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Background: Detailed injury epidemiology is an unmatched tool for reducing injury risks associated with any sport. Very little epidemiologic data exists regarding injuries sustained by kabaddi players. Objectives: To study knee injuries in kabaddi players. Patients and Methods: This is a cross-sectional, observational study. Seventy six kabaddi players (both professionals and amateurs) presenting with sports-related knee injuries were identified from previous records; data was analysed for demographic features, injury mechanism, injury scenario, duration of injury before presentation, injury pattern, management, return to sport and time lost in sport due to the knee injury. Results: The mean duration prior to presentation was 14.4 months. Majority of the injuries (88.16%) occurred during competitive games. The most common injury noted was ACL tear (89.47%), followed by meniscus tears which were noted in 68.42% of the players. Forty four players (57.89%) retired from the sport as a consequence of the knee injury. Time lost in sport in those who returned to kabaddi was an average of 16.6 months; signifying the high morbidity due to knee injuries in kabaddi players. Return to sport was significantly more (P = 0.04) in those treated surgically than in those treated conservatively; but was not affected by mechanism of injury, injury scenario, injury pattern, duration of injury at presentation or level of competition of the athlete. Conclusions: Epidemiologic studies in kabaddi are the need of the hour to assess the burden of this predominantly rural sport and to implement injury prevention programs. Our study emphasises the morbidity of knee injuries in kabaddi players of India and the exacting toll it takes on their careers.

Optimal positioning of acetabular components is crucial for maintaining stability of THA. Postoperative assessment of acetabular anteversion is a vital but difficult task. Various methods have been devised with good results for measuring anteversion on plain radiographs but these methods are either too complicated or require special objects like scientific calculators, special protectors, tables, etc. A new simplified method of measuring anteversion on plain radiographs was created based on basic geometry.Anteversion of acetabular components was estimated on computer generated images of the acetabular cup by our method and compared with two previously established methods of Liaw and Pradhan. Measurement was done at 400 different positions of acetabular cup and compared with actual values. Another analysis was done after adding the femoral head to the acetabular component, thus obscuring some of the acetabular rim.Mean and standard deviation of error for our method was 0.77° ± 0.75° as compared to 0.93° ± 0.86° and 0.72° ± 0.68° for the methods of Liaw and Pardhan, respectively, with no significant differences from actual values. Maximal errors for our method, Liaw's and Pradhan's method were 3°, 4°, and 2.91°, respectively. On analysis, after the adding femoral head, there was a significant error of measurement with Liaw's method, while our method as well as Pardhan's remained accurate. All methods showed high inter- and intraobserver reliability.Our new simplified method of measuring acetabular anteversion on plain radiographs is acceptable in comparision to other established methods and requires only routinely used goniometer and calliper.

Chondroblastoma is a relatively rare tumor that mimics giant cell tumor and displays a predilection for long bones. In the present report, we describe the case of a benign chondroblastoma localized to the second metatarsal in a 20-year-old male who presented with a 2-year history of painless left foot swelling. Treatment of the tumor involved excision of the second metatarsal with use of an autologous structural fibular bone graft to stabilize the metatarsus and second toe. After 27 months of follow-up, the patient was ambulating well in regular shoes, with no clinical or radiographic evidence of tumor recurrence.

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.

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 Martini's 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.

Objective To assess sociodemographic profile of roadside accident victims. Materials and methods Using purposive sampling technique 100 patients were enrolled in the study. A questionnaire consisting of personal identification data, personal habits and details related to occurrence of accident was used to collect the data. Results More than half subjects (59%) were in age group of 20 to 40 years with mean age being 36.5 years ± 14.2. Majority of the accident victims (84%) were male. More than half (67%) belonged to Hindu religion, educated up to secondary level (65%), were married (54%) and were rural habitants (54%). Twenty-six percent of subjects had the history of drinking alcohol. Out of these 15 subjects (57.7%) had consumed alcohol at the time of accident. Sixty-eight percent were driving two wheeler; only 27% were wearing protective equipment (helmet/seat belt) at the time of accident. Approximately one-third (39%) had 6 to 15 years of driving experience. Half (51%) of the accidents occurred in evening hours and on Saturday and Sunday. Conclusion The present study reflects that there is need to plan strategies to decrease risk of accidents and inculcate healthy driving habits in the vulnerable citizens. How to cite this article Aggarwal A, Kaur S, Dhillon MS. Sociodemographic Profile of Road Traffic Accident Victims Admitted at Emergency Surgical OPD of a Tertiary Care Hospital. J Postgrad Med Edu Res 2012;46(1):15-18.

