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We aim to report the consecutive patients diagnosed with osteonecrosis of femoral head (ONFH) following recovery from COVID-19 disease and elucidate the unique features of ONFH associated with COVID-19.Consecutive 22 patients (39 hips) recovered from COVID-19 and presented with ONFH from November 2020 to October 2021 were included. All the patients received corticosteroids as a supportive treatment during COVID-19. Patients were classified into two types based on the type of presentation, namely classic ONFH and rapidly destructive coxarthrosis (RDC) depending on radiographs, MRI, inflammatory markers and hip aspiration findings. Harris hip score was used to evaluate the functional outcome before and after treatment.The mean time to diagnose of ONFH from the onset of hip symptoms was 39.3 days (range 10-90 days). The average duration of onset of hip symptoms after COVID 19 infection was 7.5 months (range 3 - 11 months). The average cumulative dose of methylprednisolone equivalent was 811 mg (range 200-2100 mg) and the average duration of steroid intake was 2.8 weeks. There was significant elevation in the inflammatory markers in RDC group compared to classic ONFH (ONFH after COVID-19 can have a varied presentation. While the most common presentation is like classical ONFH, some patients can have an acute and aggressive presentation with rapid destruction. They have features like elevated serological markers and extensive periarticular bone and soft tissue edema. A low cumulative dose of steroids in our patients suggests that the COVID-19-associated vasculitis may play a role in the pathogenesis of ONFH.

Background We aim to report the consecutive patients with primary septic arthritis of the hip associated with COVID-19 and elucidate its unique clinical and radiological features. Methods Six consecutive patients (7 hips) who recovered from COVID-19 and presented with acute hip pain from November 2020 to October 2021 were included. All the patients received corticosteroids as a supportive treatment during COVID-19. Patients were diagnosed with septic arthritis of the hip based on radiographs, MRI, inflammatory markers and hip aspiration culture and synovial fluid analysis. Harris hip score was used to evaluate the functional outcome before and after treatment. Results The mean age was 44.3 years (range, 31 to 54 years). The average cumulative dose of methylprednisolone equivalent was 1328.2 mg (range, 460 to 2500 mg) and the average duration of steroid intake was 3.3 weeks. Two were culture positive and the rest four patients had a culture-negative infection. There was a significant improvement in Harris hip score from 12.5 ± 7.1 at presentation to 72.3 ± 13.6 after treatment (p

PURPOSE: The aim of our study is to compare the efficacy of adductor canal block (ACB), periarticular local infiltration (PLI) and both combined (ACB + PLI) in multimodal pain management after TKA. METHODS: This is a prospective, randomized controlled double-blinded study undergoing primary unilateral TKA. They were randomized into three groups with fifty patients in each group: ACB alone (30 ml of 0.2% ropivacaine), PLI alone (30 ml 0.5% ropivacaine in 20 ml of normal saline), and both combined (ACB + PLI). The primary outcome studied was pain using visual analog score (VAS) in postoperative days (POD) 1 and 2. The secondary outcomes estimated were the ambulation capacity, the knee range of motion, need for rescue analgesia and length of hospital stay. RESULTS: The mean VAS score was significantly lower at rest and after mobilization in the combined group (3.51 at POD 1, 2.04 at POD 2), compared with either alone group (ACB = 4.70, 2.86 versus PLI = 4.39, 3.41 at POD 1 and 2 respectively after mobilization, p

We aim to compare the outcome of culture-positive (CP PJI) and culture-negative (CN PJI) acute knee prosthetic joint infection (PJI) following debridement, antibiotics and implant retention (DAIR) with polyethylene insert exchange. We also aim to analyze the factors associated with the successful outcome of DAIR and the influence of failed DAIR on the outcome of subsequent two-stage revision arthroplasty.We performed a retrospective review of 36 consecutive patients who underwent DAIR for acute PJI between January 2013 and January 2018. The patient's demographic data, McPherson grade, surgical details, laboratory and microbiology data were retrieved from the medical records. All the patients have been followed up for a minimum of 3 years or until re-operation, revision or death and any complications, incidence of DAIR failure, revision and mortality were noted.The mean follow-up was 4.9 ± 2.4 years. Among the 36 patients, 16 had CP PJI and 20 had CN PJI. Among the 16 patients with CP PJI, 8 patients had success with DAIR and 8 patients had a recurrence of infection (50%) at a mean of 21 months (range, 2 weeks to 55 months). Among the 20 patients with CN PJI, 14 patients had success with DAIR and 6 patients had a recurrence of infection [30% (6/20)] at a mean of 69 months (range, 13-221 months) (p .05). The Kaplan-Meir survival analysis showed survivorship did not vary significantly between both groups (p .05). Univariate regression analysis showed symptom duration of more than one month found to be significantly associated with the DAIR failure. There was no difference in failure rate after DAIR between age, Charlson comorbidity index, early postoperative versus acute hematogenous group and type of organism grown. Ten out of 14 DAIR failures were successfully managed with two-stage revision surgery with no recurrence of infection till the final follow-up. In the remaining 4 patients, one underwent re-debridement, two underwent arthrodesis and one was left with an antibiotic cement spacer.DAIR with polyethylene exchange will give comparable results irrespective of the culture positivity. Symptom duration of more than 30 days for DAIR is significantly associated with DAIR failure. DAIR failures can be successfully managed with two-stage revision.

