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The standard driving cycles (DCs) used to evaluate spark-ignition engine-based two-wheelers are inadequate for electric two-wheelers (E2Ws). Also, they fail to accurately represent the actual driving circumstances in specific areas, resulting in inaccuracies during the evaluation of performance. The current research is centred towards constructing an electric two-wheeler urban driving cycle (E2WUDC) that considers the driving circumstances of the smart city in India. Further, the denoised speed data is utilized to extract the micro-trips and compute their driving parameters. Furthermore, the dimensions of the data are decreased through the utilization of principal component analysis. Subsequently, the data is classified utilizing various clustering methods including k-means, X-means, hierarchical clustering, and density-based spatial clustering of applications with noise (DBSCAN). Then, the Calinski Harabasz index (CHI), Davies-Bouldin index (DBI), and silhouette score are used to assess the homogeneity and completeness of selected clustering algorithms in the data cluster. Overall, the E2WUDC is developed using X-means which is selected as a suitable clustering algorithm based on the performance indices. Also, the key driving features of E2WUDC such as total time duration and distance are 14.49 km and 1914 seconds with average and maximum driving speeds of 8 and 13.88 m/s respectively. Eventually, it establishes the foundation for assessing the energy economy, driving range and energy demand for the widespread deployment of electric two-wheelers in urban commuting.

Feature selection in cancer classification is a central area of research in the field of bioinformatics and used to select the informative genes from thousands of genes of the microarray. The genes are ranked based on T-statistics, signal-to-noise ratio (SNR), and F-test values. The swarm intelligence (SI) technique finds the informative genes from the top-m ranked genes. These selected genes are used for classification. In this paper the shuffled frog leaping with Lévy flight (SFLLF) is proposed for feature selection. In SFLLF, the Lévy flight is included to avoid premature convergence of shuffled frog leaping (SFL) algorithm. The SI techniques such as particle swarm optimization (PSO), cuckoo search (CS), SFL, and SFLLF are used for feature selection which identifies informative genes for classification. The k-nearest neighbour (k-NN) technique is used to classify the samples. The proposed work is applied on 10 different benchmark datasets and examined with SI techniques. The experimental results show that the results obtained from k-NN classifier through SFLLF feature selection method outperform PSO, CS, and SFL.

