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Backgroud It has been widely reported that vitamin D (vit D) affects preoperative, postoperative, and long-term outcomes after total knee arthroplasty (TKA). Our aim was to study vit D trajectory after TKA and compare effects of oral versus intramuscular (IM) supplementation in insufficient patients and assess its effects on immediate functional recovery in the first 2 weeks after TKA. Methods Vit D levels < 30 ng/mL are considered insufficient. We prospectively enrolled 60 patients (20 per group): group I, vit D sufficient patients; group II, vit D insufficient patients given IM supplementation (cholecalciferol 6,00,000 IU); and group III, vit D insufficient patients given oral supplementation (cholecalciferol 600,000 IU). Vit D levels, knee flexion, Timed Up and Go (TUG) test results, and visual analog scale (VAS) score were recorded preoperatively and postoperatively on day 3 and 14. Results In group I, mean preoperative vit D significantly dropped at postoperative day (POD) 3 and POD 14 (p = 0.001). In group II, mean preoperative vit D rose at POD 3 and rose significantly at POD 14 (p = 0.001). In group III, mean preoperative vit D increased significantly at both POD 3 and POD 14 (p < 0.001). Also, in group III, the rise in vit D was significantly higher than that in group II both at POD 3 and POD 14 (p < 0.05). In group III, 19 of 20 insufficient patients became sufficient on POD 3 and all 20 by POD 14. In group II, even by POD 14, only 11 of 20 insufficient patients became sufficient. Functional parameters (flexion, change in flexion, TUG test results, and VAS score) were comparable (p > 0.05) in all groups. Changes in TUG test showed a significant increase in group II (48.5 seconds) when compared to group I (35.5 seconds) at POD 3 (p < 0.05), suggesting a slower recovery. It remained comparable (p > 0.05) between group III and group I. Conclusions We found that vit D insufficient patients can be rapidly supplemented on the morning of surgery with a large dose of oral cholecalciferol 600,000 IU, and the effect was consistent over 2 weeks after surgery. Orally supplemented vit D insufficient patients also showed functional recovery comparable to vit D sufficient patients. IM supplementation increased vit D levels only at 2 weeks and the rise was significantly lower than oral supplementation. Interestingly, approximately 25% of vit D sufficient patients who were not supplemented after TKA became insufficient in the first 2 weeks postoperatively.

BACKGROUND: High-flex posterior stabilised rotating platform (PSRP) implant was introduced to provide for deep knee flexion. Few short-term results have been reported, but there are no long-term outcomes reported. METHODS: We prospectively followed 48 patients (53 knees) implanted with one such design. Inclusion criteria for implantation were patients with good pre-operative flexion and wishing to perform activities requiring deep knee flexion post-operatively, with femorotibial varus angle

A 72-year-old man with bilateral knee osteoarthritis treated elsewhere with bilateral intraarticular stem cell injections (SCIs) presented to us 2 months later with signs of infection in his left knee. Aspiration culture grew fungus Penicillium sp. First-stage total knee arthroplasty (TKA) included thorough joint debridement, lavage, standard bone cuts, and insertion of antibiotic-impregnated cement spacer. Second stage included spacer removal and final implantation. At the 1.5-year follow-up, he has a satisfactory clinical outcome without evidence of infection.As far as we know, this is the first reported case of infective fungal arthritis secondary to intraarticular SCI successfully managed by a staged primary TKA.A 72-year-old man with bilateral knee osteoarthritis treated elsewhere with bilateral intraarticular stem cell injections (SCIs) presented to us 2 months later with signs of infection in his left knee. Aspiration culture grew fungus Penicillium sp. First-stage total knee arthroplasty (TKA) included thorough joint debridement, lavage, standard bone cuts, and insertion of antibiotic-impregnated cement spacer. Second stage included spacer removal and final implantation. At the 1.5-year follow-up, he has a satisfactory clinical outcome without evidence of infection. As far as we know, this is the first reported case of infective fungal arthritis secondary to intraarticular SCI successfully managed by a staged primary TKA.

