Jatin Prakash

Evaluation of Ponseti method in neglected clubfoot

Background: Gentle passive manipulation and casting by the Ponseti method have become the preferred method of treatment of clubfoot presenting at an early age. However, very few studies are available in literature on the use of Ponseti method in older children. We conducted this study to find the efficacy of Ponseti method in treating neglected clubfoot, which is a major disabler of children in developing countries. Materials and Methods: 41 clubfeet in 30 patients, presenting after the walking age were evaluated to determine whether the Ponseti method is effective in treating neglected clubfoot. This is a prospective study. Pirani and Dimeglio scoring were done for all the feet before each casting to monitor the correction of deformity. Quantitative variables were expressed as mean ± standard deviation and compared between preoperative and postoperative followup using the paired t-test. Also, the relation between the Pirani and Dimeglio score, and age at presentation with the number of casts required was evaluated using Pearsons correlation coefficient. No improvement in Dimeglio or Ponseti score after 3 successive cast was regarded as failure of conservative management in our study. Results: The mean age at presentation was 3.02 years (range 1.1 - 10.3 years). The mean followup was 2.6 years (range 2–3.9 years). The mean number of casts applied to achieve final correction were 12.8 casts (range 8 - 18 casts). The mean time of immobilization in cast was 3.6 months. The mean Dimeglio score before treatment was 15.9 and after treatment were 2.07. The mean Pirani score was 5.41 before treatment and 0.12 after treatment. All feet (100%) achieved painless plantigrade feet without any extensive soft tissue surgery. 7 feet (17%) recurred in our average followup of 2.6 years. Conclusions: Painless, supple, plantigrade, and cosmetically acceptable feet were achieved in neglected clubfeet without any extensive surgery. A fair trial of conservative Ponseti method should be tried before resorting to extensive soft tissue procedure.

Comparison of Radiological Parameters between Normal and Patellar Dislocation Groups in Korean Population: A Rotational Profile CT-Based Study

Purpose Patellofemoral instability is a common cause of anterior knee pain in adolescents and young adults. Most normal and pathological values for diagnosing patellofemoral instability are based on Western literature. We conducted this radiological study to determine normal values for different patellofemoral parameters in a Korean population and to evaluate their usefulness in diagnosis. Materials and Methods We retrospectively reviewed the rotational profile computerized tomography (CT) scans of the patellar dislocation and control groups. Trochlear, patellar, rotational profile, and trochleo-patellar alignment parameters were compared between the groups. Receiver operating characteristic curves were drawn for significant parameters, and sensitivity and specificity were calculated for the cut-off values. Results There were 48 patients in the patellar dislocation group and 87 patients in the control group. In the control group and patellar dislocation group, the mean sulcus angle was 132.5° and 143.3°, respectively, trochlear depth was 6.04 mm and 3.6 mm, bisect offset was 56.4% and 99.9%, lateral patellar tilting was 9.8° and 19.2°, patellar facet asymmetry was 63.5% and 45.16%, and the tibial tuberosity-trochlear groove (TT-TG) distance was 10.91 mm and 27.16 mm, respectively. Conclusions The trochlear depth, bisect offset, patella tilting, and TT-TG distance were parameters that significantly contributed to patellar instability. Rotational profile CT can be considered a good diagnostic tool to assess all these parameters that help to identify anatomical aberration resulting in patellofemoral instability, thereby helping in formulating the most effective treatment plan.

Hand and wrist tuberculosis in paediatric patients – our experience in 44 patients