Introduction: Interspace defects after osteochondral autograft transfer (OATS) are filled only with fibrocartilage. Attempts have been made to address these issues in OATS with procedures like mega OATS and Hexagonal Osteochondral Graft System. We have described the functional outcomes of a hybrid technique combining a regeneration and a restoration modality to address the interspace defect in OATS., Methods: Consecutive cases of full-thickness focal chondral defects of the knee were treated using the nuts-in-jelly mosaicplasty technique. Patients with less than 1 cm lesions, ligament insufficiency, and alignment abnormalities were excluded. Bone marrow aspirate concentrate (BMAC) with fibrin glue has been used to fill the defect remaining after the osteochondral cylinders are transferred, resulting in a configuration like nuts dispersed in a jelly., Results: We had a total of 12 cases-4 cases of osteochondritis dessicans (OCD) and 8 cases of traumatic chondral defects. The mean age of the patients was 32 years (range 19 - 44 years). 4 were female patients. The available cartilage was fixed in all the OCD cases. The remaining defect was filled with one or two osteochondral cylinders and the BMAC-fibrin glue or only with BMAC-fibrin glue. In traumatic defect cases, the space remaining after the OATS cylinder transfer was filled with BMAC-fibrin glue. The mean follow-up period was 3 years (range 2 - 5 years). All cases had good to excellent Tegner-Lysholm scores with a mean score of 92 (range 85 - 96)., Conclusion: Nuts in jelly mosaicplasty may address the issue of fibrous cartilage formation after OATS in the interspace. Further prospective comparative studies are necessary to validate the findings of this study., Competing Interests: Conflict of interestThe authors declare no conflict of interest., (© Indian Orthopaedics Association 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Twitter has become a part of every medical field, including orthopaedics. #OrthoTwitter is the hashtag commonly used for orthopaedic-related tweets. Researchers have assessed the impact of Twitter in orthopaedics, but no study has evaluated the individual tweets under #OrthoTwitter. The purpose of the present study was to determine the nature of the content and interactions under #OrthoTwitter and to analyze the usefulness of #OrthoTwitter., Methods: After a pilot study, an analysis of #OrthoTwitter tweets was conducted from May 1, 2021, to June 30, 2021. Data were extracted in 2 stages. In Stage I, data were manually extracted at 8 p . m . IST (Indian Standard Time) on alternate days. In Stage II, data were collected using the web-scraping tool Octoparse. Data were analyzed on the basis of 3 characteristics-topic, purpose, and format of the tweet-with each characteristic comprising 10, 6, and 7 categories, respectively. An association analysis was performed using SPSS software., Results: One thousand and twenty-three tweets were analyzed. Five hundred and fifty-three (54%) of the 1,023 tweets were from orthopaedic surgeons and 123 (12%) were from orthopaedic residents. Medical students aspiring to be orthopaedic surgeons contributed 31 tweets (3%). #OrthoTwitter was also used by non-orthopaedic departments, most frequently radiology. Tweets that were educational or informative were the most common, as compared with tweets of other purposes. Two hundred and forty-six (24%) of the 1,023 tweets were educational (e.g., discussions of cases or journals) and 368 (36%) were informative (e.g., conference announcements and advertisements). Notable tweet subcategories included those related to COVID-19 (71 tweets; 7%), those of a motivational nature (41 tweets; 4%), and those containing some type of graphic content (644 tweets; 63%), for the topic, purpose, and format characteristics, respectively. We noted significantly more likes for tweets with an educational purpose (p = 0.017) and for tweets with images (p < 0.001). We also noted a significant number of retweets of educational tweets (p < 0.001)., Conclusions: #OrthoTwitter provides a unique environment in which education, news, collegial interaction, social responsibility, and entertainment thrive, making Twitter a virtual community. Tweets with an educational purpose and those that included images generated more interactions. Orthopaedic surgeons should consider using #OrthoTwitter in their orthopaedic-related tweets for a broader reach., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H262 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Osteoarthritis (OA) is a common degenerative disorder of the synovial joints and is usually an age-related disease that occurs due to continuous wear and tear of the cartilage in the joints. Presently, there is no proven medical management to halt the progression of the disease in the early stages. The purpose of our systematic review is to analyze the possible metabolites and metabolic pathways that are specifically involved in OA pathogenesis and early treatment of the disease., Materials and Methods: The articles were collected from PubMed, Cochrane, Google Scholar, Embase, and Scopus databases. "Knee", "Osteoarthritis", "Proteomics", "Lipidomics", "Metabolomics", "Metabolic Methods", and metabolic* were employed for finding the articles. Only original articles with human or animal OA models with healthy controls were included., Results: From the initial screening, a total of 458 articles were identified from the 5 research databases. From these, 297 articles were selected in the end for screening, of which 53 papers were selected for full-text screening. Finally, 50 articles were taken for the review based on body fluid: 6 urine studies, 15 plasma studies, 16 synovial fluid studies, 11 serum studies, 4 joint tissue studies, and 1 fecal study. Many metabolites were found to be elevated in OA. Some of these metabolites can be used to stage the OA Three pathways that were found to be commonly involved are the TCA cycle, the glycolytic pathway, and the lipid metabolism., Conclusion: All these studies showed a vast array of metabolites and metabolic pathways associated with OA. Metabolites like lysophospholipids, phospholipids, arginine, BCCA, and histidine were identified as potential biomarkers of OA but a definite association was not identified, Three pathways (glycolytic pathway, TCA cycle, and lipid metabolic pathways) have been found as highly significant in OA pathogenesis. These metabolic pathways could provide novel therapeutic targets for the prevention and progression of the disease., Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-024-01169-5., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© Indian Orthopaedics Association 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Introduction: Orthobiologic agents play a significant role in regenerative medicine. The quest for newer and more effective Orthobiologic agents is never-ending, leading to the evolution of more reformed products. GOLDIC (GOLD Induced cytokine) is a recently evolving Orthobiologic agent developed by conditioning autologous serum with gold particles. We aim to collate the available evidence on GOLDIC and provide a systematic literature review., Materials and Methods: Using Cochrane and PRISMA guidelines literature search was done for GOLDIC. After duplicate removal and exclusions, 62 articles were scrutinized, of which 8 articles qualified for full-text review. A risk-of-bias assessment of the included studies was done., Results: All articles showed standardized preparation methods of GOLDIC and uniformity in the number of doses administered, except one study. Reproducible results were noted like an increase in plasma gelsolin and improved KOOS, WOMAC, and VAS scores., Conclusion: GOLDIC has the potential to be a significant Orthobiologic modality considering its standardized preparation techniques, method of administration, and uniformly reproducible outcome measures. However, further high-quality evidence is needed to analyze the clinical efficiency and safety profile of GOLDIC., Systematic Review Registration: INPLASY202350027 [https://doi.org/10.37766/inplasy2023.5.0027]., Competing Interests: Conflict of interestsThe authors declare that they have no conflict of interest., (© Indian Orthopaedics Association 2024. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Multiligamentous knee injuries (MLKIs) are rare and challenging to manage in many aspects. The injury requires prompt diagnosis, reconstruction of multiple ligaments, and management of associated neurovascular injuries. Another important aspect that surgeons should consider is resource availability. Successful management of a case of MLKI using the cost-effective 'modified confluent tunnel technique' is described in this case report. We used confluent tunnels for intra- and extra-articular ligament reconstructions at the femoral side. We incorporated the weave technique for medial collateral ligament (MCL) reconstruction, and Larson's technique for posterolateral corner (PLC) reconstruction in this construct, and augmented the anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction with the remaining PLC and MCL grafts, respectively. This was cost-effective and resulted in good functional outcomes. The technique also helped us to avoid tunnel convergence which is an expected complication in MLKI surgeries., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Regular monitoring of blood glucose levels is essential for the management of diabetes and the development of appropriate treatment protocols. The conventional blood glucose (BG) testing have an intrusive technique to prick the finger and it can be uncomfortable when it is a regular practice. Intrusive procedures, such as fingerstick testing has negatively influencing patient adherence. Diabetic patients now have an exceptional improvement in their quality of life with the development of cutting-edge sensors and healthcare technologies. intensive care unit (ICU) and pregnant women also have facing challenges including hyperglycemia and hypoglycemia. The worldwide diabetic rate has incited to develop a wearable and accurate non-invasive blood glucose monitoring system. This research developed an Internet of Things (IoT) - enabled wearable blood glucose monitoring (iGM) system to transform diabetes care and enhance the quality of life. The TTGOT-ESP32 IoT platform with a red and near-infrared (R-NIR) spectral range for blood glucose measurement has integrated into this wearable device. The primary objective of this gadget is to provide optimal comfort for the patients while delivering a smooth monitoring experience. The iGM gadget is 98.82 % accuracy when used after 10 hours of fasting and 98.04 % accuracy after 2 hours of breakfast. The primary objective points of the research were continuous monitoring, decreased risk of infection, and improved quality of life. This research contributes to the evolving field of IoT-based healthcare solutions by streaming real-time glucose values on AWS IoT Core to empower individuals with diabetes to manage their conditions effectively. The iGM Framework has a promising future with the potential to transform diabetes management and healthcare delivery., (© 2024. The Author(s).)

