Fibular Strut Arthrodesis for Salvage of Campanacci Grade III Giant Cell Tumor of the Hallucal Proximal Phalanx: A Case Report.

Involvement of toe phalanges by giant cell tumor (GCT) is extremely rare; tumors in these locations tend to be aggressive. Whereas aggressive GCTs of the distal phalanx may be managed successfully by en-bloc resection without reconstruction or amputation, management of these lesions, when they involve the proximal phalanx, can be challenging. We present a Campannaci grade III GCT of the hallucal proximal phalanx in a 14-year old girl that had breached into the dorsal soft tissues and the metatarso-phalangeal joint. Wide local resection of the proximal phalanx along with reconstruction arthrodesis with an autologous, non-vascularized fibular strut graft was performed. There was no recurrence at 3 years of follow-up. The patient had an excellent functional outcome. To the best of our knowledge, this is the first case reporting the outcomes of fibular strut arthrodesis for salvage of GCT of the hallucal proximal phalanx.

Is There an Inherent Risk to Damage the Popliteus Tendon by Femoral Component With Inbuilt External Rotation? A Pilot Study in Indian Knees.

INTRODUCTION: Femoral components with inbuilt rotation require thicker flexion resection of the lateral femoral condyle and could have a potential risk of damaging the popliteus tendon, especially in the smaller Asian knees. MATERIALS AND METHODS: We prospectively evaluated 10 patients with bilateral varus osteoarthritis knee to size the cuts and their location in relation to the popliteus tendon. Two different types of implant were used on either side; one side requires resection in 3° external rotation (group A) and the other side requires a femoral component with inbuilt external rotation (group B). We observed the incidence of injury to the popliteus tendon and distance between flexion cut to its attachment over the lateral femoral condyle between both groups. RESULTS: We had popliteus tendon injury in 3 knees all from group B. Risk of damaging the popliteus tendon was found higher in group B, as the distance between flexion cut to popliteus tendon attachment was significantly low. CONCLUSION: Femoral component with inbuilt external rotation has more risk of injuring the popliteus tendon because flexion cut takes out more bone from the lateral femoral condyle.

The natural history of knee osteoarthritis: India-based knee osteoarthritis evaluation (iKare): a study protocol.

METHODOLOGY: Multi-center, cross-sectional, observational study. STUDY CENTER(S): Multiple centers in India. NUMBER OF PARTICIPANTS: 1,000. PRIMARY RESEARCH OBJECTIVE: To characterize patients and treatment utilized for orthopedic patients presenting to both private and public hospital centers in India with knee pain and symptoms suggestive of knee arthritis. INCLUSION CRITERIA: All patients 18 years of age or older who present to a recruiting hospital for treatment of knee pain will be eligible for participation. The subjects must be able to understand and complete the questionnaire. EXCLUSION CRITERIA: Patients with total knee replacement, open wound or evidence of recent surgery, or with a current or a history of tumor and/or fracture in the tibial plateau, femoral condyle or patella, in the affected knee are not eligible. STUDY OUTCOMES: This study aims to characterize the following: general demographics of patients presenting with knee pain, severity of knee symptoms at time of presentation, severity of knee pathology at time of presentation, factors associated with the decision to seek medical care, previous treatments and health care contacts, planned treatment, and gaps in treatment perceived by the patient and treating surgeons.

Ankle Sprain and Chronic Lateral Ankle Instability: Optimizing Conservative Treatment.

The management protocol for each case of ankle sprain should be individualized and optimized in order to reduce the likelihood of development of chronic instability. Initial treatment aims to address pain, swelling, and inflammation and facilitates regaining pain-free joint motion. Short-term joint immobilization is indicated in severe cases. Subsequently, muscle strengthening, balance training, and targeted activities to develop proprioception are added. Gradually, sports-related activities are added with the ultimate goal of bringing the individual back to preinjury level of activity. This protocol of conservative treatment should always be offered before considering any surgical intervention.

Extruded talus injuries are associated with significant complications: A double center series with minimum 1-year follow up.

