Arthroscopic findings after manipulation under anesthesia in idiopathic capsulitis of the shoulder: A prospective study

BACKGROUND

Manipulation under anesthesia (MUA) of the shoulder joint is a commonly used method for the treatment of adhesive capsulitis. Though it has been known to be associated with a variety of complications, there is a paucity of studies describing the arthroscopic findings after MUA.

AIM

To describe the arthroscopic findings in patients with idiopathic adhesive capsulitis of the shoulder after MUA.

METHODS

We recruited 28 patients with idiopathic adhesive capsulitis who underwent arthroscopic capsular release. Manipulation of the shoulder was performed under anesthesia in all of these patients before capsular release. Intra-articular findings were recorded during arthroscopic capsular release in these patients.

RESULTS

All patients showed the presence of synovitis. Twenty-seven patients showed tears in the capsule on the anterior aspect. One patient had an avulsion of the anterior rim of the glenoid and labrum following the manipulation. Four patients had partial rotator cuff tears, and one patient showed a superior labrum anterior posterior lesion, which was not diagnosed preoperatively on magnetic resonance imaging.

CONCLUSION

MUA leads to rupture of the capsule, which is the desired outcome. However, the site of rupture of the capsule is dependent on the maneuvers of MUA. In addition, partial tears of the rotator cuff and osteochondral fractures of the glenoid can also occur.

Posterior Cruciate Ligament Avulsion with Posterior Tibial Rim Fracture: A Case Report

Introduction

Posterior cruciate ligament (PCL) avulsion fractures are the most common type of isolated PCL injuries. Avulsion from the tibia is more common than femoral attachment. They can present as isolated tibial avulsion or as a component of posterior tibial rim fractures. The size, geometry of the fragment, and associated ligamentous injury dictate the method of fixation.

Case Report

A 32-year-old patient presented with posterior rim tibial plateau fracture with PCL avulsion after a motor vehicle accident. We used Burke and Schaffer approach and fixed the ligamentous avulsion and rim fracture using high tensile sutures and knotless swivel lock anchors.

Conclusion

PCL avulsions can present either as an isolated injury or as a part of a complex injury involving the anterior or posterior tibial rim. These complex injuries occur due to the hyperextension mechanism which results in either anterior tibial plateau compression fracture or posterior rim avulsion injuries. The treatment of such injuries requires addressing both ligamentous and bony components. The size, geometry of the fragment, and associated ligamentous injury dictate the method of fixation. We described the fixation of both ligamentous and rim avulsion using sutures and knotless anchors.

Anterior Root Tear of the Meniscus: A Report of Two Cases

Menisci are crescent-shaped fibrocartilagenous structures that increase the tibiofemoral congruity, act as shock absorbers, and provide secondary anteroposterior stability. The root tears affect the biomechanical integrity of the whole meniscus, simulating a total meniscectomy, which can lead to early degeneration of the joint. Most of the root tears affect the posterior part rather than the anterior root. Very few reports have been described in the literature regarding anterior root tears and repairs. We present two such patients with anterior meniscal root tears, one of the lateral meniscus and one of the medial meniscus.

Demographic characteristics of patients who underwent anterior cruciate ligament reconstruction at a tertiary care hospital in India

BACKGROUND

Anterior cruciate ligament (ACL) tears are common sports-related injuries. Their incidence is not the same either for all the sports or for the same sport across various nations. This information is maintained by many sports leagues in their registries. However, very few nationwide registries exist for such injuries. This study is carried out to know the demographic characteristics of patients who underwent ACL reconstruction at our hospital in India.

AIM

To know the demographic characteristics of patients who underwent ACL reconstruction at a tertiary care hospital in India.

METHODS

All the patients who underwent ACL reconstruction from January 2020 to December 2021 were retrospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. The patients’ history was obtained from the hospital records, they were interviewed telephonically, and online questionnaires were given. Their demographic data was analyzed and compared to the existing literature.

RESULTS

A total of 124 patients were operated on for ACL reconstruction during this period. The mean age of the patients was 27.97 years. One hundred and thirteen patients (91.1%) were male and 11 (8.9%) were female. The majority of the patients (47.6%) sustained this injury by road traffic accidents (RTA) followed by sports-related injuries (39.5%). The commonest presenting complaint was giving way of the knee in 118 patients (95.2%). The mean duration from the injury to the first hospital visit among the patients was 290.1 d. The mean duration from the injury to surgery was 421.8 d.

CONCLUSION

ACL patients’ demography is different in developing nations as compared to the developed world. RTA are the leading cause of ACL injuries and are followed by recreational sports as a cause. There is delayed access to healthcare leading to delayed diagnosis as well as even greater time to surgery. This, in turn, leads to poorer prognosis and longer rehabilitation. National registries for developing nations are the need of the hour due to the different demographics of ACL injuries in developing countries.

Bone Grafting of the Bone Defects after Harvesting the Bone Patellar Tendon Bone Graft - A Novel Surgical Technique

Introduction

The anterior knee pain is the most common post-operative complaint associated with anterior cruciate ligament reconstruction (ACLR) using bone patellar tendon bone graft. It has been attributed to various factors such as loss of terminal extension, infrapatellar branch neuroma, and also due to the bone harvest site defect itself. Bone grafting of the defects in the patella and tibia has been shown to decrease anterior knee pain. At the same time, it also prevents post-operative stress fractures.

Surgical Technique

Numerous bone pieces were produced in the knee joint as a result of the drilling during ACL reconstruction. Using a wash cannula and tissue grasper, all the bone fragments were gathered into a kidney tray. The bony fragments with the saline which were collected in the metal container were allowed to sediment at the bottom. The bone that was sedimented in the metal container was collected by decantation and placed into the bony defects of the patellar and tibial sides.

Conclusion

Bone grafting of the defects in the patella and tibia has been shown to decrease anterior knee pain. Our technique is cost-effective as there is no requirement for special instrumentation like coring reamers, and no requirement for allograft or bone substitutes. Second, there is no morbidity associated with autografts harvested from elsewhere, we used the bone generated during the ACLR itself.