Cysticercosis, an infection with the larval form of pork tape worm, Taenia solium, commonly presents with multiple muscular cysts or CNS involvement. Due to vague clinical presentation and unfamiliarity of clinicians with this entity, it is difficult to diagnosis when seen as an isolated cyst. Traditional treatment is surgical excision and a course of deworming agents. We present two cases of isolated muscular cysticercosis diagnosed by USG, MRI and blood tests, who responded successfully to oral medication without need of operative intervention. Case reports A 45-year-old male patient had a tender 2 week swelling of 4 × 5 cm on medial right proximal calf. A 26-year male presented with discomfort and diffuse 6 cm swelling at inner left forearm. In both ultrasound showed characteristic hypoechoic cyst with hyperechoic scolex, and MRI revealed isolated cyst surrounded by inflamed muscles. FNAC confirmed cysticercosis, and the patient responded to oral albendazole (3 weeks) with oral steroids (2 weeks). Conclusion Although rare, possibility of isolated muscular cysticercosis should always be considered in any small musculoskeletal soft tissue swelling presenting with nonspecific clinical findings. Both our patients responded to medical therapy and were disease free, as confirmed at 3 months by follow-up MRI. These cysts can be confidently diagnosed on the basis of ultrasound and MRI, and can be very well-treated nonsurgically with an oral drug regimen consisting of albendazole and steroid. How to cite this article Rangdal SS, Prabhakar S, Dhatt S S, Prakash M, Dhillon MS. Isolated Muscular Cysticercosis: A Rare Pseudotumor and Diagnostic Challenge, can It be treated Nonoperatively? A Report of Two Cases and Review of Literature. J Postgrad Med Edu Res 2012;46(1):43-48.

Background Ultrasonographic evaluation of clubfoot is an objective method of severity assessment. The objective of this article is to assess the reliability of clubfoot severity assessment by sonographic evaluation of talonavicular angle (TNA) and the reliability of assessing change in angle on simulated Ponseti manipulation. Materials and methods Twenty-six infants with unilateral idiopathic clubfoot, treated by serial manipulation and casting by Ponseti technique, were prospectively evaluated by clinical scoring (Dimeglio and Pirani scores) and sonographic measurements of TNA at the start of treatment, after midfoot correction and after complete correction achieved. The TNA and the change in TNA on simulated Ponseti manipulation were noted. Total number of POP casts required to achieve final correction were noted; and correlated with change in TNA on attempted Ponseti manipulation. Results Mean TNA in clubfoot (66.46°) in static position was significantly different from that of contralateral normal foot (101.3°). Mean change in TNA on simulated Ponseti manipulation was 22.54° (5-50°) and it showed negative correlation with clinical scores and total number of casts required for final correction (p < 0.05). Linear regression analysis revealed that the change in TNA on simulated Ponseti manipulation was the best predictor of treatment outcome in congenital talips equinovarus (CTEV) (with predictability of 60% compared to 19 and 25% of Dimeglio score and Pirani score respectively). Conclusion Sonographic evaluation of TNA and change in TNA on simulated Ponseti manipulation can better assess the severity of clubfoot in infants. This objective method of assessment is less expensive, clinically applicable reproducible and it can better predict the treatment outcome. How to cite this article Gupta N, Sudesh P, Prakash M, Tripathy SK, Dhillon MS. Is Sonographic Calculation of Talonavicular Angle During Ponseti Correction of Clubfoot a Reliable Prognostic Indicator? J Postgrad Med Edu Res 2012;46(4):190-195.

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.

SummaryOsteochondroma is one of the most common tumors arising from the proximal fibula. Surgical treatment of proximal fibula osteochondromas may vary from debulking to resection of proximal fibula. We describe a modified surgical technique for excision of proximal fibular osteochondromas which preserves the proximal tibio-fibular joint (PTFJ). We present a series of six cases of symptomatic proximal fibular osteochondroma. Four cases were solitary osteochondromas while two were a manifestation of a hereditary multiple exostoses. Indication for surgery was peroneal nerve symptoms in three, cosmesis in one, restricted knee motion in one, and pain in one case. All these cases were operated by a modified resection technique where the head of fibula was preserved. The PTFJ was preserved. Lateral stabilizing structures of the knee were left undisturbed, and hence did not need repair. Complications occurred in two patients, one had marginal wound necrosis and one had persistent weakness of extensor haullicis longus. At a minimum follow-up of 2 years, none had recurrence or late disruption of PTFJ.

Various 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.The remnants of the ruptured ACL in 95 patients were harvested during arthroscopic ACL reconstruction and evaluated immunohistologically using hematoxylin and eosin (HE), and monoclonal antibodies to S-100 and NFP. Multiple sections from each specimen were serially examined by two histologists.The 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.Immunological 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.

