Early liver transplantation after COVID-19 infection: The first report.

COVID-19 (coronavirus disease 2019) has impacted solid organ transplantation (SOT) in many ways. Transplant centers have initiated SOT despite the COVID-19 pandemic. Although it is suggested to wait for 4 weeks after COVID-19 infection, there are no data to support or refute the timing of liver transplant after COVID-19 infection. Here we describe the course and outcomes of COVID-19-infected candidates and healthy living liver donors who underwent transplantation. A total of 38 candidates and 33 potential living donors were evaluated from May 20, 2020 until October 30, 2020. Ten candidates and five donors were reverse transcriptase-polymerase chain reaction (RT-PCR) positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pretransplant. Four candidates succumbed preoperatively. Given the worsening of liver disease, four candidates underwent liver transplant after 2 weeks due to the worsening of liver disease and the other two candidates after 4 weeks. Only one recipient died due to sepsis posttransplant. Three donors underwent successful liver donation surgery after 4 weeks of COVID-19 infection without any postoperative complications, and the other two were delisted (as the candidates expired). This report is the first to demonstrate the feasibility of elective liver transplant early after COVID-19 infection.

SpeedBridge Repair in Degenerative Achilles Tear: A Novel Technique.

Introduction: Retrocalcaneal pain in late adulthood and athletes has been attributed to insertional Achilles tendinosis (IAT). Another presentation of IAT is a degenerative Achilles tear, which can be partial or complete. Symptomatic patients with failed conservative management are treated by debridement and repair of the Achilles tendon. Often, they need augmentation with a tendon transfer. The flexor hallucis longus (FHL) is the most commonly used tendon for augmentation. The Speed Bridge technique to repair the degenerated tendoachilles tear gives better pullout strength and provides a larger surface area of contact between the bone and tendon. Case Report: We included 12 patients with symptomatic degenerative Achilles tears repaired with the Speed Bridge technique and FHL augmentation. Post-operatively, all patients were allowed active ankle mobilization on day 1 and were allowed weight bearing as tolerated in an airwalker shoe. All patients went through an accelerated rehabilitation protocol. Pre-operative and post-operative American Orthopedic Foot and Ankle Hindfoot Score (AOFAS) and Visual Analog Scale (VAS) scores were compared for all the patients. Conclusion: The mean age was 58.1 (range 50-68) years. The mean follow-up period was 13.1 (range 12-15) months. The mean pre- and post-operative AOFAS score at 12 months was 59.5 (range 58-71) and 90.2 (range 87-100), respectively. The mean pre-operative VAS for pain was 6.8 (range 6-8), and the mean post-operative VAS score was 0.5 (range 0-2). The mean interval to weight bearing was 8.4 days (range 7-10) days. Our study indicates that accelerated early rehabilitation and an early return to active life are possible with the Speed Bridge technique and FHL augmentation in degenerative Achilles tears. The mean post-operative AOFAS scores were comparable to other studies, but early return to activity, minimal need for immobilization, and accelerated rehabilitation were the advantages of the Speed Bridge technique in the repair of degenerative Achilles tears.

Neglected Posterior Hip Dislocation in Adults presenting after One Year Managed Successfully with Single Stage Total Hip Arthroplasty: A Case Series.

Introduction: Neglected hip dislocation in adults may present as a dilemma to an orthopedic surgeon and is an uncommon occurrence. Literature mentions both closed reduction and open reduction as methods of management but mostly in children. Few cases have been present in the literature regarding adults with neglected hip dislocations. While almost all have failed in closed reduction, the open reduction has not yielded good results and total hip arthroplasty (THA) as a single stage procedure has not been explored much in regard to neglected isolated posterior dislocations of the hip. We report a series of three cases all with neglected dislocation of over 1 year which was managed with single stage total hip replacement. Case Series: Three cases of neglected posterior dislocation of the hip of more than 1 year (26 years, 28 years, and 32 years of age all males) presented with right leg in adduction, flexion, and internal rotation deformity and painful limp. They were all managed inadequately by traditional bonesetters. No signs of acetabular fracture or avascular necrosis (AVN) were present in radiography and computer tomography. A global softening of the femoral head was encountered in all the cases and uncemented THA was done. All patients did well with good to excellent functional outcomes (Harris hip score [HHS] of 81, 91, and modified HHS of 83) with a minimum of 1 year follow-up. No post-operative complications were encountered. Conclusion: We want to emphasize the lack of literature concerning adult patients with neglected dislocations. Single stage THA is the best option considering the occurrence of AVN of the femoral head with global softening in such cases. A single stage THA attains good to excellent functional outcomes without any early post-operative complications.