Transfibular ankle arthrodesis with use of sagitally split fibula as a biological plate leads to excellent outcome: A retrospective analysis

Background

We studied ankle arthrodesis with a transfibular approach using sagitally spilitted fibula as a biological plate (onlay grafting) as well as other half of fibula as morcellised local interpositional graft (inlay grafting) to achieve bony union.

Material and methods

Retrospective clinico-radiological evaluation of 36 operated cases was done at 3, 6, 12 and 30 months follow-ups. Clinically union was considered once ankle became pain free on full weight bearing. Pain assessment was done by using VAS (visual analogue scale) score and functional evaluation was done by AOFAS (American Orthopaedic Foot & Ankle Society) hind foot score preoperatively and at different follow ups. Radiologically, sagittal plane ankle alignment and fusion status was determined at each follow up.

Results

Mean age of patients was 40.36 ± 10.56 years (range 18-55), who were evaluated for mean duration of 33.32 ± 11.25 months (range 24-65). Thirty-three (91.7%) ankles were fused adequately and mean duration to achieve bony union was 5.09 ± 1.3 months (range 4-9 months). Mean post-operative AOFAS score at final follow up was 76.65 ± 4.87 in comparison to 45.76 ± 3.38, preoperatively. VAS score improved significantly from 7.8 (pre-operative) to 2.3 (final follow-up). Non-union in three patients (8.3%) and ankle malalignment in one patient was observed.

Conclusion

Transfibular ankle arthrodesis achieves excellent bony unions and functional outcomes in severe ankle arthritis. Biologically incompetent fibula that to be judged individually by the operating surgeon to use it as a graft. Patients having inflammatory arthritis have more dissatisfaction than other aetiologies.

Ossified Superficial Infrapatellar Bursa: A Case Report

Bursitis, though treatable conservatively, very rarely can have ossification and calcification in its substance which requires surgical intervention. The patient should be investigated for any coexisting metabolic bone disorders before proceeding with surgical intervention. The excision biopsy of such a specimen has to be examined histopathologically to rule out any neoplastic etiology. We present an adult male with a painful lump over the tibial tuberosity and its management.

The Role of Conservative Management in the Avascular Necrosis of the Femoral Head: A Review of Systematic Reviews

Introduction/Background

Multiple medical and surgical treatments have been described in the early stages of Avascular Necrosis (AVN) of the femoral head which delay the disease progression. Similarly, multiple studies, trials, reviews, and systematic reviews exist for the various treatments described and their outcomes but with no consensus over which is superior. So in this study, we reviewed the systematic reviews of all the conservative therapies for AVN of the femoral head systematically to identify a single or a combination of non-surgical treatment choices in the initial stages of the disease.

Methodology

A thorough literature search has been carried out in January 2022 through the use of Pubmed, EMBASE, and Cochrane electronic databases using PRISMA guidelines. The Mesh words and Keywords used were "femoral head AVN", "Conservative management", and "Systematic Reviews". The inclusion criteria used during the screening were, any systematic reviews which included patients with AVN either idiopathic or secondary, who are managed with conservative therapies like bisphosphonates, Hyper Baric Oxygen Therapy (HBOT), Shock wave therapies like Extracorporeal Shock Wave Therapy (ESWT), or electrical therapy like Pulsed Electro Magnetic Field (PEMF). The quality of the included systematic reviews was assessed using AMSTAR-2 criteria.

Results

The initial search yielded 364 studies which on screening based on our inclusion criteria finally resulted in seven systematic reviews to be included in the present study. There were two systematic reviews for Hyper Baric Oxygen Therapy (HBOT), two for Extracorporeal Shock Wave Therapy (ESWT), one for electrical stimulation modalities like Pulsed Electro Magnetic Field (PEMF), and two for bisphosphonates. The follow-up of the patients in the included systematic reviews varied from 6 weeks to 10 years. The total number of patients varied from 77 to over 1000 across the systematic reviews. Almost all of the studies included a control group that either received the intended treatment with adjuncts or did not receive any treatment at all. Because of the heterogeneous nature of included articles in the systematic reviews, meta-analysis was performed in only three of the included systematic reviews.

Conclusion

Of all the modalities of treatment described, bisphosphonates are easily available and cost-effective and do not require any hospital resources/machinery for delivering the treatment. So they can be used as an initial line of treatment for patients with early stages of AVN (Ficat and Arlet 1-3) and based on the hospital availability of resources could be supplemented with any of the biophysical modalities (ESWT/PEMF/HBOT) for maximum efficacy to delay the disease progression.

Level of Clinical Evidence

Systematic review.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00818-5.

Suprapatellar Fat Pad Impingement due to Vascular Lesion: A Case Report

CASE

We present a fifteen-year-old adolescent boy with anterior knee pain and a palpable tender swelling in the suprapatellar region with painful terminal extension. Imaging was suggestive of a vascular lesion in the suprapatellar fat pad. He underwent arthroscopic debridement and postoperatively regained his terminal extension.

CONCLUSION

Suprapatellar fat pad impingement can rarely be due to vascular lesions or lipomatous tumors affecting the suprapatellar fat pad. If conservative treatment is unsuccessful, surgery can provide good pain relief. The tissue excised should always be sent for histopathological examination.

Posterior Cruciate Ligament Avulsion with Posterior Tibial Rim Fracture: A Case Report

Introduction: Posterior cruciate ligament (PCL) avulsion fractures are the most common type of isolated PCL injuries. Avulsion from the tibia is more common than femoral attachment. They can present as isolated tibial avulsion or as a component of posterior tibial rim fractures. The size, geometry of the fragment, and associated ligamentous injury dictate the method of fixation. Case Report: A 32-year-old patient presented with posterior rim tibial plateau fracture with PCL avulsion after a motor vehicle accident. We used Burke and Schaffer approach and fixed the ligamentous avulsion and rim fracture using high tensile sutures and knotless swivel lock anchors. Conclusion: PCL avulsions can present either as an isolated injury or as a part of a complex injury involving the anterior or posterior tibial rim. These complex injuries occur due to the hyperextension mechanism which results in either anterior tibial plateau compression fracture or posterior rim avulsion injuries. The treatment of such injuries requires addressing both ligamentous and bony components. The size, geometry of the fragment, and associated ligamentous injury dictate the method of fixation. We described the fixation of both ligamentous and rim avulsion using sutures and knotless anchors. Keywords: Posterior cruciate ligament avulsion, tibial rim fractures, sutures, anchors.

