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Fungal prosthetic joint infection is rare, and two-stage revision is usually advocated. We present our experience with 2 cases of fungal prosthetic knee joint infection presenting 25 months and 3 years after index surgery. Both patients were managed with single-stage revision arthroplasty and fluconazole monotherapy. They remain asymptomatic with good knee society score after 2 years of follow-up. Preoperative workup of all aseptic loosening cases should include extended culture for fungal elements. Single-stage revision with antifungal therapy for 3 months gives good results in nonimmunocompromised patients with good soft-tissue envelope.

Background: With Most patients with Osteoarthritis needing bilateral TKR for optimal functional results, the debate on whether to do a single stage bilateral TKR or staged bilateral TKR has become common. The aim of this study was to review the safety of single stage bilateral TKR done in our institution. Materials and Methods: We did a retrospective review of 127 cases of single stage bilateral TKR that was done in our institution during a period of 38 months from 2015 to 2018.Electronic medical Records of patients who underwent single stage Bilateral TKR during this period were reviewed. Only patients who received cruciate retaining prosthesis and had subvastus approach were included. Results were analysed using Chi square testing in terms of ASA grade and age and incidence of complications. Results: ASA grade and age was seen to be correlating with incidence of complications during the intraoperative and immediate postoperative period. The incidence of complications was 42.9% in the ASA-III group with p value less than 0.00001. The Incidence of complications was 16 % in the above 70 years age group with P value less than 0.00982. In the ASA-III group, the incidence was 50% in the above 70 group when compared to the 60-70 group (40%) with P value of less than 0.00001. Conclusions: Judicious patient selection using ASA grade and age may minimise complications of single stage bilateral TKR. The use of Cruciate retaining prosthesis and subvastus approach may have contributed to the low incidence of complications.

Background: Displaced patella fractures need to be treated by internal fixation for achieving good outcome. Metallic hardware related pain and irritation are one among the many reasons for reoperations. Fracture displacement can happen due to early mobilisation depending on bone quality and fracture pattern. The aim of our study was to evaluate the postoperative outcome and complication rates of patella fractures fixed with fibre wires in a vertical and figure of eight pattern. Methods: We retrospectively followed up all patella fractures fixed using fibre wires utilising Krackow stitches through patellar tendon, longitudinal fixation through fracture fragments and figure of eight wiring on anterior patella. We evaluated their clinical outcome, range of movement, time to union and complication rates. We also evaluated these for arthritic scenario and different fracture patterns. Results: We had 22 patients (mean age 50.7) with a mean follow up of 22.7 months, mean Bostman score of 23.5, mean range of movement 1150 and mean time to union 13.5 weeks. Arthritic patients though united without any complications had an unsatisfactory score. None of the patients developed any hardware related complications, fracture displacement or needed an implant removal. Conclusion: Fibre wires can be used in vertical and figure of pattern for achieving fracture union with good clinical outcome without fracture displacement or symptomatic hardware problems.

Background: The successful treatment of unstable intertrochanteric fractures of the femur in elderly patients is a challenge. Due to complications associated with internal fixation, primary hemiarthroplasty is increasingly becoming an alternative treatment to achieve early mobilisation. A transtrochanteric approach could potentially decrease the complications associated with primary hemiarthroplasty. Aim of the study is to document the postoperative outcome and complications associated with this treatment.Methods: In this retrospective study, all elderly patients with unstable trochanteric fractures, treated by primary hemiarthroplasty through a transtrochanteric approach, in a tertiary care centre, from September 2017 to December 2019, were enrolled. Their data from hospital records were analysed and results compared to literature.Results: 48 patients underwent the procedure. Average age was 85 years. One year mortality was 31.25%. Average duration of surgery is 85 min. 58.3% were ambulant at one year. One case of dislocation secondary to surgical site infection was present.Conclusions: Primary hemiarthroplasty as a primary treatment in this group of patients enables early mobilization and prevents complications associated with prolonged immobilization. Transtrochanteric approach reduces the duration of surgery. Achieving early ambulation is the key to successful treatment.

Background: Clavicular hook plates are effective fixation devices for lateral end clavicle fractures and acromioclavicular joint dislocations and have been extensively used in the last decade. Although this plate achieves a high percentage of union, there are concerns about sub-acromial osteolysis and impingement of supraspinatus tendon. Objective: To show that impingement of supraspinatus tendon can be prevented by measuring the depth between acromion and supraspinatus tendon posteriorly and using hook plates of appropriate depth. Materials and Methods: We performed a prospective study on 25 patients with lateral end clavicle fractures and acromio clavicular joint disruptions by measuring the depth between posterior border of acromion and the superior border of supraspinatus at the point of application of hook plate. Fixation is then done by appropriate sized hook plate. Results: None of the patients had impingement of supraspinatus tendon. Five patients developed subacromial osteolysis which did not have any impact on shoulder function. Conclusion: There is a variation in anatomy of the acromion in different ethnic groups. Hence uniform sized hook plate will be inappropriate. A smaller hook depth is needed in south Asian population to prevent impingement.

