Hira Lal Nag

Tubercular infection after arthroscopic anterior cruciate ligament reconstruction.

PURPOSE Tubercular infection has not been described, to our knowledge, in the literature after anterior cruciate ligament (ACL) reconstruction, and, hence, the purpose of our case series was to describe our experience, evaluate the clinical and laboratory findings, and assess the treatment outcome. METHODS We performed a retrospective analysis of 1,152 cases of arthroscopic ACL reconstruction with autografts performed at our institution between January 1998 and May 2007. Tubercular infection was considered to be present in the setting of recurrent negative bacterial cultures but a positive result on microscopy, culture, histopathology, or polymerase chain reaction (PCR). All patients underwent arthroscopic lavage and synovectomy, followed by antitubercular therapy for 12 months. RESULTS We identified 8 patients (0.69%) with infection. Bone-patellar tendon-bone graft was used in 1 and hamstring graft in 7. All patients were immunocompetent. The mean time from surgery to presentation was 64.4 days (range, 23 to 152 days). Aspirate fluid staining and culture for acid-fast bacilli was negative in all cases, synovial tissue culture was positive in 3, characteristic histopathology was positive in 7, and PCR was positive in 6. A mean of 1.25 surgeries (range, 1 to 2) were performed. The mean length of follow-up in our series was 43.6 months (range, 25 to 73 months), with no reinfections. The mean postoperative Lysholm knee score was 80. CONCLUSIONS Tubercular infection as a complication after arthroscopic ACL reconstruction, though rare, should be kept in mind as a possible cause of infection in immunocompetent patients in zones endemic for tuberculosis. It should also be kept in mind in nonendemic areas, among immigrants from endemic areas, and in cases with persistent swelling and discharge, effusion with minimal inflammatory signs, and negative cultures. We recommend deoxyribonucleic acid-PCR testing for early diagnosis of tuberculosis. Arthroscopic debridement and antitubercular chemotherapy together are the mainstay of treatment.

Seating of TightRope RT Button Under Direct Arthroscopic Visualization in Anterior Cruciate Ligament Reconstruction to Prevent Potential Complications

The ACL TightRope RT (Arthrex, Naples, FL) is a recently introduced fixation device. The adjustable graft loop allows the surgeon some freedom in terms of the length of the femoral socket, eliminates the need for bothersome intraoperative calculations for selecting loop length, ensures that the socket is completely filled with graft, and provides the possibility of tensioning the graft even after graft fixation. However, the device can be associated with the same complications that have been described with EndoButton (Smith & Nephew Endoscopy, Andover, MA) fixation. For example, in our experience, sometimes the button of the TightRope RT may not flip, may become jammed inside the femoral canal, or may flip in the substance of the vastus lateralis. To prevent this, we have introduced 2 additional steps in our procedure: (1) direct visualization of the TightRope RT button in the femoral socket with the arthroscope during its passage and (2) a controlled push directly on the button with the help of a guide pin. Thus proper seating of the button is ensured by direct visualization and the crucial push helps in flipping and seating of the button.

A prospective comparative study of clinical and functional outcomes between anatomic double bundle and single bundle hamstring grafts for arthroscopic anterior cruciate ligament reconstruction