Fungal Infection Post Arthroscopic Meniscal Repair: A Rare Complication

Infections after arthroscopic procedures are rare. Infection due to fungal organisms is rarer and difficult to diagnose due to its insidious nature and chronic presentation but when neglected has devastating consequences. We present a 23-year-old immunocompetent adult post-arthroscopic meniscal repair with fungal surgical site infection. The patient underwent open debridement and was started on antifungals. His surgical wound healed and with physiotherapy he regained his full range of movement.

Modified Masquelet technique in children

Masquelet technique is one of the modalities for the treatment of long bone defect. Using cancellous bone graft to fill the bone defect is always a concern in children due to the small size of their iliac crest and open growth plate. We reported a case of 13-year-old male who presented with gap non-union of middle third of tibia. We applied a modified Masquelet technique by using only the cortical fibular graft instead of cancellous bone to fill the space surrounded by induced membrane. Fibula was used as a nonvascularized strut graft and matched stick graft to achieve complete union. We concluded that nonvascularized fibula grafting is an easy and effective option to fill the bone defect in children in the second stage of Masquelet technique.

Bilateral Nonunion of Femoral Neck Fractures Because of Nutritional Osteomalacia: A Report of 2 Cases

CASE

We report 2 cases of atraumatic, bilateral femoral neck fracture nonunions. Both the patients were relatively young and had underlying nutritional osteomalacia. In both cases, valgus intertrochanteric osteotomy was performed along with vitamin D and calcium supplementation. The patients were followed up for an average of 3 years and achieved bone union without any complications.

CONCLUSION

Bilateral femoral neck fractures are rare, and bilateral nonunion of femoral neck fractures secondary to osteomalacia is even rarer. Valgus intertrochanteric osteotomy can salvage the hip. Correction of underlying osteomalacia by vitamin D and calcium supplementation preceeded surgical intervention in our cases.

Ramp Lesions in Chronic Anterior Cruciate Ligament Injuries

Background: Meniscus ramp lesions associated with anterior cruciate ligament (ACL) injuries are being increasingly reported in the literature. This study was carried out to know the incidence of ramp lesions in ACL injured patients and to study the characteristics of these patients in our population.

Methods: Seventy-five patients who underwent ACL reconstruction from January 2021 to December 2021 were prospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. All patients were examined clinically and all underwent MRI examinations. The findings of arthroscopy during ACL reconstruction were recorded and analyzed.

Result: Seventeen patients had ramp lesions with an incidence of 22.67%. Eight were isolated ramp lesions, and nine had other meniscus injuries. Ramp lesions were identified with 41.18% sensitivity using preoperative MRI. Thirteen out of 17 patients with ramp lesions had increased mobility of the posterior horn of the medial meniscus on anterior probing. The duration from injury to surgery was significantly longer in patients with ramp lesions as compared to patients without ramp lesions.

Conclusion: A ramp lesion is not an uncommon lesion in ACL injuries and can occur either as an isolated meniscus lesion or in association with other meniscus lesions.Ramp lesions can occur in road traffic accidents as well and are not just sports-related injuries. Ramp lesions are not visible through routine anterior portal diagnostic arthroscopy and their repair adds to the stability of the knee. The absence of ramp lesions on MRI does not rule out their presence; hence, one should always look for ramp lesions in the posteromedial compartment of the knee in all cases undergoing ACL reconstruction.

Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability

The oral route is the most common choice for drug administration because of several advantages, such as convenience, low cost, and high patient compliance, and the demand and investment in research and development for oral drugs continue to grow. The rate of dissolution and gastric emptying of the dissolved active pharmaceutical ingredient (API) into the duodenum is modulated by gastric motility, physical properties of the pill, and the contents of the stomach, but current in vitro procedures for assessing dissolution of oral drugs are limited in their ability to recapitulate this process. This is particularly relevant for disease conditions, such as gastroparesis, that alter the anatomy and/or physiology of the stomach. In silico models of gastric biomechanics offer the potential for overcoming these limitations of existing methods. In the current study, we employ a biomimetic in silico simulator based on the realistic anatomy and morphology of the stomach (referred to as "StomachSim") to investigate and quantify the effect of body posture and stomach motility on drug bioavailability. The simulations show that changes in posture can potentially have a significant (up to 83%) effect on the emptying rate of the API into the duodenum. Similarly, a reduction in antral contractility associated with gastroparesis can also be found to significantly reduce the dissolution of the pill as well as emptying of the API into the duodenum. The simulations show that for an equivalent motility index, the reduction in gastric emptying due to neuropathic gastroparesis is larger by a factor of about five compared to myopathic gastroparesis.

Chronic posterior dislocation of shoulder

PURPOSE

Chronic posterior dislocation of shoulder (PDS) is an uncommon injury and there are very few publications describing its different injury patterns and their treatment. This study was carried out to study the associated injuries in chronic PDS, which can help to classify and guide the treatment.

METHODS

We retrospectively studied 16 chronic posterior dislocation of shoulder. CT scan was used to classify the injury based on the amount of bone loss in humeral head, malunion of greater tuberosity and malunion of proximal humerus metaphysis. Visual analogue score (VAS) for pain, university of California Los Angles (UCLA) shoulder score and American shoulder and elbow surgeon (ASES) shoulder score were recorded pre operatively and at an average of 27 months post operatively.

RESULTS

- Type A1 injury was PDS with <50% humeral head bone loss with intact greater tuberosity (GT). It was managed by modified McLaughlin procedure (MMP). Type A2 injury was PDS with >50% bone loss with intact GT. It was managed by hemi-replacement (HRA). Type B1 injury was PDS with <50% bone loss with severe GT malunion. It was managed by MMP and corrective osteotomy of GT. Type B2 injury was PDS with >50% bone loss and severe GT malunion. It was managed by reverse shoulder arthroplasty (RSA). Type C1 injury was PDS with <50% bone loss and metaphyseal malunion. It was managed by MMP and osteotomy of proximal humeral metaphysis. Type C2 injury was PDS with >50% bone loss and metaphyseal malunion. It was managed by HRA. The VAS, UCLA score and ASES score improved significantly after the surgery in all cases. There was no recurrence of the instability.

