Anil Khanna

History and evolution in total ankle arthroplasty

INTRODUCTIONnThe current study provides an overview of history and evolution in total ankle arthroplasty.nnnMETHODSnWe conducted a comprehensive literature search without limitations to language. Information from any source, providing evidence of the use ankle of prostheses (e.g. biomechanical testing, cadaveric implantations or clinical use) was evaluated. Data regarding biomechanical concepts, design considerations, published results (patient numbers, surgical method, follow-up, complications and survival rates) were collected.nnnRESULTSnOnly level IV studies were found. Mobile-bearing prostheses are mainly used in Europe, and fixed-bearing implants are mainly used in the USA. The current designs failure rate is 10-12% at approximately 5 years. Survival rates vary among different institutions. Increased surgeons experience is associated with better outcomes.nnnDISCUSSIONnBiomechanical studies and review of previous implant failures has led to the development of a new generation of implants.nnnCONCLUSIONSnResults show that ankle arthroplasty is a viable alternative for the management of ankle arthritis in selected patients.

Prevention of adhesions in surgery of the flexor tendons of the hand: what is the evidence?

INTRODUCTIONnDespite advances in knowledge and refinements of technique, the management of flexor tendon injuries within the digital sheath continues to present a formidable challenge. This in turn has led to a massive expansion in search of modified surgical therapies and various adjuvant therapies, which could prevent adhesion formation without compromising digital function.nnnSOURCES OF DATAnA search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords tendon adhesion prevention, tendon healing, adhesion prevention in tendons and adjuvants for adhesion prevention. Studies detailing the use of surgical, pharmacological and non-pharmacological agents for adhesion prevention in digital flexor tendons were identified, and their bibliographies were thoroughly reviewed to identify further related articles. This search identified 41 studies, which investigated the use of various pharmacological agents in adhesion prevention in digital tendons.nnnAREAS OF AGREEMENTnThere is a need to develop and utilize an optimal method for the prevention of adhesions in the flexor tendons of the hand, due to post-surgical complications.nnnAREAS OF CONTROVERSYnEven though there have been significant advances in the prevention of adhesions in flexor tendons, it remains to be proved which, if any, of the current methods are the most beneficial.nnnGROWING POINTSnThe only thing that appears clinically justified in adhesion prevention is the need for early post-operative mobilization of digits after tendon injury or repair but the best method of mobilization remains controversial.nnnAREAS TIMELY FOR DEVELOPING RESEARCHnSuggested changes in surgical techniques and various proposed pharmacological and non-pharmacological modalities need to withstand the test of adequately powered human trials, before their justification for potential benefit in clinical practice is accepted.

The effects of LIPUS on soft-tissue healing: a review of literature

INTRODUCTIONnUltrasound is widely used for imaging purposes and as an adjunct to physiotherapy. Low-intensity pulsed ultrasound (LIPUS), having removed the thermal component found at higher intensities, is used to improve bone healing. However, its potential role in soft-tissue healing is still under investigation.nnnMATERIAL AND METHODSnWe searched on Medline using the keywords: low-intensity pulsed ultrasound, LIPUS and LIPUS and soft-tissue healing. Thirty-two suitable articles were identified.nnnRESULTSnResearch, mainly pre-clinical, so far has shown encouraging result, with LIPUS able to promote healing in various soft tissues such as cartilage, inter-vertebral disc, etc. The effect on the bone-tendon junction, however, is primarily on bone. The role of LIPUS in treating tendinopathies is questionable. Adequately powered human studies with standardisation of intensities and dosages of LIPUS for each target tissue are needed.

Minimally invasive total knee arthroplasty: a systematic review.

The concept of minimally invasive total knee arthroplasty surgery evolved to reduce quadriceps muscle strength loss and improve clinical outcome following total knee replacement. We performed a systematic review of the published literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and analyzed the reported surgical outcomes. Twenty-eight studies published from January 2003 to June 2008 that met the inclusion criteria were evaluated using the modified Coleman Methodology Score (CMS). At a mean CMS of 60, most studies reporting on outcome of MITKA are of moderate scientific quality. Patients undergoing MITKA tend to have decreased postoperative pain, rapid recovery of quadriceps function, reduced blood loss, improved range of motion (mostly reported as a short-term gain) and shorter hospital stay compared with patients undergoing standard total knee arthroplasty. These benefits, however, need to be balanced against the incidence of increased tourniquet time and increased incidence of component malalignment in the MITKA group. So far, the evidence based knowledge regarding results of MITKA comes from prospective studies of moderate quality with short follow up periods. Multicenter studies with longer follow-ups are needed to justify the long-term advantages of MITKA over standard total knee arthroplasty.

Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly

Percutaneous repair of Achilles tendon (AT) ruptures reportedly reduces the risk of rerupture compared to nonoperative treatment and reduces the risk of wound infection compared to open surgery. We retrospectively reviewed the postoperative Achilles tendon total rupture score (ATRS), and the maximum calf circumference in 35 patients over 65xa0years of age who sustained an acute tear of the AT and underwent percutaneous repair of the AT. There were 26 men and nine women with a mean age at operation of 73.4xa0±xa08.7xa0years (range, 65–86xa0years). Of the 35 recruited patients, we report on 27 patients for whom we have a full data set. The minimum followup was 49xa0months (mean, 88xa0months; range, 49–110xa0months). The ATRS had a postoperative average rating of 69.4xa0±xa014 (range, 56–93). All patients were able to bear weight fully on the affected limb by the eighth postoperative week. The data suggest that percutaneous repair of the AT is a suitable option for patients older than 65, producing similar outcomes when compared to percutaneous repair in younger patients of previous reports.Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Achilles Tendon Ruptures in Elite Athletes