BACKGROUND: Extruded talus (ET) injuries are rare, but high-energy open pantalar dislocations. Literature on these injuries is sparse and optimal treatment protocols are ill defined. The current study documents the clinical and radiological outcomes in cases seen at 2 centers, in an attempt to determine whether surgeons should choose primary reimplantation or primary talectomy and fusion for these injuries. METHODS: Patients with ET injuries were identified from the database of two hospitals. Baseline demographics and treatment details were evaluated, and patients were called for follow-up. Radiological evaluation was conducted, and function was evaluated by the AOFAS hindfoot score. Outcomes and complications were compared between patients who had undergone primary talectomy versus primary reimplantation. Predictors of poor functional outcomes were determined. RESULTS: Of 23 patients seen by us, 15 were available for follow-up at 45.7 ± 22.2 months. Of these 19 had undergone reimplantation and 4 had talectomy with tibio-calcaneal arthrodesis. The mean percentage AOFAS score was 66.2 ± 14.6 at follow up. AVN was noted in 5, ankle arthrosis in 10, subtalar arthrosis in 4 and infection in 4 cases; no patient needed salvage arthrodesis during this time. There was no difference in baseline demographics, range of motion, AOFAS scores or complication rates between patients undergoing primary reimplantation versus primary talectomy. The number of complications per patient showed a negative, moderate correlation with the AOFAS score (Pearson's correlation coefficient 0.6, P value = 0.02). CONCLUSION: Despite best treatment, ET injuries result in significant impairment of functional outcomes and complications. Within the numbers available, no difference in outcomes or complication rates was noted between primary reimplantation or talectomy. However, we recommend reimplantation as the treatment of first choice as this offers the chance to salvage the ankle joint and preserves bone stock for future fusion or arthroplasty.

Beyond the Boundary: A Bibliometric Analysis of the Published Research on Injuries in Cricket.

Background: Cricket, a sport immensely popular in the Indian subcontinent and Commonwealth countries, boasts a staggering global following of over 1 billion enthusiasts. However, injuries in cricket are prevalent, resulting in detrimental effects on player performance and leading to substantial absenteeism from the game. In recent times, there has been a surge in interest on the epidemiology, biomechanics, and prevention of cricket-related injuries. To gain comprehensive insights into the existing research landscape, we present a bibliometric analysis of the published research on cricket injuries. Materials: The Web of Science database was searched using a well-defined search strategy. Original research articles looking at any aspect of injuries in cricket were included. Search results were imported into the R Bibliometrix package for analysis. Analysis of bibliometric parameters included top authors, journals, countries and keywords. Co-occurrence networks were generated and thematic mapping was performed to identify emerging research topics. Observations: 423 publications from 126 journals were included. An increasing trend in publications was noted. JW Orchard was the highest published author; Australia was the highest published country and the Journal of Science and Sport in Medicine had the highest number of publications. Fast bowlers were the most extensively researched and the major research was noted to focus on three niche areas, i.e., epidemiology, consensus definitions and spinal issues in fast bowlers. Research on batsmen, wicketkeepers and fielders was relatively sparse. Furthermore, we observed limited representation of research from the Indian subcontinent, despite cricket's immense popularity in the region. Conclusions: Our study findings highlight that majority of the cricket injury research stems from developed countries. The primary research areas include epidemiology, injury prevention, and biomechanics, with a particular focus on fast bowlers. However, much more has to be done to encourage research publications, focused on batsmen, wicketkeeper and fielders, as well as cricket in the developing world. These insights are essential for researchers seeking to delve into cricket-related studies and organizations aiming to advance injury prevention research in cricket.

Is Neck Pain Related to Sagittal Head and Neck Posture?: A Systematic Review and Meta-analysis.

