Background: Platelet-rich plasma (PRP) has emerged as the forerunner among disease-modifying treatment options for early osteoarthritis (OA) of the knee. However, no consensus is available regarding optimum dosing schedules. Purpose: To determine whether multiple injections of PRP (3 injections) provide better short-term and long-term results than a single injection of PRP in a guinea pig model of knee OA. Study Design: Controlled laboratory study. Methods: 36 Dunkin-Hartley guinea pigs (weighing ~600-800 g) were chosen for this study. The animals were assigned to group DC (disease control group), group G1 (single-PRP group), and group G2 (multiple-PRP group) containing 10, 10, and 12 animals, respectively. Another 4 animals were used for preparation of allogenic PRP. Groups G1 and G2 received 1 and 3 injections of PRP, respectively, at weekly intervals in the intervention knee while the contralateral knee was injected with normal saline. Group DC received no intervention in either knee. Half of the animals from each group (subgroups DC.3, G1.3, and G2.3) were sacrificed at 3 months, and the remaining half (subgroups DC.6, G1.6, and G2.6) were sacrificed at 6 months after intervention. Both knee joints were harvested for histological assessment of articular cartilage and synovium. Results: The mean synovial scores for groups G1 and G2 were significantly better than those for group DC at 3 months. No difference was found between groups G1 and G2 at 3 months. At 6 months, group G2 had significantly better mean synovial scores than group G1 and group DC. The mean articular cartilage scores in group G2 were significantly better than those in group DC at 3 months. However, at 6 months, no significant difference was found among any of the groups in terms of mean articular scores. Conclusion: Both single and multiple injections of PRP exert similar anti-inflammatory effects on the synovium in the short term. However, this effect is sustained in the long term only for multiple injections. Multiple injections of PRP exert a chondroprotective effect, but only in the short term. This effect is not seen with a single injection of PRP. Clinical Relevance: This study provides insight into the histological basis for the superiority of multiple injections of PRP.

Objectives: To investigate the pathway for disease modifying effect of the PRP in osteoarthritis of knee. Design: Two experimental models (group I and II) of Twelve Dunkin-Hartley guinea pigs each were enrolled as a part of a prospective controlled experimental study. One knee was enrolled for intervention and the other knee of the same animal used as control, the intervention being three intra-articular allogenic PRP injections given at a weekly interval. Equal volume of isotonic saline injection were given simultaneously in the control knees. Six animals from each model (subgroup IA, IIA) were euthanized at three months and the remaining six (subgroup IB, IIB) at six months post intervention. Samples of synovial fluid were collected from each knee joint for COMP level analysis by ELISA and bilateral knee joints were harvested for histopathological assessment of articular cartilage and synovium at the time of euthanasia. Results: Mean synovial fluid COMP concentration was significantly lower in PRP treated knees (p<0.05) at three months. On histological examination mean synovitis scores and synovial vascularity were significantly lower in PRP treated knees as compared to controls at both three and six months (p < 0.05). Additionally mean articular cartilage degeneration was significantly lower in PRP treated knees in group 1 only (p<0.05). Conclusion: Our preliminary data from the study has shown some evidence of positive influence of PRP in knee OA, possibly due to its anti-inflammatory effect and disease modifying effect, shown by short-term chondro-protective effect in PRP injected knees. Level of evidence: V.

Objectives: Both Zoledronic acid and denosumab have been utilized in neo-adjuvant setting for facilitating surgery and downsizing the lesion in Giant cell tumor (GCT). This study is aimed at comparing Zoledronic acid and Denosumab, when used in neo-adjuvant setting, in terms of radiological and clinical outcomes in GCT undergoing surgical intervention. Patients and Methods: Patients undergoing surgical intervention for GCT who received either denosumab or Zoledronic acid as neoadjuvant agents were retrospectively analyzed for reduction in tumor load radiologically, change in surgical plan after therapy, facilitation of surgery, therapy related complications, cost of treatment, rate of local recurrence and clinical outcomes. Results: Twenty patients received denosumab and 19 patients received Zoledronic acid as neoadjuvant agent. There was no significant difference in radiological outcomes, facilitation of surgery and clinical outcomes at end of follow-up. Zoledronic acid group had lower number of recurrences, however, not statistically significant. Therapy with Zoledronic acid was significantly cheaper (p = 0.001). Conclusion: Zoledronic acid is a cheaper alternative to denosumab in terms of solidification of lesion, reducing recurrence rates and improving clinical outcomes. Larger prospective studies required to further delineate this outcome with Zoledronic acid.