Background: High tibial osteotomy (HTO) is a popular joint-preserving option for medial compartmental osteoarthritis. However, this is associated with alterations in the patellar height (PH) and tibial slope (TS). This study aims to compare the effect of ascending (AMHTO) and descending medial opening wedge HTO (DMHTO) on patella height, posterior tibial slope and functional outcomes., Material and Methods: A retrospective study was conducted between February 2018 and July 2021. Patients with medial compartment osteoarthritis, varus alignment, and complete pre- and postoperative lateral and full-length anteroposterior radiographs were included. Pre- and postoperative radiological measurements include the Caton-Deschamps index (CDI), the mechanical axis deviation (MAD), and the posterior tibial slope. The functional outcomes were measured using the Oxford Knee Score (OKS), Lysholm Knee Score (LKS), and Tegner Activity Scale (TAS). The osteotomy union was checked with serial X-rays every 6 weeks till a satisfactory union was achieved., Results: Fifty-eight patients were included in the study. Thirty-four (58%) patients received AMHTO, and 24 (42%) received DMHTO. There was no baseline difference in the demographic variables or functional scores between the two groups. The preoperative mean MAD of - 9.65° ± 3.67° was corrected significantly to + 0.08 ± 2.80° (varus -, valgus + , P = 0.034). A significant difference in preoperative and postoperative CDI of 0.93 ± 0.45 and 0.83 ± 0.27, respectively, was noted (P = 0.023). In the AMHTO group, a statistically significant decrease in PH from preoperative 1.03 ± 0.77 to 0.84 ± 0.12 was noted (P = 0.003). There was a significant improvement in functional outcomes between baseline and 9-month follow-up in both groups. There was no significant difference between the functional outcomes of the two groups at 9-month follow-up., Conclusion: The study confirmed our hypothesis that descending HTO caused less alteration in the patella height compared to ascending HTO. There is no significant difference in the functional outcomes between the groups. However, in patients with PFOA, and when attempting higher degree of correction through AMHTO, the possibility of worsening of symptoms due to change in PH must be considered., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Considering various factors that influence meniscal repairability, Ortho One PROMT score (OPS) was proposed in 2019. With an increased understanding of factors influencing meniscal repair and by analysis of OPS predictions and repair results, a modified PROMT score (MPS) has been formulated. The objective of this study is to assess the superiority of MPS over OPS., Methods: Age, chronicity, and pattern of tears were found to be important contributors to false-negative results of OPS. Considering these factors, MPS was designed. A prospective, double-blinded study was conducted between November 2020 and May 2021. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value, and accuracy of both scores were calculated. Receiver Operating Characteristic (ROC) curve was plotted., Results: Of 133 meniscal tears, 100 met the inclusion criteria. In predicting meniscal repairability, OPS demonstrated sensitivity and specificity of 90.32% and 83.33% medially and 64.71% and 79.41% laterally. MPS had sensitivity and specificity of 96.77% and 88.89% medially and 82.35% and 88.24% laterally. Both scores showed good statistical significance ( p  < 0.05) in predicting meniscal reparability. For medial meniscus repairability, area under the ROC curve was 0.868 for OPS and 0.928 for MPS. For lateral repairability, the area under the curve was 0.721 for OPS and 0.853 for MPS., Conclusion: MPS will serve as a simple and more effective tool for surgeons to predict meniscal repairability, thus enhancing their pre-surgical preparedness. This tool will also help surgeons to realistically counsel their patients and to achieve optimal patient., (© Indian Orthopaedics Association 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Introduction: Phalanx fractures of the lower limb have high rates of union when manage conservatively., Case Report: A 26-year-old male with fracture of great toe proximal phalanx fracture which was initially managed conservatively with buddy strapping, who missed follow-up and presented late to outpatient department at 6 months with persistence of pain and difficulty in weight bearing. Here, we treated the patient with L-facial plate (2.0 system)., Conclusion: Fracture non-union of proximal phalanx can be managed surgically with L- facial plates and screw and bone grafting which will provide full weight bearing and walk normally without any pain and with adequate range of movements., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Introduction: Adhesive capsulitis is clinically characterized by the gradual progressive painful loss of active and passive motion caused by the formation of adhesions of the joint capsule. Adhesive Capsulitis of the Hip (ACH) is not a well-explored clinical condition when compared to adhesive capsulitis of shoulder because of the underdiagnosis and rarity of this condition ., Materials and Methods: Cochrane, Scopus, Pubmed, Embase, and Web of Science databases were searched for original studies on ACH till December 2021 following Cochrane and PRISMA guidelines. Year of publication, authors, number of cases, baseline characteristics of the studies, causes described, presentation, associated conditions, method of diagnosis, treatment to be given, functional outcomes, and complications was extracted from each study., Results: 16 articles were included in this review. 3 of the included studies were retrospective case-control studies, 6 were case series and the remaining 7 were case reports. A total of 224 ACH cases were recorded. Pain and stiffness of the hips were the most common clinical features. Investigations like serology, radiograph, and MRI have been used to rule out other conditions. Arthrography has been used to confirm the diagnosis in 7 studies. Spontaneous recovery is expected in one to two years. Management has been in the form of physiotherapy, intra-articular injection, and arthroscopy., Conclusion: Literature on ACH is limited because of the rarity of the condition. The disease has a favorable prognosis with the possibility of spontaneous recovery. Physiotherapy has been the first line of management. Intractable cases require surgical intervention., Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-022-00808-z., Competing Interests: Conflict of InterestNil., (© Indian Orthopaedics Association 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: Even in highly credible research models, such as randomised control trials (RCTs), many pitfalls do exist that a practitioner must be aware of, to get the actual sense of the research. The one such pitfall that is much more common but ironically less explored is the Writers' bias or the spin. Particularly in the abstracts, it is a potential source of deception to the readers., Methods: We selected 250 recent RCTs from the top 5 spine journals. Baseline data and CONSORT Adherence Score (CAS) were collected. Abstracts of the RCTs were graded using the level of confidence (LOC) grading tool developed by the Orthopaedic Research Group. All possible associations of spin were studied to assess the significance., Results: The median CAS was 11 (IQR 10-12). Only 47.6% ( n  = 119) articles had High LOC with no or one non-critical spin in abstract. 12.4% ( n  = 31) had Moderate LOC and 28% ( n  = 70) had Low LOC. The rest had Critically Low LOC with more than one critical spin. Of the variables analyzed in multivariate regression analysis, only CAS had a (negative) correlation with the LOC of the abstracts., Conclusions: Spin-based grading of RCTs is the need of the hour to aid readers to interpret the true essence of research papers. 40% of the RCTs in top spine journals had low to critically low LOC. Objective structuring of abstracts with adherence to CONSORT guidelines is the way forward to prevent spin., Competing Interests: Conflict of interestThe authors declare that they have no conflict of interest., (© Indian Orthopaedics Association 2022.)

