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This simulation study on MRI of the knee was performed to assess the risk of injury to the popliteal artery (PA) and common peroneal nerve (CPN) during all-inside meniscal repairs in adults.We simulated repair of the posterior horn of both medial (PHMM) and lateral menisci (PHLM) through anteromedial (AM) and anterolateral (AL) portals, using straight and curved devices, on 200 magnetic resonance imaging (MRI) scans taken with the knee in extension. For simulation using straight devices, the shortest distance from the menisco-capsular junction (MCJ) and the free edge of the meniscus to PA and CPN in vectors of AM and AL portals was measured. In curved devices, the closest extracapsular distance from the device tip to PA was measured.With a straight device through AM portal, the mean distance from the MCJ of PHMM to the PA was 20.7 ± 3.15 mm (13.5-27.4). In PHMM repair through AM portal using a curved device, the mean extracapsular distance from the device tip to PA was 18.8 ± 4 mm (7.7-27.2) while pointing toward and 26 ± 4.5 mm (15.5-35.6) while pointing away from the midline. When using straight devices, the average distance from free edge of LM to PA was 18.5 ± 3.3 mm (9.6-31.2) and from MCJ to PA was 8.9 ± 2.4 mm (3.5-18.8). The average distance measured from the MCJ to CPN through AM and AL portals using straight devices was 19.4 ± 2.8 mm (10.2-32.5) and 22 ± 2.8 mm (10.4-36.7) respectively.In adults, PA is safe in PHMM repairs using both straight and curved devices irrespective of depth and direction of insertion. In PHLM repairs, the PA is at risk with both straight and curved devices. We recommend adjusting the depth of insertion to as minimum as possible to just penetrate the capsule. The CPN is safe in LM repairs using all-inside devices.Level IV.

Background: Managing postoperative pain in TKA is a challenge and needs an imperative strategy to bring maximal knee function early, with minimal side effects and less hospital stay. Though local infiltration analgesia emerged as a potent alternative, consensus on whether local infiltration analgesia offers clinically relevant pain relief is still lacking due to inconsistent studies and lack of standardization. The present study is an attempt to deduce the analgesic efficacy of a standardized single-shot local infiltration analgesia (LIA) with epidural analgesia with comparative analysis of previous most cited studies. Study Design & Methods: This is a prospective, randomized clinical trial done in n=74 patients with moderate to severe arthritis (Mean OKS - 15.24, SD 6.153) undergoing unilateral primary TKA in the south Indian population in a single center. The choice of analgesia, surgical technique, postoperative medications, and rescue analgesia and rehabilitation protocol on both groups are kept identical. In the LIA group, the CPN area is carefully avoided. The primary outcome is postoperative pain at rest and at activity, knee flexion and mobilization time quantified for 72hrs postoperatively. The student t-test, the chi-square test is used for analysis. Results: The LIA group had significantly lower mean VAS scores at rest (P =

Background Fracture of femoral component in total knee arthroplasty (TKA) has become a rare complication with improvements in metal alloy manufacturing technology. Methodology We report two cases of fracture of femoral components 9 and 10 years after primary TKA. The Buechel-Pappas (BP) knee system used in our two cases were designed by the same team who designed the LCS TKA implants. The femoral component is made of cobalt chromium alloy. The break in the femoral component noted in both the cases were at a similar site, at the distal medial flange just posterior to the peg of the femoral component. Result Both these cases underwent revision surgery using stemmed implants with good results. Implants retrieved were analysed with Scanning Electron Microscopy (SEM) and Energy Dispersive X-ray Spectroscopy (EDS) to study the fracture pattern and material properties respectively. Fractography analysis of both our cases showed that the crack initiated laterally from the thin edge (1mm) around the sharp angulated corner of the medial femoral condyle and spread medially towards the thicker segment. Conclusion We feel two fractures of femoral component out of 9000 TKA in ten years is significant. We recommend a re-evaluation of the femoral component of the BP knee system to ensure that the edges, specifically the sharp corners, have adequate thickness to avoid a fatigue fracture.

A 15 years old boy presented with an atypical osteoid osteoma (OO) in distal femur. He underwent radiofrequency ablation (RFA) elsewhere. He presented to our centre a year later with persisting pain. MR scan showed incomplete ablation of the nidus as there was only a single pass of the RF probe for a 14 mm long linear lesion. We also found penumbra sign and wall enhancement on contrast MRI suggestive of a Brodie’s abscess (BA). Under CT guidance the OO was drilled and BA was saucerised. Following this he was treated with culture sensitive antibiotics and his symptoms resolved. BA and OO are common differential diagnoses. RFA of OO leading to BA has not been reported in literature. Atypical linear OO requires multiple probe placements to ablate the long nidus. Diligent care should be taken to avoid intraoperative contamination in CT room which could lead to infection.