Multiplex Polymerase Chain Reaction (MPCR) is a technique in which two or more gene targets are amplified in a single reaction. This has increased sensitivity of diagnosis as a single gene target may be absent in some Mycobacterium tuberculosis strains.MPCR using two target genes specific for Mycobacterium tuberculosis, that is, IS6110 and MPB 64, ZN staining and Mycobacterial culture were performed on synovial fluid/pus samples of 80 (three confirmed, 77 suspected) patients of osteoarticular tuberculosis and 25 non tuberculosis patients.MPCR had a sensitivity of 100% in confirmed cases and 81.8% in clinically suspected cases. AFB was positive in one patient and Mycobacterial culture was positive in three patients. MPCR also had 100% specificity; MPB64 was positive in five patients in which IS6110 was negative whereas IS6110 was positive in two patients in which MPB64 was negative.MPCR is a sensitive and specific method for diagnosis of paucibacilliary conditions such as osteoarticular tuberculosis.

Primary malignant melanoma (clear cell sarcoma) of bone is a very rare neoplasm. Although metastatic melanoma to bone is not uncommon, primary malignant melanoma of bone is extremely uncommon. To date, only nine cases have been reported in the English literature. In this report, we present a case of primary malignant melanoma arising from the medial aspect of the proximal tibia in a 26-year-old woman. We treated the patient with above-knee amputation without any chemotherapy or radiotherapy. At final follow-up of 18 months, the patient was free of disease.

Clubfoot or congenital talipes equinovarus is a common congenital abnormality of uncertain etiology. The purpose of this study was to assess the results of the Ponseti method in India and to investigate the demography of relapse and resistant cases.A total of 86 children (146 feet) below 1 year of age who had presented to the paediatric orthopedic outpatient department of our institution between June 2003 and January 2007 with unilateral or bilateral idiopathic clubfoot deformity were included in our study and treated conservatively by use of the Ponseti technique.128 feet responded to the Ponseti casting technique initially and 18 feet were resistant to the conservative treatment. Of the responsive feet, for 20 feet there was a relapse of the deformity. Evaluation of the results showed that poor compliance with splintage was the most common cause of relapse; delayed presentation and atypical clubfeet resulted in high resistance to this technique. Correction achieved at our centre was 82.18%. This is less than in many recent studies and could be attributed to increased incidence of delayed presentation, poorer compliance, and atypical feet in our population.We conclude that the Ponseti technique is recommended for management of clubfoot and strict compliance with splintage is essential to prevent relapses. People of lower socioeconomic status are at high risk of relapse and must be targeted to create awareness among them about the importance of compliance with splintage.

Objectives: Increased expression of serum creatine kinase muscle type (CK-MM) in muscle overuse or injury has been documented in many situations. However, the expression of CK-MM and its correlation with the extent of traumatic damage to skeletal muscle tissue has not been explored. We studied the pattern of expression of CK-MM in substantially damaged muscle tissue and attempted to correlate its expression with the extent of muscle damage. Methods: At level 1 trauma center, 15 patients with mangled lower limb were prospectively evaluated. All patients underwent primary amputation (mangled extremity severity score ≥7) using specific criteria. Muscle tissue samples were obtained intraoperatively from 3 different zones (chosen arbitrarily based on clinical parameters of muscle viability, Zones A, B, and C) for all patients. Samples were evaluated by hematoxylin and eosin (H and E) staining and immunohistochemistry (IHC) staining with polyclonal CK-MM antibody. Results: H and E staining correlated with the clinical extent of muscle death in Zones A, B, and C; the percentage of viable muscle fibers was 6.7% in Zone A, 20% in Zone B, and 73% in Zone C. Least CK-MM expression was noted in muscle tissues on IHC in Zone A (most necrotic area) and most in Zone C (most viable area). The score developed by us corroborated with the extent of muscle damage and viability. Conclusion: IHC staining for CK-MM can be used as a definite biomarker of muscle integrity and can be used as an adjunct to clinical evaluation to help define limb viability as well as levels of amputation when that is required.

BACKGROUND Genetic predisposition to ACL tears has received tremendous interest in the past few years with many SNPs of different genes being linked to ACL tear. STUDY OBJECTIVES To examine if specific sequence variants in COL12A1 gene are associated with ACL tears in Indian population. STUDY DESIGN Case-control study. MATERIALS AND METHODS 50 patients with surgically diagnosed ACL tear and 52 healthy, age-matched controls without any ligament/tendon injuries were genotyped for rs970547 and rs240736 SNPs using real time PCR method. RESULTS The AG and GG genotypes were significantly under-represented in study group patients in rs970547 region (p=0.0361). However, there was no significant difference in genotype/allele frequencies in the rs240736 region. CONCLUSIONS The COL12A1 rs970547 SNP is associated with ACL tears in the Indian population. However, these results need to be validated further so that predisposed individuals can be screened in the future for counselling and intervention. LEVEL OF EVIDENCE III.

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.

