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Anteromedial portal technique (AMP) using hamstring autograft is a popular technique of arthroscopic ACL reconstruction allowing anatomical placement of femoral. In this technique, a cortical suspensory fixation of graft is used on the femoral side and interference screw fixation on the tibial side using a complete bone tunnel. All-inside translateral technique is a recently introduced technique which uses a closed loop of quadrupled semitendinosus graft with an adjustable cortical suspensory fixation on both sides allowing optimum tensioning of graft and near-complete filling of retrosockets created by the flip cutter on both femoral and tibial sides. With its proposed but unproven benefits, our study was planned to compare the two techniques. A total of 80 young active males requiring ACL reconstruction surgery were equally randomized to AMP and All-inside technique. The primary objective of the study was to compare the ability to return to pre-injury level of activity using Tegner activity scale and patient-reported outcome using new Knee Society Score (KSS) at two years of follow-up. The mean improvement in Tegner score was significantly better (p = 0.0005) in all-inside group (2.34 ± 0.97) as compared to AMP group (1.5 ± 1.30). Among components of new KSS, patient satisfaction was better in all-inside group. All-inside ACL reconstruction provides a better chance of return to pre-injury level of activity with accompanied patient satisfaction as compared to AMP technique at two years of follow-up. Level I, therapeutic study.

Backgroud Anterior cruciate ligament reconstruction (ACLR) remains the gold standard treatment for anterior cruciate ligament (ACL) injury. However, a good functional outcome even after a successful surgery depends on multiple factors. It has been observed that certain patients with a chronic ACL injury demonstrate knee instability voluntarily. The authors observed that these patients might not perform well even after a successful surgery. This study aims to assess the outcome after ACL and other ligament reconstruction in patients with voluntary knee instability. Methods From a total of 824 patients who underwent ACLR, 13 patients with a history of voluntary knee instability were selected, and data of these patients (demographic and clinical profile) were obtained. Outcomes of surgery in this group of patients were evaluated by using Lysholm score and Tegner activity level. Results All patients were young men with a chronic ACL injury and manifested instability. Associated injuries were lateral meniscus tear in 3 patients, medial meniscus tear in 2, and posterolateral corner (PLC) injury in 3. ACLR was done using the semitendinosus-gracilis graft in all patients. Further, anterolateral ligament reconstruction was done in 2 patients and PLC reconstruction, in 3 patients. The mean Lysholm score was 54.76 (range, 48-62) preoperatively and 60.92 (range, 54-78) at a mean follow-up of 14.3 months (range, 11-26 months). The median Tegner activity level was 6 (range, 5-7) before injury and 4 (range, 3-5) at the final follow-up. Twelve of the 13 patients were able to demonstrate instability voluntarily at the time of the final follow-up. Conclusions In patients with ACL and other ligament injuries who demonstrated voluntary knee instability, the functional outcome even after successful ligament reconstruction was poor.

BACKGROUND: With increasing numbers of primary total hip replacement (THR), there has been a substantial increase in revision total hip replacement (RTHR) surgeries. RTHR are complex joint reconstruction surgeries involving significant cost, expertise and infrastructure. With its significant socioeconomic impact, we need to keep a close watch on the epidemiological trends of these procedures. METHODS: We prospectively studied the first-time RTHR performed at our institution for a 7-year period (2011–2017). We looked at patient demographics, the workload of RTHR and its etiology. We reviewed the microbiological profiles of septic revisions. RESULTS: Of the 1244 THR procedures performed, 260 (21%) were first-time revisions. The predominant cause of revisions was a prosthetic infection (38%) followed by aseptic loosening (33%), instability (15%), peri-prosthetic fracture (11%) and implant breakage (3%). In the aseptic loosening group, 55% of cases had primary cemented implant, 44% had only stem loosening, 31% had cup loosening and 25% had both cup and stem loosening. In the early, midterm, and late-failure groups, prosthetic infection remained the main cause of failure. In 60% of the septic revisions, the offending organisms could not be identified and of those identified most (77%) were gram negative. CONCLUSION: In our study, the RTHR burden was 21%, which is similar to historic revision data from the west (1998–2001) and twice as compared to recent trends from the west (9–11%). Unlike western data, which show aseptic loosening (30–60%) as the predominant cause of hip revisions, in our study infection was the number one cause (38%).

