Gautam M. Shetty

Bone mineral density of proximal femur and spine in Korean children between 2 and 18 years of age

Ethnic factors affect bone mass acquisition during childhood. The aim of our study was to establish normative data for bone mineral content (BMC) and bone mineral density (BMD) in healthy Korean children and adolescents, using 446 lumbar spine scans (224 males and 222 females) and 364 proximal femur scans (181 males and 183 females) of healthy children between ages 2 and 18 years measured by dual-energy X-ray absorptiometry using Hologic QDR Discovery A 2004. There was an increase in both BMC and BMD during early childhood, acceleration during the adolescence spurt, and a slower increase later. Until 11 years of age, both male and female BMC and BMD were not statistically different. There was a rapid increase in both BMC and BMD in females earlier than in males, and later males caught up with the females and overshot the female values. When compared with Canadian children, BMD and BMC of total proximal femur was found to be more and BMD and BMC of total lumbar spine to be less at some ages. Tanners stage was significantly associated with BMD and BMC of spine and proximal femur in males and BMC of spine in females in the first three Tanners stages. Height, body weight, fat content, and body mass index influenced BMC and BMD at different sites by variable amount. Hence, the values presented in this study should be used as reference values in Korean children and adolescents.

Submuscular plating after distraction osteogenesis in children

Although distraction osteogenesis has solved limb length discrepancies, many complications are inevitable from long duration of external fixation. Use of intramedullary nails for early removal of fixators has its own challenges especially in pediatric age group. To facilitate early removal of external fixators in children, we tried a novel method of submuscular plating over the distraction callus, which is described, and the results and complications of this technique are presented. In eight children (four girls and four boys), of limb lengthening (four cases) and bone transport (four cases) done in three femurs and five tibiae with external fixators (five Ilizarov ring fixators and three monofixators), submuscular plating was done over the distraction callus. The causes of limb length discrepancy included traumatic and septic growth arrest, congenital pseudoarthrosis of tibia, fibular hemimelia, tumor salvage, and Perthes disease. The purpose of plating was to remove the external fixator earlier after achieving the target length. Mean age of plating procedure was 11.62 years, and mean amount of distraction was 5.47u2009cm. In all patients, the distraction callus healed on maintaining its length or correcting into the original alignment. The mean external fixation index was 26.93 days/cm and healing index was 52.01 days/cm. One complication of superficial pin-track infection occurred, which resolved completely with conservative treatment. None of the patients developed deep infection or implant failures. The mean follow-up after plating was 28 months (range, 18–62 months). Submuscular plating over the distraction callus may be a successful method that permits early removal of fixator with fewer complications. This method can be a useful alternative in children or when nailing is difficult.

Incarcerated patellar tendon in Hoffa fracture: an unusual cause of irreducible knee dislocation.

Irreducible knee dislocation due to incarcerated soft tissue structures in associated fractures is extremely uncommon. We report a case of irreducible, closed dislocation of the knee secondary to incarcerated patellar tendon in a Hoffa fracture (unicondylar fracture of femur in the coronal plane) with associated communited fracture of patella and disruption of both cruciates. We treated this case initially with open reduction and internal fixation of fracture and repair of the patellar tendon. During the total followup period of eighteen months, the patient had restricted joint range of motion with no joint instability despite aggressive physiotherapy and further surgical intervention. The prognosis of such complex knee injuries with combination of ligamentous injuries and associated fractures is much worse when compared to either injuries alone.

Upper cervical spine instability in pseudoachondroplasia.

Background: Pseudoachondroplasia (PSACH) is a rare autosomal dominant skeletal dysplasia associated with os odontoideum and atlantoaxial instability. This study aims to define the characteristics of upper cervical spine instability in patients with PSACH and analyze the relation between the incidence of upper cervical instability and os odontoideum. Methods: Fifteen patients (10 women and 5 men) with PSACH of Korean ethnicity with mean age of 23.7 years (range, 3-44 years) at presentation to our hospital with varied complaints, including short stature, limb deformity, neck pain, and neurological symptoms, were evaluated clinicoradiologically for upper cervical spine instability. The patients were separated into group 1 (n = 9) with os odontoideum and group 2 (n = 6) without os odontoideum. Comparisons were made using parameters such as instability index, rotational instability, atlantodens interval and space available for cord, and analysis done to correlate cervical instability with age and Japanese Orthopedic Association (JOA) score. Results: Significant differences were found statistically when the 2 groups were compared on the basis of the space available for the cord (SAC), JOA scoring, and rotational instability. Linear relationship was found between instability and age and JOA score. Incidence of os odontoideum was 60% in our study group. Conclusions: Os odontoideum led to an increase in the incidence of upper cervical spine instability. Instability increased with the age. The presence of os odontoideum and atlantoaxial instability did not warrant for surgery because no signs of cervical myelopathy developed or progressed in our patients during the follow-up period, but these patients should undergo regular clinical and radiological evaluation. Level of Evidence: Level IV prognostic study.

Giant synovial cyst of knee treated arthroscopically through a cystic portal

Synovial cysts are well-defined fluid filled cysts that can extend for a variable distance outside the joint space. These cysts can sometimes grow to a large size making its treatment challenging especially when associated with intra-articular pathologies.We describe a case of giant synovial cyst arising from the left knee and extending to the medial proximal calf in a 77-year old female who presented with knee joint pain, episodes of locking and calf mass occurring within 2xa0months of onset. Imaging studies also showed associated medial and lateral meniscal tears with medial compartment and patellofemoral osteoarthritis. The cyst was treated by disrupting the valvular mechanism using a standard posteromedial portal and complete excision of the cyst wall via a posteromedial cystic portal. The meniscal lesions were dealt with through the standard anterior portals. At 25-month follow up there were no signs of recurrence of the cyst clinically or with MRI. The cystic portal technique is effective in treating a giant synovial cyst of the knee even in the presence of meniscal tears and high grade chondral lesions.

