Raju Vaishya

Current Trends in Anterior Cruciate Ligament Reconstruction: A Review.

Anterior cruciate ligament reconstruction (ACLR) is an accepted and established surgical technique for anterior cruciate ligament (ACL) injuries and is now being practiced across the globe in increasing numbers. Although most patients get good to excellent results in the short-term after ACLR, its consequences in the long-term in prevention or acceleration of knee osteoarthritis (OA) are not yet well-defined. Still, there are many debatable issues related to ACLR, such as the appropriate timing of surgery, graft selection, fixation methods of the graft, operative techniques, rehabilitation after surgery, and healing augmentation techniques. Most surgeons prefer not to wait long after an ACL injury to do an ACLR, as delayed reconstruction is associated with secondary damages to the intra- and periarticular structures of the knee. Autografts are the preferred choice of graft in primary ACLR, and hamstring tendons are the most popular amongst surgeons. Single bundle ACLR is being practiced by the majority, but double bundle ACLR is getting popular due to its theoretical advantage of providing more anatomical reconstruction. A preferred construct is the interference fixation (Bio-screw) at the tibial site and the suspensory method of fixation at the femoral site. In a single bundle hamstring graft, a transportal approach for creating a femoral tunnel has recently become more popular than the trans-tibial technique. Various healing augmentation techniques, including the platelet rich plasma (PRP), have been tried after ACLR, but there is still no conclusive proof of their efficacy. Accelerated rehabilitation is seemingly more accepted immediately after ACLR.

Joint hypermobility and anterior cruciate ligament injury.

Purpose. To compare the rates of joint hypermobility in patients with and without anterior cruciate ligament (ACL) injury. Methods. Records of 135 men and 75 women (mean age, 24.6 years) who underwent ACL reconstructions were reviewed and compared with 55 male and 35 female controls with no knee injury. Joint hypermobility was evaluated by 2 examiners using the Beighton score. The maximum score was 9, and a score of ≥4 was defined as hypermobility. Results. The mean time from injury to presentation was 18 days. A non-contact mechanism of injury was more common. The inter-observer reliability was 0.7. 127 (60.5%) of the patients with ACL injury and 23 (25.5%) of the controls had hypermobility (p<0.01). Among them, 58% and 24% were men and 65% and 29% were women, respectively. Female gender was associated with hypermobility. Patients with ACL injury were more likely to have joint hypermobility with an odds ratio of 4.46. Conclusion. Joint hypermobility was more common in patients with ACL injury.

Non-operative management of osteoarthritis of the knee joint

Osteoarthritis is a chronic disorder of synovial joints in which there is progressive softening and disintegration of articular cartilage accompanied by the growth of osteophytes. Treatment designed for osteoarthritis should aim at reducing pain, improve joint mobility, and limit functional impairment. It can be achieved by pharmacological and non-pharmacological means. Non-operative treatment of OA is useful for patients with KL grade 1-3, which are early stages of OA. However, in an advanced stage of OA (KL grade 4), surgical treatment is needed as definitive treatment.

Surgical approaches for total knee arthroplasty

There are various surgical approaches to the knee joint and its surrounding structures and such approaches are generally designed to allow the best access to an area of pathology whilst safeguarding important surrounding structures. Controversy currently surrounds the optimal surgical approach for total knee arthroplasty (TKA). The medial parapatellar arthrotomy, or anteromedial approach, has been the most used and has been regarded as the standard approach for exposure of the knee joint. It provides extensive exposure and is useful for open anterior cruciate ligament reconstruction, total knee replacement, and fixation of intra-articular fractures. Because this approach has been implicated in compromise of the patellar circulation, some authors have advocated the subvastus, midvastus, and trivector approaches for exposure of the knee joint. While these approaches expose the knee from the medial side, the anterolateral approach exposes the knee joint from the lateral side. With careful planning and arthrotomy selection, the anterior aspect of the joint can be adequately exposed for TKA in different clinical scenarios.