OBJECTIVE: This study looks at the outcome of percutaneous quilting technique for the treatment of closed degloving injuries or Morel-Lavallée lesions (MLL). DESIGN: Prospective single-centre nonrandomized case series. PARTICIPANTS: Patients with MLL visiting our hospital between January 2012 and May 2018. METHOD: The method involves percutaneous single-stage suturing of skin and deep fascia with heavy, non-absorbable, non-braided sutures starting from periphery to centre. OUTCOME MEASURES: Resolution of the lesion. RESULTS: Twenty-two patients with MLL treated, which included 18 males and 4 females with an average age of 22 (range 16–52). Lesions varied in length from 12 to 60 cm. The average time gap from the injury to drainage of the lesion was 7 days (range 2–60 days). We followed these cases weekly for 4 weeks and then once a month until 6 months and then at the end of the year. All 22 cases healed uneventfully. CONCLUSION: Percutaneous drainage along with suturing of the skin and subcutaneous tissue to deep fascia prevents the discordant movement and obliterates the dead space-aiding apposition of the layers. This is a simple and effective procedure with low recurrence rates that addresses the primary pathology of MLL. LEVEL OF EVIDENCE: Therapeutic level IV.

We report a patient who was diagnosed with idiopathic genu valgum at the age of 11 years and underwent bilateral distal femur osteotomies. At age 30 years, she presented with pain around her right knee with a varus deformity. Although the corrective osteotomy was at the distal femur, she was noticed to have a bifocal deformity in both femur and tibia. She was managed with single-stage osteotomies at the distal femur and proximal tibia.This case report highlights the importance of preoperative analysis to identify the site of deformity. In bifocal pathology, a 2-level osteotomy is required to prevent an oblique joint line.

Background Recreation of the normal proximal femoral anatomy is paramount for a successful total hip arthroplasty. The study aims to look at whether the range of offset options available in the femoral stems available locally, would be adequate to restore the native femoral horizontal offset (FHO) of the South Indian population. Method This is a prospective single-center study of 1-year duration, where we study the FHO on radiographs and CT scans in 100 patients. We then look at the femoral stems available in the Indian market and see if the offset may be restored with the available stems. Result The FHO ranged from 23.3 to 46.9 mm with a mean of 35.7 ± 5.3 mm. The females in the group (33.86 ± 4.71 mm) had a lower FHO compared to males (37.78 ± 5. 21 mm). We found that 50% of the South Indian population and 62% of the females have an offset less than 35 mm. Among the 18 stems that we studied, four out of nine cemented and two out of nine uncemented stems did not offer an offset below 35 mm. Conclusion The native FHO in the South Indian population is significantly less than that of Caucasians. The surgeon should be aware that many implant systems available in India do not offer offset options in this range. In this group, even when a stem with smallest offset is used, there is a risk of increasing the FHO with a potential for intraoperative fractures due to difficult reduction and leg-lengthening. Hence, the surgeon should template carefully and choose only those implant systems which can offer an offset similar to the native offset to restore the anatomy accurately. We recommend that all manufacturers consider offering implants with smaller offset (25–35 mm).

Removal of screws from a titanium locking plate is often difficult once the screw has seized and the head is damaged. Such stripped screws are removed with an extraction screw, which can be used manually or on power. We aim to compare the extraction rates using both these methods.We used 50, 3.5 mm diameter/20 mm long titanium locking screws. Fourth-generation saw bone models (radii) were used and 3.5 mm locking plates were fixed. The screws were deliberately over tightened and heads were damaged using a carbide drill to mimic stripped, seized screws. A left turn conical extraction screw coupled with a power tool was used for the first 25 screws and extraction screws coupled with a T handle for the remaining 25. A high-definition camera with a 60 fps frame rate was used to record the event. The time taken to remove screws from the plate was recorded.When the extraction screw was used manually with T handle, we could remove 23 out of 25 screws (92%). When we used the extraction screw along with a power tool, 15 out of 25 (60%) locking screws were successfully removed.We recommend manual extraction with a T handle, rather than a power tool when removing the stripped locking screws (p-value0.001). We feel that the haptic feedback provided when using manual extraction allows the surgeon to engage the extraction screws onto the damaged heads, thereby improving the extraction rates.

Case We report a patient with a long-standing post-traumatic pubic diastasis along with acetabular nonunion who developed painful hip arthritis that needed a total hip arthroplasty. We discuss the unique challenges in the acetabular component positioning. Conclusion In patients with symphysis pubis diastasis, the surgeon should be prepared to place the cup in less than normal anteversion. This relative retroversion, which is an unusual position, is due to the external rotation of the whole hemipelvis including the femur. The degree of version of the cup should be guided by intraoperative stability checks and to ensure an impingement free range of motion.