Backgroud The indications for total knee arthroplasty (TKA) have been expanded to include younger, demanding patients. Some TKA patients expect a return to high-performance activities to restore optimum quality of life. The concept of the medial pivot (MP) TKA is that more natural knee kinematics can be achieved by altering the bearing design. In the present study, we compared the early outcomes of MP TKA with posterior-stabilized (PS) TKA in terms of patient-reported outcomes, function, and performance. Methods This randomized study was performed in a high volume joint replacement facility of a tertiary care military hospital. We enrolled 40 patients each in the MP group and PS group and assessed knee flexion, patient-reported outcome (new Knee Society Score [new KSS]), patient performance (Delaware Osteoarthritis Profile Score [DOPS]), and function (Forgotten Joint Score [FJS]) at 2 years after surgery. Results Compared to PS group patients, MP group patients had similar patient-reported outcomes assessed by new KSS (satisfaction, expectation, and activity scales) and FJS. MP knee patients had better performance in the timed up and go test (p < 0.026) and self-paced walk test (p < 0.002) of DOPS. The gain in knee flexion (9.3° ± 14°) compared to baseline was significantly greater in the PS group (p < 0.013). Conclusions When assessed by DOPS, getting up from chair and walking speed were significantly better in MP knee patients than in PS knee patients. However, considering the predictable rollback ensured by cam and post, the PS knee produced better knee flexion. Despite these results, patients were equally satisfied with the two designs.

Background: There has been a gradual increase in the revision TKA (RTKA) workload due to expanding indications of total knee arthroplasty (TKA), coupled with improving patient longevity. Western countries are already looking at their data on RTKA to plan for the future heath care needs of these patients. Limited data is available on RTKA from developing countries. Our study attempts to fill this gap in knowledge. Materials and Methods: We prospectively documented details of all RTKA performed at our centre for a period of six years (2011-16). We recorded the volume, causes and time to failure from index surgery of all RTKA and further recorded microbiological pattern in septic failures. We looked at the proportion of each cause of failure and time from index surgery. Results: Of the 5068 TKA procedures performed from January 2011 to December 2016, 201 (4%) were first-time revisions. The predominant cause of revisions was prosthetic infection (61%) followed by aseptic loosening (18%) and instability (7%). In the early, mid term, and late-failure groups, prosthetic infection remained the main cause of failure. In 47% of the septic revisions, the offending organisms could be identified and of those identified most (67%) were Gram-negative. Conclusion: The volume of first-time RTKA procedures (4%) at our center remained low compared with that of the Western countries. In Western countries, the incidence of late aseptic failures was higher than that of early-septic failures, whereas in our study, revisions were more commonly performed in the early-failure group (48%) and most failures were due to prosthetic infection (61%).

With a quest to optimize outcomes, there have been significant advancements in modern designs of total knee implants, attempting to mimic the natural knee motion and feel. One such new design reproducing the medial and lateral knee pivot is a dual-pivot (DP) knee. In the present study, we endeavored to compare the performance of the DP knee vis-a-vis an ultracongruent (UC) Knee design.This prospective cohort study was performed in a joint replacement center of a tertiary care military hospital. We enrolled 50 patients each in the DP knee group and the UC knee group and assessed knee flexion, patient-reported outcome (new Knee Society Score [nKSS]), patient performance (Delaware Osteoarthritis Profile Score), and function (Forgotten Joint Score [FJS]) at 2 years of follow-up.The nKSS was similar in the two groups. In the DP group, patients had significantly better improvement in the stair climb test (Our study showed that the DP knee design had similar knee function to the UC knee. The DP knee design had significantly better stair climbing ability, whereas getting up from chair was better in the UC knee design. With comparable patient-reported outcome and possible differences in patient performance in terms of day-to-day activities, any future trial should focus on comparing patient performance.