We present a case of vascular malformation of the lower limb mimicking varicose veins. A 52-year-old female patient presented with bilateral severe arthritis of the knees due to rheumatoid arthritis. During total knee arthroplasty, there was a huge challenge in controlling the bleeding from large tortuous veins. Magnetic resonance venogram revealed vascular malformation involving the subcutaneous tissues. We present this case to highlight the need for a high index of suspicion whenever diffuse calcification involving soft tissue plane is noted in the radiographs. It is mandatory to do venous duplex ultrasonography for all patients with varicose vein and soft tissue opacities in the preoperative radiographs to prevent missing a vascular malformation before proceeding for surgery.

BACKGROUND: Acetabular reconstruction in complex primary and revision total hip arthroplasty (THA) with bone loss poses a great challenge. We aim to evaluate the medium-term clinical and radiological outcome of reconstruction rings used in these difficult situations. METHODS: We retrospectively reviewed a consecutive series of acetabular reconstructions with Muller ring or Bursh-Schneider cage from January 2009 to December 2016. The reconstruction rings were used in 66 hips (65 patients). There were 41 complex primary THA and 25 revision THA. The mean follow-up period was 76 months (range, 37–167 months). Clinical evaluation includes the assessment of Harris hip score, visual analogue scale (VAS) score, limb length discrepancy, and activities of daily living. The radiographs were analyzed for any signs of loosening, osteolysis, acetabular migration, and heterotopic ossification. RESULTS: The overall survival rate was 95% for revision in aseptic loosening and 87% for any reason at an average follow-up of 6.3 years. Twelve patients died and 9 patients were lost to follow-up leaving 45 patients for final functional analysis. Among the 45 patients, excellent to good results were seen in 33 patients, fair results were seen in 5 patients, poor results were seen in seven patients. Two patients had aseptic loosening and another two patients developed deep chronic infection awaiting two-stage revision. CONCLUSION: Reconstruction rings still place a role in the armamentarium for complex acetabular reconstruction. It helps to reliably restore the bone stock, have an acceptable survival rate and satisfactory functional outcome at medium to long-term follow-up.

The purpose of this study is (1) to find the clinical and radiological outcome of intraoperative bony avulsion of medial collateral ligament (MCL) treated with screw and washer construct and (2) to predict the preoperative factors which may contribute to the avulsion-type MCL injury during primary total knee arthroplasty (TKA).Intraoperative MCL avulsion injury occurred in 46 (0.8%) of the 4916 consecutive primary TKA from January 2011 to December 2015. After exclusion, the 41 knees were matched 1:2 with controls without MCL injury and compared for the various clinical, radiological, and functional parameters. The clinical parameters analyzed were age, gender, body mass index, preoperative diagnosis like osteoarthritis or rheumatoid arthritis, range of motion, sagittal deformity, and vitamin D levels. The radiological parameters calculated were coronal deformity, proximal tibial varus angle, distal femur valgus angle, joint line congruence angle, posterior tibial slope, "cup and saucer" morphology, presence or absence of knee subluxation, tibia vara, and femoral bowing. The preoperative and postoperative Knee Society Score and Knee Society Functional Score were analyzed. Complications or revisions, if any, were noted during the follow-up. Multivariate logistic regression analysis was used to predict the preoperative risk factors for MCL avulsion injury.At a mean follow-up of 58.4 ± 19.3 months, there were no radiological or physical examination findings of instability. Compared to the preoperative disability, there was a statistically significant improvement in clinical scores (Knee Society Score and Knee Society Functional Score) in the final follow-up (P.001) in both cases and the control group. The mean preoperative coronal deformity was 170.6 ± 6.96 in the study group and 167.7 ± 4.3 in the control group (P = .021). The mean preoperative tibial slope was 10.5 ± 4.9 in the study group and 7.91 ± 4.15 in the control group (P = .003). The preoperative knee subluxation was present in 48.8% knees (P.001) and "cup and saucer" morphology in 68.3 knees (P.001) in the study group. The adjusted odds of MCL avulsion injury were greater for severe varus deformity (odds ratio [OR] 1.462, 95% confidence interval [CI] 1.15-1.86), knee subluxation (OR 39.78, 95% CI 3.78-418.86), and "cup and saucer" morphology (OR 33.11, 95% CI 5.69-192.66).Intraoperative MCL bony avulsion injury can be managed successfully with screw and washer construct without the need for increased prosthetic constraint in primary TKA. The presence of severe varus deformity, knee subluxation, and "cup and saucer" morphology tend to have an increased chance of MCL avulsion injury.

