Sharad Prabhakar

Efficacy of immunohistological methods in detecting functionally viable mechanoreceptors in the remnant stumps of injured anterior cruciate ligaments and its clinical importance

PurposeVarious histological and immunological methods have been used to detect the mechanoreceptors and nerve fibers on the intact ACLs as well as on the remnant stumps. However, some of these methods lack standardization, and the variable thickness of slices used often leads to misinterpretation. The study was based on the hypothesis that immunohistological methods are easier and more reliable means to demonstrate mechanoreceptors in the remnant ACL stumps as compared with the conventional methods. We also attempted to validate the methodology of immunohistology as a means of characterizing functional mechanoreceptors in the residual stump of an injured ACL.MethodsThe remnants of the ruptured ACL in 95 patients were harvested during arthroscopic ACL reconstruction and evaluated immunohistologically using hematoxylin and eosin (H&E), and monoclonal antibodies to S-100 and NFP. Multiple sections from each specimen were serially examined by two histologists.ResultsThe positivity of monoclonal antibody against NFP showed a statistically significant relationship with the presence of morphologically normal mechanoreceptors, whereas the positivity of monoclonal antibody against S-100 showed a statistically significant relationship with the presence of free nerve ending in the residual stump of an injured ACL.ConclusionsImmunological methods are more reliable and easier to use as compared with the conventional methods of histological staining for identifying remnant stumps likely to be of some proprioceptive benefit after an ACL injury. Such an identification might help us preserve certain remnant stumps during ACL reconstruction which might in turn improve the postoperative functional outcomes.

Controversies in calcaneus fracture management: a systematic review of the literature

Despite the fact that the calcaneus is the commonest tarsal bone fractured, many controversies exist in the literature regarding the management options. This stems from the fact that the understanding of the fracture pattern has evolved only recently, surgical approaches have lately been standardized, surgical timing has become more clear, and newer implants are regularly being introduced. Despite the significant advances, complications and controversies related to this common fracture abound. The present paper looks at all aspects of modern management options of calcaneus fractures and tries to review the literature with regard to the controversial issues that still persist.

Proprioception in anterior cruciate ligament deficient knees and its relevance in anterior cruciate ligament reconstruction

Injury to the anterior cruciate ligament (ACL) not only causes mechanical instability but also leads to a functional deficit in the form of diminished proprioception of the knee joint. “Functional” recovery is often incomplete even after “anatomic” arthroscopic ACL reconstruction, as some patients with a clinically satisfactory repair and good ligament tension continue to complain of a feeling of instability and giving way, although the knee does not sublux on clinical testing. Factors that may play a role could be proprioceptive elements, as the intact ACL has been shown to have significant receptors. Significant data have come to light demonstrating proprioceptive differences between normal and injured knees, and often between injured and reconstructed knees. ACL remnants have been shown to have proprioceptive fibers that could enhance functional recovery if they adhere to or grow into the reconstructed ligament. Conventionally the torn remnants are shaved off from the knee before graft insertion; modern surgical techniques, with remnant sparing methods have shown better outcomes and functional recovery, and this could be an avenue for future research and development. This article analyzes and reviews our understanding of the sensory element of ACL deficiency, with specific reference to proprioception as an important component of functional knee stability. The types of mechanoreceptors, their distribution and presence in ACL remnants is reviewed, and suggestions are made to minimize soft tissue shaving during ACL reconstruction to ensure a better functional outcome in the reconstructed knee.

Tranexamic acid for control of blood loss in bilateral total knee replacement in a single stage.

Background: Tranexamic acid (TEA) reduces blood loss and red cell transfusions in patients undergoing unilateral total knee arthroplasty (TKA). However, there is not much literature regarding the use of TEA in patients undergoing bilateral TKA in a single stage and the protocols for administration of TEA in such patients are ill-defined. Materials and Methods: We carried out a case control study evaluating the effect of TEA on postoperative hemoglobin (Hb), total drain output, and number of blood units transfused in 52 patients undergoing bilateral TKA in a single stage, and compared it with 56 matched controls who did not receive TEA. Two doses of TEA were administered in doses of 10 mg / kg each (slow intravenous (IV) infusion), with the first dose given just before tourniquet release of the first knee and the second dose three hours after the first one. Results: A statistically significant reduction in the total drain output and requirement of allogenic blood transfusion in cases who received TEA, as compared to the controls was observed. The postoperative Hb and Hb at the time of discharge were found to be lower in the control group, and this result was found to be statistically significant. Conclusion: TEA administered in patients undergoing single stage bilateral TKA helped reduce total blood loss and decreased allogenic blood transfusion requirements. This might be particularly relevant, where facilities such as autologous reinfusion might not be available.