BACKGROUND Despite a number of studies comparing postoperative stability and function after anatomic single bundle and double bundle anterior cruciate ligament reconstruction, it remains unclear whether double bundle reconstruction has better functional outcome than single bundle anterior cruciate ligament reconstruction. PURPOSE To compare the subjective functional outcome as well as clinical stability in patients treated with either anatomic single bundle or anatomic double bundle anterior cruciate ligament (ACL) reconstruction. We hypothesized that there would be no difference in the postoperative functional outcome and clinical stability between anatomical double bundle anterior cruciate ligament reconstructions when compared to single bundle anterior cruciate ligament reconstructions. METHODS We prospectively followed 40 patients out of which, 20 patients were operated for anatomic single bundle ACL reconstruction and other 20 patients underwent anatomic double bundle ACL reconstruction. Patient evaluation using the laxity tests and outcome scales was done preoperatively and at 12, 24 and 48 months after the surgery. Clinical stability was assessed by Lachman test, Pivot shift test and Delhi active test. Functional outcome was assessed by International Knee Documentation Committee (IKDC), Lysholm and Modified Cincinnati scores. Patients in both groups were evaluated at regular intervals for a minimum period of 48 months (mean 51 months, range 48-56 months). RESULTS For all subjective scores, double bundle group patients reported statistically significant higher scores compared to single bundle group patients. Graded stability results of the Lachman, and Pivot shift tests were significantly higher in the anatomically reconstructed double bundle patient group. CONCLUSION We suggest that functional outcome and clinical stability may be better with anatomical double bundle anterior cruciate ligament reconstruction as compared to anatomical single bundle anterior cruciate ligament reconstruction.

Arthroscopic anatomic double bundle anterior cruciate ligament reconstruction: Our experience with follow-up of 4 years.

BACKGROUND Double bundle (DB) anterior cruciate ligament (ACL) reconstruction has been proposed to recreate the natural anatomy of ACL. Reconstruction of the anatomy of both the bundles of ACL has been thought to be able to restore the rotational stability of the knee joint. Nevertheless, it remains unclear whether DB reconstruction has better functional outcome than single bundle (SB) ACL reconstruction. PURPOSE To evaluate the clinical outcomes, patient satisfaction and manual laxity tests of knee in patients treated with DB ACL reconstruction in Indian population. METHODS We prospectively followed 25 patients with an isolated ACL injury operated for DB ACL reconstruction after applying the inclusion and exclusion criteria. Patients were evaluated pre-operatively and in the post-operative period at regular intervals with the minimum follow up of 4 years. Clinical stability was assessed by anterior drawer test, Lachman test and pivot shift test. Functional outcome was assessed by IKDC, Lysholm and Modified Cincinnati scores. RESULTS At the end of 4 years, functional outcome in terms of all subjective scores was satisfactory. Graded stability results of the Lachman, Anterior drawer and pivot shift tests were almost near to that in normal knee. No complication occurred post-operatively. CONCLUSION Anatomical DB ACL reconstruction seems to offer satisfactory results in terms of subjective scores and stability tests to patients with ACL tear. It has been found to be associated with no obvious complications and no failures. However a larger patient pool is desired for conclusive results.

Anterior Cruciate Ligament Reconstruction With Preservation of Femoral Anterior Cruciate Ligament Stump

Anterior cruciate ligament (ACL) reconstruction with preservation of either the remnant or the tibial stump is performed with the hope of improving the vascularization and proprioceptive function of the graft. Remnant preservation is technically difficult because it hinders the visualization of the intra-articular tunnel site. Taking a cue from the concept of tibial stump preservation, we have modified our ACL reconstruction technique to preserve a sleeve of the soft tissue and ACL stump attached to the femoral condyle, in addition to tibial stump preservation, while still allowing adequate visualization of the femoral ACL insertion site. We describe our modification in this article and hypothesize that this should further improve graft vascularization and ligamentization.

An unusual cause of Wartenberg’s syndrome: tuberculosis of brachioradialis muscle

World wide there has been an increase in incidence of tuberculosis with unusual site of infections being reported in increasing number more so in association with HIV/AIDS. Isolated neuropathy of superficial branch of radial nerve or Wartenberg’s syndrome is a rarely recognized pathology. We report one such case in association with tubercular infection of brachioradialis muscle without underlying bony involvement. All physicians should have adequate knowledge of tuberculosis and awareness of its atypical presentations to ensure proper management of such patients.

Dual ACL Ganglion Cysts: Significance of Detailed Arthroscopy

Intra-articular ganglion cysts of the knee joint are rare and most frequently are an incidental finding on MRI and arthroscopy. Most of the previous studies have reported a single ganglion cyst in the knee. There have been previous reports of more than one cyst in the same knee but not in the same structure within the knee. We are reporting a case of dual ACL (anterior cruciate ligament) ganglion cysts one of which was missed on radiological examination but later detected during arthroscopy. To the best of our knowledge, no such case has been reported in the indexed English literature till date.