Zygomycosis is an aggressive fungal infection occurred in immunocompromised patients commonly involving sinuses and lungs. zygomycosis has been reported in road traffic accidents and in farmland injuries. The mortality rate of zygomycosis is 40% to 80% due to angioinvasion. We report a case of immunocompetent young girl developing zygomycosis after road traffic accident in a urban area. The extensive infection patient survived after above knee amputation and antifungal therapy.

Aim To study the efficacy of topical intraarticular vs intravenous tranexamic acid (TXA) in reducing blood loss following primary total knee replacement (TKR). Materials and methods A phase 3, single center, double blind and randomized controlled study was conducted in the Department of Orthopedics, Sri Ramachandra University, Chennai, Tamil Nadu. A prospective study of 100 patients lasted from July 2013 to July 2015. Results Postoperative transfusion rates were zero in both the groups (intraarticular and intravenous). The mean 48-hour drain collected is 285.6 ml in group A (intraarticular), while it is 325.8 ml in group B (intravenous); the mean drop in hemoglobin is 1.7 gm/dl in group A (intraarticular) while it is 2.4 gm/dl in group B (intravenous). Conclusion This study shows that topical intraarticular administration of TXA has better efficacy than intravenous TXA in controlling postoperative blood loss following primary uncomplicated TKR with no significant complications. How to cite this article Vijay A, Nageswaran J, Loganathan S, Bedford SC. Intraarticular vs Intravenous Tranexamic Acid in Reduction of Blood Loss in Primary Total Knee Replacement. J Postgrad Med Edu Res 2016;50(2):64-68.

Background: Comminution of the lateral trochanteric wall, postero-medial communition, reverse oblique fractures, fractures involving communition of greater trochanter are unstable fractures which had poor results with the regular methods of fixation. Our aim in this study is to evaluate radiological and functional outcome at the end of one year following proximal femur locking plate fixation for certain group of unstable intertrochanteric fractures. Methods: 20 patients (14 male and 6 female patients) with per trochanteric fractures underwent proximal femur locking plate fixation in Sri Ramachandra Medical College hospital. Intertrochanteric fractures were classified according to Boyd and Griffin. Mean age of the patients was 55.2 years (26-82 years). The Schatzker & Lambert Criteria used to evaluate the functional outcome at the end of one year. Minimum follow up period was six months and maximum follow up was one year. Results: The functional outcome was assessed by Schatzker and Lambert criteria and was excellent in 8 patients; good in 6, Fair in 4 and Poor in 2.The average time to bear weight fully and walk was 6.5 weeks. Conclusions: Union was achieved in unstable, comminuted trochanteric fractures without significant complications and neck shaft angle was maintained in majority of the cases following proximal femur locking plate fixation.One of the major drawbacks of using proximal femur locking plate is that weight bearing is to be controlled and done only after radiological evidence of callus formation.

Background Use of antibiotic-loaded acrylic bone cement to treat orthopaedic infections continues to remain popular, but resistance to routinely used antibiotics has led to the search for alternative, more effective antibiotics. We studied, in vitro, the elution kinetics and bio-activity of different concentrations of meropenem-loaded acrylic bone cement. Methods Meropenem-loaded bone cement cylinders of different concentrations were serially immersed in normal saline. Elution kinetics was studied by measuring the drug concentration in the eluate, collected at pre-determined intervals, by high-performance liquid chromatography. Bio-activity of the eluate of two different antibiotic concentrations was tested for a period of 3 weeks against each of the following organisms: Staphylococcus aureus ATCC 2593 (MSSA), Enterococcus faecalis ATCC 29212, Pseudomonas aeruginosa ATCC 27853, Escherichia coli ATCC 25922, S. aureus ATCC 43300 (MRSA) and Klebsiella pneumoniae ATCC 700603 (ESBL). Results Meropenem elutes from acrylic bone cement for a period of 3–27 days depending on the concentration of antibiotic. Higher doses of antibiotic concentration resulted in greater elution of the antibiotic. The eluate was found to be biologically active against S. aureus ATCC 2593 (MSSA), P. aeruginosa ATCC 27853, E. coli ATCC 25922 and K. pneumoniae ATCC 700603 (ESBL) for a period of 3 weeks. Conclusions The elution of meropenem is in keeping with typical antibiotic-loaded acrylic bone cement elution characteristics. The use of high-dose meropenem-loaded acrylic bone cement seems to be an attractive option for treatment of resistant Gram-negative orthopaedic infections but needs to be tested in vivo.