Talar Body Fracture With Closed Pan-Talar Dislocation.

Talar body fracture associated with pan-talar (tibiotalar, talocalcaneal, talonavicular) dislocation is a rare condition. Timely intervention with anatomical reduction will lead to better healing of the fracture. It will result in articular congruity of the talus and less chance of secondary arthritis. We describe a rare talar body fracture with pan-talar dislocation, which does not fit into any of the classifications mentioned in the literature. A young male of 21 years old was admitted to the trauma and emergency department of a tertiary care hospital within three hours of injury. Following the radiological investigations, the patient was found to have a talar body fracture with pan-talar dislocation. Initially, a close reduction was attempted which failed. Subsequently, it was managed with open reduction and internal fixation after eight hours of injury. Talar body fracture was fixed with cannulated cancellous screws and ankle stabilized with joint spanning external fixator. At six months the patient had satisfactory healing of fracture without any irregularity of the articular surface of talus or arthritic changes of involved joints. Early surgical intervention with anatomical reduction of talar body fracture with pan-talar dislocation may lead to better union and less chance of secondary arthritis of peri talar joints.

Comparison of bone SPECT/CT and MRI in detection of pain generator in ankle and foot pain: a retrospective diagnostic study.

OBJECTIVE: To study the sensitivity and specificity of MRI and bone SPECT-CT in detecting the pain generator in ankle and foot pain with diagnostic dilemma. METHODS: Retrospectively data of patients with ankle or foot pain who underwent both MRI and Bone SPECT-CT were analyzed. The lesions and probable pain generator sites were reported as per MRI and bone SPECT-CT findings. These lesions were correlated clinically, managed accordingly and followed up. The patients who had significant improvement in response to the treatment provided were considered to have been diagnosed accurately. The foot and ankle disability index (FADI) was used to evaluate the patient's pre- and postintervention condition. RESULTS: The study included 37 patients retrospectively (18 women and 19 men). The lesions were classified into soft tissue lesions (ligaments/tendons), joint lesions (arthritis) and bony lesions (fractures/osteomyelitis/osteochondral lesions). Overall, MRI had sensitivity, specificity, positive predictive value and negative predictive value of 82, 31, 74 and 42%, respectively, and SPECT-CT had sensitivity, specificity, positive predictive value and negative predictive value of 84, 60, 84 and 60%, respectively. The mean FADI score pretreatment for all patients was 61.5 (SD = 13.8) and posttreatment 88.4 (SD = 13.01) showing significant improvement in the score (P < 0.05), suggesting that the final diagnosis of these patients was accurate. Overall, management change due to bone SPECT-CT over MRI was seen in 26% of patients. CONCLUSION: Bone SPECT-CT has incremental value over MRI in the diagnosis of pain generator in foot and ankle pain. The overall specificity of bone SPECT-CT is higher than MRI in detection of pain generators. Bone SPECT-CT performed better than MRI in detection of culprit pathology in the bone, whereas MRI is better in soft tissue lesions. ADVANCES IN KNOWLEDGE: There are only a few published literature with direct comparison of bone SPECT-CT scintigraphy and MRI in detection of foot and ankle pain generator. This study directly compares diagnostic utility of bone SPECT-CT scintigraphy and MRI in foot and ankle pain. In the present study, the bone SPECT-CT performed better than MRI in detection of culprit pathology in the bone, whereas MRI is better in soft tissue lesions.

Paediatric Long Bone Fractures Managed with Elastic Intramedullary Nails: A Retrospective Study of 30 Patients.

Elastic intramedullary nailing or titanium elastic nail (TEN) is an alternative method for the treatment of various pediatric long bone fractures. Titanium nails are preferred over plaster cast and stainless steel nails for children older than six years. Our series included 30 paediatric long bone fractures who were managed with TEN. The mean age was 9.3 years and the mean follow-up period was 28 months. A mean time of 10 weeks was recorded for the union of all fractures. The occurrence of superficial infection in three cases healed with antibiotics and minor debridement. Limb length discrepancy was seen in three cases of femur fracture, which was functionally insignificant, but it may be a potential problem needing close follow-up until skeletal maturity is attained. An elastic intramedullary nail or TEN in long bone fractures in children is a safe and minimally invasive technique that achieves stable reduction, especially in long spiral fractures till union. We attained successful union and good results in all our 30 cases with long bone fractures in children. A few complications of hardware prominence were resolved with implant removal. Long-term studies with a comparison to casting techniques in paediatric long bone fractures are required.

Triple Blow Injury to a Limb: Ipsilateral Hip and Knee Dislocation with Vascular Occlusion.