We treated 15 cases of neglected and relapsed clubfeet by the Ilizarov distraction method using the Ponseti principle in 12 children (mean age 7.3 years). The deformities were corrected around the talar head in the sequence of the cavus, adduction, varus and finally equinus (as per the Ponseti principle). Clinical and functional outcome after 2.5 years was significant (P

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.

Spontaneous bilateral idiopathic rupture of Achilles tendon is rare and usually results from sudden dorsiflexion of a plantar-flexed foot; the tendon is most often degenerated or diseased, and spontaneous bilateral rupture is not rare in patients suffering from chronic diseases. Management problems relate to reconstruction options and issues with early ambulation and weight bearing. We report a case of idiopathic bilateral Tendo-Achilles (TA) rupture with no obvious disease process, which was initially neglected, and subsequently reconstructed with LARS polyester ligament. The patient could be mobilized early despite bilateral involvement, but developed bilateral wound dehiscence which needed debridement and local flap coverage; aggressive rehabilitation finally leads to an excellent functional outcome. Despite the fact that artificial ligaments allow biointegration and can withstand stresses of early weight bearing, they often lead to wound related problems. Judicious use is advocated and good cases for their use maybe bilateral TA repair in neglected tears with gaps.

Rapidly progressive destructive hip arthropathy due to ochronosis is a rare entity about which most of the average orthopaedic surgeons are unaware of. In a developing country like India, such rapidly progressive hip destruction is seen in the far more commonly in tuberculosis of the hip. We present one such case which was misdiagnosed and treated as tuberculosis in an attempt to increase the awareness of ochronosis amongst the orthopaedic surgeons. We also briefly review the literature and discuss the management principles in such a rare diagnosis.

Purpose To describe three cases of aggressive lesion involving the proximal femur in children presenting with pathological fracture and its treatment in children under 10 years by reconstruction using angle blade plate.

Aneurysmal bone cysts of small bones of hands are rare and pose diagnostic and therapeutic challenge. We report a case of aneurysmal bone cyst of fourth metacarpal bone in a 14-year-old boy who presented with history of pain and swelling for 6 months duration. Radiograph and magnetic resonance imaging revealed a fusiform swelling involving the diaphysis and the distal metaphysis of the fourth metacarpal bone without any cortical breach. The physeal plate was not involved. Histopathological finding confirmed the diagnosis to be aneurysmal bone cyst. The patient was treated with marginal resection of the tumour preserving the articular surface by retaining the epiphysis and the bony defect was reconstructed with autologous fibular strut graft. One-year follow-up revealed an excellent incorporation of the graft with no evidence of local recurrence and also excellent range of motion of the hand. Nonvascularized fibular strut graft is easy to harvest and provide an excellent functional outcome when used as intercalary autograft after excision of aneurysmal bone cyst of hand.

An epiphyseal injury without obvious trauma is a diagnostic dilemma; in neurologically impaired children, the lack of sensation and repetitive trauma can lead to neuropathic injuries of the physeal plate, with bizarre X-ray changes; the problem is compounded by lack of awareness in the average orthopaedist, leading to treatment delays and unnecessary procedures like biopsy, or even surgery for osteomyelitis or malignancy, with increased morbidity and disability. We report a 12-year male child with myelomeningocele and neurological deficit; he presented with painless swelling and redness of left leg and sensory-motor deficit below the knee joints. X-rays showed distal tibial epiphysis plate widening and irregularity. A diagnosis of neuropathic epiphyseal plate injury was considered; the clinico-radiological picture only resolved after rigid immobilization in below knee POP casts and abstinence of weight bearing. Lesser changes were noted in the opposite side also. The injured physis displaced somewhat posteromedially over 8 months, but ultimately fused; contra-lateral changes subsided with partial physeal fusion. The objective of reporting this unusual case is to increase the awareness levels, and to report the bizarre radiological changes. Management involves non-weight bearing immobilization; diagnostic delays lead to more reactive changes with higher incidence of subsequent physeal closure.

We present our experience in the correction of congenital vertical talus deformity in a single stage using dorsal approach. We operated on 20 feet using the dorsal approach and the average age of patients at the time of surgery was 16 months. Talonavicular reduction was achieved in all the feet and there was significant improvement in postoperative talo-calcaneal and talo-first metatarsal angles, which were well maintained at a follow-up of 4 years. In conclusion, the dorsal approach efficiently manages the deformities of a congenital vertical talus foot and provides consistent radiological and clinical outcome with minimal complications such as revision surgeries and osteonecrosis of the talus.

A case of broken drill bit during arthroscopic ACL reconstruction and the technique adopted to overcome this complication is presented. We also review the literature for intra-operative incidents and technical complications during arthroscopic ACL reconstruction and various precautions we should implement to prevent such technical pitfalls from coming into reality.