Skeletal tuberculosis (TB) of the hand and wrist is rare, accounting for less than 1% of all osteoarticular TB. Although rare, TB of the hand and wrist is a cause of major morbidity. A common feature among all available reports on TB of the hand and wrist was a delay in diagnosis, causing residual stiffness and pain after treatment. Minimal initial symptoms, rarity of the lesion and ability of wrist TB to mimic more common pathologies account for the delay. Skeletal TB may behave differently in this age compared with the adult population. Further, the disease may affect the growing bone, causing residual deformities. The paucity of studies from different countries, coupled with a difficulty in diagnosis resulting in major morbidity, led us to carry out a study on this topic. A total of 44 patients with skeletal lesions in the hand and wrist were studied. The diagnosis was confirmed by biopsy. Patients were started on multidrug antitubercular treatment (ATT). Those not responding were scheduled for debridement. All patients were assessed using the Green O’Brian scoring system. All these patients were studied separately for clinical presentation, nutritional status (Rainey–Mcdonald nutritional index), time from onset of symptoms to presentation, treatment required, prognosis and complications. The proximal phalanx of the fourth digit and the metacarpal of the fifth digit were the most commonly involved bones in our series, with five cases of each. The capitate was the most common carpal bone, followed by the lunate. The duration of symptoms ranged from 5 weeks to 24 weeks (mean: 7.6 weeks). Most of these patients presented with complaints of pain, followed by swelling. 13 patients did not respond favourably to ATT over an 8-week period and were scheduled for surgery. Three of these patients had multidrug resistance. There was one case of a pathological fracture in our series and seven cases of arthritis/residual significant pain at the end of follow-up. For all the other patients, the results were excellent. A very high index of suspicion, MRI and early biopsy are required for a timely diagnosis of skeletal TB of the hand and wrist. Early commencement of ATT was the most important factor for good results. The possibility of multidrug resistance should be kept in mind for patients not responding to treatment.

Tuberculosis of the patella imitating chronic knee synovitis

Tuberculosis of patella is a rare occurrence with incidence of less than 0.15% in the literature. Owing to its rarity the diagnosis is usually missed. Here we present a case of tuberculosis of the patella, being treated as chronic synovitis elsewhere. An 11-year-old boy presented to us with chronic knee swelling and a draining sinus of 5u2005months duration. He was being treated with broad spectrum antibiotics and incision and drainage. Standard X-rays revealed a lytic area with surrounding coke such as sequestrum in patella. MRI was suggestive of osteomyelitis of the patella with soft tissue oedema. Diagnosis was confirmed on biopsy. The patient was managed by curettage and excision of the sinus tract along with antitubercular treatment. The patient responded well to antitubercular therapy and gained excellent functional range of movement. In todays era of potent antituberculous drugs and decreasing tuberculosis incidence the rare and unusual locations of tuberculosis such as patella should be borne in mind while dealing with chronic lesions of the knee especially in tubercular endemic areas. A timely diagnosis helps in regaining good range of motion and a satisfactory outcome.

Letter to the Editor: Intra-articular tranexamic acid wash during bilateral total knee arthroplasty.

To the Editor: We read with interest the article by Zhu et al.1 The authors concluded that topical tranexamic acid (TXA) wash decreased the blood transfusion rate and length of hospital stay. Perioperative and total blood loss were mentioned, but the difference between the 2 was not elaborated. Perioperative includes the pre-, intraand post-operative periods. Only the haemoglobin balance method was described for calculation of blood loss. Generally the drop in haemoglobin level following bilateral total knee arthroplasty is 3 to 5 g/dl.2 However, the total drop in haemoglobin level in the TXA group ranged from 1.55 to 2.75 g/dl. As the minimum trigger for blood transfusion was a haemoglobin level of 9 g/dl, how did any patient receive a transfusion? What are the reasons for such a low haemoglobin drop in their series? When was the postoperative haemoglobin level measured? The haemoglobin level usually continues to drop for 2 to 4 days after surgery and then plateaues.3 The lowest value should be considered when calculating total blood loss. Please clarify the protocol for measurement of postoperative haemoglobin level. Drains were not used. Drains are thought to decrease haematoma collection, and in the TXA group, clamping of the drain for some time may have increased the contact time with TXA and may have increased its efficacy. Can the authors comment on this? In patients without a drain, was there any postoperative swelling, ecchymosis, or haematoma collection? Intra-articular TXA may be absorbed systemically. The authors used a combined dose of 3 g of TXA (1.5 g for each knee). The risk of systemic toxicity with such a high dose in the absence of a drain cannot be overlooked. Did the authors check the serum TXA level? Was there any advantage of topical use over intravenous use in bilateral cases? In our opinion, the intravenous route is preferred, particularly for bilateral cases, as a single low dose of 10 to 15 mg/kg may be effective for both knees. It avoids 10 minutes of waiting period/contact time, and decrease in surgical time itself may reduce blood loss. The authors mentioned only the functional criteria for discharge from hospital. Discharge of a patient depends on wound condition, oozing from wound, and fever. These may not have been controlled. The decision to discharge largely depends on the treating surgeon, and thus observer bias cannot be ruled out. The use of TXA is not the only cause of earlier discharge. Its effect on the length of hospital stay remains to be evaluated with further studies.