Introduction:To evaluate the incidence of anterolateral ligament (ALL) tear in acute knee injury and its association with anterior cruciate ligament tear (ACL). Methods: Forty patients with isolated early ACL tears were prospectively reviewed under 3T-MRI evaluation to identify ALL tears. This was correlated with trauma mechanisms and degree of knee instability. Patients less than 18, or more than 50 years of age, and those with posterolateral corner injury or LCL instability were excluded, which left 31 patients (30 males: 1 female; mean age: 28.6 years) for the final evaluation. Results: The ALL was visualized completely on the MRI in all 31 patients. ALL had mid substance tear in 19 knees (61.3%), proximal femoral attachment in eight knees (25.8%), at the tibial end in 6 knees (19.3%) and was seen torn at both proximal and distal ends in five knees (16.1%). Clinical correlation revealed higher number of giving way episodes, more functional loss of activities and higher grades of pivot shift test in cases with ALL tear along with ACL tear as compared with patients who had ACL deficiency without concomitant ALL tear (p value <0.05). Conclusion: The ALL can be identified in all cases with 3T-MRI. Tears are clearly seen and may be classified according to location. We found no correlation of ALL tears with injury mechanism; however ACL deficient knees with concomitant ALL tear on MRI had more functional impairment and instability. Level of evidence: II b.KEY WORDS: anterolateral ligament (ALL), knee injury, ACL deficient knee, 3T MRI, knee instability.

SummaryObjectives: To investigate the pathway for disease modifying effect of the PRP in osteoarthritis of knee. Design: Two experimental models (group I and II) of Twelve Dunkin-Hartley guinea pigs each were enrolled as a part of a prospective controlled experimental study. One knee was enrolled for intervention and the other knee of the same animal used as control, the intervention being three intra-articular allogenic PRP injections given at a weekly interval. Equal volume of isotonic saline injection were given simultaneously in the control knees. Six animals from each model (subgroup IA, IIA) were euthanized at three months and the remaining six (subgroup IB, IIB) at six months post intervention. Samples of synovial fluid were collected from each knee joint for COMP level analysis by ELISA and bilateral knee joints were harvested for histopathological assessment of articular cartilage and synovium at the time of euthanasia. Results: Mean synovial fluid COMP concentration was significantly lower in PRP treated knees (p<0.05) at three months. On histological examination mean synovitis scores and synovial vascularity were significantly lower in PRP treated knees as compared to controls at both three and six months (p < 0.05). Additionally mean articular cartilage degeneration was significantly lower in PRP treated knees in group 1 only (p<0.05). Conclusion: Our preliminary data from the study has shown some evidence of positive influence of PRP in knee OA, possibly due to its anti-inflammatory effect and disease modifying effect, shown by short-term chondro-protective effect in PRP injected knees. Level of evidence: V.

Background: It has been indicated in several instances that tall stature is also an important risk factor in the development of osteosarcoma. This relationship between height and osteosarcoma is substantiated even more by the increasing evidences being put forth in the recent literature on dependence of certain tumors on the growth factors and their receptors, acting through autocrine or paracrine mechanisms. There has been no study on the Indian population that attempts to define such a relationship. Purpose: The primary objective of this study was to define relationship between height of patients and osteosarcoma at the time of diagnosis in the Indian population. Materials/methods: Retrospective data was collected from the old hospital records. Height of patients at the time of diagnosis was compared with expected height of patients of the same age with reference to the standardized growth charts provided by the Indian Academy of Paediatrics. Results: Out of 98 patients, there were 65 male and 33 female patients with M: F ratio being 1.97:1. The mean age at diagnosis was 17 (SD ¼ 8) years with range of 5e55 years (median ¼ 17 years). Height of the patients at the time of diagnosis was 155.18 (SD ¼ 15.47) cm with range of 115 cme184 cm (median ¼ 159 cm). Overall, patients with Osteosarcoma were found to be shorter than the expected height deduced from the national growth charts. When patients were divided into two groups of those who were of growing age and those who had completed growth, results were similar. Conclusion:The observation that majority of patients with osteosarcoma in our study were stunted, is an important finding. It could be deduced from this observation that these patients are unable to mount the usual biological response to the overstimulated growth as part of tumorigenesis in osteosarcoma. This could point to a different scenario in the Indian population and more studies need to be carried out with larger number of patients to further elaborate on this observation.

Conjoined twins are a rare outcome of conception associated with numerous anomalies involving multiple organ systems. Musculoskeletal abnormalities like vertebral anomalies, sacral agenesis, foot deformities and hip dysplasia have been described in literature. We describe two cases of pyopagus twins with congenital talipes equinovarus and congenital vertical talus deformity which have not been described previously in this type of conjoined twins. The orthopaedist should look actively for such deformities in this patient population and be wary of the difficulties associated with their management.

Talonavicular dislocation is a rare injury. Isolated medial or lateral talonavicular dislocations without disruption of subtalar joint are known as medial or lateral swivel dislocations respectively, both being extremely rare. We describe a rare case of neglected medial swivel dislocation with concomitant calcaneus, cuboid and 5th metatarsal fracture, which was managed with open reduction and fixation of talonavicular joint with k-wires and an external distractor. At 1 year follow up the patient was mobilizing full weight bearing without any pain or deformity, the radiographs showing well located talonavicular joint and healed calcaneus, cuboid and 5th metatarsal fractures. This is the first reported case of medial swivel talonavicular dislocation with associated calcaneum, cuboid and 5th metatarsal fracture to the best of our knowledge. This case report highlights the importance of maintaining high level of suspicion for diagnosing midfoot injuries in a polytraumatized patient as well as need of accurate and timely reduction of dislocation for good functional outcome. Level of clinical evidence: Level 4.