Arthrodesis in a neuropathic elbow after posttubercular spine syrinx

A 46-year-old man, who was left-hand dominant with knownparaplegia due to tuberculosis spondylitis, presented withcomplaints of progressively increasing weakness and instability ofthe left upper limb for the past 2 years. The patient had difficultyusing his left upper limb for activities of daily living such aseating, combing his hair, and maneuvering his wheelchair. Onexamination, the left elbow was swollen, but not warm, and wasnot tender. Range of motion was 25 to 100 , with palpable andaudible crepitation. There was grade 3 weakness of the inteross-eous muscles and digital flexors of the ipsilateral hand. A sensoryexamination revealed sensory loss in the ulnar nerve distribution.Examination showed the median, radial, and musculocutaneousnerves were normal.Radiographs of the left elbow showed severe destruction of thedistal humerus and proximal radioulnar joint with dislocation, andsevere erosion into the intercondylar area left both condyles in aninverted U-shape. The proximal radioulnar joint was dislocatedposterolaterally but no dissociation was noted in the proximalradioulnar bones. Diffuse soft-tissue swelling, especially in theposterior elbow and heterotopic ossification, was noted in theadjacent soft tissue (Figure 1).The patient gave a history of tuberculosis of the thoracic spineinvolving the second, third, and fourth thoracic vertebrae, whichwas treated with anterolateral decompression and antituberculardrugs 4 years previously. He remained paraplegic and wheelchair-bound, but bladder and bowel functions were spared. Previousmagnetic resonance imaging of his cervicothoracic spine revealeda cervicodorsal syrinx extending from C6 to T4, which wasdiagnosed 3 years previously (Figure 2). The patient had refusedany surgical intervention for syrinx at that time.Results of blood investigations of patient were within normallimits. Computed tomography (CT)-guided aspiration of fluidfrom the elbow joint was investigated for gram stain and acid-fastbacilli stain as well as culture and polymerase chain reaction testfor tuberculosis. All the results were negative. We discussed thetreatment options, both conservative and surgical, including thehigh risks of failure in the latter with patient. Our patient insistedon having a stable elbow.Through a posterior approach, we performed ulnar nervedecompression and anterior transposition with arthrodesis of theelbow joint. Intraoperatively, the ulnar nerve was markedly dis-placed to the radial side (Figure 3). The radial head was excised.The articular margins of the humerus and ulna were freshened,and a prebent 12-hole locking plate (AO, Synthes Inc, WestChester, PA) was applied with the elbow in a functional position at70 flexion. An anterior submuscular transposition of the ulnarnerve was performed. Results of gram stains, acid-fast bacillistain, and culture of removed tissue were negative.Postoperatively, the limb was supported in an above elbowsplint for 4 weeks. The patient was followed up at monthly

Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients

BACKGROUND Fracture of the capitellum is an often missed or inadequately treated serious elbow injury. Anatomic reduction and proper stabilization are essential to obtain articular congruity so that late-onset arthritis can be avoided. The main areas of interest in this intriguing fracture are the choice of implant and the surgical approach. We describe the use of anterolateral approach and headless double-threaded compression screws for the fixation of this fracture. MATERIALS AND METHODS This prospective study included 16 capitellar fractures. A computed tomography scan was done for delineating the fracture line and planning the fixation technique. All fractures were treated with headless double-threaded compression screws using an anterolateral approach, over a period of 3 years, with a mean follow-up of 2.3 years (range, 1.5-4 years). RESULTS The average time to bony union was 3.5 months (range, 2.5-5 months) with no malunion or nonunion. The mean range of flexion was 132° (range, 125°-135°). The average extensor lag was 10° (range, 0°-25°), but the range of motion remained functional in all patients. On the final follow-up, no evidence of osteonecrosis, post-traumatic osteoarthritis, or heterotrophic ossification was seen. The outcome was excellent in 10 patients, and 6 patients had a good result. CONCLUSIONS The success of management of a capitellar fracture depends on an early diagnosis by keeping a high index of suspicion and timely management. Adequate exposure of the fracture is of paramount importance to achieve accurate reduction. This can be satisfactorily achieved by an anterolateral approach to the elbow. An adequate fixation of the fractured fragments can be achieved by the use of headless double-threaded compression screws.

Resurgence of vitamin D: Old wine in new bottle

There are early references of it in ancient text and physicians have discussed its importance and features of its deficiency in the past. Vitamin D has again regained interest with recent dramatic rise in the incidence of deficiency in the developing as well as developing world. In this review article, we discuss the biochemical and role of vitamin D in the skeletal system. We also discuss the recommended dietary requirements and features of skeletal deficiency. Extra-skeletal roles of vitamin D deficiency have been a matter of debate lately and it has also been discussed in detail in this article. In conclusion, it would not be wrong to label vitamin D as one of the most important vitamin involved in the metabolism of the musculoskeletal system and any clinician, especially the orthopaedician, should be well versed with its overall mechanism and roles in the human body.

