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Alcohol-induced osteonecrosis of femoral head is common but multifocal osteonecrosis secondary to alcohol is very rare. The authors report one case of multifocal alcohol-induced osteonecrosis involving both hips and both knees and its subsequent progression and management over a period of 14 years. There was bilateral involvement of hips in pre-collapse stage for which a core decompression was done. The left hip responded well and at 14-year follow-up was asymptomatic with full range of motion. The core decompression surgery failed in the right hip within 1 year and subsequently hybrid total hip replacement arthroplasty was done with good functional results at 13 years follow-up. The diagnosis of knee osteonecrosis was most probably missed initially and was subsequently diagnosed 6 months back due to symptoms of pain and radiographic findings for which a core decompression was done with good early results. The results of treatment of hip was excellent in our patient and despite the rarity, a high degree of suspicion and regular screening is necessary to detect involvement of other areas like the knee in alcohol-induced osteonecrosis. [ABSTRACT FROM AUTHOR]

The use of autologous quadrupled hamstring tendon graft is a well-known technique for anterior cruciate ligament reconstruction. In cases where the diameter of the graft is inadequate, the stability of graft fixation and subsequent bone to tendon healing may be compromised. We describe a new technique to augment the autologous double looped hamstring tendon graft during anterior cruciate ligament reconstruction using cancellous bone chips. This simple technique effectively enhances graft fixation and stability. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this retrospective study was (1) to evaluate the radiographic features to differentiate arthroscopically confirmed complete and incomplete discoid lateral meniscus (DLM) (2) to determine the cutoff values for any parameter that was found to differentiate complete from incomplete DLM. Materials and Methods: We retrospectively analyzed plain knee radiographs of 130 arthroscopically proven DLM. Seventy-nine patients had complete DLM and 51 patients incomplete DLM. Knee radiographs from 52 patients with arthroscopically proven normal lateral meniscus acted as control group. Radiographic parameters measured included fibular height, lateral joint space, condylar cutoff sign, height of lateral tibial spine, obliquity of lateral tibial spine, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Results: Among radiographic parameters, high fibular head, widening of the lateral joint space and femoral condylar cutoff sign showed statistically significant (p < 0.0001) differences between complete and incomplete DLM. At specific threshold points of fibular height< 11mm, lateral joint space > 6mm and condylar cutoff sign< 0.80, the diagnosis of complete DLM revealed 87.3% sensitivity, 81.6% specificity and 78.4% positive predictive value (PPV) for the fibular height, 81.0% sensitivity, 86.6% specificity and 83.1% PPV for the lateral joint space, and 86.1% sensitivity, 83.5% specificity and 80% PPV for the condylar cutoff sign. Conclusions: Radiographic features of fibular height, lateral joint space and condylar cut off sign can be used for screening of a complete type of DLM. However, radiographs are not a reliable screening tool for an incomplete DLM. Level of evidence: IV, Case Series [ABSTRACT FROM AUTHOR]

Background: Successful outcomes following high tibial osteotomy (HTO) require precise realignment of the mechanical axis of the lower extremity. The present study investigated whether the weight-bearing limb scanogram (WBS) technique provided a more accurate mechanical axis realignment than the navigation technique in open high tibial osteotomy (OHTO). Methods: This prospective study involved 80 knees (78 patients) undergoing OHTO. The WBS technique was used in 40 knees and the navigation technique in 40 knees. Each technique was performed by a different surgeon in a different hospital. Postoperative coronal limb alignment was assessed using the weight-bearing line (WBL) ratio on full-length standing hip-to-ankle radiographs. Results: We found that the mean postoperative WBL ratio was greater in the WBS compared to the navigation group (p = 0.001), and hence the ratio for the WBS group was closer to the ratio target of 62%. There was a greater proportion of WBL ratio outliers in the navigation group than the WBS group (25% vs. 10%, p = 0.034). Conclusion: We conclude that the WBS technique was more accurate than the navigation technique for restoration of coronal leg alignment in OHTO. Level of Evidence: Level II. [ABSTRACT FROM AUTHOR]