Attune (DePuy Synthes) prosthesis was designed to overcome patellofemoral complications associated with PFC Sigma (DePuy Synthes) prosthesis. The aim of our study was to compare the incidence of anterior knee pain (AKP), patellofemoral crepitus (PCr), and functional outcome between them.This prospective matched-pair study was conducted between January 2014 and June 2015, during which 75 consecutive Attune total knee arthroplasties (TKAs) were matched with 75 PFC Sigma TKAs based on age, sex, body mass index, pathology, and deformity. A single surgeon performed all the operations with aid of computer navigation, using a posterior-stabilized prosthesis with patellar resurfacing. Outcome was assessed by new Knee Society Score (NKSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. AKP and PCr were assessed by a patient-administered questionnaire till 2 years of follow-up. Three pairs were lost to follow-up and finally 72 pairs were analyzed.One patient in each group reported AKP and 1 patient from each group had PCr at 2 years postoperatively. None of these patients required additional surgery. The incidence of lateral retinacular release was higher with PFC Sigma (5/72) than Attune (2/72); however, this was statistically not significant (We observed that both Attune and PFC Sigma had a low and comparable incidence of AKP and PCr up to 2 years of follow-up. The Attune group achieved a significantly greater ROM at 3 months postoperatively. At 2 years of follow-up, both prostheses had excellent and comparable clinical and functional results.

Background: Osteochondritis dissecans (OCD) is a disorder primarily affecting subchondral bone, with secondary effects on the overlying articular cartilage. Knee joint (75%) and radiocapitellar joint (6%) are the most common sites for OCD lesions. The presence of an open growth plate differentiates juvenile osteochondritis dissecans from adult form of osteochondritis. Early diagnosis and treatment produce best long term results. The objective of this study is to determine the best mode of management of a Grade I osteochondritis lesion in a young athlete. Materials and Methods: A PubMed search was made using the keywords “OCD” and “athlete”. Articles that were based on participants between the ages of 6–24 years (children, adolescent and young adult) and early stages of OCD were included in this study. A total of 25 articles were thus included for the review. Results: The healing potential is based on the age of the patient, status of physis, and stage of the lesion. Most authors have observed good to excellent results of drilling of early OCD in skeletally mature patients. Similarly, most authors also reported equally successful outcomes of nonoperative treatment for early OCD in skeletally immature patients. Conclusions: We recommend initial nonoperative line of management in patients with open physis. In case of progression of the lesion or failure of conservative treatment a reparative, restorative or palliative surgical intervention can be done. For Stage I OCD lesions in patients with closed physis, we advocate reparative surgery either by means of retro- or trans-articular drilling.

INTRODUCTION: The commonly recognized causes of post-operative neurological deterioration in spinal tuberculosis are inadequate decompression, damage to vascular supply of the spinal cord, and multi-drug resistant organisms. There are no known cases of syringomyelia developing after surgical decompression of spinal tuberculosis. CASE PRESENTATION: A teenage girl presented with rapid onset quadriparesis secondary to a tubercular epidural abscess extending from C4-T8. The neurological status deteriorated to quadriplegia immediately following decompression by hemilaminectomy at C7 and T7 levels. Investigations into the cause of neurological deterioration revealed syrinx formation at T5–9 levels. The patient had partial motor and sensory recovery in the first 3 weeks post-operatively. Tubercular infection was treated with a 1-year course of multi-drug anti-tubercular therapy. However, there was no further neurological improvement at 2 years follow-up. DISCUSSION: Syringomyelia in tuberculosis has been associated with tubercular meningitis, intradural tuberculomas, and post-surgical vascular insult. None of these were implicated as the cause of syrinx formation in this case. We hypothesize that the rapid evolution of epidural abscess in an intact vertebral column led to an acute “epidural compartment syndrome”, which caused ischemic damage to the spinal cord. Compression caused by the epidural abscess was relieved by surgical decompression, allowing the central canal to dilate and expand into the softened spinal parenchyma, hence leading to syrinx formation.

Primary leiomyosarcoma of the bone is exceedingly rare. In this case, we describe a middle-aged female with a primary leiomyosarcoma of the distal femur. The patient was treated by hip disarticulation. The patient continues to be disease-free at one-year follow-up.

Trapping of fingers in metallic bands is a commonly encountered situation. The children, elderly people, and psychiatric patients are the usual victims. The constricting object in the digit causes obstruction to lymphatic and venous drainage leading to oedema distal to the constriction, which leads to further neurovascular compromise and presents as a surgical emergency. A 7-year-old boy presented to us with his right middle finger being stuck in a steel door latch. Multiple attempts were made to remove the trapped finger with conventional methods, and subsequently, it was removed by electric-driven metal cutting saw, which was not previously described in medical literature to the best of our knowledge.

