Sandesh S Madi

Does application of moderately concentrated platelet-rich plasma improve clinical and structural outcome after arthroscopic repair of medium-sized to large rotator cuff tear? A randomized controlled trial

BACKGROUND Platelet-rich plasma (PRP) has the potential to improve tendon-bone healing. The evidence is still controversial as to whether PRP application after repair of medium-sized to large cuff tears leads to superior structural and clinical outcome, especially after single-row repair. METHODS In a randomized study, 102 patients (PRP group, 52 patients; control group, 50 patients) with medium-sized and large degenerative posterosuperior tears were included for arthroscopic repair with a minimum follow-up of 2 years. Patients were evaluated with clinical scores (visual analog scale score, Constant-Murley score, University of California-Los Angeles score, and American Shoulder and Elbow Surgeons score) and ultrasound to assess retear and vascularity pattern of the cuff. RESULTS Visual analog scale scores were significantly lower in the PRP group than in controls at 1 month, 3 months, and 6 months but not later. Constant-Murley scores were significantly better in the PRP group compared with controls at 12 and 24 months, whereas University of California-Los Angeles scores were significantly higher in the PRP group at 6 and 12 months (P < .05). The American Shoulder and Elbow Surgeons score in both groups was comparable at all the times. At 24 months, retear in the PRP group (n = 2; 3.8%) was significantly lower than in the control group (n = 10; 20%; P = .01). The retear difference was significant only for large tears (PRP:control group, 1:6; P = .03). Doppler ultrasound examination showed significant vascularity in the PRP group repair site at 3 months postoperatively (P < .05) and in peribursal tissue until 12 months. CONCLUSION Application of moderately concentrated PRP improves clinical and structural outcome in large cuff tears. PRP also enhances vascularity around the repair site in the early phase.

A benign ancient schwannoma of the tibia nerve

A 46-year-old man, an engineer, presented with chronic left calf pain and tingling sensation in the foot for the past 2 years. There was no history of associated back pain and spine MRI study (performed elsewhere) was essentially normal. Several medics had treated the patient conservatively, yet his symptoms persisted. At the time of presentation, he also pointed out a slow growing swelling in the left popliteal fossa, of 3 months’ duration. Clinical examination revealed a small, mobile, non-pulsatile, non-transilluminant, non-tender soft tissue swelling in the popliteal fossa. Ultrasonography of the popliteal fossa observed a well-defined heterogeneous mass suggestive of a Bakers cyst. In prone position, the popliteal fossa was exposed through a lazy S incision. …

A dual injury of the shoulder: acromioclavicular joint dislocation (type IV) coupled with ipsilateral mid-shaft clavicle fracture

A direct blow to the shoulder, as may be sustained in a road traffic accident (RTA), can result in various combinations of fracture dislocations in the shoulder joint complex. Among these, a rare variety is an acromioclavicular joint (ACJ) dislocation coupled with ipsilateral mid-shaft clavicle fracture. Diverse treatment options have been described in the literature, ranging from non-operative and operative, to hybrid management. Treatment for this complex injury is predominantly dictated by the type of dislocation and displacement of the clavicle fracture, as well as age and demand of the patient. Acute high grades of ACJ dislocation require restoration of the coracoclavicular relationship (in place of torn coracoclavicular (CC) ligament) by some form of internal fixation, thereby maintaining the ACJ reduction. An arthroscopic reinstatement of the coracoclavicular relationship using a dog bone button and fibre tape implant for this composite injury pattern has not been previously described. Furthermore, a comprehensive review of the literature associated with this injury pattern is briefly described.

A case of bilateral aberrant pectoralis minor insertion with absent coracohumeral ligament: Clinical relevance and controversies

Aberrant insertions of the pectoralis minor tendon are quite rare. Most cases are incidental findings during cadaver dissections, on an MRI or during surgical procedures of the shoulder joint. Rarely the aberrant insertion points can be a source of pain or restriction of the shoulder joint. From the literature review, we found that there has been no mention regarding the frequency of occurrence of this variation with respect to unilateral or bilateral occurence, and only three cases have been reported, in which aberrant bilateral insertions have been documented of which two were noted during cadaveric dissection and one radiologically. We report a rare case of aberrant bilateral insertions of the pectoralis minor, which was found during an arthroscopic procedure, and we discuss its clinical and surgical implications.

An annoyance from an anomalous OS

A 32-year-old man, a farmer, presented with chronic pain in his left foot of 9 years duration. There was no history of trauma. Pain was typically aggravated by walking in the fields (uneven ground) or after prolonged standing. Several orthopaedists had treated this condition as an ankle sprain and plantar fasciitis for the past 9 years. However, the symptoms persisted. Clinical examination revealed a normal gait and normally arched left foot. No swelling was noted anywhere in the foot and ankle. Tenderness was noted over the lateral border of the foot, close to the calcaneocuboid joint. Eversion of the foot was characteristically painful and limited. A bony prominence was noted distal to the fibula on plain X-rays (anteroposterior and lateral views) of the ankle …

An isolated case of first metatarsal tuberculosis

An apparently healthy adolescent presented to us with multiple discharging sinuses from his right foot for the past 1 year. All serological parameters were within normal limits. X-ray picture revealed an expansile osteolytic lesion of first metatarsal. Tissue biopsy and PCR confirmed it be of tubercular etiology. The incidence of isolated occurrence of metatarsal tuberculosis is very rare and the diagnostic dilemma it brings about is briefly discussed in the following report.

