Deepak Gautam

Total hip arthroplasty in Hurler syndrome – 8 years follow up – A case report with review of literature

Life expectancy in Hurler syndrome is significantly improved by enzyme therapy with bone marrow transplantation. However, the deterioration of skeletal abnormalities persists. Hip dysplasia is a common presentation which may progress to significant hip arthritis requiring total hip arthroplasty at later stage. We report a long-term outcome of cementless total hip arthroplasty in a patient with Hurler syndrome who was successfully treated with bone marrow transplant.

Distal tibial metaphyseal allograft cone for proximal tibial bone loss in revision knee arthroplasty – A novel technique

Large bone defects in femur or tibia are common at the setting of revision knee arthroplasty. Filling up the defect remains a challenging problem to the orthopaedic surgeons. A variety of options are available to fill up these defects depending upon the type of defect. We report a case of large contained defect in proximal tibia managed with distal tibial metaphyseal allograft cone. We also discuss the operative details and the advantages of using the allograft.

Total Hip Arthroplasty in Ankylosing Spondylitis with Extension Contracture of Hips

BACKGROUND Despite significant pain relief following total hip arthroplasty (THA) in patients with ankylosing spondylitis, a small subset of patients presenting with extra-articular extension contracture of hips remains unsatisfied. METHODS We retrospectively evaluated the patients with ankylosing spondylitis who underwent simultaneous bilateral THA and had extensor tightness of both hips preoperatively. They were managed with modified Z-plasty of iliotibial band. Patients with windswept deformity, commonly seen in bilateral hip arthritis caused by ankylosing spondylitis, were excluded. RESULTS Between July 2011 and June 2015, out of 148 patients with bilateral hip involvement, 10 patients (20 hips) had extension contracture of both hips that was addressed during surgery. All patients were followed up for a minimum of 2 years. They could sit comfortably on a chair of height 18 inches with hips and knees flexed to at least 90°. The mean postoperative sum range of motion was 144.6° with an average hip flexion of 95° (range, 90°-105°). None of them had recurrence of extension contracture. There was significant improvement in range of motion and hence ambulation and function. No radiolucent lines exceeding 2 mm were seen in any of the zones around either of the components as evaluated in latest X-rays. CONCLUSION Extension contracture of hip although rare is a noticeable problem and needs to be addressed during THA. Modified Z-plasty technique of iliotibial band is a reliable method in managing these patients.

Combination drug chemotherapy and massive skeletal allograft in the management of hydatid disease of femur

Hydatid disease of long bone is a rare presentation. Chemotherapy and surgery constitute the standard treatment of choice. Non-union of a pathological fracture of femur particularly due to hydatid disease has been known to be resistant to treatment. These resistant cases require combination drug chemotherapy and excision of the lesion. Reconstruction of a large skeletal defect following resection of the lesion poses a challenge to the orthopaedic surgeons. We discuss the staged treatment of hydatid disease of shaft of femur with resection and cement spacer application followed by reconstruction using massive skeletal allograft under cover of combination drug chemotherapy.

Missing head sign

A 56 years old male, farmer by occupation, presented with an altered gait. Five years back he had pain in right hip associated with fever and loss of body weight. On investigation, Erythrocyte Sedimentation Rate was raised (70 mm in first hour), X-ray revelaed dimunition of joint space and erosion of articular margins (A). On further investigation he was found to be mantoux test positive. Based on the clinicoradiological finding, he was started on Antitubercular Therapy (ATT). He was well counselled regarding the duration of treatment and the need of regular intake of drugs as prescribed from a nearby Directly Observed Treatment Short Course (DOTS) centre. After starting ATT, the fever subsided. The pain gradually settled. However, still he was having painless limp. He took ATT for 18 months as per our protocol. Two years later he followed up. X-ray revealed loss of major part of femoral head (B). The treatment options were discussed with the patient. As he was not having any problem in doing his activities of daily living, he did not opt for any surgical intervention rather went with a shoe raise option. A year further when he followed up, the X-rays revealed near complete loss of femoral head (C). At latest follow up, his x-rays showed that the femoral head was completely missing (D). We have given an acronym to this unusual presentation as a “Missing Head Sign”. As the patient was still managing his activities of daily living despite the limp, we have just kept him in regular follow up.