CONCLUSIONS

We concluded that chronic PDS could have fractures of tuberosities and/or proximal metaphysis in addition to bone loss in humeral head. The treatment is guided by all three factors-amount of bone loss in humeral head, malunion of GT and proximal humeral metaphysis. The proposed classification can help in choosing the optimum treatment out of joint salvage procedure, anatomic shoulder replacement and reverse shoulder arthroplasty.

Chronic Osteochondral Fractures of the Patella Managed with Open Reduction and Internal Fixation Yields Excellent Knee Function

Currently, the management of acute osteochondral fractures (OCFs) of the patella is well established. However, the management of chronic OCFs remains debatable, as it is not clear whether such lesions can be accurately reduced or whether they will reliably heal. With well proven results of open reduction and internal fixation (ORIF) with headless compression screws (HCS) for acute OCFs, the application of this technique in late presenting cases is inconclusive. Thus, we present the clinicoradiological outcome of patients with chronic osteochondral injuries managed with ORIF. Fifteen patients who underwent surgical fixation by ORIF with HCS for chronic OCFs of the patella, between February 2013 and June 2018, were retrospectively analyzed after a mean follow-up of 3.8 years (range: 2-7 years). The mode of injury, size of the osteochondral fragment, and knee range of motion along with Kujala's scoring were examined clinically and radiological assessment was done by X-rays and magnetic resonance imaging (MRI) scans. Fifteen patients (11 males and 4 females), with a mean age of 17 years with chronic OCF of patella were enrolled. Noncontact twisting injuries were the most common mode of injury seen in 86.66% of patients and postcontact injuries in two patients (13.33%). The mean time from trauma to presentation was 7 weeks (range: 6-14 weeks). The mean preoperative Kujala's score improved from 44 to 84.8 at 6 months and 92.6 at 2 years, postoperatively. Intraoperatively, the lesion was found in medial patellar facet in 12 patients and 3 had lesions in the central facet. The mean size of the lesion was 20 mm × 18 mm. Radiological union was observed in all patients, at a mean duration of 16 weeks (range: 12-20 weeks). One patient underwent implant removal 1 year after initial surgery for mechanical symptoms. ORIF of OCFs of the patella using headless cannulated screws is simple, reliable, reproducible, and provides satisfactory outcomes. This technique can be considered for fixation of fragments with adequate subchondral bone.

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

Subintermeniscal Ligament Pullout Suture Technique for Anterior Cruciate Ligament Avulsion Fracture Fixation-AIIMS Technique

Many methods have been described, including pullout suture technique, for arthroscopic fixation of displaced tibial eminence fracture. We are describing our technique of pullout suture, which is a modification of previously described techniques. We passed two sutures arthroscopically through anterior cruciate ligament (ACL) just above the avulsed fragment and then pulled them out through medial and lateral bone tunnel in anterior aspect of crater in tibial plateau. The third suture passed through ACL was pulled out anteriorly under the transverse intermeniscal ligament through a submeniscal route. All sutures were tied under tension to a screw post placed on the anterior tibia after reducing the avulsed bone fragment. Our technique provides good reduction and even overreduction of the fragment. It also provides good initial fixation strength to work against displacing forces even in small and comminuted bony fragment. This is helpful for achieving adequate stability of knee, complete extension of knee, early rehabilitation, and quicker recovery.

Role of 18F-FDG PET/CT in the Assessment of Response to Antitubercular Chemotherapy and Identification of Treatment Endpoint in Patients With Tuberculosis of the Joints: A Pilot Study

AIMS

The aim of this study was to explore the utility of 18F-FDG PET/CT in the assessment of response to antitubercular treatment (ATT) and identification of treatment endpoint.

PATIENTS AND METHODS

Forty patients (mean age, 35.3 years; 27 men) with clinically, radiologically, and histopathologically proven joint tuberculosis prospectively underwent clinical, biochemical, and PET/CT evaluation at baseline and after ~6, 12, and 18 months of ATT. Two patients were lost to follow-up, and 1 defaulted treatment. The remaining 37 were followed up until complete response (CR) was achieved. Images were visually and quantitatively (SUVmax ratio and metabolically active disease volume [MV]) evaluated by 2 experienced nuclear medicine physicians.

RESULTS

Knee (n = 18) and ankle (n = 7) were the most frequently involved sites. The median MV and SUVmax ratio at baseline were 85.10 mL and 7.21, respectively. Five patients had noncontiguous vertebral involvement, 12 had pulmonary lesions, 2 had abscesses, 6 had mediastinal, and 30 had local lymph nodal involvement. Complete response was seen in 1/39, 11/37, and 30/37 patients after 6, 12, and 18 months of ATT. Significant reductions in visual analog scale score, tenderness, joint swelling, SUVmax ratios, and MVs (Friedman test, P < 0.001) were seen after each follow-up. The median time-to-CR in skeletal lesions was significantly longer than extraskeletal lesions (591 vs 409 days; Wilcoxon signed-rank test, P < 0.001). Time-to-CR in joint lesions positively correlated with MV at first follow-up (Pearson = 0.452, P = 0.005) and negatively correlated with percentage change in MV (first follow-up from baseline) (Pearson = -0.620, P < 0.001). ROC analysis yielded a cutoff of ≤71% reduction in MV at first follow-up (80.8% sensitivity, 81.8% specificity) to predict extension of ATT beyond 12 months. Using ROC analysis at second follow-up, a cutoff of ≤12.67 mL (for CR) was derived and was validated in patients at the third follow-up, with an accuracy of 84.4%. Patients with CR in PET/CT maintained disease-free state during a mean follow-up of 271 days.

CONCLUSIONS

18F-FDG PET/CT is an excellent tool in estimating total disease burden, assessing response to ATT and identification of treatment endpoint in joint tuberculosis.

