major Protease Inhibitor mutation (M46I commonest) however 87.5 % were still susceptible to darunavir. CONCLUSIONS: Second line therapy has shown high early mortality but good virological suppression under programmatic conditions.

A Giant Ganglion Cyst Arising from Lateral Hoffa's Fat Pad of the Knee.

INTRODUCTION: The ganglion cysts are benign fluid-filled sacs, which often arise from a tendon sheath or a joint capsule. Their origin from the fat pad of the knee is rare. Several studies have described intra-articular ganglion cysts in detail; however, extra-articular soft-tissue ganglion cysts have been reported sparingly. We report a rare case of giant ganglion cyst arising from lateral Hoffa's fat pad (HFP). CASE REPORT: A 59-year-old male patient presented with a 3-year history of swelling of the left knee, with occasional pain. There was no history of trauma or any constitutional symptoms. There was an apparent swelling (10 cm ×5 cm in size) around the anterolateral aspect of the knee joint. A magnetic resonance imaging (MRI) scan revealed a multilobular, complex cystic lesion of the lateral HFP. Surgical excision of the cyst was done, and histopathological examination confirmed the diagnosis of the ganglion cyst. CONCLUSION: Cysts and cystic-appearing lesions around the knee are not uncommon, but a ganglion cyst arising from HFP is rare. The presence of multipotent cells in the HFP may be responsible for producing a variety of cyst and cyst-like tumors around the anterior aspect of the knee joint. An MRI is the best imaging modality for the diagnosis of these cysts and cysts-like lesions around the knee. We recommend that the smaller intra-articular lesions can be resected arthroscopically, but larger lesions, with extraarticular extension, are best treated by open resection to avoid incomplete excision and recurrence.

Erratum: Retraction notice to 'Surgical approaches for Total Knee Arthroplasty' J Clin Orthop Trauma volume 7 (71-79).

[This corrects the article DOI: 10.1016/j.jcot.2015.11.003.].

Is early exploration of secondary radial nerve injury in patients with humerus shaft fracture justified?

BACKGROUND: Radial nerve is commonly injured with a fracture of the shaft of the humerus. Primary radial nerve injury occurs at the time of fracture, and secondary nerve injuries are seen after closed reduction or operative management. Management of these secondary nerve injuries is controversial regarding conservative approach verses early exploration. MATERIALS AND METHODS: The PubMed, Science Direct, Scopus, and Google Scholar were used to find out relevant studies in the English language from October 2007 to October 2017. After a search of total 114 articles, we excluded 107 articles which did not meet our inclusion criteria, and only seven studies were thoroughly reviewed. RESULTS: Among the seven studies, three studies by Wang JP, Wang X, and Reichert P have included only secondary radial nerve injuries. Studies by Noaman H, Gouse M, Schwab TR and Bhardwaj A have included both primary as well as secondary radial nerve injury cases. Four studies used a conservative strategy and late exploration was advocated only if no nerve recovery was found within three to five months. Three studies recommended early radial nerve exploration (within the first two weeks) in patients with secondary radial nerve injury. CONCLUSIONS: The pattern and duration of radial nerve recovery in secondary nerve injury was similar to that seen in primary radial nerve palsy. No advantage was seen in the early exploration of the radial nerve in most of these studies. If there is no misplaced instrumentation, macroscopic laceration of nerve or fracture displacement in the postoperative radiograph, secondary radial nerve injury can be treated as a primary radial nerve injury, and we recommend observation for a minimum of four to five months before exploration.

Bilateral simultaneous anterior cruciate ligament reconstruction: A case series and review of the literature.

Bilateral ACL rupture is a relatively uncommon injury with an incidence of 2-4%. Most bilateral ACL rupture occurs at two different times, but few cases of single-staged bilateral ACL ruptures have also been reported. There have been reports of both single-staged, and two-staged reconstruction of bilateral ACL ruptures in the literature but without a clear consensus. We present a series of five bilateral ACL rupture cases managed by single-staged arthroscopic ACL reconstruction, using quadrupled hamstring grafts. All of them were young males, with an average age of 26.8 years (Range: 19-39 years). Three out of five of these cases (60%) had sustained the injury to both the knees simultaneously while playing sports. All the five patients had generalized joint laxity with significant hyperextension of their knees. All the ten knees (in five patients) were clinically stable, at their last follow-ups. None of the knees had any early or late complications. A single-staged bilateral ACL reconstruction is a safe, reproducible, and cost-effective procedure for patients with a bilateral ACL deficient knee, in experienced hands.

Management of loose osteochondritis dissecans in an adolescent.