Tuberculosis of the foot: An osteolytic variety.

Background: Foot involvement in osteoarticular tuberculosis is uncommon and isolated bony involvement of foot bones with an osteolytic defect is even more rare; diagnostic and therapeutic delays can occur, worsening the prognosis. We present a retrospective series of osteolytic variety of foot tuberculosis. Materials and Methods: We present 24 osteolytic variety of foot tuberculosis (Eleven calcaneus, four cuboid, two cunieforms, one talus, three metatarsals, three phalanges) out of 92 foot TB cases collected over last 20 years. There were 16 adults and eight children. Tissue diagnosis was established in 23 of 24 cases based on PCR AFB staining, culture, and histopathology. Surgical intervention was reserved for patients with either a juxtaarticular focus threatening to involve a joint or an impending collapse of a midfoot bone with cystic destruction. Results: Fifteen cases had an osteolytic lesion on the radiographs resembling a space-occupying lesion, five had patchy osteolysis, while four showed coke like sequestra; one patient had a lesion in two bones. Antitubercular chemotherapy after biopsy was sufficient to heal the lesion in 19 cases, while in five cases surgical debridement needed to be done. The lesions healed eventually. At an average followup of 8.3 years, (range 2-15 years) there were no recurrences and all patients were free from pain, with no restriction of movements. Six patients complained of occasional pain during walking on uneven ground. Conclusion: When tuberculous pathology is limited to the bone, the prognosis is better than in articular disease, as there is less deformity, and hence, less residual pain and disability.

Nature and incidence of upper limb injuries in professional cricket players a prospective observation

IntroductionCricket is the most popular sport in India, and is gaining in importance in all south-east Asian countries. The purpose of this study was to prospectively investigate the incidence, nature, and site of acute upper limb injuries sustained by professional cricketers of north India over a period of one year.Material & methods95 cricket players (mean age 18.9 years) were prospectively evaluated for nature and incidence of upper limb injuries from 1st November 2008 to 31st October 2009. For the purpose of comparison the calculated injury incidence included injuries sustained during match as well as practice. Injuries were also grouped according to the type of cricket activities such as batting or fielding.ResultsOut of 95 players evaluated, 24 were bowlers, 19 were batsmen, 8 were wicket keepers and the other 44 cricketers declared themselves as all rounders. There were a total of 16 upper limb injuries in 16 (16.8%) players. The majority of injuries (10/16) occurred while fielding. Out of 16 injuries, 11 were seen in hand, 3 were observed in elbow, while 2 patients suffered from shoulder problem. Twelve were acute injuries while 4 were classified as repetitive stress injuries (RSI).ConclusionThe incidence of upper limb injuries in cricketers at the professional and semi-professional level is significant, causing them to miss matches or practice for a significant number of days. This is the first study of Indian cricketers which documents the high incidence of upper limb injuries. The study highlights the importance of injury surveillance for Indian cricket. It is a concern which needs to be addressed by the players, coaches, teachers, administrators and medical personnel involved with cricket.

Evaluation of outcomes in conservatively managed concomitant Type A and B posterolateral corner injuries in ACL deficient patients undergoing ACL reconstruction

INTRODUCTION There is paucity of literature regarding the outcomes of ACL reconstruction in ACL deficient knees with concomitant Type A and Type B PLC injuries. MATERIALS AND METHODS A total of 102 patients undergoing isolated ACL reconstruction for an ACL injury were evaluated prospectively in this study. The patients with divided into three groups: group A with isolated ACL injury, group B1 with concomitant Type A PLC injury and group B2 with concomitant Type B PLC injury. The associated PLC injury in all these patients was managed conservatively. Outcome assessment was based on IKDC scores measured preoperatively and at last follow up visits. RESULTS The mean age of the patients was 25.33 years (16-38 years) with 95 males and seven females. The average follow up was almost 2.5 years (13-46 months). Group A had 88 patients while groups B1 and B2 had six and eight patients respectively. The preoperative IKDC scores were comparable for all the groups. The follow up IKDC scores were similar (statistically insignificant, p value: 0.421) for group A and group B1. Group B2 had poorer follow up IKDC scores as compared to group A and this result was found to be statistically significant (p value: 0.0001). CONCLUSION Conservative management of a concomitant Type B PLC injury adversely affects the outcomes of ACL reconstruction in these patients. Type A PLC injuries, on the other, do well without surgery and can be left as such even when associated with a concomitant ACL tear. LEVEL OF EVIDENCE Level 2.