Radiographic evaluation of complete and incomplete discoid lateral meniscus

OBJECTIVESnThe aim of this retrospective study was (1) to evaluate the radiographic features to differentiate arthroscopically confirmed complete and incomplete discoid lateral meniscus (DLM) (2) to determine the cutoff values for any parameter that was found to differentiate complete from incomplete DLM.nnnMATERIALS AND METHODSnWe retrospectively analyzed plain knee radiographs of 130 arthroscopically proven DLM. Seventy-nine patients had complete DLM and 51 patients incomplete DLM. Knee radiographs from 52 patients with arthroscopically proven normal lateral meniscus acted as control group. Radiographic parameters measured included fibular height, lateral joint space, condylar cutoff sign, height of lateral tibial spine, obliquity of lateral tibial spine, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau.nnnRESULTSnAmong radiographic parameters, high fibular head, widening of the lateral joint space and femoral condylar cutoff sign showed statistically significant (p<0.0001) differences between complete and incomplete DLM. At specific threshold points of fibular height<11 mm, lateral joint space>6 mm and condylar cutoff sign<0.80, the diagnosis of complete DLM revealed 87.3% sensitivity, 81.6% specificity and 78.4% positive predictive value (PPV) for the fibular height, 81.0% sensitivity, 86.6% specificity and 83.1% PPV for the lateral joint space, and 86.1% sensitivity, 83.5% specificity and 80% PPV for the condylar cutoff sign.nnnCONCLUSIONSnRadiographic features of fibular height, lateral joint space and condylar cut off sign can be used for screening of a complete type of DLM. However, radiographs are not a reliable screening tool for an incomplete DLM.nnnLEVEL OF EVIDENCEnIV, Case Series.

Posterior Reattachment of a Radial Tear in the Posterior Root of the Medial Meniscus

The new posterior vertical mattress suture technique is technically easier to perform and provides more secure fixation than the arthroscopic simple or horizontal stitch techniques and may contribute to restoring function of the medial meniscus.

A simple and effective technique of femoral tunnel bone grafting in revision anterior cruciate ligament reconstruction

Restoring the bone stock in the femoral tunnel during revision anterior cruciate ligament reconstruction is vital for better surgical results and to avoid potential complications. The technique must be easy, effective, simple, reproducible and cost effective. We describe a new, simple and inexpensive technique of femoral tunnel bone grafting in revision ACL reconstruction using universally available materials.

Alcohol-induced multifocal osteonecrosis: a case report with 14-year follow-up

Alcohol-induced osteonecrosis of femoral head is common but multifocal osteonecrosis secondary to alcohol is very rare. The authors report one case of multifocal alcohol-induced osteonecrosis involving both hips and both knees and its subsequent progression and management over a period of 14xa0years. There was bilateral involvement of hips in pre-collapse stage for which a core decompression was done. The left hip responded well and at 14-year follow-up was asymptomatic with full range of motion. The core decompression surgery failed in the right hip within 1xa0year and subsequently hybrid total hip replacement arthroplasty was done with good functional results at 13xa0years follow-up. The diagnosis of knee osteonecrosis was most probably missed initially and was subsequently diagnosed 6xa0months back due to symptoms of pain and radiographic findings for which a core decompression was done with good early results. The results of treatment of hip was excellent in our patient and despite the rarity, a high degree of suspicion and regular screening is necessary to detect involvement of other areas like the knee in alcohol-induced osteonecrosis.

Clinical Outcome of Posterior Cruciate Ligament Reconstruction With and Without Remnant Preservation

PURPOSEnThe purpose of this study was to analyze clinical outcomes in patients who underwent posterior cruciate ligament reconstruction (PCLR) with and without remnant preservation.nnnMETHODSnA search of the literature was performed with the established medical databases Medline, Embase, and the Cochrane Register. Two authors screened the selected articles for title, abstract, and full text in accordance with predefined inclusion and exclusion criteria. The inclusion criteria were as follows: English-language articles on isolated posterior cruciate ligament injury; clinical trials with a clear description of surgical technique; outcome evaluation using a well-defined knee score, arthrometry, and posterior stress radiography; follow-up longer than 2 years; and a Coleman Methodology Score (CMS) of 65 points or greater. The methodologic quality of all articles was assessed by 2 authors according to the CMS.nnnRESULTSnEleven studies were included, with a mean CMS of 78.9 points (SD, 5.37 points). There was no direct comparative study between remnant-preserving PCLR and standard PCLR. At final follow-up, the knees of 72% to 100% of patients who underwent remnant-preserving PCLR and 41% to 95% of patients who underwent standard PCLR were rated as normal or nearly normal on the International Knee Documentation Committee subjective knee assessment. Patients who underwent remnant-preserving PCLR showed an increase of 16.4 to 47 points in Lysholm scores, and patients who underwent standard PCLR showed an increase of 22 to 29 points. The ranges of mean postoperative side-to-side differences on KT-1000 (MEDmetric, San Diego, CA) testing were 0.7 to 2.8 mm in patients who underwent remnant-preserving PCLR and 1 to 3.5 mm in patients who underwent standard PCLR. The ranges of mean postoperative side-to-side differences on stress radiography were 2.2 to 5 mm in patients who underwent remnant-preserving PCLR and 4.7 to 6 mm in patients who underwent standard PCLR.nnnCONCLUSIONSnAll studies on PCLR with remnant preservation showed satisfactory outcomes despite using numerous surgical techniques, graft types, intervals from injury to surgery, and follow-up periods.nnnLEVEL OF EVIDENCEnLevel IV, systematic review of Level II through IV studies.