Vivek Morey

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.

Skeletal Tuberculosis Following Proximal Tibia Fracture

Over the past several years, there has been a rise in incidence of tuberculosis in both developing and developed countries. Tuberculosis complicating a fracture is uncommon. In this article, we report the case of a 10-year-old patient with a proximal tibia fracture who developed discharging wound over the fracture site after 2 weeks of initial trauma. The fracture was showing no signs of healing. A diagnosis of tuberculosis of proximal tibia was made on the basis of polymerase chain reaction and histology. After antituberculous treatment was started, the sinus healed and the fracture united. To the best of our knowledge, such a presentation has not been documented.

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.

Isolated Spontaneous Primary Tubercular Erector Spinae Abscess: A Case Report and Review of Literature

Isolated spontaneous primary tubercular erector spinae abscess in an immunocompetent patient is very rare. Here, we report such a case of 21-year-old female, which was successfully managed with timely diagnosis and intervention. Isolated primary tubercular abscess of erector spinae is a rare differential diagnosis of low back pain; however, it must be suspected in an endemic region for tuberculosis, especially when raised erythrocytic sedimentation rate and C-reactive protein are present. Excision along with anti tubercular therapy proved to be a successful strategy in our patient.

Pigmented villonodular synovitis of 1st metatarsophalangeal joint: a case report and literature review.

Pigmented villonodular synovitis is a common disease entity particularly in the knee joint but its incidence in the foot is quite rare. A case of first metatarsophalangeal (MTP) joint pigmented villonodular synovitis (PVNS), presented to us with recurrence of symptoms after surgical excision done outside our institute. After histological confirmation of recurrence of the disease, repeat open surgical excision was performed. After being asymptomatic for two months she presented to us with recurrence of symptoms for which hyperkeratotic plaque at the ventral aspect of the first MTP joint was found to be responsible on physical examination. It was treated surgically by pairing it and now patient is symptom free for last 1 year. It signifies the importance of the histopathology in the diagnosis and recurrence of the PVNS and thorough physical examination in the management of the foot pathologies.

Transient patellar dislocation resulting in simultaneous osteochondral fractures of patella and lateral femoral condyle - a case report.

Transient Patellar dislocations are commonly associated with bony contusions or osteochondral fractures involving the medial facet of patella or lateral femoral condyle. Simultaneous osteochondral fractures are rare and have not been reported in the adult. The authors report a case of combined osteochondral fracture of patella and lateral femoral condyle following acute patellar dislocation in an adult, which was misdiagnosed as meniscal injury. Both the osteochondral fracture fragments were rigidly fixed with headless compression screws and repair of the medial retinaculum was done. At latest follow up after two years, patient had regained full range of motion with no further episodes of patellar dislocation. The rarity of this combination of injury along with difficulty in interpreting radiographs makes this case interesting.

Primary repair of capsuloligamentous structures of trapeziometacarpal joint: A preliminary study

BACKGROUND Isolated trapezio-metacarpal joint dislocation is uncommon and challenging since controversy still exists regarding its management. DESCRIPTION We present a short case series in which direct repair of trapezio-metacarpal ligaments was done in three patients who had isolated, unstable dislocation of the thumb carpometacarpal joint. All of them were engaged in tasks where no compromise in hand functions and grip strength was affordable. The dislocation was addressed primarily by repair of volar oblique and dorsoradial ligaments with suture anchors. The joint was immobilised in a cast for 4 weeks followed by gradual mobilisation. RESULTS At an average follow up of 15 months, all the three patients have no restriction in the range of motion. There are no symptoms and signs of instability. In two patients, there is no pain at all; while one patient has occasional pain which is mild and does not interfere with the hand function. Radiographic examination showed normal joint alignment and no signs of subluxation or early osteoarthritis. CONCLUSION Repair of the capsuloligamentous complex with suture anchors may be considered as a treatment option in unstable trapezio-metacarpal joint dislocations in high demand patients.

Osteochondroma of the Proximal Fibula-Revisited.

It was interesting to read the case report by Kumar et al., [1]. “Osteochondroma arising from the proximal fibula: a rare presentation”, where the authors mentioned about a case of a giant osteochondroma arising from the proximal fibula in an 18-year-old male without the complications of distal neurovascular deficit or a sarcomatous change. We congratulate the authors for such a nice presentation of this common tumour with various case scenarios. The authors mentioned in the title ‘Osteochondroma arising from the proximal fibula: a rare presentation’ which in fact contradicts the statement written in the discussion ‘the most common tumours found in the proximal fibula are osteochondromas, giant cell tumours, osteosarcomas and ewing’s sarcomas’ [1]. Literature gives identical statistics and concludes that the proximal fibula is a common site for symptomatic Osteochondroma [2]. Involvement of the tibia in a case of solitary osteochondroma of proximal fibula is rare and coalescence of kissing osteochondromata (facing osteochondromas of both tibia and fibula may show an interlocking growth at the abutting parts) in patients with multiple cartilaginous exostoses (MCE) may result in tibiofibular synostosis. Hence, the tibial involvement as mentioned by the authors could actually be the scalloping of the proximal tibia due to erosion on the contagious surface adjacent to the giant proximal fibular lesion. Though there were no symptoms of neurovascular involvement in the case reported by the authors, knowledge of the possible complications from the neurovascular involvement as mentioned by the authors should be born in mind especially in cases of a giant tumours at such a notorious anatomical site [1,3,4]. Preoperative nerve conduction studies and the angiography or colour doppler ultrasonography would be invaluable in planning definitive treatment. The authors did an en block resection of the lesion leaving a very small portion of the head of fibula where the lateral collateral ligament (LCL) was attached. In the one year follow-up they did not mention about the status of the knee joint laxity which could have judged the requirement of a LCL repair or reconstruction. Type 1 en block resection of proximal fibula is indicated for aggressive or epiphyseally located tumours where LCL repair and reconstruction is necessary to address the knee instability. Abdel Matthew et al., [5], in their study did en block resection of tumours at proximal fibula followed by LCL and biceps femoris repair or reconstruction. They found no functional knee instability. Last but not the least, further follow-up of the case is required keeping in mind the possibility of recurrence or the malignant transformation. The purpose of this letter is to highlight the key points regarding such an important entity. In the end, we wish to thank the authors for presenting such a difficult to treat case to the readers.

Intraarticular osteochondroma of the knee

Osteochondromas are usually extra articular and grow away from the joint towards the diaphysis. Intraarticular osteochondromas are very rare and often misdiagnosed. We report a case of 16-year-old boy who presented with pain and clicking sound in the right knee for last 6 months. On examination, click was felt at the terminal flexion of the knee. The lateral radiograph of the right knee showed a radio opaque shadow at the posterior aspect of the distal end of femur, which was further evaluated with an MRI. Arthroscopy showed a hard lesion arising from the roof of the intercondylar notch of femur. It was excised arthroscopically. Histopathology revealed it to be an osteochondroma. Thus, intraarticular osteochondroma of the knee can be considered as a rare cause of pain in young patients.