Heralding change: The evolution of the IJO in 2019, Indian Journal of Orthopaedics 2019 53(6):679-681,Murali Poduval, Lalit Maini,

Chondromalacia patella among military recruits with anterior knee pain: Prevalence and association with patellofemoral malalignment Meltem Ozdemir, Rasime Pelin Kavak Indian Journal of Orthopaedics 2019 53(6):682-688 Background: The aim of this study was to investigate the frequency of chondromalacia patella (CMP) and to evaluate its relation with trochlear morphometric and patellofemoral alignment measurements as well as with edema in superolateral region of Hoffa's fat pad (SHFP) in military recruits with anterior knee pain (AKP). Materials and Methods: Knee magnetic resonance imaging examinations of 288 military recruits with AKP were retrospectively evaluated. Patellar cartilage lesions were graded using modified Noyes system. Quantitative measurements of trochlear morphology (sulcus angle, trochlear sulcus depth, and lateral trochlear inclination [LTI]) and patellofemoral alignment (patellar translation [PT], lateral patellofemoral angle (LPA), Insall-Salvati index, and tibial tuberosity-trochlear groove distance) were made. The SHFP region was assessed for the presence of edema. Mean values of measurements in knees with and without CMP and in knees with early and advanced stage CMP were compared. Results: We found CMP in 169 (58.7%) patients. Patients with CMP demonstrated a significantly greater sulcus angle (P = 0.012), smaller LTI (P = 0.004), greater PT (P = 0.01), smaller LPA (P = 0.036), greater Insall-Salvati ratio (P = 0.034), and higher incidence of SHFP edema (P = 0.001) compared to those without CMP. While none of the measurements were associated with the severity of cartilage damage, the incidence of SHFP edema was significantly correlated with the severity of CMP (P = 0.001). Conclusion: CMP is a common disorder among military recruits with AKP. Patellofemoral malalignment is an important contributory factor in the development of CMP, and the presence of edema in SHFP may be a strong indicator of underlying severe CMP in this population.

Monofilament cerclage wiring fixation with locking plates for distal femoral fracture: Is it appropriate? Sung Hyun Lee, Young Chae Choi, Suc Hyun Kweon Indian Journal of Orthopaedics 2019 53(6):689-694 Purpose: We aimed to determine the efficacy of cerclage wiring by comparing the clinical and radiological results between internal fixation with locking plates after distal femoral fracture reduction with or without cerclage wiring. Materials and Methods: One hundred and one patients who received open reduction internal fixation for distal femoral fractures of oblique, spiral, and spiral wedge type between 2007 and 2014 were reviewed retrospectively. Only locking plate fixation was performed in 46 patients, and locking plate fixation with additional cerclage wiring was performed in 55 patients (Group CW). Demographic, clinical, and radiologic factors were evaluated in both the groups. Age, gender, bone mineral density, bone graft, and the presence of concomitant fractures were measured as demographic factors. The range of motion of knee joint, Lysholm knee score, visual analog scale score, procedure time, and C-arm time were measured as clinical factors preoperatively and at the final followup. We also evaluated the duration of bone union and knee joint alignment radiologically. Results: There were no demographic differences between the two groups. Furthermore, there were no statistically significant differences between the two groups in terms of clinical and radiological parameters. However, the procedure time used was significantly longer in Group LP than in Group CW (108.4 vs. 95.2 min; P= 0.027). The C-arm time was longer in Group LP (2.8 vs. 1.2 s; P= 0.017). Conclusions: Open reduction and locking plate fixation with additional cerclage wiring is a useful method for the reduction of complicated distal femoral fractures, without increased complications such as nonunion. Level of Evidence: Level III, retrospective cohort design, treatment study.

Cement pedestal spacer technique for infected two-stage revision knee arthroplasty: Description and comparison of complications Ahsan Akhtar, Chris Mitchell, Catarina Assis, Farhad Iranpour, Anna Kropelnicki, Robin Strachan Indian Journal of Orthopaedics 2019 53(6):695-699 Background: Infection following total knee arthroplasty (TKA) is a significant complication, with an incidence of up to 2% in primary TKA and 4%–8% in revision cases. Two-stage revision is the gold standard treatment for long-lasting infections of TKA. The purpose of this study was to describe the cement pedestal spacer technique used in infected two-stage revision knee arthroplasty and compare complications against conventional fixed and mobile cement spacers. Patients and Methods: A retrospective review was conducted in all cases who underwent two-stage TKA revision for infection between 2009 and 2015. These cases were separated into groups depending on the cement spacer utilized (fixed, mobile nonpedestal, and mobile spacers with cement pedestal). The cement pedestal technique involves press fitting a cement cylinder into the femur before definitive spacer insertion. Results: Forty four patients underwent two-stage revision TKA. Fewest complications were observed in the pedestal group, with no spacers having subluxed/tilted. The longest followup was also observed in the pedestal group (mean 52.5 months). Mobile spacers with no cement pedestal displayed the highest reinfection rate (16.7%) and the greatest number of cases with complications (malalignment, subluxation, tilting, and spacer fracture). All patients in the pedestal group were ambulatory after the first-stage revision. Conclusions: The cement pedestal technique minimizes complications by optimizing component positioning and balancing. It also safely extends the indication for an articulated spacer into a set of cases with more extensive bone loss and allows for extended monitoring of inflammatory markers.