Introduction: The results of primary total knee replacement (TKR) using hinge implants performed in the Indian population with post-polio residual paresis (PPRP) are unknown. The purpose of this study was to report the outcome of primary rotating hinge TKR in Indian patients with PPRP at a minimum follow-up of 12 months., Materials and Methods: We retrospectively reviewed the clinical and radiological records of six patients treated with primary rotating hinge TKR. Pre-and post-operative (at final follow-up) knee range of motion (ROM), knee sagittal deformity, knee society score (KSS), and Oxford knee score (OKS) were compared to determine improvement in function., Results: Six rotating hinge TKRs (five female and one male patient) were analyzed for this study. At a mean follow-up of 27 ± 22 months (range, 12-71 months), the mean pre-operative KSS of 50.6 ± 2.5 significantly improved (P < 0.0001) to 72.5 ± 1.6, and the mean pre-operative OKS of 23.6 ± 1.6 significantly improved (P < 0.0001) to 35.3 ± 1.7. The mean pre-operative knee ROM of 94° ± 10° changed to 92° ± 4° (P = 0.64) and the mean pre-operative sagittal deformity of 7° ± 23.5° changed to -3° ± 2.5° (P = 0.32) at final follow-up. None of the knees had any intra- or post-operative complications or showed radiologic evidence of post-operative loosening, subsidence, or periprosthetic radiolucent lines at the final follow-up., Conclusion: Rotating hinge TKR gave excellent clinical and radiological results at a mean follow-up of 27 months in the present study. Despite TKR being a technically challenging procedure in patients with poliomyelitis-affected limbs, a rotating hinge design, along with meticulous surgical technique, can significantly improve function in such patients., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Objective  To determine the correlation between posttreatment trunk range of motion (ROM) and isometric strength (TIS) and pain and disability in patients who underwent multimodal rehabilitation for low back pain (LBP). Methods  In this prospective cohort study, 122 patients undergoing multimodal rehabilitation for LBP were analyzed. The pre- and posttreatment numerical pain rating scale (NPRS) and the Oswestry disability index (ODI) scores, as well as trunk ROM and TIS were compared. The Pearson correlation was used to determine correlation between posttreatment clinical outcomes and ROM and TIS. Results  At the end of treatment, the mean NPRS ( p  < 0.0001) and ODI ( p  < 0.0001) scores, mean trunk extension ( p  < 0.0001), and flexion ( p  < 0.0001) ROMs improved significantly. Similarly, posttreatment, the mean extension ( p  < 0.0001) and flexion ( p  < 0.0001) TISs improved significantly. There was a weak correlation between the NPRS score and ROM extension (r = -0.24, p  = 0.006) and flexion strength (r = -0.28, p  = 0.001), as well as between the ODI score and TIS extension (r = -0.30, p  = 0.0007) and flexion (r = -0.28, p  = 0.001). Conclusion  Despite significant improvement in pain, disability, trunk ROM, and TIS with multimodal treatment, there was a weak correlation between posttreatment pain and function and trunk ROM and TIS. Improvement in pain and function with physical rehabilitation treatment for LBP is a complex phenomenon and needs further investigation., Competing Interests: Conflito de Interesses Os autores não têm conflito de interesses para declarar., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Dislocation after total hip arthroplasty (THA) partly under the surgeon's control, by appropriate placement of the components. We aimed in this study to determine the accuracy of using intra-operative smartphone applications (Apps) to place the acetabular cup within the safe abduction angle by less experienced surgeons during THA surgery when compared to the conventional freehand technique for cup placement., Methods: Sixty primary THAs were performed, 30 using the conventional freehand technique (control group) and 30 using the smartphone app technique (study group) to determine the acetabular cup abduction angle by the same young surgeon with less than one year of experience. Postoperative mean cup abduction angle, mean cup anteversion angle, and the percentage of cups within the safe abduction zone as measured on radiographs were compared between the two groups., Results: In the study group, the mean cup abduction angle was significantly lower ( P=0.0008 ), and the acetabular cup was placed within the safe zone in a significantly higher ( P<0.001 ) percentage of patients (93% vs 63%) when compared to the control group. However, there was no significant difference ( P=0.40 ) between the two groups when the mean cup anteversion angle was compared., Conclusion: The smartphone app technique may help achieve an accurate acetabular cup abduction angle and a higher percentage of cups placed within the safe zone of abduction by a less experienced surgeon when compared to the conventional freehand technique. Using tools such as the smartphone app to measure the acetabular cup position can reduce intraoperative errors by young and less experienced surgeons during THA surgery.

Purpose: We aimed to determine variation in femoral valgus correction angle (VCA) between the two limbs in a patient with windswept deformity undergoing total knee arthroplasty (TKA)., Methods: Femoral VCA was measured on full-length, hip-to-ankle, standing radiographs and was compared between the varus and the valgus limbs in 66 patients with windswept deformities., Results: The mean VCA in varus knees was significantly higher compared to mean VCA in valgus knees ( p  = 0.002)., Conclusion: Significant difference in VCA is present between the varus and the valgus limbs in most patients with windswept deformity undergoing TKA.