The existing scoring system like American Orthopaedic Foot and Ankle Society (AOFAS)-ankle hindfoot scale, Leppilahti et al scoring system, Achilles tendon total rupture score, foot and ankle outcome score, the physical activity scale (PAS) questionnaire and Tegner activity score were not designed to evaluate all the parameters following surgical treatment of Achilles tendon rupture. Hence, we developed a comprehensive score called the comprehensive Sri Ramachandra Medical College (SRMC) scoring system. We compared the results of 60 patients who were surgically treated for acute Achilles tendon rupture using our comprehensive SRMC scoring system with the most commonly used AOFAS-ankle hindfoot scale. Results We found that there was 6.7% poor results using our scoring system, whereas no poor results using AOFAS scoring system mainly because our scoring system also assesses quality of life, patient satisfaction and tendon strength. Similarly, there was 10% fair results in our scoring system compared to 3.3% in AOFAS scale indicating that our scoring system is more sensitive. Comprehensive SRMC scoring system was found to be reliable statistically as per alpha method (α = 0.7787) and was statistically significant at p < 0.001. Conclusion Comprehensive SRMC scoring system was found to be superior to AOFAS scale specifically for analyzing Achilles tendon repair. Poor results are likely to be picked up by our scoring system which has been shown in our results. How to cite this article Nageswaran J, Ram GG, Bedford SC. Ankle Hindfoot Scale vs Comprehensive Srmc Scoring System in Acute Achilles Tendon Rupture. J Foot Ankle Surg (Asia- Pacific) 2015;2(2):77-79.

This study aimed to determine the efficacy of PEMF (pulsed electromagnetic field) treatment in experimental osteochondral defect healing in a rabbit model. The study was conducted on 12 New Zealand white rabbits. Six rabbits formed the study group and six rabbits the control group. The right knee joints of all 12 animals were exposed and a 3.5-mm diameter osteochondral defect was created in the trochlear groove. The defect was filled with calcium phosphate scaffold. Six animals from the study group were given PEMF of one hour duration once a day for six weeks with set parameters for frequency of 1 Hz, voltage 20 V, sine wave and current ±30 mA. At six weeks the animals were sacrificed and histological evaluation was done using H&E, Safranin O, Maissons trichrome staining and immunohistochemistry for type 2 collagen. The quality of the repair tissue was graded and compared between groups with the Wakitani histological grading scale and a statistical analysis was done. The total histological score was significantly better in the study group (p = 0.002) with regeneration similar to adjacent normal hyaline cartilage. Immunohistochemistry for collagen type II was positive in the study group. PEMF stimulation of osteochondral defects with calcium phosphate scaffold is effective in hyaline cartilage formation. PEMF is a non-invasive and cost effective adjuvant treatment with salvage procedures such as abrasion chondroplasty and subchondral drilling.

BackgroundPulsed electromagnetic field (PEMF) therapy is used as an adjuvant therapy for promoting fracture healing. We performed this study in an animal model to determine the efficacy of PEMF therapy in fracture healing and to identify and quantify growth factor TGF-s1 and TGF-s2 by quanti

Osteopoikilosis presents as round or ovoid sclerotic lesions with an appearance like enostosis on pathology. Synovial osteochondromatosis occurs due to cartilaginous metaplasia with synovial villous proliferation with calcified nodules in proximity to joints. A case of osteopoikilosis associated with synovial osteochondromatosis is described. Intraosseus and juxta osseus sclerotic bone lesions were identified on radiographs and computed tomography in a patient with knee pain. The association of osteopoikilosis with synovial osteochondromatosis is rare and to our knowledge has received little attention in the literature.

We present a patient with an open, infected Achilles tendon injury with a soft tissue defect of 12 cm x 5 cm and a tendon defect of 10 cm. He underwent a two-stage procedure. A first stage debridement of tendon and soft tissue was followed by a second stage tendo Achilles reconstruction using fascia lata graft and soft tissue cover with a reverse flow sural flap. He had a good functional outcome with minimal donor site morbidity.