Background and Aims: A high percentage of patients undergoing arthroscopic repairs on day care basis complain of inadequate postoperative pain relief. Clonidine was evaluated for the best route as an adjuvant in regional anesthesia in anterior cruciate ligament (ACL) repair to prolong analgesia. Material and Methods: A prospective randomized double-blinded study was planned in a tertiary care hospital in North India in which 85 American Society of Anesthesiologists I and II patients undergoing ACL repair were enrolled. All groups received 0.5% hyperbaric bupivacaine intrathecally as in control group C. Group IT received intrathecal 1 μg/kg of clonidine along with hyperbaric bupivacaine, group IA received 0.25% bupivacaine and 1 μg/kg clonidine intra-articularly, and group NB received 0.25% bupivacaine and 1 μg/kg clonidine in femoro-sciatic nerve block (FSNB). Postoperative pain free interval and block characteristics were the primary outcomes studied. Results: Pain-free duration was 546.90 (±93.66) min in group NB (P < 0.001) in comparison to 234.90 (±20.99), 367.80 (±47.40) and 172.20 (±54.82) min in groups IA, IT and C, respectively. Sensory block and motor blockade in NB were 474.90 (±43.80) and 267.40 (±34.59) min, respectively, and were significantly prolonged (P > 0.001) in comparison to other groups. The mean rescue analgesic requirement and cumulative frequency of rescue analgesia were least in group NB, followed by groups IT, IA and C. Conclusion: Clonidine is safe and effective adjuvant with bupivacaine in prolonging analgesia through various routes employed for post knee surgery pain. The maximum prolongation of analgesia is achieved through FSNB with a risk of prolonging postanesthesia care unit stay.

Sports-related knee injuries occur commonly in athletes. However, there is no published epidemiological study from India till date.The purpose of this study was to identify common injuries sustained by Indian athletes participating in different sports and to study various associated demographic features. A secondary objective was to investigate different factors, which may affect return to sport by the athlete.Cross-sectional study (observational study).Sports injury clinic, PGIMER, Chandigarh.Out of 465 athletes who presented to us with sports-related knee injuries over a 5-year period, 363 athletes (from 24 different sports) with complete records were identified. Data were analysed for demographic features, type of sport, mechanism of injury, injury scenario, athlete's level of play, injury duration at presentation, injury patterns and type of management. Telephonic interviews were conducted with each athlete to enquire about return to sport and time lost in sport due to the knee injury. Factors associated with return to sport were investigated using statistical tests of association.Soccer was found to be the most common sport associated with knee injuries accounting for 30.6% of the injuries followed by kabaddi (20.9%). The most common mechanism was non-contact injury (64.4%). Competitive injuries were found to be significantly more than practice/training injuries (p 0.0001). The most common injuries noted were ACL tears (n = 314) followed by meniscus injuries (n = 284) and the most common combination of injuries were an ACL tear with medial meniscus tear (n = 163). Only 39.8% of the athletes returned to sport. Mean duration of time lost in sport among those who returned to sport was 8.84 months. Return to sport was significantly associated with body mass index, level of competitiveness of the athlete and type of management (p = 0.017, 0.045 and0.0001, respectively).Knee injuries take a huge toll on an athlete's career as observed in this study. Prevention of knee injuries is of paramount importance and more focussed epidemiological studies are needed for formulating policies to prevent sports injuries in both professional and amateur athletes.IV.

Introduction Platelet Rich Plasma (PRP) contains numerous growth factors; Platelet poor plasma (PPP) is plasma proteins without platelets, containing growth factors other than platelet derived. We planned to evaluate the effect of both autologous PRP & PPP on human ACL cell growth characteristics in culture conditions to see if one was better than the other. Methods ACL remnants were collected from eleven patients during ACL reconstruction surgery; PPP and PRP were prepared from blood of these patients. Cells were isolated, identified and cultured and were then divided into six groups. Groups A-D had Fetal Bovine Serum (FBS) added to them along with different concentrations of PRP and PPP. Groups E and F had 5% and 10% PRP respectively but lacked FBS. Cell viability was assayed by MTT and Annexin V assay, and DNA content was evaluated by propidium iodide staining and flow cytometry. Results analysis of cultured cells showed that addition of PRP (5 or 10%) increased the viability of ACL cells in 4 out of 11 and promoted cell proliferation in 8 of 11 donor samples; 10% PRP was more effective than 5% PRP. However, the difference in effectiveness of 10% PRP was not significantly better than 5% PRP. 5% PPP had no significant effect on cell viability, but it led to an increase in DNA content in 5 of 11. There was no statistically significant effect of either PRP or PPP in preventing cell death (depicted by apoptosis rate). Conclusion PRP may have an enhancing effect on ACL cell viability and promotion of cell proliferation but the ideal concentration of PRP for these positive effects needs to be determined before it could be used in clinical settings for enhancing primary repair of torn ACL. Also larger, more controlled and better studies are needed to confirm its clinical utility.