Osteochondritis dissecans (OCD) of the knee joint affects subchondral bone first, and then it involves the articular cartilage. It can cause pain, effusion and loose body formation. Nonoperative treatment is for the stable lesion, but if the lesion is unstable and symptomatic, then operative management is needed. Short term goal of the treatment is pain relief, and the long-term goal is the prevention of early arthritis. Surgical treatment includes removal of loose body, microfractures, osteochondral autograft and allograft transplantation, autologous chondrocyte implantation (ACI), arthroscopic removal of the loose body and internal fixation of the fragment using k wire or screw. We successfully managed an adolescent with a loose OCD fragment with an arthroscopic evaluation, removal of the loose body and refixation of the loose fragment to the parent location, using three bio screws.

Heterotopic Ossification of Tendo Achilles: An Uncommon Clinical Entity.

INTRODUCTION: Heterotopic ossification of tendo Achilles (HOTA) is an uncommon clinical condition with unknown etiology. However, there are noted factors associated with this condition including trauma, metabolic conditions, infections, and genetic predisposition. The diagnosis can be made clinically and radiologically. We are reporting a rare case of HOTA managed surgically. CASE REPORT: A 48-year-old healthy man with no history of trauma presented with pains and swelling of the posterior aspect of the left ankle and lower calf. The local examination revealed mass about 2 inches above the left ankle. A plain radiograph revealed a bony mass at the left TA region. The magnetic resonance imaging confirmed the presence of a bony mass within the substance of TA. All the clinical and biochemical laboratory tests were within normal limits. The heterotopic bone mass was removed, using a posterior longitudinal incision over the left TA, centering over the bony mass. At 6 months of follow-up, the patient had no pain, swelling, and a full range of ankle movements. CONCLUSION: Conservative approach may suffice in most of the patients while surgery is reserved for failed conservative treatment.

A systematic review and meta-analysis of complications in conversion arthroplasty methods for failed intertrochanteric fracture fixation.

BACKGROUND: Conversion arthroplasty for failed primary fixation of intertrochanteric fractures can be achieved using various methods, including cemented total hip arthroplasty, uncemented total hip arthroplasty, hybrid total hip arthroplasty, and hemiarthroplasty. Complication rates vary between each conversion method. The purpose of this paper is to examine the effect of conversion method on total conversion complication rates. METHODS: We performed a meta-analysis of five studies with sufficient data for analysis. We created a null hypothesis stating that the expected distribution of complications across conversion methods would reflect the distribution of conversion method used for failed primary fixation. Using a z test, we compared proportions of the expected distribution of complications to the observed distribution of complications. RESULTS: A total of 138 cases of conversion arthroplasty with 49 complications were available for analysis. The mean age was 73 (range, 32-96) years. 19 males and 48 females were included, with one study not including patient gender. The mean time from primary fixation failure to conversion was 11 months, and the mean duration of conversion surgery was 132 min. Expected and observed complication rate distributions were as follows: cemented total hip arthroplasty, 6.5% versus 4.1% (p = 0.79); uncemented total hip arthroplasty, 77.5% versus 81.6% (p = 0.69); hybrid total hip arthroplasty, 2.9% versus 2.0% (p = 1); and hemiarthroplasty, 13% versus 12.2% (p = 1). CONCLUSIONS: Our findings suggest that the method of conversion arthroplasty following failed primary intertrochanteric femur fracture fixation does not influence complication rate.

Vascular supply at risk during lateral release of the patella during total knee arthroplasty: A cadaveric study.

INTRODUCTION: Lateral release to improve patellar tracking is commonly performed during total knee arthroplasty. Blood is supplied to the lateral patella by two main arteries: the superior and inferior lateral genicular arteries. The transverse infrapatellar artery also branches off the lateral inferior genicular artery to supply the inferior half of the patella. Severance of any of these arteries during lateral release can lead to avascular necrosis of the patella. This cadaveric study investigates the lateral vasculature to the patella and whether it can be visualized and preserved during lateral release of the patella. MATERIALS AND METHODS: This study involved ten cadavers, each of which underwent lateral release of the patella. One senior joint surgeon performed and supervised the incisions and attempted to locate and preserve these vessels. We then quantified the number of cadavers with visualized blood vessels and analysed their location and course to determine whether they could be preserved during lateral release of the patella. RESULTS: In our study, three of the ten cadavers had an artery that was visible within the incisional plane and preserved. Two were the inferior lateral genicular artery, and one was the superior lateral genicular artery. In the other seven cadavers, no vessels were visualized during the lateral dissection. CONCLUSIONS: These results demonstrate that it is difficult to visualize blood supply to the patella during lateral release. Every attempt should be made to preserve these blood vessels to avoid devascularization to patella in the setting of an already severed medial vascularity due to standard approach to knee replacement.

Growth modulation by hemi epiphysiodesis using eight-plate in Genu valgum in Paediatric population.