Epidural versus Intra-Articular Infusion Analgesia following Total Knee Replacement

To the Editor: We read with interest the article by Kasture and Saraf.1 What was the method of randomisation? Was there a pilot study or power analysis to calculate the sample size? Was ethical clearance or approval obtained? Was the patella resurfaced? Was there a significant difference in patellar resurfacing between the 2 groups? Was there any difference in postoperative range of motion? The intra-articular infusion group could have had better range of motion given that they were able to stand and walk early. Early range of motion is an advantage of local infiltrative analgesia over epidural analgesia, which has late motor recovery.2 Why was this criterion not used in the rehabilitation period? Complications of intra-articular infusion were not mentioned. Continuous intra-articular infusion is associated with knee swelling, wound-related complications, and blisters.3 The catheter tips may grow staphylococcus after 21 hours.4 Were cultures on the tips studied? Was there any early infection? Was there cardiotoxicity of bupivacaine? In addition, ketorolac, a non-steroidal anti-inflammatory drug, was used in the intra-articular infusion group. Owing to its inhibition of platelet aggregation, there may be a risk of increased bleeding.5 Was there any difference in drain output between the 2 groups? Multimodal analgesia is recommended, with medication started before the actual surgery.6 Was any regimen of multimodal analgesia used? Were any analgesics given prior to surgery? Why were only patients with moderate knee deformity included? Postoperative pain would be higher in those with severe osteoarthritis owing to more soft-tissue release. Was there any patient with valgus deformity? Patients with postoperative infection or deep vein thrombosis were excluded. Both these complications develop after 4 to 5 days. Why were they excluded? Patients were discharged at 5 days. How did the authors evaluate these complications after discharge and for how long? Continuous intra-articular infusion may be a source of infection. Excluding these patients may have caused bias. In addition, patients with previous lower limb surgeries were also excluded. How would a previous ankle or hip surgery affect the present study? There are concerns regarding toxicity of local anaesthesia used in local infiltration.7 Did the authors measure the serum bupivacaine level? A single application of local infiltration is effective to control postoperative pain.8 In our experience, continuous infusion has no added advantage over single administration, but has an increased risk of infection and drug toxicity. We agree that intraarticular infusion is an effective modality for pain control and has fewer complications, but 48 hours of continuous administration is too long and may affect early rehabilitation.

Modern Abbreviated Computer Navigation of the Femur Reduces Blood Loss in Total Knee Arthroplasty

et al reported that coronal alignment within 3 of the neutral mechanical axis did not improve the 15-year survival rate of modern TKA implants [8]. In our study, we hypothesize that the “optimized” implants sizing in PSI surgery may confer better functional outcomes and quality of life. 3. Although PSI technology is available to Vaishya et al. within 5 working days at a cost of <

Giant cell tumour--a very rare differential for a lytic lesion of the medial condyle of the humerous.

400, local manufacturing of the PSI jigs is still not available in many regions of the world. In the current literature, the additional cost associated with PSI surgery has been reported to be in the range of

Transient osteoporosis of the hip in a non-pregnant woman

520-

Isolated tuberculosis of scaphoid in the skeletally immature: a rare cause of chronic wrist pain

1020, whereas the time frame across different commercial manufacturers to deliver the PSI jigs has been found to be approximately 23 days [9,10]. Furthermore, we should consider that this additional cost, however affordable it may become, does not translate to better mechanical alignment or superior functional outcome in the patients. 4. In their reference provided, although Vaishya et al stated that they are convinced customized cutting blocks may offer other advantages such as decreased operative time, reduced blood loss, and faster recovery after TKA, they have not provided objective outcome measures or published the results for their computed tomography (CT)ebased PSI system (Preplan; Stryker). On the other hand,we recently published our results for CT-based PSI surgery (TRUMATCH; DePuy Synthes). We found that CT-based PSI surgery did not improvemechanical alignment and functional outcome when compared to conventional TKA. CT-based PSI surgery also did not reduce the operating time, blood loss, transfusion rate, or length of hospital stay [11]. 5. A meta-analysis reviewing the various commercially available magnetic resonance imagingor CT-based PSI systems is in place.