Ochronotic black meniscus during knee arthroscopy

Ochronotic arthropathy is a rare condition found in patients with alkaptonuria, which is a hereditary metabolic disease associated with deposition the of homogentisic acid derivatives in various connective tissues of the body. We present the case of a 30-year-old woman in whom arthroscopic examination of the left knee prior to meniscectomy for bucket handle tear of medial meniscus revealed brown-black discoloration of the articular cartilage and menisci leading to the diagnosis of alkaptonuria by further laboratory evaluation. After medical and surgical treatment, patients complaints were alleviated and no further complaints were registered, during the next follow-up.

Giant Subdeltoid Tubercular Bursitis: a Case Report

Introduction Osteoarticular tuberculosis comprises 1%–3% of all tubercular and one-third of extrapulmonary tuberculosis infections. The spine is the site affected in 50%–70% of cases. The bones and joints of the lower limb are affected more commonly than are those of the upper limb. Tubercular infection of the shoulder joint accounts for 1%–2% of skeletal tuberculosis. This infection usually starts in bone in the glenoid cavity or humeral head but sometimes in the synovium. Primary infection of extra-articular bursae or tenosynovial sheaths is very rare. Tuberculous bursitis has also been reported in the prepatellar, trochanteric and olecranon bursae. Involvement of the subdeltoid bursa is extremely rare, only four cases having been reported. Our patient had the largest bursal collection reported so far. We present here a case of a 70-year-old woman with tuberculous subdeltoid bursitis and a very large cystic collection. We treated the lesion with excision and anti-tubercular drug therapy; this achieved good results throughout 2 years of follow-up.

A new technique in double-bundle anterior cruciate ligament reconstruction: some concerns.

1. The two femoral tunnels were 6 mm in diameter, with a divergence of 6 mm being observed via arthroscopy, but Fig. 5 (in [1]) shows that there is minimal bone bridge between the two femoral tunnels. Two tunnels, in close relation to each other, could cut through the metaphysis, leading to a higher fracture risk [2]. 2. In the above-mentioned method the absence of femoral implant-fixation could lead to increased tunnel widening, but greater tunnel widening was observed in the tibial side, where implant fixation was used bimodally and where the pull-out forces were the most important. One of the reasons for tibial tunnel widening may be because it was not anatomic on the tibial side. The anatomic tunnel placement group shows less tunnel enlargement. 3. The authors labelled the new technique for anatomic double bundle ACL reconstruction. Anatomic ACL reconstruction must be defined as the reconstruction in which all four ends of the two tendon grafts are grafted at the centre of the anatomical attachment of the anteromedial (AM) and posterolateral (PL) bundles not only on the femur, but also on the tibia, because only such a procedure allows for the reconstruction of two bundles in an anatomical orientation [3]. Although femoral tunnels may be double, there was a single tibial tunnel which is inserted at the same site, so it cannot be labelled as anatomic ACL reconstruction. Is there any evidence that a single tibial tunnel with double bundles in it can be labelled as anatomic ACL reconstruction? 4. Traditionally, the ACL has been divided into two major parts: anteromedial and posterolateral bundles. Although the former is relatively consistent in tension throughout the range of motion, the latter becomes taut in extension and slack in flexion. In the author’s technique the tension will be distributed equally between the two bundles whether the knee is in flexion or extension and may not mimic the biomechanics of the knee. The AM and PL grafts should be tensioned separately, with the AM in approximately 45° of flexion, and the PL graft in full extension, which is not possible with the described technique. 5. Meuffels et al. concluded that the resistance to elongation in the double-tibial tunnel group is higher than that in the single-tibial tunnel group. This could have a clinical advantage in favour of the double-tunnel reconstruction, because this stiffness more closely resembles the stiffness of the intact ACL [4]. S. Meena :V. K. Digge :H. L. Nag : S. Mittal Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi 110029, India