Computational insights of phytochemical-driven disruption of RNA-dependent RNA polymerase-mediated replication of coronavirus: a strategic treatment plan against coronavirus disease 2019

The current pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has raised global health concerns. RNA-dependent RNA polymerase (RdRp) is the prime component of viral replication/proliferation machinery and is considered to be a potential drug target against SARS-CoV-2. The present study investigated the anti-RdRp activity of phytochemicals against SARS-CoV-2 infection. Virtual ligand screening was carried out to determine the potent compounds against RdRp. Molecular docking and an MD Simulation study were employed to evaluate the spatial affinity of selected phytochemicals for the active sites of RdRp. Structural stability of target compounds was determined using root mean square deviation computational analysis and drug-like abilities were investigated using ADMET. Bond distances between ligand and receptor were marked to predict the strength of interaction. Aloe, azadirachtin, columbin, cirsilineol, nimbiol, nimbocinol and sage exhibited the highest binding affinities and interacted with active sites of RdRp, surpassing the ability of chloroquine, lamivudine, favipiravir and remdesivir to target the same. All the natural metabolites exhibited stable conformation during MD Simulation of 101 ns at 310 K. Kinetic, potential and electrostatic energy were observed to be least in the case of natural metabolites in comparison with synthetic analogues. Deviations and fluctuations were observed to be structurally least in target phytochemicals. Physiochemical and biological properties of these compounds further validated their drug-like properties. Non-bonded distance was found to be short enough to form hydrogen bonding or hydrophobic interactions, which revealed that these target compounds can strongly bind with RdRp. The study found potential phytochemicals to disrupt the replication domain of SARS-CoV-2 by hindering RdRp. We therefore anticipate that the current findings could be considered as valuable for the development of an efficient preventive/therapeutic expedient against COVID-19.

Use of impregnated catheters to decrease colonization rates in neonates - A randomized controlled pilot trial

OBJECTIVE

Nosocomial infections increase mortality and morbidity in preterm infants. Central venous line colonization is a major risk factor for the development of such infections. In adults and children, antibiotic and antimycotic impregnated catheters have been demonstrated to reduce colonization. However, recently published data showed no significant difference in bloodstream infection in neonates when an impregnated catheter was used. We investigated the effect of impregnation of percutaneously inserted micro-catheters (PICC) on colonization in preterm and sick term infants in our unit.

METHODS

Neonates were randomly assigned to receive either a standard (S-PICC; n = 34) or antibiotic and antimycotic impregnated (IP-PICC; n = 37) PICC. Catheters were placed and removed according to a standard procedure and subsequently examined by roll-out culture. The primary outcome was the rate of colonization defined as >15 colony-forming-units/ml. Additional outcomes were catheter associated or systemic infections.

RESULTS

The rate of colonization was lower in neonates who received an IP-PICC as compared to S-PICC (5.6% vs. 12.1% respectively; p = 0.42). However, the difference was not significant. In IP-PICC vs S-PICC, catheter related local infection (CRI) although lower was not statistically significant (2.9% vs. 6.1%; p = 0.60). We observed no difference in catheter related systemic infection (CR-SI) (0% vs. 3.1%, p = 0.48). The neonates whose catheters were colonized were predominantly of a lower gestational age (median 254/7, p = 0.05) and males (100%, p = 0.01). In addition, the median colony count in the colonized IP-PICC catheters was lower as compared to S- PICC group (53 vs 250, p = 0.06).

CONCLUSIONS

The use of antibiotic and antimycotic impregnated PICC-lines in neonates tended to decrease colonization rates in neonates in our centers but this difference was not significant. Lower gestational age and male sex are risk factors for catheter colonization.

Eden-Hybinette Procedure for Revision Surgery in Recurrent Anterior Shoulder Instability in Epilepsy

AIMS

The purpose of this study was to analyze the clinical outcomes after Eden-Hybinette procedure for revision surgery in recurrent anterior shoulder instability in patients with epilepsy.

MATERIALS AND METHODS

We retrospectively evaluated eight such patients between 2015 and 2018. Four patients had failed Latarjet/Bristow procedure and two had failed arthroscopic Bankart procedure, while two had history of both the procedures. After medical control of epilepsy, Eden-Hybinette procedure was performed in all patients. WOSI score and Rowe shoulder score was recorded preoperatively and in subsequent post-operative follow-up. A paired t test was used to analyze and compare preoperative and postoperative outcomes and was considered significant if p value was < 0.05.

RESULTS

The average follow-up was 30 months (range 24-48 months). There was no recurrence of shoulder instability. The mean WOSI score before surgery was 77.3 (range 70-83), which improved to 24.2 (range 19-30) at 24-month follow-up. The mean Rowe score before surgery was 11.3 (range 5-15), which improved to 81.8(range 65-90) at 24-month follow-up. The improvement in WOSI and Rowe score was found to be statistically significant [p value < 0.05].

CONCLUSIONS

We conclude that Eden-Hybinette is a useful revision procedure to manage recurrent anterior shoulder dislocation in patients with epilepsy. Optimum medical control of seizure is also an important factor in preventing recurrent shoulder instability.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons

AIM

Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology.

MATERIALS AND METHODS

22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics.

RESULTS

Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection.

CONCLUSIONS

A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Bilateral gluteus maximus contracture due to intra muscular injections

Gluteus maximus contracture, characterised by contracture of gluteus maximus, iliotibial band and covering fascia, can be caused by repeated intramuscular injections in the gluteal region. It is amenable to open surgical release.

A Case Report of Chondromyxoid Fibroma of the Neck of Femur, Intracapsular Location

Introduction:

Chondromyxoid fibroma (CMF) is an uncommon benign tumor accounts for <2% of all benign and <1% all bone tumors. It is a cartilage tumor with myxoid and fibrous elements. Because of rarity and resemblance with other benign and malignant tumor, diagnosis of this tumor always remains challenging. Often, this lesion affects metaphysis of long growing bones of children and young adults. Common locations of this tumor are around the growth plate of proximal tibia and fibula and distal femur.

Case Report:

A 21-year-old male presented to orthopedic outpatient department with a history of the left hip pain for 1 year, following a trivial fall before 1 year. The patient was not able to do heavy strenuous activities such as running, jumping, and other sports activities. Terminal range of movements were painful. Magnetic resonance imaging suggested of cystic lesion involving synovial lining near head-and-neck junction of the left femur. Curettage of the lesion was done. The bone defect was not found to be large enough to be filled with bone graft. Histopathological examination showed lobular pattern with stellate to spindle-shaped cells on the myxoid background.