Ten patients (11 feet) with severe, high-velocity, open injuries to the midfoot were treated with uniplanar external fixation. The mean patient age was 38 years. Five wounds measured >10 cm, and 3 had extensive degloving of the foot extending into the lower leg. All had grossly comminuted fractures of the tarsal and metatarsal bones: 9 patients had a fractured cuboid; 6 had a fractured navicular; 7 had a fractured cuneiform; and all had metatarsal fractures. Lisfranc joint dislocations were present in 7 feet, and intertarsal dislocations were seen in 3 cases. Six patients underwent split-thickness skin grafting, and 1 required a myocutaneous flap. The average duration of fixator use was 9 weeks (range, 6–15 weeks). Clinically, patients were evaluated 1 year after fixator removal for any residual pain in the foot, ability to stand on tiptoe, presence of a limp, deformity of an arch, and range of motion at the ankle, subtalar, and metatarsophalangeal joints. Each parameter was graded as good, fair, or poor. All patients had sensate plantigrade feet, with 2 patients who experienced pain on weight bearing, 5 who had difficulty standing comfortably on tiptoe, and 2 who limped because of pain. Three patients exhibited flatfoot deformity, whereas 4 had cavus deformity. All demonstrated stiffness at the midfoot and restriction of subtalar and forefoot motion, with 5 also having restricted ankle motion. Radiographically, all fractures were healed at the time of follow-up; 4 were malunited, with 1 demonstrating ankylosis across the tarsometatarsal joint. These results suggest that crush injuries to the midfoot often result in persistent morbidity despite early comprehensive management with external fixation.

The evolution of orthopedic implants has witnessed a great evolution and allowed insights into the various metals and alloys compatible with the human body. However, some recent reports have raised concerns regarding hypersensitivity to several metals used in orthopedic implants. These cases are mostly documented in the field of arthroplasty. Metal ion release following hip or knee arthroplasty is a known phenomenon and associated immune reactions to these metal ions have been implicated in the causation of these hypersensitivity reactions. These reactions frequently lead to poor outcome following these implant surgeries. We here present two rare cases of metal induced hypersensitivity reactions following orthopedic surgeries. We have also reviewed the literature in this context to look into the various causes of metal reactions, types of implant involved in hypersensitivity, methods of testing and management options in these cases. How to cite this article Kanojia R, Kumar V, Garg B, Dhillon MS. Implant-related Metal Hypersensitivity—A Cause for Concern: A Report of Two Cases and Literature Review. J Postgrad Med Edu Res 2014;48(1):37-39.

Ľadministration centro-neuraxiale et parenterale de ketamine peut produire une analgesie, limitee toutefois par des effets indesirables. Nous avons voulu verifier la qualite de ľanalgesie selon ľutilisation de ketamine seule ou en combinaison avec de la bupivacaine a la suite ďune arthroscopie du genou. Soixante patients, ďetat physique ASA I ou II, devant subir la reparation arthroscopique ďun menisque sous anesthesie generale, ont ete repartis au hasard pour recevoir 1,0 mg·kg-1 de ketamine (Groupe K), de la bupivacaine a 0,25 % (Groupe B) ou une combinaison de 1,0 mg·kg-1 de ketamine et de bupivacaine a 0,25 % (Groupe BK) dans un volume total de 20 mL administre par voie intra-articulaire apres ľoperation. Les scores de ľechelle visuelle analogique 0,5, 1, 2, 4, 6, 8, 12 et 24 h apres ľoperation, la duree de ľanalgesie et les analgesiques supplementaires pendant 24 h de plus (dextroproxyphene/acetaminophene) ont ete enregistres. Les scores de douleur ont ete significativement plus eleves chez les patients du Groupe K, compare aux Groupes B et BK. La duree de ľanalgesie a ete plus courte aussi dans le Groupe K (Groupe B = 5,7 ± 0,8 ; Groupe BK = 5,1 ± 1,1 vs GroupeK = 1,7 ± 0,9 h ; P < 0,05).La consommation ďanalgesique supplementaire a toutefois ete similaire dans les trois groupes. Ľadministration intra-articulaire ďune combinaison de bupivacaine et de ketamine fournit une meilleure analgesie que la ketamine seule apres une arthroscopie du genou en chirurgie ďun jour.

