Orthopedic Surgery

To biomechanically compare anterior cruciate ligament (ACL) tibial bony avulsion fixation by suture anchors, EndoButtons (Smith & Nephew, Andover, MA), and high-strength sutures subjected to cyclic loading. Methods: Type III tibial eminence fractures were created in 49 ovine knees, and 7 different types of repairs were performed. Each repair group contained 7 specimens. The repair groups were as follows: No.

We carried out a blinded prospective randomised controlled trial comparing 2-octylcyanoacrylate (OCA), subcuticular suture (monocryl) and skin staples for skin closure following total hip and total knee arthroplasty. We included 102 hip replacements and 85 of the knee. OCA was associated with less wound discharge in the first 24 hours for both the hip and the knee. However, with total knee replacement there was a trend for a more prolonged wound discharge with OCA. With total hip replacement there was no significant difference between the groups for either early or late complications. Closure of the wound with skin staples was significantly faster than with OCA or suture. There was no significant difference in the length of stay in hospital, Hollander wound evaluation score (cosmesis) or patient satisfaction between the groups at six weeks for either hips or knees. We consider that skin staples are the skin closure of choice for both hip and knee replacements.

Introduction: The injuries involving the femoral head fractures are relatively uncommon but for the prevention of post-sequel complications like osteoarthritis, the treatment of such kind of fractures is of utmost importance. Less than 20 % of the cases of posterior hip dislocations have been observed to be associated with fractures of femoral head. Several cases have been published in the literature ever since the first description of a femoral head fracture, no firm conclusions have been reached regarding optimal treatment. Hence; we compared the various treatment modalities available for the treatment of femoral head fractures. Material and methods: The present study included 26 patients of femoral head fractures who reported in the department of Orthopedics and Traumatology of the institution from June 2002 to July 2012. The patients were classified in accordance with Pipkin's proposal. Surgical treatment was performed in all cases. Analysis of the post-surgical results was done by performing separate assessment for clinical and radiological features separately. For the follow up purposes, cases that underwent total primary hip arthroplasty. Results: 75% were males and 25% were females out of total 26 patients. The mean age of the patients was 34.5 years and ranged from 18 to 60 years. 47 % of the total cases were of type 1 while type 2 contained 24 % of the individuals according to Pipkin classification. Type 3 and 4 contained 14 % and 15 % individuals respectively. 12 out of the 26 patients showed excellent result when evaluated both clinically and radiographically according to Thompson and Epstein criteria. Conclusion: Surgical treatment should be followed while treating femoral head fractures. Different personalities are presented by femoral head fractures and therefore the treating clinician must have the proper understanding of the pattern of the fracture on the basis of which, they should do the treatment planning.

Anterior approaches to the shoulder involve partial or complete detachment of the subscapularis muscle. We have developed a new technique that permits adequate access to the humeral attachment of the inferior glenohumeral ligament (IGHL) without any detachment of the subscapularis, and have used this to successfully repair humeral avulsions of glenohumeral ligament lesions. Preliminary diagnostic arthroscopy using air insufflation of the glenohumeral joint is used to identify and grade the lesion. A 1-inch axillary incision is used to access the subscapularis tendon through the deltopectoral approach. Thereafter, anatomic landmarks are identified to expose the lateral aspect of the inferior border of the subscapularis muscle. Blunt dissection is used to separate the musculocapsular plane, and the subscapularis is retracted in an anterosuperior direction. Adequate exposure for visualization and repair of the avulsed IGHL is possible in a majority of cases where this approach is attempted. The use of arthroscopic instruments and suture anchors facilitates suture passage through the mid and posterior regions of the IGHL. If exposure is inadequate, the approach can be easily converted to a conventional L-shaped tenotomy approach through the lower or upper region of the subscapularis.

Purpose: The purpose of this study was to develop a meniscus scaffold that has increased porosity and maintains the native meniscus extracellular matrix in an ovine model. Methods: The medial menisci of skeletally mature ovine (n ϭ 16) were harvested; half were made into meniscus scaffolds (n ϭ 8), and half remained intact (n ϭ 8). Intact and scaffold meniscus tissues were compared by use of histology, DNA content analysis, in vitro cellular biocompatibility assays, and ultrastructural analysis. An additional 16 knees were used to investigate the biomechanics of the intact meniscus compared with the meniscus scaffold. Results: DNA content and histology showed a significant decrease in cellular and nuclear content in the meniscus scaffold (P Ͻ .003). Biocompatibility was supported through in vitro cellular assays. Scanning electron microscopy and micro-computed tomography showed a substantial increase in porosity and pore connectivity in the meniscus scaffold compared with the intact meniscus (P Ͻ .01). There was no statistical difference between the ultimate load or elastic modulus of the intact and meniscus scaffolds. Conclusions: In this study a meniscus scaffold was evaluated for potential clinical application as a meniscus transplant construct in an ovine model. The data showed that a decellularized meniscus scaffold with increased porosity was comparable to the intact meniscus, with an absence of in vitro cellular toxicity. Although some compositional alterations of the extracellular matrix are to be expected during processing, it is evident that many of the essential structural components remained functional with maintenance of biomechanical properties. Clinical Relevance: This meniscus scaffold has potential for future clinical application as a meniscus transplant construct.