Introduction: Lytic lesions of the proximal tibia include a plethora of differential diagnoses. The most common ones are the Giant cell tumor, fibrous dysplasia, adamantinoma, chondromyxoid fibroma, and osteoblastoma. The rarer ones include vascular tumors such as hemangioma and hemangioendothelioma. A systematic line of investigations is essential to pick up the right diagnosis especially in case of rarer conditions. In this background, we present a case of lytic lesion of the proximal tibia which turned out to be epitheloid hemangioendothelioma (EHE)., Case Report: A 37-year-old female presented with pain and swelling in the left knee for 2 years. On examination, the patient had a 3 × 4 cm firm, non-tender, and well-defined swelling on the anterolateral aspect of the proximal tibia. X-ray showed a lytic lesion of the proximal tibia. Magnetic resonance imaging was suggestive of a giant cell tumor. However, the biopsy revealed a rare diagnosis of epithelioid hemangioendothelioma., Conclusion: The patient was managed with wide excision. In a young adult, arthrodesis may not be the best option; hence, we reconstructed the joint with a custom mega prosthesis (CMP). At 3 years follow-up, our patient had no signs of recurrence. To our best knowledge, this is the first report on the use of CMP in a case of EHE., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

The incidence of musculoskeletal tuberculosis (TB) is on the rise due to the current Acquired Immunodeficiency Syndrome (AIDS) pandemic. Spine is the most common osseous site, followed by other joints. TB identified in the elbow accounts for 2%-5% of skeletal TB cases, which are secondary to pulmonary TB. Primary elbow TB is rare. We report a case of primary TB of the elbow which had a negative synovial biopsy. A 46-year-old right-hand dominant female patient with chronic pain and disability of the right elbow was diagnosed with chronic non-specific arthritis based on an arthroscopic synovial biopsy. The case was diagnosed retrospectively as active TB from bone cuts post total elbow arthroplasty. Anti-tuberculosis treatment (ATT) was given postoperatively for 12 months. The patient reported good functional outcomes at 3 years of follow-up. Such atypical presentations of osteoarticular TB are challenging to diagnose. Therefore, particularly in endemic areas, clinicians should be careful before excluding such a diagnosis even after a negative biopsy. Further research should investigate whether active TB of small joints such as the elbow can be treated with ATT, and early arthroplasty should be a focus of this research.

Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as "forgotten or hidden lesions" are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears., Competing Interests: Nil., (© 2022 Delhi Orthopedic Association. All rights reserved.)