In the February 2013 issue of The American Journal of Sports Medicine, Patel et al8 published a randomized trial (‘‘Treatment With Platelet-Rich Plasma Is More Effective Than Placebo for Knee Osteoarthritis’’) that showed the efficacy of platelet-rich plasma (PRP) over a placebo saline injection in the treatment of knees affected by osteoarthritis (OA), with no difference in the beneficial effect between 1 or 2 PRP injections. For this study, a total of 74 patients with bilateral OA were divided randomly into 3 groups, treated, and followed up to 6 months

SINCE times immemorial, man has needed to depend upon his physical ability combining speed and strength, to be able to survive. With the progress of civilization, these skills have been harnessed for organized sports; the modern Olympics where highly trained athletes compete against one another, are a byproduct of man’s ability to run faster, throw further and jump higher. This has complicated things as many sportsmen now extend the endurance levels of their body, or just do too much to be able to reach specific goals. Injury is often the result, and Sports medicine now encompasses the many specialties where sport, exercise, and medicine meet. It comprises two main areas: the health benefits of regular physical activity and the health problems associated with sport and physical activity. The former has become increasingly important in modern sedentary society where inactivity and obesity are common. Health problems associated with sport have also assumed increasing importance because of more people taking part, perhaps at younger and even older ages, and more intense commitment due to the monetary and other rewards involved in professional sport. As the activities became more intense, and the stakes of the competitions grew, maintaining fitness and early recovery from injury became more important. This was recognized early in the Western world, where physicians, trainers and therapists who were specially trained in rehabilitation and preventive aspects were organized into a specialized discipline. In India also, modern sporting activities are now assuming dimensions where the athlete tends to overstrain himself; this maybe due to improper training methodology or conditioning, and most sportspersons will be anxious for an early recovery so that return to sports is facilitated. This has lead to the recognition of sports medicine as a rapidly evolving subspeciality in recent times, and the realm of this discipline now extends beyond Orthopaedics alone.

Context: Nonpharmacological interventions (NPIs) have been advocated for knee osteoarthritis (KOA). There are many gaps in the evidence to their efficacy in India. Aims: The study aims to compare the impact of two packages of NPIs on various outcome variables of KOA patients. Settings and Design: This was a randomized controlled trial in a tertiary care hospital. Subjects and Methods: A study population (n = 123) of KOA patients aged 40–65 years. Stratified block randomization was done for mild or moderate KOA into two groups. Group “A” patients received a package of NPIs including a set of supervised exercise sessions, kinesthesia, balance, and agility (KBA), meditation, weight reduction advice, and weekly telephonic reminders. Group “B” patients received the same package except for KBA & meditation. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) and performance-based measures were measured. Analysis: t-test and repeat measures ANOVA were undertaken. Results: A significant intragroup reduction in WOMAC score was seen from baseline in Group A (P = 0.00, mean difference: −9.7) as well as in Group B (P = 0.00, −12.9). There was also significant reduction inVAS scores at the end of intervention in Group A and Group B as compared from baseline (−3.62, −3.8, P = 0.00). No intergroup difference was observed in either of the scores. VAS score reduction to 0 at different stages of intervention was noticed in 46% (n = 57) cases. There was a significant intergroup difference for 50-Foot Walk Test (P = 0.055, F = 3.28) at 12 months. Conclusion: Both packages of NPIs were effective in providing relief in symptoms. No specific benefit of KBA or meditation was seen except for 50FWT.

In the modern era, rehabilitation after sports injury has become a domain for specialists, and its evolution has necessarily brought together the sports physiotherapist, the sports physician, and the orthopedic surgeon. The changing profile of sports related injury, as well as limited availability of facilities for rehabilitation in many areas of India, is a matter of concern. Elite sportspersons have some protection, but the average athlete is often left to fend for himself. Key factors in successful sports injury rehabilitation protocols are the application of modern rehabilitation protocols under appropriate supervision, appropriate and well timed surgical interventions, and judicious and need based use of pharmaceutical agents. Modern rehabilitation protocols emphasize teamwork and proper rehabilitation planning, and the rehabilitation team has to be lead by a trained sports physiotherapist, with an understanding of the protocols and interventions required at various stages. Injury specific rehabilitation protocols are being practiced worldwide but need to be introduced according to the nature of the sport as well as available facilities. Even in India, sports physicians are increasingly joining specialist rehabilitation teams, and they can help with medication, nutritional supplements, and specialized tests that could improve injury understanding. Inputs from surgeons are mandatory if surgical interventions have been performed. What is often missing in the underdeveloped world is psychological support and a clear understanding by the athlete of his/her rehabilitation protocols. World over, the primary aims are safe return to sports and minimizing reinjury on return to sport; this involves rehabilitation in stages, and current methodology clearly demarcates acute and chronic phases of injury. Close coordination with trainers and coaches is mandatory, and all need to understand that the reconditioning phase is crucial; skill assessment before progression has now become a specialized domain and needs to be introduced at all levels of the sport. A key factor in all sports injury rehabilitation protocols is injury prevention; this involves data maintenance by teams or trainers, which is still not fully developed in the Indian context. The injury and subsequent problems need to be comprehended both by athletes and their coaches. The current review is an attempt to clarify some of the issues that are important and routinely used world over, with the aim to improving rehabilitation after sports even in the underdeveloped world.