Late quadriceps tendon rupture at the donor site following cruciate ligament reconstruction using central quadriceps tendon graft

Central quadriceps tendon (CQT) graft has been successfully used as a viable autograft option in cruciate ligament reconstruction of the knee. The prime emphasis in the majority of the literature is given to surgical details of quadriceps graft harvesting and outcome of cruciate ligament reconstruction. There is less discussion about donor site morbidity in CQT graft, and it is less frequent as compared to that in bone patellar tendon bone graft. We report an extremely unusual case of late quadriceps tendon rupture at the donor site following anterior cruciate ligament reconstruction using CQT graft.

Clinical outcome of primary medial collateral ligament-posteromedial corner repair with or without staged anterior cruciate ligament reconstruction

INTRODUCTION Medial collateral ligament (MCL) is a prime valgus stabilizer of the knee, and MCL tears are currently managed conservatively. However, posteromedial corner (PMC) injury along with MCL tear is not same as isolated MCL tear and the former is more serious injury and requires operative attention. However, literature is scarce about the management and outcome of PMC-MCL tear alongside anterior cruciate ligament (ACL) tear. The purpose of this study is to report the clinical outcome of primary repair of MCL and PMC with or without staged ACL reconstruction. METHODS A retrospective evaluation was performed on patients with MCL-PMC complex injury with ACL tear who underwent primary repair of MCL-PMC tear followed by rehabilitation. Further, several of them chose to undergo ACL reconstruction whereas rest opted conservative treatment for the ACL tear. A total of 35 patients of two groups [Group 1 (n=15): MCL-PMC repaired and ACL conserved; Group 2 (n=20): MCL-PMC repaired and ACL reconstructed] met the inclusion criteria with a minimum follow-up of two years. Clinical outcome measures included grade of valgus medial opening (0° extension and 30° flexion), Lysholm and International knee documentation committee (IKDC) scores, KT-1000 measurement, subjective feeling of instability, range of motion (ROM) assessment and complications. RESULTS While comparing group 2 versus group 1, mean Lysholm (94.6 vs. 91.06; p=0.017) and IKDC scores (86.3 vs. 77.6; p=0.011) of group 2 were significantly higher than group 1. 60% patients of group 1 complained of instability against none in the group 2 (p<0.0001). All the knees of both the groups were valgus stable with none requiring late reconstruction. The mean loss of flexion ROM in group 1 and 2 was 12° and 9° respectively which was not statistically different (p=0.41). However while considering the loss of motion, two groups did not show any significant difference in clinical scores. CONCLUSIONS Primary MCL-PMC repair renders the knee stable in coronal plane in both the groups and further ACL reconstruction adds on to the stability of the knee providing a superior clinical outcome. Minor knee stiffness remains a concern after primary MCL-PMC repair but without any unfavorable clinical effect.

Ulnar Nerve Injury due to Lateral Traction Device During Shoulder Arthroscopy: Was it Avoidable?

Most of the nerve injuries reported during shoulder arthroscopy in a beach chair, or lateral position is related to inappropriate patient positioning or excess traction. The lateral decubitus position is more vulnerable for traction-related neuropraxia. The present case serves as an important lesson from an avoidable situation of “having a one track mind” of the surgical team during the arthroscopic repair of shoulder instability performed in the lateral decubitus position. The operating surgeon must supervise the appropriate positioning of the patient on operation table and adequate padding of vulnerable bony points before beginning of shoulder arthroscopy to prevent any position-related nerve injuries. This is probably the first case to illustrate an unusual cause of ulnar nerve compression particularly related to the use of an additional traction device in the arthroscopic repair of shoulder instability performed in lateral decubitus position, which has not been previously defined.

Bilateral tarsal tunnel syndrome attributed to bilateral fibrous tarsal coalition and symmetrical hypertrophy of the sustentaculum tali

Tarsal tunnel syndrome (TTS) is one of the frequently encountered entrapment neuropathies of the lower limb. Most often the aetiology is considered to be idiopathic. However, it has to be thoroughly investigated to rule out diverse extrinsic and intrinsic causes. The sustentaculum tali (ST) forms the superior part of the distal tarsal tunnel, and any increase in its size may result in irritation of the tibial nerve or its branches, the medial and lateral plantar nerves or decrease the overall volume of the tarsal tunnel culminating to clinical features of TTS. A hypertrophied ST is an extremely rare cause for TTS, and we report perhaps a first case of bilateral TTS in a young adult due to bilateral symmetrical hypertrophied ST which in turn was a result of bilateral fibrous tarsal coalition. Staged bilateral surgical excision of the hypertrophied part of ST and the underlying fibrous tarsal coalition ensured prompt symptomatic relief.