Background: Neck pain (NP) is common in all age groups and adversely affects the patients' entire lifestyle. There exists inconclusive evidence relating faulty craniocervical posture with pain-related disability. This review aims to determine whether sagittal head and neck posture differs in NP and pain-free subjects, to critically appraise the correlation of posture with NP. Methods: Of 3796 articles identified at primary search from CINAHL, PubMed, Google Scholar, EMBASE, 26 were included based on eligibility criteria. Mean pooled difference (MPD) and effect size (ES) were calculated to establish relationship among studies, to assess postural correlation with NP measures [Visual Analogue Scale (VAS), Numeric Pain Rating Scale (NPRS), neck disability index (NDI), Northwick Park NP Questionnaire (NPQ)] and for age- and gender-wise variation. Risk of bias was assessed using Newcastle-Ottawa Quality Assessment Scale. Results: Craniovertebral angle (CVA) had a significant MPD of - 2.93(95% CI - 4.95 to - 0.91). Sagittal head angle (SHA) and forward head posture (FHP) had an insignificant MPD of 1.15 (95% CI - 1.16 to 3.46) and - 0.26 (95% CI - 1.89 to 1.36), respectively. Age- and gender-wise CVA difference was found to be 2.36° and 2.57°, respectively. ES was significant for correlation between CVA and pain intensity [NPRS: - 0.44 (95% CI - 0.61 to - 0.26); VAS: - 0.31 (95% CI - 0.46 to - 0.16)], and between CVA and disability [NDI: - 0.18 (95% CI - 0.31 to - 0.05); NPQ: - 0.47 (95% CI - 0.61 to - 0.320)]. Conclusion: CVA differs for age, gender, and pain vs pain-free subjects, and correlates negatively with NP measures. Other surrogate measures (SHA, cranial and cervical angles, FHP) warrant further research. PROSPERO Registration: PROSPERO 2021 CRD42021275485.

A Novel Wall Touch-Single Limb Stance Exercise for Dynamic Activation o f Gluteus Maximus - A Cross Sectional Study.

Objective: Gluteus maximus (GM) dysfunction is associated with spinal/lower extremity musculoskeletal conditions. Studies on weightbearing GM exercises that can be used earlier in rehabilitation is limited. Utilizing GM isometric contraction and load transmission to thoracolumbar fascia during trunk straightening under unilateral stance, we for the first time describe Wall Touch Single Limb Stance (WT-SLS) exercise. Specific exercise prescription may be rationalised using knowledge of how upper and lower fibres of GM (UGM, LGM) respond during novel WT-SLS. Methodology: Surface EMG signals from UGM and LGM were compared among WT-SLS, Step up (SU) and Unilateral wall squat (UWS) in healthy subjects (N = 24). Raw data was normalized and expressed as percentage of maximum voluntary isometric contraction (%MVIC). Relative easiness in performing the exercises was scored using Borg's CR10 scale. Statistical significance was defined as p < 0.05. Results: WT-SLS had the highest %MVIC for both UGM and LGM (p < 0.0001), suggesting maximum activation of GM in healthy adults by our novel exercise. WT-SLS generated more motor unit action potentials, and had significantly greater activity for UGM than LGM (p = 0.0429). Remaining exercises had no differential activation of UGM and LGM. WT-SLS was perceived as only 'slight' exertion. Conclusions: WT-SLS depicted the greatest muscle activation, suggesting possible better clinical and functional outcomes considering GM activation and strengthening. UGM was preferentially activated during WT-SLS, but not during SU and UWS. Therefore, targeting GM with our novel exercise may improve gluteal weakness and dysfunction in lumbar radiculopathy, knee ligament injuries; as preventive measure for injury; or for postural correction.

The Outcome of Surgically Treated Proximal Femur Fractures Managed by Ortho-anesthetic Geriatric Care Pathway: A Prospective Observational Study with 2-Year Follow-Up.

Background: Evaluation of the ortho-anesthetic geriatric care pathway for patients with proximal femur fracture in a tertiary care referral center was done by reporting the peri-operative morbidity and mortality. Clinical and demographic predictors of mortality were also identified in this cohort. Material and Methods: This prospective observational study was conducted between August 2017 and November 2018. Demographic, anesthetic and surgical characteristics were recorded. Telephonic post-discharge follow-up was done for a period of 2 years. Factors predicting mortality were estimated using multivariate logistic regression. Results: The cohort was characterized by frailty, high ASA physical status, NYHA class and Charlson co-morbidity index. The delay in presentation to hospital and subsequent surgical fixation was 7 (1-8) and 8 (5-13) days, respectively. The 30, 60, 90-day, 1-year and 2-year mortality was 13.6%, 21.8%, 25.45%, 36.5% and 44%, respectively. Intra-operative blood transfusion was a predictor of 30-day mortality (OR 9.2, 95% CI 1.02-83.17; p = 0.048). Pre-operative respiratory dysfunction predicted 60-day (OR 11.245, 95% CI 1.38-91.58; p = 0.024) and 90-day (OR 11.654, 95% CI 1.91-71.1; p = 0.008) mortality. Post-operative morbidity was reported in 31 (28.1%) patients; incidence of pneumonia (n = 9), sepsis (n = 8), MI (n = 6), PTE (n = 5) and ARF (n = 3) were 8.18%, 7.27%, 5.45%, 4.54% and 2.72%, respectively. Conclusion: Existing pathway facilitated surgical fixation with median delay of 8 days which should be shortened to 48 h. High mortality in our cohort needs to be decreased by preventing admission delays and aggressively managing co-morbidities. Acceptable benchmark goals for pre-operative optimization of lung disease and decrease in intra-operative blood transfusion need to be incorporated in existing care pathway.

