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Cardiac complications represents a major cause of morbidity and mortality especially after bilateral simultaneous total knee arthroplasty (BS-TKA). Takotsubo syndrome after BS-TKA has not been described in the literature. A 60 years-old women underwent BS- TKA and she suddenly developed bradycardia and hypotension after second knee wound closure. The electrocardiography revealed ST elevation and echocardiography showed apical hypokinesia of left ventricle. Coronary angiography revealed normal epicardial coronaries and a provisional diagnosis of Takotsubo cardiomyopathy was made. Serial ECGs revealed resolution of ST elevation and normal LV function within 5 days. On one-year follow up, she was able to do all her normal activities, and 12-lead electrocardiography were back to normal. Cardiac complications represents a major cause of morbidity and mortality especially after BS-TKA. Surgeons must be vigilant in the postoperative period for any likely precipitating factors of stress induced cardiomyopathy. Takotsubo syndrome should be considered as a differential diagnosis with features of acute coronary syndrome in elderly post-menopausal patients. [ABSTRACT FROM AUTHOR]

Purpose: Tibial bowing in valgus knees with arthritis can lead to component malplacement during total knee arthroplasty (TKA). Incidence of valgus knees with medial tibial bowing, its effect on tibial component placement during primary TKA and methods to improve accuracy of the component placement were studied. Methods: Full-length weight-bearing alignment radiograph was taken in 117 patients (149 knees) with valgus deformity undergoing TKA. In these cases, the proximal tibial reference for extramedullary jig placement was planned preoperatively with reference to the tibial spines and classified as four zones. Results: The mean preoperative hip–knee–ankle (HKA) angle was 192.9° (180.3–234.5°). Bowing >3° was considered significant ( p < 0.001) and at this level of bowing, the proximal tibial reference was shifted from centre to medial. Tibial bowing 3° as tibia valga. Tibia was bowed in 70 knees (46.97%). Severity of valgus deformity had strong positive correlation with the tibia valga ( p < 0.001). The post-operative medial proximal tibial angle (MPTA) and HKA angle were 91.63° (87.9–95.7°) and 182.6° (178.1–189.7°), respectively. The mean MPTA and post-operative HKA angle in bowed and straight tibiae were 90.35° versus 89.78° ( p = 0.547) and 181.5° versus 180.7° ( p = 0.5716), respectively, and the difference was not statistically significant. Conclusion: Medial tibial bowing is very common in valgus knees. Tibia valga has a strong positive correlation with the severity of valgus deformity. Accurate tibial component placement can be achieved with a medialized reference point for extramedullary tibial cutting jig in knees with significant tibia valga. The study has been registered in clinical trials registry – India (CTRI/2018/03/012283).

Introduction: Proximal tibia stress fractures with knee osteoarthritis pose a challenging situation. We evaluated the radiological and functional outcome of one-stage total knee arthroplasty (TKA) and long stem for patients with varied grades of knee arthritis and proximal tibia stress fractures. Methods: We analysed 20 patients from April 2012 to March 2017 with proximal tibia stress fractures associated with knee osteoarthritis of varied grades. Out of 20 patients, five were acute fresh fractures. The mean age was 64 years (range, 52–78) which includes three men and 17 women. Previous surgery in the same limb, rheumatoid arthritis, valgus deformity were excluded. All patients were treated with posterior stabilised TKA with long stem, of which, four patients had screw augmentation for medial tibial bone defect and two patients with malunited fracture at stress fracture site required osteotomy, plating and bone grafting. Two patients had two level stress fracture of tibia in the same leg. Results: The mean follow-up period was 28 (range, 6–60) months. The mean tibiofemoral angle improved from 18.27° varus to 1.8° valgus. The mean knee society score improved from 21.9 (range, −10 to 45) to 82.8 (range, 15–99) [p