Tourniquet use in foot and ankle surgery is common practice; however, the technique varies among foot and ankle surgeons and there are no standard guidelines. To analyze trends in foot and ankle tourniquet use, the authors conducted an e· mail sUlVey. One thousand six hundred sixty-five foot and ankle surgeons were sent a tourniquet-use survey via a-mail, across Canada and the United States. Nineteen percent of the recipients completed and returned the surveys. Eleven (3.4%) rarefy or never use a tourniquet and 8 (2.5%) use an Esmarch bandage toumiquet at the ankle. Most use pneumatic ankle cuffs (92% use, 27% use exclusively); many also use thigh cuffs (69%) and some a/so use calf cuffs (15 %). Most thigh-cuff users (62%) experience problems with cuff fit sometimes or often. All but 3 respondents exsanguinate the limb before tourniquet inflation. Specific devices used for exsanguination varied among surgeons. Most commonly used tourniquet pressures range from s 200 to 350 mm Hg at the ankle and s 200 to 2:.351 mm Hg for the thigh (64% use pressures between 301 and 350 mm Hg). Only 7% of respondents consider limb occlusion pressure when selecting tourniquet cuff pressure. Based on published studies of limb occlusion pressures, these ranges suggest that some of the more common pressure settings may be higher than necessary for many patients. Vascular disease or previous bypass (91 %) and deep vein thrombosis (83%) were the most commonly listed contraindications to tourniquet use. Approximately 10% of respondents have either experienced or learned of skin and nerve injuries secondary to lower extremity tourniquet use at any level. The varied responses show a lack of overall consensus on tourniquet pressure settings. Guidelines for optimizing cuff pressure and technique should be established to minimize the risk of complications.

Fracture healing can be stimulated by exogenous application of growth factors. Using porcine and rat models the efficacy of locally delivered IGF-I and TGF-b1 from an implant coating has been demonstrated. A thin and biomechanical stable biodegradable poly(D,L-lactide) was used to coat implants and serve as a drug carrier. Due to reports of possible foreign body reactions caused by polymer materials in orthopedic surgery, this study investigated the biocompatibility of the polylactide implant coating and the locally released growth factors during the time course of rat tibial fracture healing (days 5, 10, 15, and 28 after fracture). Monocytes/macrophages and osteoclast were detected using an monoclonal antibody against ED1 (comparable to CD68 in mice and human). The antibody ED1 stains monocytes, macrophages and osteoclast in the bone marrow and in the newly formed fracture callus. A moderate density of the monocytes/macrophages was seen in the proximal part of the medullary canal, but almost no cells were detectable in the region distal to the fracture. The amount of stained cells increased during the observation time with a maximum at days 10 and 15 followed by a decrease at day 28. No differences were detectable between the investigated groups from day 5 to 15 post fracture indicating, that the used poly(D,L-lactide) or the incorporated growth factors do not evoke an elevated immunological response compared to the uncoated titanium implant at the investigated time points. A significantly higher amount of ED1 positive cells was measured 28 days after fracture in the control group compared to the groups with the coated implants.

Nowadays, fracture management is an essential part of everyday clinical decisionmaking prior to any fracture-related surgery. The way to carry out such preoperative planning involves tracing the bones over paper using the X-Rays, and then placing the resulting drawings together as if reconstructing the fractured bones. This action, although proven eective, is quite rudimentary and time consuming. In recent years,

Abstract: A total of 13 cadavers (12 men and 1 women) of different age group were used for the study with the purpose to determine the prevalence of femoral vein duplication. Lower limb regions (26 sides) were carefully dissected as per the standard dissection procedure. Femoral vein (unitruncular) was found in 96.15% of specimen. Bitruncular configurations (total bifidity) was found in a male cadaver of 75 years of age (3.85%). In the right lower limb, 6.5 cms below the inguinal ligament the femoral vein - lateral ramus received the lateral circumflex femoral vein, and the medial circumflex femoral vein, and the lateral and medial ramii formed a common venous trunk. Knowledge of the truncular venous variations is important to recognize and avoid potential errors in diagnosis of deep venous thrombosis of the femoral vein, in the case of an occluded duplicated trunk.

The purpose of this study was to determine the relationship between anterior knee pain secondary to suspected patellofemoral malalignment and tibial tubercle lateralization, patellar tilt, and patellar lateralization on magnetic resonance imaging. Methods: We compared the bony relationships of the knee in patients with anterior knee pain and patients with nonspecific internal derangements of the knee. We measured the lateral deviation of the tibial tubercle and the patella from the trochlea, patellar tilt, and patellar and patellar tendon length. Results: The symptomatic knees of patients with anterior knee pain had significantly (P Յ .01) greater lateralization of the tibial tubercle and lateral patellar tilt than did knees of the control group. Patella alta appears to be more common in subjects with anterior knee pain. Conclusions: Magnetic resonance imaging determination of tibial tubercle lateralization and patellar tilt correlates positively with the clinical diagnosis of anterior knee pain, suggesting that patellofemoral pain is caused by subtle malalignment. Level of Evidence: Level III, development of diagnostic criteria on basis of nonconsecutive patients.