Spontaneous osteonecrosis of the knee affects the medial femoral condyle in patients above 55 years of age. Many reports and studies are available from western countries. But there is a gross paucity of literature on spontaneous osteonecrosis of the knee (SPONK) in the Indian subcontinent, either it is under-reported or detected at a later stage. The aim of our study was to detect SPONK in Indian population and describe its characteristics, treatment, and outcome. A prospective study was conducted over a period of three years. All patients above 18 years with knee pain at rest and medial condyle tenderness without joint laxity were evaluated with plain radiographs and MRI. Further tests were done if radiological signs of osteonecrosis were present. Various parameters were recoded like Visual Analog Scale (VAS), Knee Society Score (KSS), and MRI Osteoarthritis Knee Score. Conservative treatment consisted of a combination of NSAIDs and bisphosphonates. Decompression with bone grafting was done if there was no improvement or deterioration at three month follow-up. Ten patients were diagnosed with SPONK. The mean age was 50 years with male predominance (60%) with the involvement of medial femoral condyle (80%) or left knee (70%). Most cases were in Koshino stage 1. Mean VAS was 6.5 and mean KSS was 59. All clinical parameters showed improvement at one year. A study with a bigger sample size and longer follow-up is needed to fill the lacunae of literature on this topic from the Indian subcontinent. In spite of the limitations, we did observe that in our population, males were more commonly affected than females, which is contrary to most studies on the subject. Also, the disease had an early age of onset (50 years) in Indian population as compared to Western and East Asian populations. Combined therapy of NSAIDs and bisphosphonates shows excellent results over a period of one year. Joint-preserving surgeries are effective even in Koshino stage 3 SPONK.

Case A patient who underwent first-stage revision procedure elsewhere for prosthetic joint infection (PJI) of the knee with Kocuria rosea presented to us 9 months after the index surgery, with persistent infection. First-stage revision surgery was repeated and Mycobacterium wolinskyi, a rare rapidly growing nontuberculous mycobacterium (RGM), was isolated from samples obtained by sonication of the cement spacer. After a prolonged antibiotic course, definitive implantation surgery was done. One-year postimplantation, patient remains infection free. Conclusions This is only the second known case of knee PJI caused by M. wolinskyi. This case highlights the possibility of RGM getting masked by other organisms.

Background Postoperative suction drains are used after total knee arthroplasty to avoid intra-articular hematoma formation although they can increase blood loss due to a negative suction effect. The use of tranexamic acid to reduce blood loss may nullify this. The aim of this study was to compare outcomes in patients undergoing total knee arthroplasty with or without drains and to analyze whether the drain's diameter also has an impact. Methods This is a prospective randomized study of patients undergoing unilateral total knee arthroplasty performed by a single surgeon. The study population was divided into three groups (A, 10G drain; B, 12G drain; and C, no drain). Pain, blood loss, swelling, wound-related complications, functional outcomes and questionnaire-based outcomes were assessed postoperatively. Results Each group had 35 patients comparable in most demographic and pre- and intraoperative characteristics. During the first 6 hours postoperatively, opioid consumption was significantly higher when the drain was not used (p = 0.036). At 3 months postoperatively, new Knee Society Score (NKSS) was highest with the use of 12G drain (p = 0.018). However, NKSS at 1 year was comparable across the three groups. With the use of tranexamic acid, blood loss and incidence of soakage of dressing were unaffected by the presence or absence of a drain. The calf girth, suprapatellar girth, soakage of dressing and range of motion were comparable in all three groups. There was no incidence of surgical site infection or deep vein thrombosis. Conclusions Presence of a suction drain significantly reduces opioid consumption during the first 6 hours after total knee arthroplasty. Use of a drain made no difference to the functional outcome at 1 year postoperatively. With the use of tranexamic acid in total knee arthroplasty, the total blood loss and the requirement of blood transfusion were unaffected by the presence or absence of closed suction drainage or by the bore of the drain used. The clinical parameters such as swelling, range of motion, infection and deep vein thrombosis also remained the same.

Background: Chronic plantar fasciitis is often a difficult to treat entity and platelet-rich plasma (PRP) is an upcoming modality instead of steroid in chronic cases of plantar fasciitis resistant to traditional non-operative management.Methods: Sixty patients with chronic plantar fasciitis were prospectively randomised into 2 groups and treated with either a single injection of 3 cc PRP or 40 mg DepoMedrol (Cortisone) injection and followed for a year. Immediately prior to PRP or cortisone injection American Orthopedic Foot and Ankle Society (AOFAS) hind foot scoring was done for all patients. These scores were repeated at 6 weeks, 6 months and 12 months.Results: Six weeks evaluation of AOFAS after PRP and corticosteroid administration, the mean visual analogue scale (VAS Score) showed a significant increase in corticosteroid group (4.2) as compared to PRP group (5.8). But, the PRP group (1.8) showed significant improvement in mean VAS scores as compared to Steroid group (3.4) after a year of the treatment. Similarly, the AOFAS score improved significantly in the steroid group (64.4) at 6wks as compared to the PRP group (52.2) but at 12 months however, the PRP group sustained its effect with a mean AOFAS score of 92.2 while in the steroid group, the score dropped to a mean of 78.4.Conclusions: PRP was more effective than steroid for the long term treatment of chronic plantar fasciitis. Level of Evidence: Level I, prospective randomized comparative series.