Purpose: The aim of our study was to determine the surgical outcomes of patients who underwent lateral femoral sliding osteotomy (LFSO) with total knee arthroplasty (TKA) for Ranawat's type 2 fixed valgus deformity. Methods: The consecutive patients who underwent primary TKA with posterior-stabilized implant and LFSO for fixed valgus deformity were reviewed. The radiological parameters analyzed were pre- and postoperative hip-knee-ankle (HKA) angle and tibio-femoral angle in varus-valgus stress views. The clinical outcome was measured by Oxford knee score (OKS), knee society score (KSS), and functional score (KSS-F). The complications and any reoperation were noted in the follow-up. Results: There were total 28 patients included with an average follow-up time of 47.2 ± 24.9 months. The average arc of motion was 101.3 ± 23.8° preoperatively and 102.7 ± 11.8° postoperatively (p > 0.05). The average deformity in varus and valgus stress views was 196.6 ± 4.8 and 207.8 ± 7.4°, respectively. There was significant improvement in HKA from 205.2 ± 8.3° preoperatively to 181.9 ± 3.7° postoperatively (p < 0.05). At the final follow-up, bony union of the osteotomy fragment was noted in all the patients. There was significant improvement in OKS, KSS, and KSS-F score from a preoperative 15.1 ± 3.9, 35.1 ± 10.6, and 26.6 ± 12.6 to 40.3 ± 2.9, 85.6 ± 4.8, and 89.4 ± 7.7, postoperatively (p < 0.05), respectively. One patient had acute periprosthetic joint infection that was managed with debridement and polyethylene insert exchange. Conclusion: Lateral femoral sliding osteotomy is an effective technique for optimal soft tissue balance in fixed valgus deformity. It provides satisfactory clinical outcome with restoration of knee alignment without using the constrained implants. [ABSTRACT FROM AUTHOR]

Purpose: Osteoarthritis of knees with varus deformity is associated with a compensatory valgus deformity of the hindfoot and a lateral loading foot pressure pattern. However, whether this abnormal loading pattern is corrected in total knee arthroplasty (TKA) is unclear.Methods: The alignment and loading pattern of 91 consecutive patients (121 knees) undergoing TKA with pre-operative varus more than 10° were evaluated prospectively with functional outcome scores, static conventional radiography and dynamic pedobarogaphy pre-operatively and 1-year post-operatively. Outcomes assessed were Oxford Knee Scores, American Orthopaedic Foot and Ankle Scores, femorotibial mechanical angle, tibia-hindfoot angle, hindfoot valgus/varus index (VVI), foot line of pressure (LOP) laterality and peak pressure (PP) at both time points.Results: Of 121 knees, 98 (81%) regained normal alignment of the knee and 114 (92%) of the hindfoot. Similarly, PP (p < 0.001), VVI (pre-operative: - 0.29 ± 0.22, post-operative: - 0.04 ± 0.23, p < 0.001) and LOP laterality (pre-operative: 7% medial, post-operative: 96% medial, p < 0.001) all medialised post-operatively. All patients had improved functional outcomes at the knee (pre-operative: 20 ± 2, post-operative: 40 ± 2, p < 0.001) and ankle (pre-operative: 59 ± 10, post-operative: 89 ± 6, p < 0.001).Conclusion: The present study shows, following the correction of knee varus with TKA, hindfoot alignment and foot loading pattern are both restored in the majority of patients. TKA offers both static and dynamic correction as seen in the hindfoot and loading pattern, respectively.Level Of Evidence: Level III: prospective case-control study. [ABSTRACT FROM AUTHOR]

Purpose Of the Study: To evaluate the outcomes and complications using cemented megaprosthesis in elderly patients with distal femur nonunions (DFN).Materials and Methods: Between 2012 and 2016, 24 patients of DFN with an average age of 71.8 years (66-83) and an average 1.9(1-3) prior surgery was managed with distal femur replacement using cemented modular endoprosthesis. Outcomes were analysed on the following criteria: implant status, complications, knee range of motion, Knee Society Score (KSS) and Musculoskeletal Tumor Society (MSTS) score.Results: All patients were extremely satisfied with their outcomes. At an average 22.1 months (10-43) follow-up, patients had an average 69.5° (40°-110°) knee flexion, an average KSS of 75.7 (63-88) and an average MSTS score of 19.3 (17-25). Four patients died at an average 21.3 months after surgery due to causes unrelated to the fracture. One patient (4.1%) had implant-related complication; deep infection which required debridement and intravenous antibiotics. There were no late amputations or peri-operative deaths and no patient had aseptic loosening of components.Conclusion: By permitting immediate full weight-bearing ambulation and with most patients returning to an acceptable functional status, cemented megaprosthesis is a viable and useful single-stage management option in elderly patients with DFN. [ABSTRACT FROM AUTHOR]