Study Design: Systematic review and meta-analysis., Objectives: We performed this meta-analysis to evaluate whether intradiscal Platelet Rich Plasma(PRP) injection has any beneficial role in the management of lumbar disc disease., Methods: We conducted independent and duplicate electronic database searches including PubMed, Embase, and Cochrane Library till September 2020 for studies investigating the role of intradiscal PRP in the management of lumbar disc disease. The analysis was performed in the R platform using OpenMeta[Analyst] software., Results: 13 studies including 2 RCTs, 5 prospective, and 6 retrospective studies involving 319 patients were included in the meta-analysis. A single-arm meta-analysis of the included studies showed a beneficial effect of the intervention in terms of pain relief outcomes like VAS score (p < 0.001), pain component of SF-36 (p = 0.003) while such improvement was not seen in functional outcome measures like ODI score (p = 0.071), the physical component of SF-36 (p = 0.130) with significant heterogeneity noted among the included studies. No structural improvement in magnetic resonance imaging was observed (p = 0.106). No additional procedure-related adverse events were noted in the included studies (p = 0.662)., Conclusion: There is a paucity of high-quality studies to give conclusive evidence on the benefits of intradiscal PRP for lumbar disc disease. Although intradiscal PRP injection has shown some beneficial effect in controlling pain for lumbar disc disease, we could not find structural or functional improvement from the included studies. Hence, we recommend large double-blind double-arm randomized controlled studies to analyze the benefits of the intervention being analyzed.

Purpose: Active research in arthroscopy in all its domains has been transcending into evidence-backed clinical practice over years. A look-back at the research developments in arthroscopy using scientometry for the past thirty years will help the researchers identify what has been investigated so far, and what needs to be done in the future., Methods: We used the Web of Science-core collection database as the source for data retrieval. We used CiteSpace (5.7.R1) for scientometric and visualization analysis Visualization of the structure, regularity, and distribution of research domains in the arthroscopy was done with the analysis of the article co-citation data to mine the knowledge clustering and citation space distribution. We also analyzed the co-occurrence between the additional research units such as cooperation among authors, institutions, and countries in the field of arthroscopy., Results: We recovered 383 RCTs and 11,853 non-RCT articles in the field of arthroscopy from the global literature of 15,766 arthroscopy-related publications from 1990 to 2019. Research co-operation group with the top contribution to the arthroscopic literature was from BG Domb, MJ Philippon, and SJ Nho for non-RCT articles and Casati A, Pluta A, and Lund B for RCTs. Weaker collaboration exists among the institutions globally, but the network of domestic institutions seemed stronger in co-institution analysis. USA and England have been the pioneers in research particularly the RCTs. The current hotspots were around the outcome analysis, particularly in the knee and shoulder pathologies. In the hip the main area of focus was the Femoro-Acetabular Impingement (FAI). The other areas of arthroscopy remain relatively less explored., Conclusions: Research in arthroscopy is rapidly progressing. Poor international collaboration, the concentration of research only in certain areas of arthroscopy, and conduction of most RCTs only by certain institutes seem to be gross problems in arthroscopic research. Setting up of an International authoritative body for arthroscopic research is the way forward for arthroscopy., Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00586-0., Competing Interests: Conflict of InterestsThe authors declare that they have no conflict of interest., (© Indian Orthopaedics Association 2021.)

Background: The treatment for acromioclavicular joint injuries (ACJI) ranges from a conservative approach to extensive surgical reconstruction, and the decision on how to manage these injuries depends on the grade of acromioclavicular (AC) joint separation, resources, and skill availability. After a thorough review of the literature, the researchers adopted a simple cost-effective technique of AC joint reconstruction for acute ACJI requiring surgery., Methods: This was a prospective single-center study conducted between April 2017 and April 2018. For patients with acute ACJI more than Rockwood grade 3, the researchers performed open coracoclavicular ligament reconstruction using synthetic sutures along with an Endobutton and a figure of 8 button plate. This was followed by AC ligament repair augmenting it with temporary percutaneous AC K-wires. Clinical outcomes were evaluated using the Constant Murley shoulder score., Results: Seventeen patients underwent surgery. The immediate postoperative radiograph showed an anatomical reduction of the AC joint dislocation in all patients. During follow-up, one patient developed subluxation but was asymptomatic. The mean follow-up period was 30 months (range, 24-35 months). The mean Constant score at 24 months was 95. No AC joint degeneration was noted in follow-up X-rays. The follow-up X-rays showed significant infra-clavicular calcification in 11 of the 17 patients, which was an evidence of a healed coracoclavicular ligament post-surgery., Conclusions: This study presents a simple cost-effective technique with a short learning curve for anatomic reconstruction of acute ACJI. The preliminary results have been very encouraging.