Improved pain and function in knee osteoarthritis with dexamethasone phonophoresis: A randomized controlled trial Mohamed Ahmed Said Ahmed, Emad Samuel Boles Saweeres, Nasr Awad Abdelkader, Salwa Fadl Abdelmajeed, Ahmed Roshdy Fares Indian Journal of Orthopaedics 2019 53(6):700-707 Background: Intraarticular corticosteroid injection is an adjunct to core treatments for relief of moderate-to-severe pain in osteoarthritis (OA) patients. This randomized controlled trial was conducted to determine the effect of dexamethasone phonophoresis (DxPh) on knee OA. Patients and Methods: Forty six female patients with knee OA were randomized into two equal groups. The study group received DxPh over the medial side of the knee, transcutaneous electrical nerve stimulation (TENS), and quadriceps strengthening exercises. Control group received ultrasound therapy and the same TENS and exercise program. Pain was assessed using the visual analog scale (VAS) and the pain subscale of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pre- and posttreatment. Functional mobility was assessed by the Timed Up and Go (TUG) test, total WOMAC, and the joint stiffness and physical function subscales of WOMAC. The minimal clinically identifiable difference was used to calculate treatment effect sizes of both modalities, which was compared to intraarticular steroid injections. Results: The VAS, TUG, and WOMAC scores improved with both modalities. Pain intensity improved by 50.6%–58.0% in the study group (VAS and pain subscale of WOMAC, respectively) compared to 17.8%–28.6% for the control group. Functional mobility showed a higher rate of improvement in the DxPh group compared to control (37.7 vs. 17.5% for TUG and 53.2 vs. 23.0 and 56.1 vs. 26.4% for the joint stiffness and physical function subscales of WOMAC, respectively). Posttreatment results revealed statistically and clinically significant improvement in pain intensity and functional mobility in the DxPh group. Conclusion: DxPh resulted in a greater improvement in pain and function in patients with knee OA than therapeutic ultrasound combined with exercise and TENS. The effect size of phonophoresis was clinically significant and higher than that reported for intraarticular steroid injection from pooled data in the literature.

Effectiveness and safety of the combined use of tranexamic acid: A comparative observational study of 1909 cases Charles-Herve Vacheron, Pascal Roy, Pierre Yves Petit, James Appery, Michel Fessy, Vincent Piriou, Anthony Viste, Arnaud Friggeri Indian Journal of Orthopaedics 2019 53(6):708-713 Background: Tranexamic acid (TA) use in lower-limb arthroplasty has been valued in these surgeries high-risk hemorrhagic due to its antifibrinolytic action. The objective of the present study was to determine the effectiveness of the combined intravenous (IV) and intraarticular (IA) administration of TA in lower-limb arthroplasty. Methods: We conduct a prospective observational study between January 1, 2014, and December 31, 2017, including all programmed lower-limb arthroplasties. Patients were divided into four groups: no TA, 15 mg/kg IV TA, 3 g IA TA, and 15 mg/kg IV and 3 g IA. The effect on calculated total blood loss (milliliter of red blood cell [RBC]), hemoglobin, transfusion, and duration of hospitalization was studied after adjustment on age, American Society of Anesthesiologists, surgery, and postoperative curative anticoagulation. Complications related to TA administration were systematically reported. Results: A total of 1909 patients were included – “no TA,” n = 184; “IV,” n = 1137; “IA,” n = 214; and “IV + IA,” n = 374. In the IV + IA group, a decrease in blood loss was observed compared to the no TA group (+220 ml 95% confidence interval [CI] [184; 255] of RBCP < 0.001) and in the IA group (+65 ml 95% CI [30; 99] of RBCP < 0.001). The length of hospital stay of the IV + IA group was shorter compared to the no TA group (hazard ratio [HR] 0.35, 95% CI [0.29; 0.43],P < 0.001) to the IA group (HR 0.57, 95% CI [0.48; 0.69],P < 0.001) and the IV group (HR 0.45, 95% CI [0.39; 0.50],P < 0.001). One case of deep vein thrombosis occurred in the group without TA. Conclusion: Administration of combined TA appears effective and safe; further studies are needed in order to establish a consensual protocol.