Background: Diagnosis of patellofemroal pain syndrome has been challenging due to lack of clinical test with better sensitivity and specificity, axial imaging has been considered as the standard modality for evaluation. Patients with anterior knee pain because of patellofemoral pain syndrome can be sub-grouped as those with or without radiological positive parameter for patellar maltracking. The aim of the present study was to evaluate reliability of clinical tests in two subgroups of patients presenting with patellofemoral pain syndrome.Methods: 45 knees with anterior knee pain without any episode of patellar instability were evaluated clinically using four standard tests (patellar apprehension test (PAT), eccentric step test (EST), active instability test (AIT) and Waldron’s test. On the basis of CT scan finding (at least one positive radiological parameter of instability) 28 knees were categorized in Group A (potential patellar instability group) and 17 knees in Group B (PFPS).Results: All patients with 3 or more than three clinical test positive were cases with potential patellofemroal instability except two. Whereas other true patellofemroal pain patients all except 2 were have less than 3 positive clinical tests. Conclusions: Clinical test have more diagnostic accuracy in evaluating anterior knee pain due to potential patellofemroal instability in comparison to patellofemroal pain without radiological instability.

Purpose Conventional instruments are known to result in high numbers of outliers in restoring femoral component rotation primarily due to fixed degree of external rotation resection relative to the posterior condylar line (PCL). Outliers can be reduced by determining the patient specific posterior condylar angle (PCA) preoperatively or intraoperatively. There is a paucity of methods that can be used during surgery for determining the PCA. We propose two simple, real-time methods to determine the PCA and hence to measure the axial anatomical variation during surgery. Materials and Methods The study was conducted using axial computed tomography (CT) scans of the knees of 26 patients. The commercial software K-PACS and our proposed two methods (trigonometric and protractor) were used to measure the angle between the transepicondylar axis and PCL, i.e., PCA. Statistical comparison between the mean angles obtained by K-PACS and our methods were done. Results The three methods resulted in similar PCAs. The mean PCA measured by the three methods were similar. The mean PCA value measured by the K-PACS, trigonometric method and protractor method was 6.27° (range, 0° to 12°), 6.23° (range, 0° to 11.11°) and 6.31° (range, 0° to 12°), respectively. There were significant correlations between the K-PACS measured PCA and trigonometrically or protractor measured PCA. Conclusions Our novel, simple, easily reproducible, real-time and radiation-free PCA measurement methods obviate the need for preoperative CT scan for identification of patient specific PCA.

Introduction Femoral components with inbuilt rotation require thicker flexion resection of the lateral femoral condyle and could have a potential risk of damaging the popliteus tendon, especially in the smaller Asian knees. Materials and Methods We prospectively evaluated 10 patients with bilateral varus osteoarthritis knee to size the cuts and their location in relation to the popliteus tendon. Two different types of implant were used on either side; one side requires resection in 3° external rotation (group A) and the other side requires a femoral component with inbuilt external rotation (group B). We observed the incidence of injury to the popliteus tendon and distance between flexion cut to its attachment over the lateral femoral condyle between both groups. Results We had popliteus tendon injury in 3 knees all from group B. Risk of damaging the popliteus tendon was found higher in group B, as the distance between flexion cut to popliteus tendon attachment was significantly low. Conclusion Femoral component with inbuilt external rotation has more risk of injuring the popliteus tendon because flexion cut takes out more bone from the lateral femoral condyle.

METHODOLOGY Multi-center, cross-sectional, observational study. STUDY CENTER(S): Multiple centers in India. NUMBER OF PARTICIPANTS: 1,000. PRIMARY RESEARCH OBJECTIVE: To characterize patients and treatment utilized for orthopedic patients presenting to both private and public hospital centers in India with knee pain and symptoms suggestive of knee arthritis. INCLUSION CRITERIA All patients 18 years of age or older who present to a recruiting hospital for treatment of knee pain will be eligible for participation. The subjects must be able to understand and complete the questionnaire. EXCLUSION CRITERIA Patients with total knee replacement, open wound or evidence of recent surgery, or with a current or a history of tumor and/or fracture in the tibial plateau, femoral condyle or patella, in the affected knee are not eligible. STUDY OUTCOMES This study aims to characterize the following: general demographics of patients presenting with knee pain, severity of knee symptoms at time of presentation, severity of knee pathology at time of presentation, factors associated with the decision to seek medical care, previous treatments and health care contacts, planned treatment, and gaps in treatment perceived by the patient and treating surgeons.