Purpose Of the Study: To document and compare the functional outcome of neutral alignment and under-correction after total knee arthroplasty (TKA) in severe varus knees of more than 15° at three and 12 months post-surgery.Materials and Methods: One hundred twenty-four consecutive patients (163 TKAs) of an average age of 61.9 years (52-79) with a pre-operative varus more than 15° were managed with jig-based TKA. Based on the post-operative mechanical femorotibial alignment (FTMA), they were categorised into three groups, namely neutral (180 + 3°), mild varus (173° to 176°) and severe varus (172° and below). The outcomes of these three groups were assessed at three and 12 months by the Oxford knee score and the WOMAC score were calculated and co-related to the extent of correction.Results: At three months, knees in the mild varus group (n = 88) had the best results with an Oxford knee score of 41.76 + 1.44 and a WOMAC score of 19.29 + 2.93 compared to the severe varus group and the neutral alignment group which had Oxford knee scores (OKS) of 37.43 + 2.51 and 31.91 + 3.51 and WOMAC scores of 22.57 + 1.51 and 24.46 + 4.15 respectively. However at 12 months, knees in all the groups (neutral, mild varus, severe varus) had similar good functional outcomes with OKS of 39.08 + 1.68, 39.24 + 1.88, 39.29 + 1.11 and WOMAC scores of 17.42 + 2.15, 16.48 + 2.11, 16.14 + 1.21 respectively. A scatter plot done for post-operative FTMA and the functional outcome score for both scores showed a bell curve with the best outcome corresponding to a FTMA of 175° at 3 months and equal distribution for both scores at 12 months.Conclusion: The results of our study showed that minimal under-correction gave superior functional outcomes at three months. But this advantage was temporary and both, under-correction and neutral alignment achieved equally good outcomes at one year. Considering the increased prosthesis longevity associated with neutral alignment, we propose that neutral alignment must be aimed for during TKA for knees with severe varus.Study Design: Prospective study. [ABSTRACT FROM AUTHOR]

The integrated crop–livestock system (ICLS) is a farming strategy that helps to sustain agrobiodiversity, ecosystem services, and restores environmental sustainability. Furthermore, ICLS provides food and nutritional security to the small and marginal farmers in developing nations. In this context a mass-balanced ecosystem model was constructed for a smallholder ICLS along the Indian west coast to analyze the agro-ecological performance in terms of sustainability, resource use, nutrient balance and recycling. Thirteen functional groups were defined in the ICLS model with trophic levels ranging from 1.00 (detritus and benthic nitrogen fixers) to 3.00 (poultry and ruminants). The total system throughput index was estimated to be 1134.9 kg N ha−1 year−1 of which 60% was from consumption, 15% from exports, 10% from respiration, and the remaining 15% eventually flowing into detritus. The gross efficiency of the ecosystem was estimated to 0.3, which indicated higher growth rates and low maintenance energy costs. The higher food self-sufficiency ration of 7.4 indicated the integration of crop–livestock as an imperative system to meet the food and nutritional requirement of the farm family. The indices such as system overhead (60%), Finn's cycling index (16.6) and mean path length (3.5) denoted that the ICLS is a small, resource-efficient, stable, maturing and sustainable ecosystem in terms of the ecosystem principles and recycling. The present model will serve as the first model on the ICLS from the humid tropics and will help in the evaluation of the other agro-ecological systems using the Ecopath modelling approach. In conclusion, farm intensification through crop and animal diversification has the highest impact on farm productivity, food self-sufficiency and resource-use-efficiency of the smallholder's livelihood security. [ABSTRACT FROM AUTHOR]