Comment on Conteduca et al.: patient-specific instruments in total knee arthroplasty.

Dear Editor, The recently published article on “Patient-specific instruments in total knee arthroplasty” [1] caught our attention. Contemporary techniques like custom cutting blocks (CCB), computer-assisted surgery (CAS) etc. are being promoted and developed for improving the mechanical alignment of the limb in total knee arthroplasty (TKA), which has so far not been achievable [2]. It is also not yet proven if achieving a near normal mechanical alignment improves the survival of the TKA and has any significant clinical repercussion [3]. We are however convinced CCB may offer certain other advantages like decreased operative time [2] and bleeding [4] and faster recovery [4]. The major disadvantages of CCB include increased cost and delay in their procurement for surgery. In our set-up, typically this lag time has been reduced to five to seven working days and the cost for a single knee block has come down to about US

Computerized tomography based “patient specific blocks” improve postoperative mechanical alignment in primary total knee arthroplasty

400 [4]. We believe that the additional cost of CCB can be offset by decreased operative time, less need for blood transfusion and reduction of number of trays used with CCB [2] and less need for sterilisation of the trays used in the surgery. It could also potentially lead to decreased change over time in a high volume set-up. We also have the following concerns about the results in the article: The authors state that “the mean deviation of the EM tibial guides from the ideal alignment (0°) was 0.7° ± 0.39 and of the VISIONAIRE was 129° ± 1.55 (P = 0.22).” There seems to be a significant oversight in the data for VISIONAIRE as the variations from ideal alignment cannot be 129°. The authors state that the EM guide group had a mean posterior tibial slope of −1.62 and the patient-specific had a slope of +1.16, an anterior slope. This seems contrary to other studies published which measured the component alignment between conventional and patient-specific jigs [5] and reported a posterior slope in both groups. The problem of not being able to reproduce the posterior slope may be inherent to the magnetic resonance imaging (MRI)-based jig of VISIONAIRE. Chotanaphuti et al. [5] in their study comparing component alignment in both sagittal and coronal planes used computed tomography (CT)-based custom jigs and were able to reproduce the posterior slopes. It is possible to predetermine and reproduce the tibial slope in CCB by CT-based techniques like PrePlan (Stryker). Koch et al. [6] in their review of 301 TKA performed with CT-based custom jigs reported a posterior tibial slope in both computer-assisted and patient-specific instrumentation (PSI). Whether this advantage is inherent to the CT-based PSI needs further exploration. We believe that CT-based manufacturing of CCB may prove to be superior to MRI-based techniques. We hope that with further developments in computer analysis of CT images, manufacturing techniques of CCB and clinical experience of the surgeons their accuracy will be enhanced and it may be possible to provide a near normal mechanical alignment of limbs after TKA.

Sartorius muscle pedicle iliac bone graft for the treatment of avascular necrosis of femur head

AIM To compare the postoperative mechanical alignment achieved after total knee arthroplasty (TKA) using computer tomography (CT) based patient specific blocks (PSB) to conventional instruments (CI). METHODS Total 80 knees were included in the study, with 40 knees in both the groups operated using PSB and CI. All the knees were performed by a single surgeon using the same cruciate sacrificing implants. In our study we used CT based PSB to compare with CI. Postoperative mechanical femoro-tibial angle (MFT angle) was measured on long leg x-rays using picture archiving and communication system (PACS). We compared mechanical alignment achieved using PSB and CI in TKA using statistical analysis. RESULTS The PSB group (group 1) included 17 females and seven males while in CI group (group 2) there were 15 females and eight males. The mean age of patients in group 1 was 60.5 years and in group 2 it was 60.2 years. The mean postoperative MFT angle measured on long-leg radiographs in group 1 was 178.23° (SD = 2.67°, range: 171.9° to 182.5°) while in group 2, the mean MFT angle was 175.73° (SD = 3.62°, range: 166.0° to 179.8°). There was significant improvement in postoperative mechanical alignment (P value = 0.001), in PSB group compared to CI. Number of outliers were also found to be less in group operated with PSB (7 Knee) compared to those operated with CI (17 Knee). CONCLUSION PSB improve mechanical alignment after total knee arthroplasty, compared to CI. This may lead to lower rates of revision in the PSB based TKA as compared to the conventional instrumentation.