CASE We report 2 patients who were involved in high-velocity road traffic accidents. Both these patients had congenital pubic diastasis with very subtle clinical and radiological signs that were misdiagnosed as posttraumatic diastasis on initial radiographic evaluation. CONCLUSION Trauma surgeons should be aware of this anomaly because congenital pubic diastasis could present without any major clinical signs and could easily be mistaken for a traumatic diastasis.

A 15-year-old boy presented with insidious onset bilateral thigh pain for 6 months. Examination of hips showed restricted internal rotation. Pelvis radiograph (figure 1) showed bilateral slipped capital femoral epiphysis (SCFE) with subchondral bone resorption in right inferior pubic rami and ilium . Hand radiograph (figure 2) showed subperiosteal bone resorption along the radial aspect of middle phalanges. Figure 1 Anteroposterior view of pelvis shows whole epiphysis lying inferior to the line (Klein’s line) suggestive of SCFE. In normal hip, one-third of physis should be above the line. Subperiosteal resorption along the ilium (black arrow) …

Background: Abnormal spino-pelvic mobility is increasingly recognized as a leading cause for hip instability following arthroplasty.Methods: We studied the lateral spino-pelvic radiographs of 90 patients, with no spine/hip pathology in standing and sitting positions. We measured the change in sacral slope and grouped them into three spino-pelvic patterns.Results: We found that 50% of study subjects had normal spino-pelvic mobility. The remaining 50% were either hypermobile (24%) or stiff (26%). The stiff spines were either fixed (11%) or hypomobile (15%).Conclusions: Our study shows that in a normal population without any prior hip/spine pathology a significant percentage (50%) have abnormal spino-pelvic mobility. The significance of spinal stiffness in younger age group need to be looked further to make any changes in acetabular cup placement during hip replacement.

We report 3 patients who underwent total hip arthroplasty (THA) using large diameter metal-on-metal bearing. These patients initially presented with pain but went on to develop dislocation of the THA while awaiting investigations. Any pain following metal-on-metal bearing THA should be taken seriously and should trigger investigations to identify a metal reaction. If left untreated, these reactions can cause progressive soft tissue necrosis leading to instability. These patients should be considered for early revision of the bearing surface to prevent further soft tissue damage.

A 63-year-old woman presented with a 3-week history of worsening right knee pain. She was fully unable to bear weight and denied any history of trauma, locking or giving way. On examination, she was systemically well with posterolateral joint line tenderness and a reduced range of movement. Blood tests and a joint aspirate were normal. Radiographs reported no fracture, but suggested a loose body in the lateral gutter of the knee. She was discharged with analgesia and physiotherapy. Subsequent follow-up X-rays demonstrated the opacity in the later gutter to be appearing less dense until it eventually disappeared. This correlated to a progressive improvement in the patient’s pain and range of movement in the knee leading to the diagnosis of acute calcific tendinitis of the popliteus tendon. This case report suggests that calcifying tendinitis of popliteus tendon should be considered in the differential diagnosis of acutely painful knee. The case demonstrates that the natural history of calcifying tendinitis of popliteus is similar to that in supraspinatus and that conservative treatment will eventually resolve the symptoms.

Resume Les kystes synoviaux provenant de l’articulation tibiofibulaire proximale (tibioperoniere superieure) sont souvent symptomatiques. Leur progression peut entrainer la compression du nerf peronier commun (nerf sciatique poplite externe). L’importance de la resection du kyste et de son pedicule est soulignee en prevention des recidives. Le traitement peut etre difficile dans les cas recidivants. Nous decrivons une intervention ou, apres recidive, la resection de l’articulation tibiofibulaire proximale (tibioperoniere superieure) associee a celle du kyste a conduit a une guerison complete dans deux cas.

Synovial cysts originating from proximal tibiofibular joint are commonly symptomatic. They can progress to cause pressure effects over the common peroneal nerve. In order to prevent recurrence the importance of excision of the ganglion and its stalk is emphasised. In recurrent cases treatment can be difficult. We describe an operation where after recurrence superior tibiofibular joint excision along with the cyst led to complete recovery in two cases.

We report 3 patients who underwent total hip arthroplasty (THA) using large diameter metal-on-metal bearing. These patients initially presented with pain but went on to develop dislocation of the THA while awaiting investigations. Any pain following metal-on-metal bearing THA should be taken seriously and should trigger investigations to identify a metal reaction. If left untreated, these reactions can cause progressive soft tissue necrosis leading to instability. These patients should be considered for early revision of the bearing surface to prevent further soft tissue damage.

We report a case of progressive cubitus varus deformity caused by a physeal bar following a supracondylar humeral fracture in a 4-year-old girl. Malreduction is thought to be the commonest cause of this deformity, which is nonprogressive. A corrective osteotomy in cases like ours should be deferred until skeletal maturity.