Tuberculosis of the elbow: A clinicoradiological analysis

Background: The incidence of Tuberculosis (TB) of elbow is 2-5% of all skeletal locations. Most reports of TB elbow have focused attention on the diagnosis. The management options and classification has been missing. We present a retrospective clinicoradiological analysis of 38 cases (40 elbows) of TB of elbow joint. Materials and Methods: The patients presented with pain, swelling and loss of motion. Two cases had bilateral involvement. The average delay between onset of symptoms and presentation was 8 months. The elbows were classified according to modified Martinis radiological classification, which distinguishes between osseous lesions close to joint line (e.g. coronoid, condyles) and lesions away from the joint line (e.g. epicondyles, olecranon). We modified the classification to subdivide into para-articular bony lesions that had invaded the joint and those that were threatening to invade joint. All patients received antitubercular chemotherapy and immobilization in above-elbow plaster slab for 4–8 weeks. Twenty patients underwent surgical interventions (synovectomy, intraarticular debridement). Results: The average followup period was 5.3 years (range 1.5-14.2 years). The range of movement at final followup averaged 107° for stage 2, 90° for stage 3A, 47° for stage 3B and 32° for stage 4. Range of supination and pronation was less satisfactory as compared to flexion and extension and all elbows with bony involvement had less than 90° arc of supination and pronation. Conclusion: Surgical intervention could appreciably alter the outcome especially in patients with extra-articular involvement close to the joint. We have classified this subgroup separately.

Preliminary experience with biodegradable implants for fracture fixation.

Background: Biodegradable implants were designed to overcome the disadvantages of metal-based internal fixation devices. Although they have been in use for four decades internationally, many surgeons in India continue to be skeptical about the mechanical strength of biodegradable implants, hence this study. Materials and Methods: A prospective study was done to assess the feasibility and surgeon confidence level with biodegradable implants over a 12-month period in an Indian hospital. Fifteen fractures (intra-articular, metaphyseal or small bone fractures) were fixed with biodegradable implants. The surgeries were randomly scheduled so that different surgeons with different levels of experience could use the implants for fixation. Results: Three fractures (one humeral condyle, two capitulum), were supplemented by additional K-wires fixation. Trans-articular fixator was applied in two distal radius and two pilon fractures where bio-pins alone were used. All fractures united, but in two cases the fracture displaced partially during the healing phase; one fibula due to early walking, and one radius was deemed unstable even after bio-pin and external fixator. Conclusions: Biodegradable -implants are excellent for carefully selected cases of intra-articular fractures and some small bone fractures. However, limitations for use in long bone fractures persist and no great advantage is gained if a “hybrid” composite is employed. The mechanical properties of biopins and screws in isolation are perceived to be inferior to those of conventional metal implants, leading to low confidence levels regarding the stability of reduced fractures; these implants should be used predominantly in fracture patterns in which internal fixation is subjected to minimal stress.

Functional outcome of neglected perilunate dislocations treated with open reduction and internal fixation

Introduction: Management of neglected perilunate dislocations is controversial. The various procedures such as open reduction and internal fixation (ORIF), proximal row carpectomy, lunate excision, and wrist arthrodesis have been advocated. The aim of our study was to evaluate the functional outcome of neglected perilunate dislocations managed by ORIF. Materials and Methods: Over a period of 10 years (1996 to 2006), 14 patients with neglected perilunate dislocations (undiagnosed or untreated for 6 weeks or more) were managed by ORIF. Six patients had dorsal trans-scaphoid perilunate dislocation, 6 patients had volar lunate dislocation while the remaining two had a dorsal perilunate dislocation The results were evaluated by clinical scoring system of Cooney et al. Results: The average followup was 4.1 years (range 2-12 years). All except one of the patients operated earlier than 5 months had good results. Of the four patients operated after 5 months, two had a fair result while two had a poor outcome. Chondral damage to the capitate was noted intraoperatively in both the cases with poor outcomes. The two patients were found to have avascular necrosis (AVN) of the lunate; however, functional outcome was fair in both, and both were able to return to their profession. Conclusion: We observed favorable functional results of ORIF in neglected perilunate dislocations up to 5 months after injury. The development of AVN or midcarpal arthritis was not a major disabling factor as long as stability of wrist has been restored. Beyond 5 months, an alternative surgical procedure such as proximal row carpectomy should be contemplated as results of ORIF have not been good uniformly.