Megaprosthesis versus Allograft Prosthesis Composite for massive skeletal defects

Massive skeletal defects are encountered in the setting of tumors necessitating excision, failed total hip arthroplasty with periprosthetic bone loss, periprosthetic fracture, complex trauma, multiple failed osteosynthesis and infection. Reconstruction of the segmental defects poses a tremendous challenge to the orthopaedic surgeons. The goal of osseous reconstruction of these defects is to restore the bone length and function. Currently the most commonly employed methods for reconstruction are either a megaprosthesis or an Allograft Prosthesis Composite (APC). Megaprosthesis, initially created for the treatment in neoplastic pathologies are being used for the non-neoplastic pathologies as well. The longevity of these implants is an issue as majority of the patients receiving them are the survivors of oncologic issue or elderly population, both in which the life expectancy is limited. However, the early complications like instability, infection, prosthetic breakage and fixation failure have been extensively reported in several literatures. Moreover, the megaprostheses are non-biological options preventing secure fixation of the soft tissue around the implant. The Allograft Prosthesis Composites were introduced to overcome the complications of megaprosthesis. APC is made of a revision-type prosthesis cemented into the skeletal allograft to which the remaining soft tissue sleeve can be biologically fixed. APCs are preferred in young and low risk patients. Though the incidence of instability is relatively low with the composites as compared to the megaprosthesis, apart from infection, the newer complications pertaining to APCs are inevitable that includes non-union, allograft resorption, periprosthetic fracture and potential risk of disease transmission. The current review aims to give an overview on the treatment outcomes, complications and survival of both the megaprostheses and APCs at different anatomic sites in both the upper and lower limbs.

Total Hip Arthroplasty in Severe Osteoporosis - Technical Tips to Avert Complications Prophylactic Locked Plating Along With Total Hip Arthroplasty for Severe Osteoporosis with Intramedullary Nail In Situ

Patients with osteoporosis requiring orthopedic procedures have more adverse outcomes. We present a case of 72 years old severely osteoporotic female with one-year-old neglected fracture neck of femur. She also had an intramedullary nail in situ done for fracture lower end of ipsilateral femur 20 years back. At the time of presentation the lower end of nail was penetrating the anterior femoral cortex. The femur was fixed preemptively with distal femoral locking plate followed by cemented total hip arthroplasty. We also discuss the surgical principles along with the tips and pearls adopted in this case.

Simultaneous anterior cruciate ligament repair and medial unicompartmental knee replacement

We present the case of a 55-year-old female who sustained avulsion of anterior cruciate ligament (ACL) from its tibial attachment while undergoing unicompartmental knee replacement (UKR). The fibers of ACL were intact. Realizing the paramount importance of ACL in a knee undergoing UKR, we promptly performed a primary repair of the ACL and continued with the surgery in the same sitting. At the latest follow-up, the patient is doing well both clinically and functionally and has no antero-posterior or varus-valgus laxity. We discuss the cause for ACL avulsion during UKR and precautions to avoid it.

Salmonella typhimurium infection in total knee arthroplasty: A case report with review of literature

Salmonella enterica serotype Typhimurium is a rare cause of prosthetic joint infection (PJI). The recognized predisposing risk factors for Salmonella septic arthritis include diabetes mellitus, renal failure, human immunodeficiency virus infection and chronic corticosteroid use. We describe a case of PJI of the knee in a 74-year-old lady who was on antitubercular treatment. The patient presented with discharging sinus and raised inflammatory markers. She was successfully treated by the removal of prosthesis and debridement followed by ciprofloxacin therapy for 6 weeks. This case report highlights the potential virulence of Salmonella in immunocompromised patient with a joint prosthesis. Continuous monitoring and close collaboration of microbiologists and orthopedicians helped obtain the resolution of infection in our patient.

Tuberculous periprosthetic infection precipitated by infliximab therapy

Biological therapy with TNF-α inhibitors have been increasingly used in the treatment of inflammatory arthritis. Systemic tuberculosis infections are often known to occur following treatment with these biological agents. However, no case of periprosthetic tuberculous infection of the hip following this therapy has been reported. We report a case of a 45-year-old man who developed periprosthetic tuberculous infection soon after infliximab injection. We also discuss the need of pretreatment awareness, high index of suspicion, early diagnosis and management of such case.