INTRODUCTION: Genu valgum is an angular deformity of the knee, often treated surgically by osteotomy or by growth modulation (using tension band, staples, transphyseal screws and eight-plate which require removal after correction). With this study, we attempt to evaluate the efficacy, rate of correction and complications with the use of 8-plate in the correction of genu valgum deformity in children. MATERIAL AND METHOD: In a retrospective study of 24 patients with 11 bilateral and 13 unilateral (35 knees) genu valgum deformity which required surgical corrections were included. There were 11 males, and 13 females and all of them were treated with Steven's technique (Stevens, 2006) using eight-plate and monitored closely. RESULT: Twenty-four patients with an average age of 10 years and 8 months (range: 5 yrs, 7 months-14 yrs, 2 months), with the mean preoperative & post-implant removal (Post-IR) tibiofemoral angle of 22.02° ± 5.15° (range 14°-31°) & 6.14° ± 1.92° (range 2°-10°) respectively, required an average time period of 1yr & 5m ± 5 m (range 10 months-28 months) for correction after which implants were removed. Of the 35 limbs, we achieved excellent results in 91.6%. One case (4.16%) had a partial correction of the deformity, and one case (4.16%) had reported with a superficial infection which was taken care. There were 2 cases (8.33%) of over-correction, which was gradually self-corrected during follow-up. CONCLUSION: Our results reflect the efficacy of flexible titanium eight plate which corrects angular deformity by acting as a tension band on one side of the growth plate and offers the advantage of reversible Hemi epiphyseal growth modulation. Guided growth modulation is a best available alternative for the treatment of an angular deformity in the patients with open physis.

Short term outcomes of long duration versus short duration tourniquet in primary total knee arthroplasty: A randomized controlled trial.

INTRODUCTION: A tourniquet is used during the total knee replacement surgery to improve the visibility, to reduce the blood loss and for better cementation. Indirectly it decreases the duration of surgery and enhances the recovery of the patient. Their use however is controversial due to some side effects associated with the use of tourniquet. They may increase the risk of deep vein thrombosis and pulmonary embolism by causing venous stasis, endothelial damage and increased platelet adhesion secondary to distal limb ischemia. MATERIAL AND METHODS: We conducted a randomized controlled trial (RCT) to examine the benefits and risks associated with the use of long duration over short duration tourniquets during TKA. The study was a prospective randomised control trial with a total of 80 knees (40 knees in each group) included in the study. The knees selected for surgery were randomly allocated to one of the two groups: Group A - long duration tourniquet (LT-group) or Group B - short duration tourniquet (ST-group). RESULT: The average operating time in Group A (43.53±3.11 minutes) was statistically less significant than that of Group B (51.7±2.56 minutes). Intra-operative blood loss in Group B, was significantly more than that of Group A. Post-operative blood loss in the drain was more in long duration tourniquet group. Total blood loss (intra-operative + post-operative) was more in short duration tourniquet group. Pain score (using VAS scale) was comparable in both the groups at the end of the second and sixth week. At sixth weeks there was no significant difference in the range of motion in both the groups. The KSS score was not significantly different in both the groups in post operative period at first, second, and six weeks. There were no events of thrombo-embolism and deep vein thrombosis in either groups. In 11 patients (27.5%) of long duration tourniquet group, swelling, and redness of knee was seen post operatively as compared to three patients (7.5%) of short duration tourniquet group. CONCLUSION: The use of a short duration tourniquet during TKA gives better symptomatic pain relief in the early postoperative period as compared to long duration use of tourniquet. However, this is associated with increased blood loss, more operating time and not having a clear operative field. We suggest that a rational thinking and reconsidering the practice of routine use of long duration tourniquet in each and every case of TKA is required.

Medical textiles in orthopedics: An overview.

The use of textile in the medical field is not new; this has given rise to a new branch known as medical textiles. These are being used to repair or replace various other musculoskeletal tissues. The most common uses of biomaterials are to create aseptic conditions for protection, general health care, and hygiene including bedding and clothing, surgical gowns, face masks, head and shoe covers, sterilization wraps, suture anchors, fiber cast and braces/orthotics. These are also used as materials for preparation of wipes, swabs, wound dressings, bandages, gauzes, plasters, pressure garments, orthopedic belts and for new applications, such as heart valves, vascular grafts, artificial veins, artificial ligaments, artificial joints, artificial skin, and artificial cartilage. The truth is that nowadays the use of biomedical textiles is more rampant than anyone realizes. Commonly used materials for preparation of biomedical textiles includes Cotton, Nylon, Silk, Ultra-high molecular weight polyethylene, Polyester, Polypropylene, Poly tetra-fluoro ethylene, Polyether ether ketone, and Polyether ketone. These are prepared from various monomers in varying proportions as per the requirement of the material to be used. Various methods are used in their preparation like Braiding, Knitting, and Weaving, which helps in the development of certain kinds of materials with different specificity and character. Other important measures in the preparation of the medical textile include Denier (the filament counts in multifilament fibers), Tenacity (the strength per denier) and Heat shrink (the amount of shrinkage at a particular time and temperature).