The treatment of rheumatoid arthritis (RA) has been closely evolving with an understanding of disease pathogenesis with disease modifying anti-rheumatoid drugs (DMARDS) and Biologic DMARDS being the main stay. platelet rich plasma (PRP) has been the center of research in many specialties in the past decade. Its ability to stop and reverse inflammation have attracted researchers to try PRP in RA. A systematic review of studies on PRP in RA is lacking. The study protocol was prospectively registered in PROSPERO. Detailed search of Cochrane, Scopus, Medline, Embase, and Web of science databases were made to identify the relevant articles till Sep 2020 following Cochrane and PRISMA guidelines. Number of subjects, Animal model used, cell lines used for the study, method of induction of arthritis, PRP dose, concentration used, frequency of administration and clinical, histologic, and molecular changes from baseline following PRP use were extracted and analysed. Eight studies were included for the review. Four of these were in-vitro studies. Two were exclusive animal studies. One study analysed the effects of PRP in RA in both animal models (mice) and Hela cell lines. One study was a report of a series of patients of resistant RA treated with PRP. In the in vitro studies while platelets increase the migration and invasion of RA-FLS, they suppressed the inflammation on the whole. Available animal studies and the Human study have shown encouraging results. There has been no evidence of exacerbation of inflammation in these studies. The quantity and quality of literature on the effects of PRP in treating joint pathologies in RA is limited. Preclinical studies show decrease in disease activity with good safety profile. Invitro studies show suppression of inflammation. Thus, the available literature is encouraging towards the use of PRP in RA. Larger trials and molecular studies to understand the exact role of platelets in disease pathogenesis and treatment mechanisms are needed to decide the future course of PRP in RA., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Anterior fractures of the tibial plateau are either compression or avulsion injuries. Anterior compression fractures of the tibial plateau (ACFT) are rare being traditionally described as involving the rim and often associated with ligament injuries. We have presented 7seven cases of the "large'' type of ACFT, an uncommon pattern of ACFT., Materials and Methods: 7Seven cases of large type ACFTs were identified on retrospectively analyzing the institutional database from 2014 to 2019. The bony and ligamentous injury patterns, fixation, and functional outcomes of these cases have been analyzed., Results: All were males with a mean age of 40 years. Along with the bony injury, we had posterior cruciate ligament (PCL) injuries in three cases and anterior cruciate ligament ACL with medial collateral ligament (MCL) injury in two cases. Our protocol was bony fixation first and later ligament reconstruction based upon knee instability pattern. The locking plates were used in 4 cases and screw fixation in three cases. One patient underwent PCL and MCL reconstruction and another patient underwent PCL reconstruction. The mean union time was 13 weeks. The mean ROM was 128° degrees. Rasmussen's clinical and radiological scores showed good to an excellent outcome (Mean scores: 28.42, 8.7). No patients had apparent instability at follow-up on clinical examination and stress X-rays., Conclusion: Large ACFTs are rare and associated with anterior joint depression and ligament injuries. Their management significantly differs from that of small type ACFTs (Rim compression injuries) where only ligament reconstruction is needed. Recognition of this pattern is essential for the appropriate management and good functional outcome., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Study Design: Systematic review and meta-analysis., Objectives: We performed this meta-analysis to evaluate whether endoscopic discectomy (ED) shows superiority compared with the current gold standard of microdiscectomy (MD) in management of lumbar disc disease., Materials and Methods: We conducted independent and duplicate electronic database search including PubMed, Embase, and Cochrane Library from 1990 till April 2020 for studies comparing ED and MD in the management of lumbar disc disease. Analysis was performed in R platform using OpenMeta[Analyst] software., Results: We included 27 studies, including 11 randomized controlled trials (RCTs), 7 nonrandomized prospective, and 9 retrospective studies involving 4018 patients in the meta-analysis. We stratified the results based on the study design. Considering the heterogeneity in some results between study designs, we weighed our conclusion essentially based on results of RCTs. On analyzing the RCTs, superiority was established at 95% confidence interval for ED compared with MD in terms of functional outcomes like Oswestry Disability Index (ODI) score ( P = .008), duration of surgery ( P = .023), and length of hospital stay ( P < .001) although significant heterogeneity was noted. Similarly, noninferiority to MD was established by ED in other outcomes like visual analogue scale score for back pain ( P = .860) and leg pain ( P = .495), MacNab classification ( P = .097), recurrences ( P = .993), reoperations ( P = .740), and return-to-work period ( P = .748)., Conclusion: Our meta-analysis established the superiority of endoscopic discectomy in outcome measures like ODI score, duration of surgery, overall complications, length of hospital stay and noninferiority in other measures analyzed. With recent advances in the field of ED, the procedure has the potential to take over the place of MD as the gold standard of care in management of lumbar disc disease.