With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies.This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA.TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (Screening and RM can reduce 90-day complications in patients undergoing TKA.

Background: Fracture healing is a complex biological phenomenon which is influenced by various environmental factors. From time immemorial, there has been a constant endeavor to look for means to enhance fracture healing which would limit disability and restore preinjury level of function at the earliest. Hyperbaric oxygen therapy is one such therapy which has shown some role in enhancing fracture healing in established fracture nonunion but its role in acute fracture healing has not been studied. Materials and Methods: The study was conducted in a military hyperbaric oxygen therapy (HBOT) facility co-located with a tertiary care military hospital. Sixty patients between 20 and 50 years of age with acute closed fractures of the metacarpal, planned to be managed conservatively, were equally randomized to the HBOT (n = 30) and sham HBOT (n = 30) group. Patients in the sham HBOT group, apart from receiving standard of care for the fracture, received a sham exposure of HBOT for 4 weeks, whereas those in the HBOT group, received HBOT therapy for the same duration. The patients were actively followed up for 6 months. Primary outcome measure was rate of fracture healing as assessed by radiology and ultrasound evaluation and functional recovery as assessed by the disabilities of the arm, shoulder, and hand score (DASH). Secondary outcomes included the assessment quality of life and complication rate. Results: The 6-month follow-up rate was 100%. All fractures in both the groups united, there was no significant difference in rate of fracture healing at 12 weeks (P = 0.731) or functional outcome at 24 weeks, as assessed by DASH score (P = 0.127), between the groups. There were 6 (20%) malunions in sham HBOT group and 2 (07%) in HBOT group. There were four cases of reflex sympathetic dystrophy in sham HBOT group and three cases in HBOT group. Conclusions: HBOT in acute diaphyseal fractures does not alter the rate of healing when assessed clinicoradiologically and has no effect on functional outcome at 6 months of follow-up. Level of Evidence: Level I

Profunda femoris artery injury following osteosynthesis of the proximal femur fracture is a rare complication and is usually caused by iatrogenic trauma or rarely due to bony spikes. Presentation can be delayed because of nonspecific features such as pain, swelling, anemia, fever, and hematoma. We report a case of posttraumatic profunda femoris aneurysm which presented more than a year after surgery with near-complete resorption of proximal femur and failure of implant requiring evacuation of huge layered thrombus, ligation of profunda femoris, and reconstruction of proximal femur with tumor megaprosthesis. Literature has not described a similar case.

Today, there is increasing demand for quality medical care to be made available for a large population at a reasonable cost. In a society with limited health-care infrastructure and budget, it has become imperative to evolve scientifically proven clinical care pathways. No country is willing to accept infructuous expenditure on treatment modalities with ambiguous patient outcomes. Hence, evidence-based medicine has been introduced into most health-care systems. When it comes to orthopedics, a serious concern is that, the existing literature has extremely poor quality of evidence. There are very few best practice guidelines, which are supported by high quality clinical studies. In this review article, we have made an attempt to bring out the recurring lacunae in orthopedic research papers. Following which we have also given tips on how to plan, design, and conduct a high quality clinical trial. We have made an attempt to explain commonly required knowledge of statistical tools. In the end we have briefly described, how to prepare a protocol, execute the study, analyze the results, and write the final article to get published.