Purpose: The purpose of this study was to analyze clinical outcomes in patients who underwent posterior cruciate ligament reconstruction (PCLR) with and without remnant preservation., Methods: A search of the literature was performed with the established medical databases Medline, Embase, and the Cochrane Register. Two authors screened the selected articles for title, abstract, and full text in accordance with predefined inclusion and exclusion criteria. The inclusion criteria were as follows: English-language articles on isolated posterior cruciate ligament injury; clinical trials with a clear description of surgical technique; outcome evaluation using a well-defined knee score, arthrometry, and posterior stress radiography; follow-up longer than 2 years; and a Coleman Methodology Score (CMS) of 65 points or greater. The methodologic quality of all articles was assessed by 2 authors according to the CMS., Results: Eleven studies were included, with a mean CMS of 78.9 points (SD, 5.37 points). There was no direct comparative study between remnant-preserving PCLR and standard PCLR. At final follow-up, the knees of 72% to 100% of patients who underwent remnant-preserving PCLR and 41% to 95% of patients who underwent standard PCLR were rated as normal or nearly normal on the International Knee Documentation Committee subjective knee assessment. Patients who underwent remnant-preserving PCLR showed an increase of 16.4 to 47 points in Lysholm scores, and patients who underwent standard PCLR showed an increase of 22 to 29 points. The ranges of mean postoperative side-to-side differences on KT-1000 (MEDmetric, San Diego, CA) testing were 0.7 to 2.8 mm in patients who underwent remnant-preserving PCLR and 1 to 3.5 mm in patients who underwent standard PCLR. The ranges of mean postoperative side-to-side differences on stress radiography were 2.2 to 5 mm in patients who underwent remnant-preserving PCLR and 4.7 to 6 mm in patients who underwent standard PCLR., Conclusions: All studies on PCLR with remnant preservation showed satisfactory outcomes despite using numerous surgical techniques, graft types, intervals from injury to surgery, and follow-up periods., Level of Evidence: Level IV, systematic review of Level II through IV studies., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this prospective, randomized, computed tomography-based study was to investigate whether the press-fit technique reduces tunnel volume enlargement (TVE) and improves the clinical outcome after anterior cruciate ligament reconstruction at a minimum follow-up of 1 year compared with conventional technique., Methods: Sixty-nine patients undergoing primary ACL reconstruction using hamstring autografts were randomly allocated to either the press-fit technique group (group A) or conventional technique group (group B). All patients were evaluated for TVE and tunnel widening using computed tomography scanning, for functional outcome using International Knee Documentation Committee and Lysholm scores, for rotational stability using the pivot-shift test, and for anterior laxity using the KT-2000 arthrometer at a minimum of 1-year follow-up., Results: There were no significant differences in TVE between the 2 groups. In group A, in which the press-fit technique was used, mean volume enlargement in the femoral tunnel was 65% compared with 71.5% in group B (P = .84). In group A, 57% (20 of 35) of patients developed femoral TVE compared with 67% (23 of 34) of patients in group B (P = .27). Both groups showed no significant difference for functional outcome (mean Lysholm score P = .73, International Knee Documentation Committee score P = .15), or knee laxity (anterior P = .78, rotational P = .22) at a minimum follow-up of 1 year., Conclusions: In a comparison of press-fit and conventional techniques, there were no significant differences in TVE and clinical outcome at short-term follow-up., Level of Evidence: Level II, therapeutic study, prospective randomized clinical trial., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

This study aimed to determine the accuracy and reliability of visual estimation of limb alignment and knee flexion by orthopaedic surgeons when compared to recordings done by computed navigation. Orthopaedic surgeons attending a national conference were asked to place a lower limb synthetic bone model in 6 positions of the knee in the coronal and sagittal planes. These were simultaneously quantified and recorded by a computer navigation system. In the sagittal plane, 44%, 54% and 60% of the surgeons deviated by more than 5 degrees when positioning the knee in 0 degrees flexion, 10 degrees flexion and 90 degrees flexion respectively. In the coronal plane, 15%, 12% and 8% of the surgeons deviated by more than 5 degrees when positioning the knee in 0 degrees varus/valgus, 5 degrees varus and 5 degrees valgus respectively. Only 25% of the surgeons could position the knee both within 3 degrees of neutral varus/valgus and within 5 degrees of neutral flexion. Accuracy of visual estimation was not different when surgeons were compared based on time since residency, experience with TKA and experience with computer-assisted TKA. Visual estimation of knee alignment in both the sagittal and coronal plane is prone to error and may lead to inaccurate limb alignment during procedures such as TKA.