Purpose: Pioneering works on the quality appraisal of RCTs have recognized and addressed most of the issues that affect the RCT quality but some issues such as "Writers' bias" or "Spin" are yet to be sorted out. Spin, particularly in the abstracts, is a potential source of deception to the readers. The purpose of this study is to grade the RCTs of arthroscopy and sports medicine based on a spin in their abstracts, analyze the prevalence of spin, and explore methods to remove spin., Methods: 250 recent RCTs from the top 5 arthroscopy and sports medicine journals were selected. Baseline data of the articles were collected. Consort Adherence Score (CAS) was calculated. The abstracts of the RCTs were graded using the Level Of Confidence (LOC) grading tool developed by the Orthopaedic Research Group. The association of the spin grade with other characteristics of the articles was analyzed., Results: The median CAS for the included studies was 9 (IQR 8-10). It was found that only 49.6% (n = 124) articles had high LOC with no or one non-critical spin in the abstract. 20.8% (n = 52) had Moderate LOC with more than one non-critical spin. 19.6% (n = 49) had at least one critical spin and 10% (n = 25) had more than one critical flaw making their results have Low and Critically Low LOC, respectively. Of the ten variables analyzed in multivariate regression analysis, it was found that CAS was the only significant factor that determines the level of confidence in the abstract of RCTs CONCLUSION: Spin is prevalent in abstracts of sports medicine and arthroscopy journals with 50.4% having some form of spin. Grading the LOC of the RCTs based on spin is the necessity of the day for the readers. Only 49.6% of the RCTs had high LOC. Objective structuring of the abstracts would help eliminate spin in the future., Level of Evidence: Level 1., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Introduction: Homocystinuria has a wide range of clinical presentations ranging from near normal intelligence and appearance with just lens dislocation and minimal skeletal deformities to severe mental retardation with gross skeletal deformities. In this background, we describe one such case with skeletal deformity managed comprehensively., Case Report: A 17-year-old boy presented with complaints of deformity of the left lower limb since childhood more evident for the past 5 years along with a history of blurring of vision. On examination the pubis-heal length > crown-pubis length along with genu valgum of left lower-limb with 16 cm intermalleolar distance. He also had a superolateral subluxation of the lens in both eyes. Valgus angle was 16° on the left leg compared to 6° on the right. The diagnosis of homocystinuria was confirmed by biochemical investigations. The left side genu valgum was addressed with medial closing wedge osteotomy and fixed with distal femur locking compression plating. Lens subluxation was treated with posterior chamber intra-ocular lens surgery. He was also given medical treatment and on regular monitoring of his homocysteine levels. The patient had good functional outcome at 2-year follow-up., Conclusion: Homocystinuria is a rare disease that needs early identification and effective management to avoid complications. Skeletal complications are common and include genu valgum, pes cavus, chest wall deformities, and skeletal deformities such as kyphosis and scoliosis. Skeletal deformities can be avoided when identified early and associated osteoporosis which is managed effectively. A holistic approach is needed in the management of such patients with inter-departmental coordination to bring quality to the life of patients with homocystinuria., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Introduction: Arthritis in primary antiphospholipid antibody syndrome (PAPS) is a rare manifestation that is much more common in secondary antiphospholipid antibody syndrome (APS), particularly those associated with systemic lupus erythematosis (SLE), and has been reported to be non-erosive responding to conservative management. In this background, we describe a case of secondary erosive arthritis of knee (SEAK) in a female patient with PAPS., Case Report: Thirty-seven-year-old working women presented with chronic right knee pain for the past 2 years which was increasing in severity and interfering with her activities of daily living for the past 3 months. The patient was a known case of PAPS with a history of one early and one late abortion. On radiological examination, Grade IV secondary osteoarthritis knee was made out. The patient underwent total knee replacement. At 2 years follow-up, the patient had a good functional outcome. To the best of our knowledge, this is the first report of secondary osteoarthritis in PAPS requiring arthroplasty. Perioperative management is crucial in PAPS to prevent thromboembolic complications. Multimodality approach with strict patient compliance is a key to achieve good functional recovery., Conclusion: SEAK can be a rare presentation of PAPS. Secondary causes like SLE or rheumatoid arthritis must be ruled out before a diagnosis of PAPS is made. Perioperative management in APS is critical and challenging. Multidisciplinary team approach involving internal medicine, anesthesiology, orthopedics, and rehabilitative departments is essential., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Introduction: Of the largest series on osteoarticular tuberculosis (TB) by Tuli et al. involving 1074 cases, only seven involved clavicle. It is also noted that the lateral end of the clavicle has been less frequently involved by tubercular disease than the medial end. We present a case of primary tubercular involvement of the lateral end of the clavicle and discuss its management by an innovative modification of the Weaver-Dunn procedure., Case Report: Twenty-five-year-old working women came with complaints of swelling in her left shoulder for the past 2 months. On examination, swelling with restricted shoulder movements was noted. Radiological evaluation revealed an osteolytic lesion with a pathological fracture in the lateral end of the clavicle. With a provisional diagnosis of giant cell tumor, we proceeded with fine-needle aspiration cytology which was inconclusive. Blood parameters were within normal limits. We proceeded with the excision biopsy of the lateral end of the clavicle and stabilization with a modified Weaver-Dunn procedure involving the reconstruction of the coracoclavicular ligament and augmentation with an Endobutton loop. Biopsy reported the lesion to be of tuberculous etiology. The patient made a good recovery without any complications., Conclusion: Primary TB of the clavicle is a rarity that mimics other diseases like a tumor; hence, clinicians should be aware of a wide range of presentations to diagnose such an entity. Although antitubercular treatment remains the mainstay of treatment, surgical resection is justified in cases of uncertain diagnosis or disease not responding to conservative lines of management and in cases that need the removal of the sequestrum., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

A 60-year-old man presented to our hospital with complaints of pain and deformity on his right thigh for the past 2 days following a history of accidental slip and fall. Radiological investigations suggested a pathological type 2 Seinsheimer subtrochanteric fracture of the right femur with a 'bone within bone' appearance, which posed a diagnostic dilemma as this radiological appearance is seen in a spectrum of conditions. Radiographic skeletal survey failed to identify a similar appearance elsewhere in the body. Laboratory investigations pointed in favour of bone mineral disease, and histopathological examination of the bone narrowed it down to Paget's disease. The fracture was fixed with a contralateral distal femur locking compression plate. The fracture site failed to show signs of union until 6 months postsurgery and hence the patient was advised for grafting procedure. The patient deferred surgery and remains without major complications until 18 months of follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