Bilateral Femoral neck stress fractures (FNSFs) are rare without any underlying metabolic disease or repeated strenuous activities like athletes or military recruits. It constitutes about 5–8% of all stress fractures. Treatment options are still controversial. We report two young women with bilateral simultaneous FNSFs without any metabolic cause, presented to us following failed internal fixation with cancellous screws and neck resorption salvaged with total hip arthroplasty. Compression type stress fracture healed in the final follow-up on the other side.

Alkaptonuria is a rare metabolic disorder, and only a few case reports of total joint arthroplasty (TJA) for ochronotic arthropathy are described in the literature. We aim to analyse the functional and radiological outcomes of TJA in patients with ochronotic arthropathy. We retrospectively collected the data of twenty-seven TJA in sixteen patients with ochronotic arthropathy from April 2007 to December 2017. We assessed the functional outcome through pre- and post-operative modified Harris hip score (HHS) and knee society score (KSS). The hip radiographs were analysed for migration and radiolucent zones, and the knee radiographs were assessed using knee society roentgenographic evaluation and scoring system. The mean follow-up was 39.4 months (12–132 months). Two patients died before the final follow-up. There was a statistically significant improvement in mean HHS from 17.8 preoperatively to 78 at the final follow-up (p

Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. We report the successful percutaneous excision of OO in five patients (upper end of femur - 3, tibia - 2). All patients had a minimally invasive reflective array fixed to the same bone followed by registration of anatomy by Iso-C three-dimensional (3D) C-arm. A tool navigator was used to plan the keyhole incision then a sleeve was introduced which allowed the usage of burr and curette to remove the tumor. After excision, the 3D C-arm was again used intraoperatively to confirm the complete eradication of the nidus. Adequate material for histology was obtained in four patients that confirmed the diagnosis of OO. In one child postexcision scans were successful in identifying incomplete removal requiring further excision of the nidus. All patients achieved excellent pain relief and were asymptomatic at an average follow-up of 3.2 years. 3D C-arm-based navigation offers the advantage of excellent localization, percutaneous excision, and intraoperative confirmation of adequate excision.

Introduction: Proximal tibia stress fractures with knee osteoarthritis pose a challenging situation. We evaluated the radiological and functional outcome of one-stage total knee arthroplasty (TKA) and long stem for patients with varied grades of knee arthritis and proximal tibia stress fractures. Methods: We analysed 20 patients from April 2012 to March 2017 with proximal tibia stress fractures associated with knee osteoarthritis of varied grades. Out of 20 patients, five were acute fresh fractures. The mean age was 64 years (range, 52–78) which includes three men and 17 women. Previous surgery in the same limb, rheumatoid arthritis, valgus deformity were excluded. All patients were treated with posterior stabilised TKA with long stem, of which, four patients had screw augmentation for medial tibial bone defect and two patients with malunited fracture at stress fracture site required osteotomy, plating and bone grafting. Two patients had two level stress fracture of tibia in the same leg. Results: The mean follow-up period was 28 (range, 6–60) months. The mean tibiofemoral angle improved from 18.27° varus to 1.8° valgus. The mean knee society score improved from 21.9 (range, −10 to 45) to 82.8 (range, 15–99) [p p Conclusion: TKA with long stem gives excellent outcome, irrespective of severity of arthritis associated with stress fracture. By restoring limb alignment and bypassing the fracture site, it facilitates fracture healing. Early detection and prompt intervention is necessary to prevent the progression to recalcitrant non-union or malunion.