Conclusion:

CMF of subcapital region of femoral neck is an extremely unusual presentation. When occurring in middle-aged persons and in uncommon locations, this can raise suspicion of chondrosarcoma. Although intralesional curettage has the risk of recurrence in post-operative period, sufficient and careful curettage and excision of lesion will be enough to treat these benign lesions with good prognosis.

Habitual Patellar Dislocation-Management by Two in One Procedure, Short Term Results

AIM

Habitual dislocation of patella is an uncommon pathological condition. Though numerous techniques have been described in the literature for the treatment of patellar dislocations, none of the single procedure is fully effective in the surgical treatment of habitual dislocation of patella. We described our experience with a two in one procedure for habitual dislocation of patella in ten children.

PATIENTS AND METHOD

Ten children having habitual dislocation were reviewed prospectively for twelve months following surgical procedure. The age ranged between 5 and 9 years. We performed graded lateral soft tissue release and patellar tendon transposition as described by Roux Goldthwait. Clinical results were evaluated using Kujala score, ability to do straight leg raise, knee range of motion and visual analogue scale.

RESULT

There has been no recurrence of dislocation. The mean Kujala score before surgery was 48 which improved to 97.8 at 12 months follow-up after the surgical procedure. At 12 months follow-up all patients were able to do straight leg raise and had almost full range of motion.

CONCLUSION

We conclude that extensive proximal lateral release along with Goldthwait Roux procedure helps in treating the habitual dislocation in patella in children. Decision for the extent of lateral release must be taken intra-operatively. Our method of treatment is simple, cost effective and reproducible with excellent functional outcome.

Phonons and oxygen diffusion in Bi2O3 and (Bi0.7Y0.3)2O3

We report investigation of phonons and oxygen diffusion in Bi2O3 and (Bi0.7Y0.3)2O3. The phonon spectra have been measured in Bi2O3 at high temperatures up to 1083 K using inelastic neutron scattering. Ab initio calculations have been used to compute the individual contributions of the constituent atoms in Bi2O3 and (Bi0.7Y0.3)2O3 to the total phonon density of states. Our computed results indicate that as temperature is increased, there is a complete loss of sharp peak structure in the vibrational density of states. Ab initio molecular dynamics simulations show that even at 1000 K in δ-phase Bi2O3, Bi-Bi correlations remain ordered in the crystalline lattice while the correlations between O-O show liquid like disordered behavior. In the case of (Bi0.7Y0.3)2O3, the O-O correlations broadened at around 500 K indicating that oxygen conductivity is possible at such low temperatures in (Bi0.7Y0.3)2O3 although the conductivity is much less than that observed in the undoped high temperature δ-phase of Bi2O3. This result is consistent with the calculated diffusion coefficients of oxygen and observation by quasielastic neutron scattering experiments. Our ab initio molecular dynamics calculations predict that macroscopic diffusion is attainable in (Bi0.7Y0.3)2O3 at much lower temperatures, which is more suited for technological applications. Our studies elucidate the easy directions of diffusion in δ-Bi2O3 and (Bi0.7Y0.3)2O3.

Efficacy and safety comparison of combination of 0.04% tretinoin microspheres plus 1% clindamycin versus their monotherapy in patients with acne vulgaris: a phase 3, randomized, double-blind study

Background and objectives: There is an unmet need for topical treatments with good tolerability in management of acne vulgaris. The present study aimed to evaluate efficacy and safety of a novel tretinoin (microsphere, 0.04%) formulation in combination with clindamycin (1%) gel for treatment of acne vulgaris.Materials and methods: This phase 3 randomized, double-blind study included patients with moderate-to-severe acne. Patients were treated with tretinoin (microsphere, 0.04%) + clindamycin (1%) or one of the monotherapies (tretinoin, 0.025%; clindamycin, 1%). Key endpoints included percent change in lesion counts, and improvement in Investigator's Static Global Assessment (ISGA) score.Results: 750 patients were randomized (combination, n = 300; tretinoin and clindamycin, each n = 150). At week 12, reductions in inflammatory (77%), non-inflammatory (71%) and total lesions (73%) were significantly greater with combination treatment versus either monotherapy (p < .03). Proportion of patients rated 'clear' or 'almost clear' with ≥2-grade ISGA improvement was higher with combination (46%) versus monotherapies (p < .02). Adverse events occurred in 20 patients, most were mild-moderate; no deaths or serious adverse events were reported. The discontinuation rates due to adverse events with combination therapy were low (≤1%).Conclusion: The once-daily, microsphere-based formulation was generally tolerable with a positive impact on therapeutic outcomes and patients' compliance. ClinicalTrial Registration No.: CTRI/2014/08/004830.

Arthroscopic Repair of a "U" Shaped Rotator Cuff Tear: Modified Margin Convergence with a Single Triple-loaded Suture Anchor

Introduction Repair of a "U" shaped rotator cuff tear tends to create extreme tensile forces at the central part of the rotator cuff margin, causing tensile overload and may result in subsequent failure. We describe our technique of repairing the "U" shaped tear in which margin convergence is done using Ethibond (Ethicon Inc., New Jersey) and a single triple-loaded suture anchor. It results in the reduction of the strain and also allows the repair of seemingly irreparable tears. Patients and method We included 10 patients having a "U" shaped degenerative rotator cuff tear. All patients were assessed preoperatively. The University of California at Los Angeles Shoulder score (UCLA shoulder score) recorded preoperatively and at final follow-up was used to assess functional outcome. Result Out of 10 patients, six were males and four were females. The mean age was 60 years (range 50-70 years). The average follow-up was for 31 months (range 24 - 48 months). The UCLA score increased from an average of 9 preoperatively (range 8 - 12) to an average of 29.6 (range 27 - 31) at the terminal follow-up. The UCLA increased in the postoperative period and was statistically significant (unpaired t-test; p < 0.0001). All patients had good/excellent outcomes (UCLA score > 27). Abduction increased from average 27 degree preoperatively (range 20 degree - 35 degree) to an average 131 degree (range 125 degree - 140 degree) at final follow-up (unpaired t-test; p < 0.0001). Conclusion Our technique of modified margin convergence achieves low tension repair and anatomical footprint reconstruction with good clinical outcomes using a single triple-loaded anchor.