Background: Multimodal periarticular cocktail injection (MPCI) containing local anesthetics, adrenaline, and anti-inflammatory agents such as NSAIDS have been promising in terms of quick functional recovery. This study evaluates the efficiency of steroid as a component of MPCI in knee arthroplasty.Methods: This is a prospective, double-blind, RCT where 36 patients with osteoarthritis were included and randomized to receive MPCI either with steroid or without steroid. Pain was evaluated by visual analogue scale (VAS) at preoperative and postoperatively at rest, and during activity. The range of motion of the knee was looked for in a similar way. The amount of NSAIDs and the duration of NSAID usage were noted till the last follow-up.Results: Both non-steroid and steroid groups were similar with regard to VAS at rest and during activity, or range of motion, at all postoperative observations. The postoperative knee society knee score in the steroid group improved significantly as compared to that in non-steroid group at the one-month (84.1±13.1 and 65.9±12.1; pConclusions: The Study validates usage of steroid in MPCI due to faster rehabilitation and less consumption of NSAIDs and no additional risk of post-operative complications.

Background: The purpose of this study was to review the cases of isolated tuberculous osteomyelitis of calcaneum in terms of clinical features, radiological features, treatment and outcome.Methods: Medical records of 9 patients (7 males and 2 females) aged 4 to 45 years (mean 21.33 years) who presented with isolated calcaneal tuberculous osteomyelitis were reviewed. Clinical features, laboratory tests result, findings of imaging modalities, and histopathological examination were noted. The location of involvement of tuberculosis and treatment offered were noted. Multifocal tuberculosis and articular involvement were excluded.Results: All patients presented with pain and swelling around the heel; three of them presented with a discharging sinus. Patients had involvement of calcaneal body (n=5), tuberosity (n=2), and anterior process (n=2). The erythrocyte sedimentation rate of all patients was elevated. All the patients were treated conservatively with immobilization and chemotherapy.Conclusions: Isolated calcaneal tuberculosis is rare and the prognosis with non-operative treatment is good.

BACKGROUND: Indiscriminate use of intra-operative fluoroscopy can incur harm both to the patient as well as the surgeons. Orthopedic surgeons seldom do in skin marking prior to cleaning and draping of the operative site. This study aims to study the feasibility and utility of pre-operative skin marking with henna in conjunction with marker radiograph.METHODS: Out of 54 patients undergoing spine surgery, vertebral level localization was done by fluoroscopy in 26 patients. In the rest of the 28 patients, preoperative marker radiograph with steel wires was taken in conjunction with henna line markings on the skin. These were correlated for vertebral level localization. Difference in time taken for vertebral localization by these two methods, and the difference in the number of fluoroscopic images required was observed and recorded.RESULTS: Approximately 4 minutes were needed for level localization via fluoroscopic technique, whereas the henna marking technique did this in approximately 30 seconds. No adverse effects of henna application were observed during the study.CONCLUSIONS: The use of preoperative skin marking with henna along with the appropriate marker radiograph can reduce the surgical time and radiation exposure without increasing the chances of a wrong level surgery in the spine.

Background: Spontaneous epidural haematoma is a rare clinical presentation and may be associated with coagulation disorders. These hematomas present usually with rapidly developing paraparesis and any delay in diagnosis may be disastrous.Methods: We included five patients of spontaneous epidural hematomas in hemophilia A with neurological deficit. They were treated non-operatively with factor VIII replacement therapy with oral tranexamic acid and intravenous dexamethasone as per protocol. All patients were followed up for 6 months and assessed for signs of neurological recovery and radiological resolution of hematoma.Results: All patients had complete motor recovery within 3 months of initiating treatment and showed resolution of hematoma on MRI. Conclusions: Prognosis following early initiation of correction of factor deficiency is good.

Wilson's disease (WD) is a rare inherited disorder of copper metabolism. It chiefly has hepatic, neurological and ophthalmic manifestations. Although osteoporosis, rickets and early arthritis are common features of WD, they are under-recognized. Musculoskeletal manifestations very rarely lead to diagnosis of the disease. Here we present a case of a 12-year-old girl who presented with a 3-month-old pathological fracture of neck of femur. WD was diagnosed on investigating the cause of the pathological fracture, which was managed by performing a conventional McMurray's intertrochanteric osteotomy. At 6 months follow up, fracture had united and patient was able to ambulate with support. WD can be a rare cause of pathological fracture. A high index of suspicion must be maintained in patients of pathological fracture presenting with associated neuropsychiatric or hepatic manifestations.