Background: The management of Achilles tendon (AT) ruptures in elite athletes can be challenging. We performed a retrospective review of prospectively collected data study to evaluate the results of percutaneous repair of an acute AT rupture in elite athletes. Materials and Methods: Seventeen elite athletes with prodromal tendinous problems sustained an acute tear of the AT and underwent percutaneous surgical repair. We performed preoperative evaluations the day of surgery, and report the results of postoperative evaluation at a final followup at an average of 72 months from the procedure. Each patient was evaluated for limb dominance, trauma history, duration and type of preoperative symptoms, and postoperative AT Total Rupture Score (ATRS). Results: All patients were able to fully weightbear on the operated limb by the end of the 8th postoperative week. The average time to return to full sport participation was 4.8 ± 0.9 months. Two of the 15 elite athletes on whom we have full data suffered from a superficial infection of the surgical wound. Conclusion: Our study suggests that percutaneous repair of the AT is a good option for elite athletes, allowing a safe and prompt return to sport activities. Level of Evidence: IV, Retrospective Case Series

Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures

A laboratory study was performed to evaluate the histopathological features of the macroscopically intact portion of the Achilles tendon in patients undergoing surgery for an acute rupture of the Achilles tendon. Tendon samples were harvested from 29 individuals (21 men, 8 women; mean age: 46xa0±xa012) who underwent repair of an Achilles tendon tear tear, and from 11 male patients who died of cardiovascular events (mean age: 61). Three pieces of tendon were harvested: at the rupture site, 4xa0cm proximal to the site of rupture, 1xa0cm proximal to the insertion of the Achilles tendon on the calcaneum. Slides were assessed using a semiquantitative grading scale assessing fiber structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinization. Intra-observer reliability of the subscore readings was calculated. The pathological features were significantly more pronounced in the samples taken from the site of rupture than in the samples taken proximally and distal to it (0.008xa0<xa0Pxa0<xa00.01). There were no significant differences in the mean pathologic sum-scores in the samples taken proximally and distal to the site of rupture. Unruptured Achilles tendons, even at an advanced age, and ruptured Achilles tendons are clearly part of two distinct populations, with the latter demonstrating histopathological evidence of failed healing response even in areas macroscopically normal.

Achilles tendon ruptures in diabetic patients

AimThe aim of this study is to evaluate the results of percutaneous repair of an acute AT rupture in diabetic patients.MethodThe study included 39 subjects who were operated at our institution. We performed pre-operative evaluations the day of surgery, and report the results of post-operative evaluation at the final follow-up.ResultsThe Achilles tendon total rupture score had a post-operative average rating of 70.4xa0±xa013 (range 55–92). All patients were able to fully weight bear on the operated limb by the end of the eighth post-operative week. Eight patients suffered from a superficial infection of the surgical wound.ConclusionIn conclusion, percutaneous repair of the AT is a viable option for diabetic patients.

The evidence of low-intensity pulsed ultrasound for in vitro, animal and human fracture healing

BACKGROUNDnPhysical stimulation therapies are currently available to enhance fracture healing.nnnSOURCES OF DATAnA search of PubMed, Medline, CINAHL, DH data and Embase databases was performed using the keywords ultrasound and fracture healing.nnnAREAS OF AGREEMENTnThe evidence in vitro and animal studies suggests that low-intensity pulsed ultrasound (LIPUS) produces significant osteoinductive effects, accelerating the healing process and improving the bone-bending strength.nnnAREAS OF CONTROVERSYnThe evidence in human trials is controversial in fresh, stress fractures and in limb lengthening. LIPUS is effective in delayed unions, in smokers and in diabetic population.nnnGROWING POINTSnLIPUS is an alternative, less invasive form of treatment for complicated fractures, in patients with poor bone healing and may play a role in the management of large-scale bone defects producing substantial cost savings and decreasing associated disability.nnnAREAS TIMELY FOR DEVELOPING RESEARCHnThere is heterogeneity among in vitro, animal studies and their application to human studies. Further randomized controlled trials of high methodological quality are needed.

Supination-External Rotation Ankle Fractures Stability a Key Issue

Stability is a key issue in treating supination-external rotation ankle fractures, but we do not know how it affects functional outcome and subsequent development of radiographic osteoarthritis. With a systematic literature review, we identified 11 clinical studies (Level IV evidence) published in peer-reviewed journals reporting on at least 10 ankles. Followup was at least 1xa0year. Two authors independently scored the quality of the studies using the modified Coleman Methodology Score; the mean score was 58 of 100, with substantial agreement between the two examiners. Four studies used a general health assessment questionnaire. Several literature limitations (debatable fracture stability criteria, few cohort studies with heterogeneous methodology, small patient numbers and limited followup in some studies) do not allow definitive conclusions. Of 213 stable fractures treated nonoperatively, 2.8% of ankles had radiographic osteoarthritis develop (18xa0years’ mean followup) and 84% were free of symptoms. The incidence of radiographic osteoarthritis in 420 unstable fractures treated operatively was 20.9% at 5.5xa0years versus 65.5% at 6.8xa0years in 137 ankles treated nonoperatively. The complication rate in 355 operatively treated fractures was 10.4%. A medial malleolus fracture, female gender, older age, higher American Society of Anesthesiologists grade, smoking, and lower educational level negatively influenced general health outcome, physical function, and pain.Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.