Protocol for a quasi-experimental study to ascertain the effectiveness of using eKnee School approach to impart self-care education to patients suffering from knee osteoarthritis during COVID-19 pandemic.

BACKGROUND: Knee osteoarthritis (KOA) patients seek improvement in their quality of life by attaining independence in activities of daily living. Literature recommends nonpharmacological intervention as first-line treatment for KOA. The study aims to ascertain the effectiveness of online supervised nonpharmacological intervention sessions of virtual knee school (eKS) training among mild and moderate KOA patients in comparison to routine care during COVID-19 pandemic and assessment of cost-effectiveness of eKS against the routine care for KOA patients during COVID-19 pandemic. MATERIALS AND METHODS: A quasi-experimental pre-post with control group, enrolling 50 participants each in two groups: usual/routine KOA care or usual care plus KS interventions via virtual mode. Our primary outcome measures are pain, quality of life, and incremental cost-effectiveness ratio. Secondary outcomes include performance-based tests (30-second chair test, timed up and go test, 6-minute walk test) and patient satisfaction. Intervention fidelity will be assessed with a priori checklist tailored to eKS assessing adherence, dose, quality, and user engagement in the key components. Quantitative data collection will be conducted at baseline and 6 months. Descriptive data analysis will be carried for quantitative data. For qualitative data, the thematic analysis will be performed; we propose to undertake a deterministic and probabilistic sensitivity analysis to address the issue of uncertainty in the present cost-effectiveness analysis model. CONCLUSION: The management of KOA through virtual mode emphasizes the concepts of patient-as-person, family-centered, with socially interactive approach. The study will provide information on the effectiveness of nonpharmacological interventions for improving the quality of life of patients suffering from KOA through virtual knee school. Nevertheless, pitfalls in running eKS will be noted, which will help improve all aspects of online medical communications in the future.

Efficacy of immunohistological methods in detecting functionally viable mechanoreceptors in the remnant stumps of injured anterior cruciate ligaments and its clinical importance.

PURPOSE: Various histological and immunological methods have been used to detect the mechanoreceptors and nerve fibers on the intact ACLs as well as on the remnant stumps. However, some of these methods lack standardization, and the variable thickness of slices used often leads to misinterpretation. The study was based on the hypothesis that immunohistological methods are easier and more reliable means to demonstrate mechanoreceptors in the remnant ACL stumps as compared with the conventional methods. We also attempted to validate the methodology of immunohistology as a means of characterizing functional mechanoreceptors in the residual stump of an injured ACL. METHODS: The remnants of the ruptured ACL in 95 patients were harvested during arthroscopic ACL reconstruction and evaluated immunohistologically using hematoxylin and eosin (H&E), and monoclonal antibodies to S-100 and NFP. Multiple sections from each specimen were serially examined by two histologists. RESULTS: The positivity of monoclonal antibody against NFP showed a statistically significant relationship with the presence of morphologically normal mechanoreceptors, whereas the positivity of monoclonal antibody against S-100 showed a statistically significant relationship with the presence of free nerve ending in the residual stump of an injured ACL. CONCLUSIONS: Immunological methods are more reliable and easier to use as compared with the conventional methods of histological staining for identifying remnant stumps likely to be of some proprioceptive benefit after an ACL injury. Such an identification might help us preserve certain remnant stumps during ACL reconstruction which might in turn improve the postoperative functional outcomes.