Purpose: The aim of this retrospective study was to evaluate the clinical and radiographic outcomes of arthroscopic partial meniscectomy for complete posterior medial meniscus root tear (PMMRT) in patients with early radiographic evidence of knee osteoarthritis at a minimum follow-up of 5 years., Methods: Forty-six cases had complete PMMRT with follow-up of at least 5 years and were treated with arthroscopic partial meniscectomy. On the basis of medical records, we reviewed the arthroscopic findings of joint degeneration (Outerbridge grading), clinical results using the modified Lysholm (ML) knee score and a patient questionnaire, and radiographic evaluation of degeneration using Kellgren-Lawrence (KL) grading., Results: The incidence of complete PMMRT in the study population was 15%. At a mean follow-up of 78 months (range, 60 to 103 months), the mean ML score significantly improved from 72 (range, 62 to 78) preoperatively to 77 (range, 70 to 98) at final follow-up (P < .01), 16 patients (35%) showed progression of degeneration from KL grade 0 to 2 preoperatively to KL grade 2 to 4, 56% of patients indicated improvement in pain, 67% of patients were satisfied with the results of the procedure, and 19% of patients underwent reoperation. There was a significant negative correlation between chondral wear during arthroscopy (ρ = -0.516, P = .002) and preoperative KL grade (ρ = -0.429, P = .004) with ML score at final follow-up., Conclusions: Although arthroscopic partial meniscectomy for complete PMMRT significantly improved ML scores postoperatively, only 56% of patients had improvement in pain, 67% were satisfied with the outcome of the procedure, and 35% showed radiographic progression of osteoarthritis at a mean follow-up of 77 months., Level of Evidence: Level IV, therapeutic study., (Crown Copyright © 2010. Published by Elsevier Inc. All rights reserved.)

Although distraction osteogenesis has solved limb length discrepancies, many complications are inevitable from long duration of external fixation. Use of intramedullary nails for early removal of fixators has its own challenges especially in pediatric age group. To facilitate early removal of external fixators in children, we tried a novel method of submuscular plating over the distraction callus, which is described, and the results and complications of this technique are presented. In eight children (four girls and four boys), of limb lengthening (four cases) and bone transport (four cases) done in three femurs and five tibiae with external fixators (five Ilizarov ring fixators and three monofixators), submuscular plating was done over the distraction callus. The causes of limb length discrepancy included traumatic and septic growth arrest, congenital pseudoarthrosis of tibia, fibular hemimelia, tumor salvage, and Perthes' disease. The purpose of plating was to remove the external fixator earlier after achieving the target length. Mean age of plating procedure was 11.62 years, and mean amount of distraction was 5.47 cm. In all patients, the distraction callus healed on maintaining its length or correcting into the original alignment. The mean external fixation index was 26.93 days/cm and healing index was 52.01 days/cm. One complication of superficial pin-track infection occurred, which resolved completely with conservative treatment. None of the patients developed deep infection or implant failures. The mean follow-up after plating was 28 months (range, 18-62 months). Submuscular plating over the distraction callus may be a successful method that permits early removal of fixator with fewer complications. This method can be a useful alternative in children or when nailing is difficult.

The treatment of spondyloepiphyseal dysplasia (SED) congenita patients with severe bilateral hip involvement is difficult because it involves deformities of multiple joints and of the spine. The purpose of this study was to evaluate the results of the procedure described below as a method of treatment for bilateral hip involvement in SED congenita patients. We performed proximal femoral valgus-extension osteotomy with distal femoral varus osteotomy using a hybrid external fixator in eight patients (seven male patients and one female patient) or 16 hips. The patients had a mean age of 16.37 years (range, 9-25 years) at the time of surgery. The mean valgus angle at the proximal osteotomy site was 53.4 degrees on the right side and 52.5 degrees on the left side, and the mean varus angle at the distal osteotomy site was 22 degrees . Mean fixator time was 19.8 weeks (range, 10-42 weeks). After an average follow-up of 25.9 months, the mean modified Harris hip score had improved from 67.9 points to 79.1 points, which was statistically significant (P=0.012). Preoperative knee range of motion was achieved at the last follow-up in all patients. Waddling gait was absent in three patients, reduced in four patients, and was the same in one at the last follow-up. Mean limb length gain was 3.5 cm (range, 0-5 cm), mean limb length discrepancy less than 0.5 cm, and the mechanical axis was realigned in all. In conclusion, our early results suggest that proximal valgus-extension osteotomy with distal femoral varusization can be a useful treatment option in young patients with bilateral hip involvement in SED congenita.