Arthroscopic and 3D CT Scan Evaluation of Femoral Footprint of the Anterior Cruciate Ligament in Chronic ACL Deficient Knees

The outcome of single-bundle anterior cruciate ligament (ACL) reconstruction depends largely on the anatomic placement of bone tunnel. The lateral intercondylar ridge (LIR) and bifurcate ridge (BR) are useful bony landmarks for femoral tunnel placement. The purpose of our study was to compare the bony landmarks of ACL footprint on femur by three-dimensional computed tomography (3D CT) scan and arthroscopy in chronic ACL-deficient knees. Fifty patients above 18 years of age who were diagnosed of having ACL tear were selected for the study. All the cases were more than 6 months old since the injury. Preoperative 3D CT scan of the affected knee was obtained for each of them. They underwent single-bundle anatomic ACL reconstruction. Measurements were done on the preoperative 3D CT and arthroscopy to quantify the position of the LIR and BR. The proximodistal distance of lateral femoral condyle was 21.41+/-2.5 mm on CT scan and 22.02+/-2.02 mm on arthroscopy. On preoperative 3D CT scan, the midpoint of the LIR was found to be located at a mean distance of 11.17±2.11 mm from the proximal margin of the lateral femoral condyle. On arthroscopy, it was at 10.18+/-1.52 mm from the proximal margin the lateral femoral condyle. The "bifurcate ridge"(BR) was not visible in any of the cases during arthroscopy or CT scan. We concluded that LIR is an easily identifiable bony landmark on arthroscopy in all cases. It can also be identified on CT scans. BR is not identified both on arthroscopy and CT scans in chronic ACL tears. The arthroscopic measurements of bony landmarks are quite close to those of CT scan. Midpoint of LIR is at 52.185% of the proximodistal distance on CT scan evaluation and it is at 46.21% on arthroscopic evaluation.

Interplay of phosphorus doses, cyanobacterial inoculation, and elevated carbon dioxide on yield and phosphorus dynamics in cowpea

Phosphorus (P) demand is likely to increase especially in legumes to harness greater benefits of nitrogen fixation under elevated CO₂ condition. In the following study, seed yield and seed P uptake in cowpea increased by 26.8% and 20.9%, respectively, under elevated CO₂ level. With an increase in phosphorus dose up to 12 mg kg^-1, seed yield enhanced from 2.6 to 5.4 g plant^-1. P application and cyanobacterial inoculation increased the microbial activity of soil, leading to increased availability of P. Under elevated CO₂ condition, microbial activity, measured as dehydrogenase, acid phosphatase, and alkaline phosphatase activities showed stimulation. Soil available P also increased under elevated CO₂ condition and was stimulated by both P application and cyanobacterial inoculation. Higher P uptake in elevated CO₂ condition led to lower values of inorganic P in soil. Stepwise regression analysis showed that aboveground P uptake, soil available P, and alkaline phosphatase activity of soil influenced the yield while available P, and organic and inorganic P influenced the aboveground P uptake of the crop. This study revealed that under elevated CO₂ condition, P application and cyanobacterial inoculation facilitated P uptake and yield, mediated through enhanced availability of nutrients, in cowpea crop.

Comparison of F18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and Dynamic Contrast-Enhanced Magnetic Resonance Imaging as Markers of Graft Viability in Anterior Cruciate Ligament Reconstruction

BACKGROUND

F18-fluorodeoxyglucose positron emission tomography/computed tomography (F18-FDG PET/CT) can be used to assess changes in the metabolism of an anterior cruciate ligament (ACL) graft as it is undergoing "ligamentization." Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is the preferred modality for noninvasive assessment of graft structure and graft vascularity.

PURPOSE

To compare the use of F18-FDG PET/CT and DCE-MRI to assess ligamentization within the ACL graft and correlate the results with clinical tests.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Among 30 recruited patients, 27 patients (3 females and 24 males) completed 2 follow-up assessments at a mean of 125 ± 22 days and 259 ± 38 days after arthroscopic ACL reconstruction. At both assessments, anterior drawer test, Lachman test, and Lysholm scoring (LS) were conducted. Images from F18-FDG PET/CT and MRI were analyzed qualitatively and quantitatively (maximum standardized uptake value [SUVmax], SUVmax ratio to the contralateral side [SUVmax CL], normalized enhancement [NE]) in 3 zones: femoral, intra-articular (IA), and tibial. Of the 27 recruited patients, 1 patient had reinjury due to a fall. Therefore, 26 patients were considered for the final analysis.

RESULTS

A significant improvement ( P = .0001) was found in median LS, from 78.5 (range, 62-90) to 94.5 (range, 84-100), at the second follow-up. All grafts were found to be viable on PET/CT and vascularized on MRI. All grafts were seen as continuous on MRI, with exception of 1 graft at the second follow-up. Dynamic MRI identified single-vessel supply to all of the grafts at the first follow-up and multiple-vessel supply in 10 patients at the second follow-up. Reduction in the median SUVmax, SUVmax CL, and NE at second follow-up was seen in all 3 zones. Only SUVmax CL in the IA zone showed a significant reduction ( P = .032); patients with excellent LS at the second follow-up showed significantly higher reduction ( P = .005) than patients with good LS. NE in the IA zone was correlated (0.39; P = .048) with LS only at the first follow-up, whereas SUVmax CL (-0.52; P = .006) and SUVmax (-0.49, P = .010) in the IA zone negatively correlated with LS at the second follow-up only. No correlation was observed between PET/CT and MRI parameters.

CONCLUSION

Glucose metabolism and vascularity in the graft tissue can be used to assess ligamentization of ACL graft. A viable and vascularized graft at first follow-up is associated with good to excellent final outcome, regardless of LS at this stage. Since no correlation was observed between PET/CT and MRI parameters, they may be assessing different domains of the same process. Higher NE in the IA zone at the first follow-up and lower SUVmax CL in the same region at second follow-up are associated with better outcome.