Primary malignant melanoma of proximal tibia.

Primary malignant melanoma (clear cell sarcoma) of bone is a very rare neoplasm. Although metastatic melanoma to bone is not uncommon, primary malignant melanoma of bone is extremely uncommon. To date, only nine cases have been reported in the English literature. In this report, we present a case of primary malignant melanoma arising from the medial aspect of the proximal tibia in a 26-year-old woman. We treated the patient with above-knee amputation without any chemotherapy or radiotherapy. At final follow-up of 18 months, the patient was free of disease.

Bilateral inferior dislocation of the hip---a case report.

Inferior dislocation of the hip is the ra- rest type in hip dislocation. Very few cases have been reported in the anglophonic literature, most of which involved the pediatric age group. Surprisingly, we came across a 30-year-old patient with a bilateral inferior hip dislocation. He had sustained a road traffic accident and the attitude of both hip joints was flexion and abduction. The diagnosis was confirmed by radiographs which revealed the long axis of the femur at an angle of 110 (right) degrees and 100 (left) degrees respectively away from the axis. Closed reduction under sedation was successfully performed. Skin traction for a period of 6 weeks was advised and the follow-up revealed an excellent result. We present the details of this case, the first of its kind along with a review of the literature, discussing the various modes and mechanisms of injury inducing inferior dislocation of the hip.

Outcomes of Primary Total Knee Arthroplasty in Fractures Around the Knee in the Elderly: A Systematic Review and Pooled Analysis of 212 Patients Across 11 Studies.

Background: Treatment of fractures around the knee in the elderly is somewhat controversial with primary total knee arthroplasty (TKA) gaining prominence over the past decade or so, as an alternative for open reduction and internal fixation. The present review was conceptualized to review the published literature and evaluate outcomes of TKA in these patients, and to understand whether this is a viable treatment option for these fractures. We have further tried to identify complications and the challenges faced while performing this surgery. Methods: PRISMA guidelines were followed and search was conducted on three databases-PubMed, EMBASE and SCOPUS. Studies evaluating multiple factors related to outcomes and complications in primary TKA performed for fractures around the knee in the elderly were included. Cadaveric studies, conference abstracts, case reports, and any studies that included non-traumatic cases or revision after failed internal fixation, were all excluded. Results: Eleven studies, published between 2011 and 2021 were included in our review. There was significant female preponderance in the study population (M:F = 1:3). Implants with higher constraint (high post, hinged prosthesis) were frequently required to compensate for ligamentous laxity due to the fractures. On pooled analysis the mean Knee Society Score (KSS) knee score was 84.62 (excellent), and mean knee range of motion was 107.25°. However, the mean KSS function score was 56.71 (poor), which could have been due to co-morbid conditions and pre-operative status. Overall complication rate was 14.6%; surgical site infection was the most commonly reported. Conclusion: There remains limited evidence for the use of TKA as a primary treatment option for these injuries. In the presence of specific conditions, and in expert hands-it may be a viable alternative to osteosynthesis with comparable outcomes. More focused studies are needed to compare the two treatment options and to formulate guidelines.

Chondroprotective effects of multiple PRP injections in osteoarthritis by apoptosis regulation and increased aggrecan synthesis- Immunohistochemistry based Guinea pig study.

OBJECTIVE: Use of Immunohistochemistry as a tool to assess anti-apoptotic effects and cartilage regeneration effects of PRP in guinea pig model of spontaneous OA. STUDY DESIGN: Controlled Laboratory Study involving Dunkin-Hartley guinea pigs. METHODS: 12 Dunkin-Hartley guinea pigs (weighing ∼600-800 g) were chosen for this study. One knee of each animal received 3 injections of allogenic PRP at weekly intervals (Group A = 12 Knees). The other knee received normal saline and acted as the control group (Group B = 12 Knees). Half of the animals from each group (subgroups A3 & B3 = 6 Knees each) were sacrificed at 3 months, and the remaining half (subgroups A6 & B6 = 6 Knees each) were sacrificed at 6 months after intervention. Immunohistochemistry (IHC) staining and evaluation were done for Collagen-II, Caspase-3 and Aggrecan. RESULTS: The mean IHC score for Caspase-3 were significantly low in PRP knees compared to placebo Knees at 3 months (P = 0.031) and 6 months (P = 0.012) suggesting its down-regulation and inhibition of apoptosis. The mean IHC score for content of collagen- II and aggrecan at 3 months were higher in PRP Knees (A3) compared to placebo (B3) (Not significant). At 6 months, the Mean IHC Score decreased in both PRP (A6) and Control Knees (B6) for Collagen, but increased for aggrecan compared to its value at 3 months; and this was better in PRP group than in the control (P = 0.024). CONCLUSION: Multiple injections of PRP has a chondroprotective role by its anti-apoptotic effect and by increasing the aggrecan content in ECM.