Background Simultaneous bilateral total knee arthroplasty (SBTKA) offers significant socioeconomic benefits. However, retrospective studies and public health data show increased mortality and morbidity rates in patients undergoing SBTKA compared with those undergoing unilateral TKA (UTKA), and there have been recommendations against the use of SBTKA. High-volume centers, which feature careful patient selection and fast-tracked surgery, continue to perform SBTKA and have published their results in favor of the procedure. However, the quality of evidence remains poor. Methods We prospectively examined 90-day morbidity and mortality of SBTKA compared with UTKA in risk-screened and optimized patients in our high-volume joint replacement facility. A total of 1200 consecutive patients were recruited in each arm. Results Ninety-day mortality was higher in SBTKA patients than in UTKA patients (0.58% vs 0.42%, respectively; P = .5646). Overall procedure-related complications were significantly higher in the SBTKA group (7.25% vs 4.42%, respectively; P = .0034). The relative risk of cardiovascular complications in SBTKA patients was 6.5 times higher than that in UTKA patients (1.08% vs 0.17%, respectively; P = .0136). Neurological complications were 9.5 times more common in the SBTKA group (1.58% vs 0.17%, respectively; P = .0024). All other complications were comparable in the 2 groups. Conclusion Risk screening and preoperative optimization reduce mortality and overall complication rates in SBTKA patients; however, overall procedure-related complications, specifically cardiovascular and neurological, remain significantly high in SBTKA patients, for which a guarded approach is recommended.

Background Hip fractures are a significant cause of morbidity and mortality in the elderly. Fast-track multidisciplinary co-management of these patients, rapid preoperative optimization, early surgery, and expeditious rehabilitation may minimize morbidity and mortality. In this study, we evaluated outcomes of fixation of hip fractures in the elderly patients managed by Geriatric Hip Fracture Program at a military hospital in India. Methods A total of 114 patients above 60 years of age with hip fractures were enrolled. They were comanaged by a team of specialists and fast-tracked to surgery. Independent ambulation with support of a walker was achieved before discharge to home. Patients were followed up for 1 year. Results The average age of the 114 patients was 77 years; 24 patients were octogenarian. Eighty-four percent of injuries were due to a domestic fall. Hypertension (41%) and diabetes (22%) were the most common comorbidities. All patients were optimized before surgery. The average delay from injury to admission was 1.7 days (range, 0 to 14 days) and that from admission to surgery was 1.8 days (range, 0 to 19 days). Hence, the average time from injury to surgery was 3.5 days. The length of stay in hospital was, as per rehabilitative milestones achieved, 2 to 5 days in 40% of the patients and 6 to 15 days in 60% of the patients. At 1 year after surgery, 95 patients were independently ambulant (56 patients with support and 39 patients without support). Twenty-three percent of the patients had postoperative complications and eight patients died (7.7%) at 1-year follow-up; 11 patients were lost to follow-up. Conclusions Elderly hip fracture has a high risk of mortality (14%-58%). Thus, expeditious surgery within 24 hours of admission has been advocated in the Western literature to minimize mortality. Mortality rate at 1 year after surgery remains at 10% to 24%. In our study, even with aggressive co-management, the average delay to hip fracture fixation was more than 3 days; however, the 1-year mortality was relatively low (7.7%). This indicates the importance of preoperative optimization and postoperative rehabilitation for independent ambulation and mortality reduction in the elderly population.

The American College of Chest Physicians (ACCP) recommended routine anticoagulation for thromboprophylaxis in patients undergoing lower limb arthroplasty. We compared results of routine anticoagulation Vs risk stratified approach for Deep Venous Thrombosis (DVT) prophylaxis after TKA in terms of symptomatic DVT and wound complications. Nine hundred TKAs done in 673 patients were randomized after DVT risk screening to routine anticoagulation (n = 450) or to risk stratification (n = 450) and selective anticoagulation. 194 patients in the risk screening group received only Aspirin. Primary outcome was symptomatic DVT and wound complication. This randomized study showed that the symptomatic DVT rates after TKA were similar whether patients were routinely anticoagulated or selectively anticoagulated after risk screening. However there was a significantly higher incidence of wound complications (P0.014) after routine anticoagulation.