Ipsilateral hip and knee dislocation (double blow) occurring simultaneously during trauma are rare occurrences that are associated with secondary complications. These are high energy injuries that warrant acute emergency management more so if associated with vascular compromise. We encountered a poly trauma patient having a combined right anterior hip and ipsilateral knee dislocation with vascular occlusion at popliteus level apart from associated segmental radius fracture of the left upper limb. This young patient presented after 22 h being referred form elsewhere making the situation critical to the surgical team. An attempted thrombolysis was done but as gangrenous changes started, we ended up in a below knee amputation. This case highlights a typical scenario in a developing country where facilities involving super specialty services are scarce and even patients are complacent about need for emergent referral. All this adds to surgical dilemma as guidelines are unclear for the best treatment.

Factors Affecting the Outcome of Unstable Intertrochanteric Fractures Managed With Proximal Femoral Nail Anti-Rotation 2: A Prospective Outcome Study in Elderly Indian Population.

Background The proximal femoral nail anti-rotation Asia (PFNA 2) is an implant designed for unstable osteoporotic intertrochanteric fractures in Asians as the PFNA was designed for Caucasians and had various complications when applied to the Asian population due to the femoral geometrical mismatch. This study observes the functional outcomes and complications associated with PFNA 2 in unstable intertrochanteric fractures in the elderly Indian population. Methods Sixty-one above 60 years old patients with an unstable intertrochanteric fracture who were operated with PFNA 2 were included in this prospective observational study. They were followed up for one year. The functional and radiographic evaluations were done at 6, 12, 20 weeks, and the functional outcome was evaluated at the end of one year. Association of age, American Society of Anaesthesiologists (ASA) grade, AO Foundation classification, osteoporosis to the functional outcome of modified Harris hip score (MHHS) was evaluated. Results Type A2 fractures demonstrated a statistically higher-good reduction than Type A3 (Student t-test, P < 0.05). The difference in mean surgical duration in Type A3 (45.47 minutes) and Type A2 (40.30 minutes) was statistically significant (Student t-test, P < 0.05). Mean blood loss was 110.66 ml (SD = 48.40 ml). MHHS at 6, 12, 20 weeks, and one year were 40.37, 63.93, 79.03, and 82.34, respectively. At the end of the year, 46 (82.1%) patients achieved good scores, eight (14.3%) achieved fair scores, and two (3.5%) achieved poor scores. There was one case of nonunion and medial migration of the helical blade. The mortality rate was 6.55% at the end of one year. Conclusion A good reduction was associated with a better functional outcome. PFNA 2 is an efficient implant in managing unstable intertrochanteric fractures in elderly Indian patients with good outcomes, low morbidity rates, and mortality. Implant mismatch was not a problem in the Indian population. However, large multi-centric studies with a larger sample size are required. Moreover, achieving a good reduction cannot be over-emphasized in unstable intertrochanteric fractures, especially in the elderly, to achieve a good functional outcome.

Response to Zoledronic Acid Infusion in Children With Fibrous Dysplasia.

Objective: This retrospective study evaluated the outcome and safety of long-term treatment with zoledronic acid, in both polyostotic and mono-ostotic fibrous dysplasia (FD) of children. Methods: The case records of children and adolescents with symptomatic FD who received zoledronic acid (0.1 mg/kg IV infusion over 1 h) and have completed at least 2 years follow-up were analyzed. The relevant details were recorded in a predesigned chart. Clinical assessment [pain assessment by visual analog scale (VAS) and incidence of new fracture], radiological changes (cortical thickening, ossification, and decrease in the diameter of the osteolytic lesions) and biochemical parameters [alkaline phosphatase (ALP)] were used to evaluate the improvement. Results: The mean age of presentation was 9.1 years, with four males and six females. All patients had symptomatic FD in the lower limb with complaints of pain, tenderness, swelling, or deformity. Four children had associated pathological fracture. The radiological evaluation with bone scan revealed polyostotic involvement in eight patients and mono-ostotic involvement in two patients. Three patients had associated systemic features like café-au-lait spots or precocious puberty. The fracture united within 3 months and the radiological improvement was evident in the form of filling of the osteolytic defect. The pain score in six patients showed significant improvement (VAS < 3). The ALP level decreased to 544.12 ± 47.35 IU/L from an initial value of 895.75 ± 79.64 IU/L (p = 0.04) at 12 months. One patient had symptomatic hypocalcaemia after zoledronic acid infusion. Conclusion: The clinical and radiological response of zoledronic acid treatment in FD of children is promising. Further randomized control trials with a larger sample size are required to establish this drug as a first-line medical treatment in FD.