A 26-year-old wheelchair-bound man was brought to our institute with progressive painful deformity of both lower limbs involving bilateral hip and knee for the past 5 years. The patient was wheelchair-bound for the past 18 months. He was only able to crawl to meet his locomotor demands. On examination, the patient was in a crouched posture with mild kyphosis at the thoracolumbar region and ankylosis of bilateral hip and knee in an unfavourable position. Radiological and serological evaluation diagnosed him to be a case of neglected ankylosing spondylosis. We planned for arthroplasty of the bilateral hip and knee for correcting his posture and to regain his locomotor ability. The severity of the deformity mandated extensive releases and the handling of neurovascular structures. Hence, a holistic treatment plan with various surgical strategies was devised to manage his deformities. The patient made a good recovery and regained his locomotor ability without any major complications at a 2-year follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: Systematic review, meta-analysis, evidence synthesis., Objectives: To analyse the literature evidence available to support the usage of wound drain in various scenarios of spine surgery and provide an evidence summary on the surgical practice., Materials and Methods: We conducted independent and duplicate electronic database searches adhering to PRISMA guidelines in PubMed, Embase, and Cochrane Library till April 2020. Quality appraisal was done as per Cochrane ROB tool, and evidence synthesis was done as per GRADE approach. Five domains of spine surgery with associated key questions were identified. Evidence tables were generated for each question and critical appraisal done as per the GRADE approach., Results: Twenty-three studies (9-RCTs, 4-prospective studies, 10-retrospective studies) were included. Analysis of studies in cervical spine either by anterior or posterior approach and single/multilevel thoracolumbar spinal surgeries did not show any evidence of reduction in surgical site infection (SSI) or haematoma formation with the use of drain. Deformity correction surgeries and surgeries done for trauma or tumour involving spine also did not find any added benefit from the use of wound drains despite increasing the total blood loss., Conclusion: Evidence from this review suggests that routine use of drain in various domains of spine surgery does not reduce the risk of SSI and their absence did not increase the risk of haematoma formation. The current best evidence is presented with its limitations. High-quality studies to address their use in spine surgeries in cervical, trauma, and tumour domains are required to further strengthen the evidence synthesised from available literature.

Trochanteric lateral wall fracture (LWF) indicates instability and is found to be an important predictor of reoperations following trochanteric fracture fixation. A single unified technique for lateral wall reconstruction may not adequately stabilize all the fracture patterns. We have presented morphology specific lateral wall reconstruction techniques using cerclage wire around proximal femoral nails. Various LWF patterns have been simplified into three types. Type-specific lateral wall reconstruction techniques using cerclage wire were adopted in 49 consecutive unstable trochanteric fractures presented to our institute between 2016 and 2018. We analyzed the fracture pattern, fixation method used, union time, and complications. The functional outcome was analyzed using the Harris hip score (HSS). The mean follow-up period was 13 months (range 10-36 months). The mean age of the population was 66 years (range 36-91 years). There were 15 patients with type 1 LWF pattern, 26 patients with type 2, and 8 were of type 3 pattern. The mean operating time was 66 min. The mean union time was 14 weeks (10-24 weeks). HSS was excellent in 9 patients, good in 33 patients, fair in 4 patients, and poor in 5 patients. Complications include one patient with avascular necrosis (AVN) of the femoral head, varus collapse with non-union in one patient, screws back out in one patient, superficial infection in 4 patients, and distal screw breakage in one patient. Type 2 is the most common LWF type in our study. In unstable trochanteric fractures, morphology specific lateral wall reconstruction using cerclage wire loops around the proximal femoral nail is a simple technique with promising results with minimal complications., Competing Interests: Conflict of InterestAll authors declare that there is no conflict of interest., (© Indian Orthopaedics Association 2020.)

Objective: We performed this meta-analysis to compare the safety of unilateral with bilateral instrumented fusion in 2-level degenerative disorders of the lumbar spine., Methods: We conducted an independent and a duplicate electronic database search including PubMed, Embase, and Cochrane Library until January 2020 for randomized controlled trials (RCTs) comparing unilateral pedicle screw fixation with bilateral pedicle screw fixation for multilevel lumbar degenerative disorders. Fusion and complication rates were the primary outcomes analyzed. Analysis was performed in R platform using OpenMeta[Analyst] software., Results: Five RCTs including 215 patients (Unilateral/Bilateral = 106/109) were included in the meta-analysis. There was no significant difference between the 2 groups regarding fusion rate, complication rate, blood loss, duration of hospital stay, functional outcome scores like Visual Analog Scale, Oswestry Disability Index, and Short-Form 36 health survey at the final follow-up. Unilateral pedicle screw fixation was associated with a significant reduction in operation time (P < 0.001). Compared with the open approach, the minimally invasive approach showed a significant difference in terms of factors like operative time, blood loss, hospital stay, Visual Analog Scale, and Oswestry Disability Index (P = 0.004)., Conclusions: Our meta-analysis establishes the immediate safety and significant lesser operative period of unilateral pedicle screw fixation in lumbar fusion. However, due to lack of evidence on complications like cage subsidence and adjacent segment disease, unilateral pedicle screw fixation cannot be recommended as an alternative to bilateral pedicle screw fixation for 2-level degenerative spinal disease. Our analysis established the lacunae in literature for high-quality evidence on the subject; hence we recommend further large multicenter studies with longer follow-up to arrive at a conclusion., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: 3,181,642 cases and 224,301 deaths in 212 regions of the world-this is the status of COVID-19 (Coronavirus Disease 2019) pandemic as of May 1, 2020. This pandemic has managed to overwhelm the health care system of the most advanced countries in the world. As the whole of the medical fraternity stands robed as health care professionals to fight against COVID-19, specialty emergencies like trauma continue to pester the already overburdened health care community. This situation calls for the need for a pandemic response protocol (PREP) in each specialty that helps the doctors to manage specialty emergencies without chaos and at the same time allowing them to play their part in pandemic management., Conclusion: PREP as an integrated pragmatic approach is essential in containing pandemics as they need international cooperation at various levels starting from knowledge sharing to monetary support. PREP which is in line with the WHO action plan, will be an essential minimum response of a non-frontline pandemic response specialty like orthopedics to combat and curtail the effects of a pandemic in a multispecialty tertiary health care centre.