Failure to return to preinjury activity level after hamstring anterior cruciate ligament reconstruction: Factors involved and considerations in goal setting Jonathan D Kosy, Jonathan RP Phillips, Adaeze Edordu, Rahul Pankhania, Peter J Schranz, Vipul Mandalia Indian Journal of Orthopaedics 2019 53(6):714-720 Background: Recent interest in the return to sports, following anterior cruciate ligament reconstruction, has focused on the influence of psychological factors. However, many factors contribute to this endpoint. This study aimed to investigate the ability of nonprofessional athletes to return alongside the reasons for failure. Materials and Methods: We retrospectively studied 101 postreconstruction patients with followup in excess of 12 months. All patients underwent hamstring autograft anterior cruciate reconstruction. The Cincinnati Sports Activity Scale was used to define activity level preinjury, postinjury, and postreconstruction. Structured questionnaires were used to identify factors in those who did not return to the same level. Results: Seventy percent of patients returned to their preinjury activity score. Of the 30% of patients who failed, age, reconstruction type, and associated pathology were unrelated. However, reconstruction within 6 months of injury resulted in increased return to preinjury score (P < 0.05). Failure was associated with continued knee symptoms (57%), lifestyle changes (27%), anxiety (27%), fear (23%), and other musculoskeletal problems (10%). Considerable interplay was found between these factors. Failure to return was associated with increased further surgery, but this was successful in only one-third of patients. Conclusion: Psychological factors are important (and may require targeted input), but return-to-sport is multifactorial. Ongoing symptoms may prompt further surgery, but this is frequently unsuccessful in achieving return. Patient-specific goals should be sought and revisited throughout the rehabilitation program. Acknowledging psychological barriers, in those aiming to return to the same level, may help achieve this goal. In other patients, success may be return to a desired lower level. Understanding the patient's expectations is important in goal setting.

No difference in outcome of anterior cruciate ligament reconstruction with “bone–patellar tendon-bone versus semitendinosus-gracilis graft with preserved insertion:” A randomized clinical trial Ravi Gupta, Anil Kapoor, Ashwani Soni, Sourabh Khatri, Gladson David Masih, Mukta Raghav Indian Journal of Orthopaedics 2019 53(6):721-726 Background: The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction. Purpose: This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone–patellar tendon-bone (BPTB) graft. Materials and Methods: One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score. Results: Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain. Conclusion: There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Measurement of the whole and midsubstance femoral insertion of the anterior cruciate ligament: The comparison with the elliptically calculated femoral anterior cruciate ligament footprint area Genki Iwama, Takanori Iriuchishima, Takashi Horaguchi, Shin Aizawa Indian Journal of Orthopaedics 2019 53(6):727-731 Purpose: The purpose of this study was to measure the detailed morphology of the femoral anterior cruciate ligament (ACL) footprint. The correlation and the comparison between the measured area and the area which mathematically calculated as elliptical were also evaluated. Materials and Methods: Thirty nine nonpaired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. The ACL was carefully dissected, and the periphery of the ACL insertion site was outlined on both the whole footprint and the midsubstance insertion. Lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The area, length, and width of the femoral ACL footprint were measured with Image J software (National Institution of Health). Using the length and width of the femoral ACL footprint, the elliptical area was calculated as 0.25 π (length × width). Statistical analysis was performed to reveal the correlation and the comparison of the measured and elliptically calculated area. Results: The sizes of the whole and midsubstance femoral ACL footprints were 127.6 ± 41.7 mm[2] and 61 ± 20.2 mm[2], respectively. The sizes of the elliptically calculated whole and midsubstance femoral ACL footprints were 113.9 ± 4.5 mm[2] and 58.4 ± 3 mm[2], respectively. Significant difference was observed between the measured and the elliptically calculated area. In the midsubstance insertion, significant correlation was observed between the measured and the elliptically calculated area (Pearson's correlation coefficient = 0.603, P= 0.001). However, no correlation was observed in the whole ACL insertion area. Conclusion: The morphology of the femoral ACL insertion resembles an elliptical shape. However, due to the wide variation in morphology, the femoral ACL insertion cannot be considered mathematically elliptical.

Arthroscopic excision of angio-fibro-lipomatous hamartoma of the knee: A rare case report Silvampatti R Sundararajan, Ramakanth Rajagopalakrishnan, Shanmuganathan Rajasekaran Indian Journal of Orthopaedics 2019 53(6):732-735 Angio-fibro-lipomatous hamartoma is a benign adipose tissue tumor very rarely seen in musculoskeletal distribution, and its incidence in the knee joint has never been reported. The patient in our case presented with knee pain of 2 years' duration, following blunt trauma. Preoperatively, veno-lymphatic malformation/hemangioma was considered as the diagnosis. Only after arthroscopic excision biopsy, histopathological examination, retrospective radiological analysis, and a review of literature, we were able to diagnose this rare condition. The histopathological picture of this benign adipose tissue tumor contained a mixture of mature adipose tissue and fibrous and vascular tissues. Here, in this case report, we discuss about PTEN gene causing PTEN hamartoma of soft tissue and angiolipoma presentations and its variants.