Pseudo primary abscess of the cavum septum pellucidum due to pus entrapment: A rare case report

The cavum septum pellucidum (CSP) is defined as a crevice-like space of variable width between the left and right transparent septum. In this report, a rare case of pseudo primary abscess formed in the CSP due to ventriculitis is presented.

Phonons, phase transitions and thermal expansion in LiAlO2: an ab initio density functional study

We have used the ab initio density functional theory technique to understand the phase transitions and structural changes in various high temperature/pressure phases of LiAlO₂. The electronic band structure as well as phonon spectra is calculated for various phases as a function of pressure. The phonon entropy used for the calculations of Gibbs free energy is found to play an important role in the phase stability and phase transitions among various phases. A sudden increase in the polyhedral bond lengths (Li/Al-O) signifies the change from the tetrahedral to octahedral geometry at high-pressure phase transitions. The activation energy barrier for the high-pressure phase transitions is calculated. The phonon modes responsible for the phase transition (upon heating) from high pressure phases to ambient pressure phases are identified. Moreover, ab initio lattice dynamics calculations in the framework of quasi-harmonic approximations are used to study the anisotropic thermal expansion behavior of γ-LiAlO₂.

Habitual patellar dislocation in children: Results of surgical treatment by modified four in one technique

BACKGROUND

Habitual patellar dislocation is a rare condition affecting children. The growth plates are open in children and any surgical intervention should take that in to consideration. We are describing a modified four in one technique for habitual patellar dislocation, which is a soft tissue procedure without the use of any implant.

METHOD

In this study we included 6 children (4 females and 2 males) with open growth plates, which were diagnosed with habitual patellar dislocation. The average age of the patients were 9.6 years (range 5-13 years). Our technique included lateral retinaculum release, vastus medialis obliques (VMO) advancement, partial patellar tendon transposition and reconstruction of medial patellofemoral ligament (MPFL). Patients were evaluated with Kujala scoring pre and post operatively. The average follow up period was 12 months (range 7-24 months).

RESULTS

There were no recurrence of patellar instability in any of the cases. The mean Kujala score was 48 before surgery and it improved to 95 after 12 months of average follow-up after surgery.

CONCLUSION

We conclude that our method of treatment of habitual patellar dislocation by using modified four in one technique in children with open physis reproduced excellent functional outcome. It is simple, cheap and does not require any image guidance.

THERAPEUTIC STUDY

Level of evidence IV.

Correlation between MRI and hip arthroscopy in children with Legg-Calve-Perthes disease

BACKGROUND

Most of the information available about Legg-Calve-Perthes disease (LCPD) at present is gained through imaging modalities including plain radiographs and magnetic resonance imaging (MRI). But the accuracy of MRI in this disease and its predictive value to reveal various intra-articular pathologies is not known. We correlated the findings of MRI with those seen on hip arthroscopy in children with active stage of LCPD.

METHODS

We conducted a prospective observational study in which MRI findings were correlated with corresponding findings on hip arthroscopy in a cohort of 25 patients of active LCPD below 12 years of age. The parameters noted on MRI included status of ligamentum teres, status of the labrum, synovial effusion if any, condition of the femoral and acetabular articular cartilage including chondral flaps, chondral indentation and intra-articular loose bodies. The indication of performing hip arthroscopy was persistent severe hip pain (Wong-Baker FACES pain scale ≥ 3) after 6 months of conservative management. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for MRI considering arthroscopy as a gold standard.

RESULTS

Synovial effusion was seen in a large number of patients on both MRI (17) and hip arthroscopy (24). The sensitivity (95% confidence interval) of MRI was found to be low, especially with respect to labral tears [25% (0.63-80.6)] and intra-articular loose bodies [20% (0.51-71.6)]. NPV for synovial effusion was also found to be low [12.5% (0.32-52.7)], although specificity and PPV of MRI were found to be good for all the parameters.

CONCLUSIONS

MRI cannot be completely relied upon for identifying all the intra-articular pathologies in children with LCPD, although it has a good complimentary role. In patients with severe persistent pain with suspicion for joint changes, hip arthroscopy can provide a safe and efficient procedure (better than MRI) for eliciting the associated joint pathology.

Evaluation of Effect of Ascorbic Acid on Ferritin and Erythropoietin Resistance in Patients of Chronic Kidney Disease

OBJECTIVE

This study was planned to evaluate the effect of short term intravenous ascorbic acid on reducing ferritin and erythropoietin resistance in patients of chronic kidney disease (CKD) on maintenance haemodialysis (MHD).

METHODS

Forty adult patients [20 patients in group A with increased serum ferritin level (>500 ng/ml), transferrin saturation (TSAT) ≤20% and 20 patients in group B with normal serum ferritin level (<200 ng/ml), TSAT ≤20%] of end stage renal disease (ESRD) with erythropoietin hyporesponsiveness undergoing maintenance hemodialysis were included in the study. Group A was given intravenous (i.v.) ascorbic acid in a dose of 500 mg once a week after each 4 hours session of dialysis for 3 weeks in a month (total 1500 mg/month), for a period of 3 months along with erythropoietin 6000 IU subcutaneous (S/C) twice weekly without iron therapy. Group B was given erythropoietin (6000 IU S/C twice weekly after each hemodialysis) and intravenous (IV) iron 100 mg/week for 3 months. Hematological and renal investigations, erythrocyte sedimentation rate (ESR), high sensitivity C-reactive protein (HsCRP), serum ferritin and TSAT were done at baseline and then one monthly intervals for three months whereas intact parathyroid hormone (iPTH) was measured at the start and end of the study.

RESULTS

At the end of 3 months of study, in group A, Hemoglobin (Hb) and TSAT significantly increased while ferritin, HsCRP and erythropoietin resistance index (ERI) decreased significantly. In group B, the increase in Hb and TSAT were not significant statistically while ferritin increased significantly and fall in HsCRP and ERI were not significant statistically. The mean rise in Hb between subsequent months was higher in group A as compared to group B.

CONCLUSIONS

Short term i.v ascorbic acid could be a new successful adjuvant in reducing ferritin and erythropoietin resistance and enhancing Hb and TSAT in CKD patients on MHD.