A combined Galeazzi and Monteggia fracture dislocation is very rare and there are few reported cases in the English literature worldwide. However, the described injuries are not classical of either fracture dislocation. Both in children and in adults the reported literature does not show classical fracture types of either Galeazzi or Monteggia lesion in the same forearm. Our patient had the classical combination of both Galeazzi and Monteggia fracture in the same forearm. We have described the rare mechanism of injury and management for this injury based on a review of the literature.

The objectives of treating open knee joint injuries with disruption of the distal quadriceps mechanism are to ensure rapid wound healing and to restore joint function. For this it is necessary to provide soft tissue cover, control infection, restore full extension of the knee by reconstruction of the extensor apparatus and prevent joint stiffness by early mobilisation. Two cases are presented where the gastrocnemius (medial half) musculotendinous unit has been used to reconstruct, in one stage, the extensor apparatus and at the same time to provide soft tissue cover.

Viscoelastic properties of skin, ie, creep and stress relaxation, allow it to stretch beyond its normal state within a short period of time. Presented here is a technique of "wound coverage by skin stretching" that uses this principle. Kirschner wires were passed through the skin edges on either side of the wound margins. Dynamic traction was applied with traction bands improvised by the surgeon from surgical glove wrist rings. We used this method in eight patients to close 10 wounds that were not feasible to close with direct methods. We have found that this simple, economic, and effective method provides rapid functional wound closure when bone and other structures are exposed. It does not require specialized training or devices. Careful attention to the described surgical technique gives good results and few complications.

Skin necrosis and prosthetic subluxation are dreaded complications after total knee arthroplasty. It can result in deep infection with subsequent failure of prosthesis. The incidence of infection in patients with rheumatoid arthritis who undergo knee arthroplasty is high when compared to patients with primary osteoarthritis. The gastrocnemius muscle flap has been described for cover of proximal tibia and tendon loss because of malignancy and has been used as a bridge graft in trauma patients with patellar tendon loss. We describe a patient with total knee arthroplasty with anterior knee skin necrosis and prosthesis subluxation because of attenuation and loss of continuity of patellar tendon. This was managed by using gastrocnemius bridge grafting. Here, the gastrocnemius bridge graft was used as a soft tissue cover as well as a dynamic anterior stabilizer for the prosthesis.

Articular cartilage defects have a poor capacity for repair. Most of the current treatment options result in the formation of fibro-cartilage, which is functionally inferior to normal hyaline articular cartilage. We studied the effectiveness of allogenic chondrocyte transplantation for focal articular cartilage defects in rabbits. Chondrocytes were cultured in vitro from cartilage harvested from the knee joints of a New Zealand White rabbit. A 3 mm defect was created in the articular cartilage of both knees in other rabbits. The cultured allogenic chondrocytes were transplanted into the defect in the right knees and closed with a periosteal flap, while the defects in the left knees served as controls and were closed with a periosteal flap alone, without chondrocytes. Healing of the defects was assessed at 12 weeks by histological studies. Allogenic chondrocyte transplantation significantly increased the amount of newly formed repair tissue (P=0.04) compared with that found in the control knees. The histological quality score of the repair tissue was significantly better (P=0.05), with more hyaline characteristics in the knees treated with allogenic chondrocytes than in the control knees. Articular cartilage defects treated with allogenic chondrocyte transplantation result in better repair tissue formation with hyaline characteristics than those in control knees.

Study Design Efficacy of the percutaneous biopsy of the spine under computed tomographic guidence was investigated, Seventy-five patients, ranging in age from 7 to 72 years, underwent this procedure. Objectives To determine the usefulness of computed tomographically guided biopsies in the treatment of patients with spinal disorders. Summary of Background Data The results of 68 biopsies (90.6%) were judged to be accurate insofar as the samples of tissue obtained could be diagnosed as specific types of enoplasm, infective lesions, reactive lesions of nonspecific type, or noramal bone. Methods Biopsies that yielded a specific abnormality were categorized as true positives. The “normal” biopsies were followed for 6–8 months and were than deemed true negatives. Nondiagnostic ones were considered false negatives. Results The results are acceptable with an accuracy rate of 90.6%. It is a safe and simple procedure with a short learning curve. Conclusions Computed tomographically guided biopsy of the spine is recommended as a procedure of choice, especially in cervical and thoracic lesions. Computed tomography is superior to fluiorascopy when dealing with small, deep-seated lesions especially in the cervical and thoracic regions and with lesions picked up on bone scan only, radiographs being negative. Needle biopsy under computed tomographic guidance is safe and precise.

We have used the extensor digitorum brevis musculotendinous unit elevated on its neurovascular pedicle and transposed it to reconstruct the Achilles tendon in a case of neglected rupture.