Postural deviation in pregnancy: A significant debilitating balance problem which can be rectified by physiotherapeutic intervention.

Objective: The purpose of this study was to evaluate the effect of physiotherapeutic intervention to improve the deviated balance of pregnant women. Method: A total of 174 subjects were included in the study out of which 62 had postural deviation. They were divided into three groups, two intervention groups and one control group. The target population consisted of women in the antenatal stage, randomly selected from Obstetrics and Gynecology OPD, PGIMER, Chandigarh. The study was conducted over a period of 3 years (2014-2017). They were advised exercises, postural correction, regular walking, and hot water fomentation. Six follow-ups were taken into consideration throughout the pregnancy and postnatal stage. Result: The impact of the intervention package on both ante-natal and postnatal women with balance problems showed significant improvement. Conclusion: Postural deviations, pain, heaviness in the lower limb, incontinence, breathlessness, etc., are common complaints during and after pregnancy. The problem starts early in pregnancy and increased over time and may persist throughout life if treatment does not start early in the pregnancy. This intervention can be practiced in primary care setting after giving proper training to the health care workers by experienced physiotherapists.

Management options for total knee arthroplasty in osteoarthritic knees with extra-articular tibial stress fractures: a 5-year experience.

Difficult primary knees are fairly common in Asian countries, and tibial stress fractures in deformed osteoarthritic knees add to the challenge. Management options are ill-defined because of limited experience; for 5 years, 8 osteoarthritic knees with extra-articular tibial stress fractures ranging from unicortical stress lesions to frankly mobile fractures were managed by total knee arthroplasty. At mean 42.25 months follow-up, average Knee Society Score improved from 23.62 to 80.87; and average functional score improved from 18.75 to 67.75. All 8 fractures united; 1 (plate plus stem extender) had wound breakdown and delayed union. We present our learning experience with single-stage modular total knee arthroplasty using stem extenders or plates; with proper planning and additional use of image intensifier, these unique cases can reliably be managed with satisfactory outcomes.

Neglected lateral process of talus fracture presenting as a loose body in tarsal canal.

Lateral process fractures of talus are rare injuries with a potential to cause significant morbidity if misdiagnosed. The appropriate management of these fractures is still controversial and only a few reports are avai- lable on this subject. We presented a case of a 37-year-old male with neglected fracture on the lateral process of talus which was misdiagnosed at the time of injury. The patient presented to 7 months after misdiagnosis with a chronic ankle pain. Our case is unique in the sense that it is a rare case of neglected fracture on the lateral process of talus which presented as a loose body in sinus tarsi. However, a surgery with an excision of the loose body presented a satis- factory outcome along with 2 years' follow-up. To our knowledge, it ought to be the first case reported in the English literature. Through this case report, we highlight the importance of high index of suspicion for such rare bony injuries while evaluating trauma to the lateral side of ankle and discuss the principles of management of these fractures.

Subtalar Dislocations.

Subtalar dislocations are uncommon injuries that involve disruption of the talocalcaneal and talonavicular joints. Whereas medial subtalar dislocations are usually caused by low-energy mechanisms and are reducible by closed means, lateral subtalar dislocations occur due to high-energy trauma, have associated foot injuries, and may require open reduction. Good outcomes can be expected for low-energy medial dislocations, whereas high-energy dislocations have guarded outcomes. Hindfoot deformity and chronic instability can result from nonanatomic reduction and inadequate stabilization. Arthrosis of the subtalar joint can occur despite anatomic reduction and is attributable to the cartilage damage at the time of injury.