This audit reviewed the trauma theatre time utilisation during April 2000 to March 2001. Instead of a scheduled 8 30 am start, first patient was on the table by only 9 40 am because of various reasons. To use this redundant time carpal tunnel release was started under local anaesthesia, as first case. On re-auditing, it was found that the patient for carpal tunnel release was on the table at 8 44 am. The first trauma case was on the table at 9 46 am. This simple idea has helped in the performing of an additional case every day with a delay to the trauma list of only six minutes (p

A prospective clinical study of first metatarsophalangeal joint arthrodesis using memory compression staples is presented. In 27 patients, 30 feet underwent surgery. There were 24 women and 3 men, with a mean age of 61.2 years. Two memory compression staples were used at right angles to each other to achieve compression at the fusion site. Postoperatively, patients were allowed full weightbearing in a rigid-soled shoe. Subjective assessment was performed with a standard questionnaire, which included questions regarding level of pain, ambulation, and patient satisfaction. Objective assessment was performed by a clinical and included a radiographic examination. There was a postoperative reduction in the pain score from 4.6 to 1.6 (P.0001). Ambulation ability improved from 4 to 2.5 (P.0001). Patients reported 86.6% excellent to good results, and 96.7% achieved radiographic fusion at an average 8.2 weeks. The only significant postoperative complication was a single nonunion. The authors advocate memory compression staples for the internal fixation of first metatarsophalangeal joint arthrodesis. The implant is low profile, and postoperative cast immobilization is not required. The use of this device has a predictable success rate comparable to previously reported methods.

We read the article by Vasukutty et al with interest, care and appreciation, especially since reports in this field are rare. We have some additional questions for the authors. One of the conclusions is the importance of a thorough physical examination. On that we agree. However, we feel that the approach described by the authors lacks structure. In the results section the authors report a lot of data but patient history, patient complaints and physi cal examination are mentioned interchangeably. In our opinion, it would have been useful to provide a simple diagram indicating history, complaints, physical exami nation, additional diagnostics, the examination under anaesthesia (EUA) and the arthroscopy as the golden standard, for each patient. In this way the combination of history, a good physical examination and additional diagnostics will allow for accurate diagnosis and neither EUA nor diagnostic arthroscopy of the ankle will prove necessary.1 We believe patient feedback on the physical examination is mandatory to differentiate between anterior ankle pain related to anterior ankle impingement and typical deep ankle pain related to a symptomatic osteochondral defect.2 This also goes for the physical examination of a child. We feel that the (long) term results for each patient re main unclear because the authors did not use validated outcome scores nor seemingly easy Likert or visual ana logue scales that are developed for children.3 In order to be able to conclude that ankle arthroscopy ‘is an ef fective way of treating post-traumatic ankle pathology', it would be wise to present intermediate and long-term results with validated outcome scores. Besides this, in 25% of the cases no traumatic event was reported. We do not understand the thinking behind the setup of this research. Why did the authors not use magnetic res onance imaging (MRI) in every patient? Only then can the conclusion about the accuracy of MRI on diagnosing ankle impingement truly be made. What was the argu ment for using MRI? The authors do, however, perform an EUA in every patient - but for what purpose? We feel that the information from the patients’ medical history and the findings on physical examination (eg recognis able or deep ankle pain, or even tenderness on palpation on the anteromedial distal tibial rim) is sufficient. There is therefore no need for EUA. Complication rates in ankle arthroscopy vary widely but rates up to 17% have been reported.4 Several children underwent diagnostic arthroscopy, for which the authors refer to an article published in 1996.5 Nowadays, ankle arthroscopy should be used only as a therapeutic tool since less invasive radiological modalities exist.1,6 How many children suffered from complications following the (diagnostic) ankle arthroscopy in their series? (See also arguments under point 1.)

To The Editor: We read with great interest the article “Surgical Treatment of Limb-Length Discrepancy Following Total Hip Arthroplasty” (2003;85:2310-7), by Parvizi et al. The study retrospectively reviewed the cases of twenty-one patients who had had revision total hip replacement for limb-length discrepancy. According to the authors, in six patients (Cases 2, 6, 9, 12, 13, and 20), the primary problem leading to limb-length inequality was excessive anteversion or retroversion of the acetabular component. In these patients, there was no obvious longitudinal malalignment of the cup or of the femoral component (Table I). All of these six patients underwent revision of the acetabular component alone, and the limb lengths equalized in four patients and the discrepancy decreased in the other two. The authors described two different categories of limb-length discrepancy. The six patients mentioned above obviously … Corresponding author: William J. Hozack, MD Rothman Institute of Orthopaedics 925 Chestnut Street, 5th Floor Philadelphia, PA 19107 rihip{at}aol.com