Background:Posterior tibial slope (PTS) is an important factor affecting postoperative range of motion (ROM) following total knee arthroplasty (TKA). Metaphysio-diaphyseal angle (MDA) is a new entity defined as angle between proximal anatomical axis and metaphyseal axis of tibia. This study was undertaken to determine PTS in Indian patients and find its correlation with MDA of tibia. Accuracy of extramedullary jigs and the influence of MDA on the accuracy was also evaluated. This study is a retrospective analysis of prospectively collected data in a tertiary healthcare center.Materials and Methods:Data of 100 consecutive patients undergoing TKA in a single center by a single surgeon was analyzed. Posterior cruciate ligament (PCL) substituting TKA was done with same jig to achieve different PTS in different patients. MDA, preoperative PTS and postoperative PTS were calculated. The data was analyzed using appropriate statistical analysis.Results:Mean preoperative PTS was 11.64° and mean MDA was 23.76° with a strong correlation between them (Pearson's coefficient 0.72). Extramedullary jigs were accurate in 53% cases. In remaining 47%, postoperative PTS was less than planned PTS in 30%, and more in 17%. Mean postoperative PTS was 2.54°. In patients with MDA < 20°, postoperative PTS was significantly less (P = 0.0176) compared with those with MDA > 20°.Conclusions:The study establishes the positive correlation between MDA and PTS in Indians; and that MDA is an independent factor affecting accuracy of extramedullary jigs in TKA.
Background:Failed infected internal fixation produces significant pain and functional disability. In infected internal fixation of hip fractures with partial or complete head destruction, total hip arthroplasty (THA) can be technically challenging; however, it restores hip biomechanics. The present study is to evaluate the results and assess the complications of THA following failed infected internal fixation of these fractures.Materials and Methods:A retrospective review of prospectively collected data in a tertiary healthcare center was performed of 20 consecutive patients of THA following failed infected internal fixation operated between September 2001 and November 2007. There were 11 dynamic hip screw failures for intertrochanteric fractures, 6 failed osteotomies following transcervical fractures, and 3 failed screw fixations for transcervical fractures.Results:The average age of the patients was 48.5 years (range 28-70 years) and the average followup period was 6.5 years (range 3.5-10.5 years). An indigenously designed cement spacer was used in a majority of patients (n = 15). The custom-made antibiotic impregnated cement spacer was prepared on-table, with the help of a K-nail bent at 130°, long stem Austin Moore's prosthesis (n=1), Charnley's prosthesis (n=1), or bent Rush nail (n=1). The antibiotic mixed cement was coated over the hardware in its doughy phase and appropriately shaped using an asepto syringe or an indigenously prepared spacer template. Nineteen of the 20 patients underwent two-stage revision surgeries. The average Harris hip score improved from 35.3 preoperatively to 82.85 postoperatively at the last followup. A significant difference was found (P < 0.0001). None of the patients had recurrence of infection.Conclusions:The results were comparable to primary arthroplasty in femoral neck fractures. Thus, THA is a useful salvage procedure for failed infected internal fixation of hip fractures.
BackgroundWith the advent of MRI (Magnetic Resonance Imaging), Synovial lesions around knee are being more and more easily detected. Synovial lesions of knee present with boggy swelling, effusion, pain, and restriction of motion. Differential diagnoses of such lesions include pigmented villonodular synovitis, synovial lipoma, synovial chondromatosis, rheumatoid arthritis, synovial hemangioma, amyloid arthropathy, xanthomata and lipoma arborescens. CT and MRI often help in diagnosis of such lesions. MRI of Lipoma Arborescens has been regarded to have characteristic diagnostic appearance – it includes a synovial mass with frond-like architecture and fat signal intensity on all pulse sequences. Sometimes Lipoma Arborescens can present in conjunction with inflammatory arthritis. Synovectomy is often curative for such conditions.FindingsWe report two cases where lesions diagnosed as Lipoma Arborescens on MRI subsequently revealed to be chronic inflammatory synovitis, characterized by absence of fat infiltration in histopathological examination – refuting the original diagnosis. There was infiltration of lymphocytes and neutrophils in the synovium, suggestive of chronic inflammatory arthritis. Both of these patients required management from rheumatologist, and had relief of symptoms after use of methotrexate and hydroxychloroquine. We also report a third case, where a loose body appearing as chondral fragment on arthroscopy was subsequently diagnosed as an organized hematoma on histopathological examination.ConclusionDiagnostic pitfalls after MRI of the knee is not uncommon. For example - normal variant of meniscomeniscal ligaments have been reported as meniscal tears; motion artifacts have been falsely reported as meniscal injuries; and meniscofemoral ligament can appear as free osteochondral fragment. In most of these cases, a routine arthroscopy is enough to clear the confusion. However, as evident in the three cases described here - in some synovial lesions of knee joint, even after MRI and arthroscopic examination, histopathological confirmation may still be prudent. In spite of availability of advanced imaging technologies and high definition arthroscopy equipment, an arthroscopy surgeon still must not forget the value of histopathological examination in establishing the true nature of synovial lesions of the knee joint.
Heterotrophic ossification has been defined as abnormal formation of mature lamellar bone in soft tissues. Neurogenic heterotopic ossification has been well described in adults. However, it is uncommon in the pediatric population, where it has been noted to recede in some cases. There are very few reports of postmeningitis bilateral involvement of the hip. We describe a case of bilateral heterotopic ossification of hip in a 13-year-old female. The patient had a history of encephalitis, prolonged vegetative state, and intubation for 6 weeks. The patient had fixed deformities of both hips in 30° of flexion and 30° of external rotation. A diagnosis of Brooker stage 4 heterotopic ossification was made. The patient underwent a staged procedure for excision of the heterotopic mass. Postoperatively, the patient was administered radiotherapy and indomethacin for 6 weeks. At the 2-year follow-up, there was no recurrence and both the hips were mobile with full range of motion. The patient was satisfied with the result. The incidence of heterotopic ossification is less than that observed in the adult population and alkaline phosphatase levels are not significantly elevated unlike in adults. To our knowledge, there is no reported case of postencephalitic bilateral anterior heterotopic ossification of the hip in a pediatric patient treated with excision successfully. Postencephalitic heterotopic ossification in children is an uncommon condition. This condition can be treated successfully with surgical excision, combined postoperative protocol of radiotherapy, indomethacin, and immediate postoperative mobilization of the joint.
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