Background With increasing number of patients with early osteoarthritis of knee opting for total knee arthroplasty (TKA), there has been increase in patients dissatisfied with surgical outcomes. It is being presumed that offering unicondylar knee arthroplasty (UKA) to them would improve outcomes. Methods Primary objective of our study was to look for any difference in patient-reported outcome and function at 2-year follow-up in patients undergoing UKA as compared to TKA. Our study was a randomized study with parallel assignment conducted at a high-volume specialized arthroplasty center. Eighty patients with bilateral isolated medial compartment knee arthritis were randomized into simultaneous 2-team bilateral TKA (n = 40) and UKA (n = 40) group. We finally analyzed 36 patients in each group. Main outcome measure was improvement in Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) and High Activity Arthroplasty Score (HAAS) obtained at 2-year follow-up. Results Improvement in KOS-ADLS and HAAS at 2 years was similar ( P = .2143 and .2010) in both groups. Performance as assessed with Delaware index was also similar. Length of hospital stay was less in UKA group (6.6 days as against 5.4 days). Complications and readmission rates were more in TKA group (nil in UKA group; 08 in TKA group). Conclusion At 2-year follow-up, UKA provides similar improvement in patient-reported outcomes, function, and performance as compared to TKA when performed in patients with early arthritis. However, UKA patients have shorter hospital stay and fewer complications.

To compare results of primary internal fixation of acute displaced midshaft clavicle fractures with those managed nonoperatively in terms of fracture union and functional outcome.Prospective cohort study.Level II military trauma center.Seventy-three patients (civilian and military) between 20 and 50 years of age with displaced midshaft clavicle fractures were allocated either to the operative (n = 45) or nonoperative (n = 28) group.Patients in the nonoperative group were managed by simple sling immobilization, whereas in the operative group, fractures were reduced and fixed with a contoured reconstruction plate.The patients were actively followed up during an 18-month period. Primary outcome measures were the rates of nonunion and symptomatic malunion; secondary outcomes included the assessment of the Constant score and the overall local complication rate.The 18-month follow-up rate was 90%. All fractures in the operative group united compared with eight nonunions (29%) in the nonoperative group (P = 0.002). Ten symptomatic malunions (36%) occurred in the nonoperative group, whereas only two (4%) were reported for the operative group (P = 0.0008). Constant shoulder scores were significantly better for the operative group at all follow-ups (P0.0001). All six operative complications were implant-related.In this prospective cohort study, primary open reduction and internal plate fixation of acute displaced midshaft clavicular fractures resulted in improved outcomes and a decreased rate of nonunion and symptomatic malunion compared with nonoperative treatment.

Background: A major drawback of conventional fixator system is the penetration of fixator pins into the medullary canal. The pins create a direct link between the medullary cavity and outer environment, leading to higher infection rates on conversion to intramedullary nailing. This disadvantage is overcome by the AO pinless fixator, in which the trocar points are clamped onto the outer cortex without penetrating it. This study was designed to evaluate the role of AO pinless fixators in primary stabilization of open diaphyseal tibial fractures that received staged treatment because of delayed presentation or poor general condition. We also analyzed the rate of infection on early conversion to intramedullary nail. Materials and Methods: This study is a retrospective review of 30 open diaphyseal fractures of tibia, which were managed with primary stabilization with pinless fixator and early exchange nailing. Outcome was evaluated in terms of fracture union and rate of residual infection. The data were compared with that available in the literature. Results: All the cases were followed up for a period of 2 years. The study includes Gustilo type 1 (n=10), 14 Gustilo type 2 (n=14), and type3 (n=6) cases. 6 cases (20%) had clamp site infection, 2 cases (6.7%) had deep infection, and in 28 cases (93%) the fracture healed and consolidated well. Conclusion: This study has highlighted the valuable role of pinless external fixator in the management of open tibial fractures in terms of safety and ease of application as well as the advantage of early conversion to intramedullary implant without the risk of deep infection.