Background and Objectives. Brachial plexus block is clinically useful. Although the infraclavicular approach to brachial block is the less commonly used form it may offer advantages. We describe the results with three local anesthetic mixtures used during this observational study. Methods. Three hundred and sixty patients, ASA physical status I and II, scheduled for upper extremity orthopedic surgery, were anesthetized with an infraclavicular brachial plexus block. They were divided into three groups (120 patients each) by type of 40-mE anesthetic mixture: group I had even parts of 2 % plain lidocaine and 0.5 % bupivacaine with epinephrine 1:200,000; group II had even parts of 1% plain lidocaine and 0.25 % bupivacaine with epinephrine 1:200,000; and group III had even parts of 1.5% plain lidocaine and 0.37% bupivacaine with epinephrine 1:200,000. Plexus identification was made by nerve stimulator. The observational assessments were: adequacy and latency time of the block, tourniquet tolerance, postoperative analgesia, local anesthetics doses, sedative doses, complications, and side effects. Results. In groups I, II, and III, adequacy of the block was 95, 75, and 96%, latency time was 10.4, 12.9, and 10.9 minutes, tourniquet tolerance was 99, 84, and 98%, postoperative analgesia time was 663, 331, and 502 minutes, anesthetic doses of lidocaine/bupivacaine were 5.2/1.3, 2.9/0.7 and 4.i/1.i mg/kg, respectively. Differences were noted between group II and groups I and III (P range: .0I-.0001). Sedatives in adequate blocks were midazolam with/without fentanyl (2-3 mg/50-100 I~g) in all groups. There were two complication cases with no consequences: two vascular punctures that did not hold up or delay the anesthetic or surgical procedure. There were no clinical manifestations or side effects. Conclusions. The infraclavicular approach described is effective. It produced reliable anesthesia and is associated with minimal complications and side effects. The mixture of local anesthetics used in group II is not adequate for producing reliable anesthesia. Reg Anesth Pain Med 1999: 24:411-416.

The purpose of the present study was to evaluate 4 commercially available shoulder external rotation braces to determine their ability to achieve and maintain shoulder external rotation. In addition, for each brace, we collected patient-derived data on comfort level, ease of application, and ease of performing activities of daily living during brace wear. Methods: Four commercially available shoulder external rotation braces were evaluated for their ability to achieve and maintain external rotation in 12 healthy subjects. Results: Significant differences were noted between braces in their ability to achieve and maintain shoulder external rotation, as well as in their comfort ratings.

Purpose: To study the use of a methylprednisolone taper (Medrol Dosepak; Pfizer, New York, NY) short-term oral corticosteroid treatment modality by sports medicine physicians; included is discussion on indications, perceived efficacy, and complications. Methods: A survey specific to Medrol Dosepak (MDP) use was mailed to all members of the Arthroscopy Association of North America (AANA) and the American Orthopedic Society for Sports Medicine (AOSSM). Surveys were collected and data were collated and analyzed. Results: Total response rate was 41% (1,290/3,167), US response rate 43% (1,247/2,906), and international response rate 16% (43/261). Prescribing of MDP for sports injuries was significantly associated with average patient age Յ40 years ( square; P ϭ .001), but it was not associated with years in practice or patients seen per year. It was found that 47% of members (603/1,290) prescribe MDP. Postinjury disease was the most common indication. The most frequent complication was glucose intolerance (37%; 222/603). Of members who prescribe MDP, 8.5% (51/603) reported that they had seen 101 total cases of osteonecrosis, predominantly in the hip. Results revealed that 52% of members (672/1,290) do not prescribe MDP. The most frequent reasons for not prescribing included fear of osteonecrosis (30%; 201/672), fear of complications in general (27%; 183/672), lack of proven efficacy (27%; 180/672), and fear of malpractice (4.5%; 30/672). Of nonprescribing members (171/672), 25% had seen 500 cases of osteonecrosis, most often in the hip. Conclusions: The responding membership of AANA and AOSSM is evenly split regarding MDP use. Average patient age Յ40 years was associated with a greater likelihood that MDP would be prescribed for sports injuries. Postinjury disease is the most common indication; lack of proven efficacy and osteonecrosis are deterrents to prescription. Level of Evidence: Level V, expert opinion.

Squamous cell carcinoma (SCC) is a rare but well-documented complication of chronic osteomyelitis. Between February 1991 and March 1999, 13 cases (12 men and one woman) of SCC arising in chronic osteomyelitis were diagnosed and treated in our clinic. Mean age was 56.5 (38–70) years. Twelve patients underwent amputation and one underwent limb salvage. Average follow-up was 56 (24–121) months. Among the 13 patients two died of the disease. Treatment of choice for these tumours has been amputation. Carcinome cellulaire squameux est une complication d'ostéomyélite, peu fréquente, mais bien connue. Entre le février 91–mars 99, dans notre clinique, nous ont constate 13 malades (12 hommes et 1 femme) a qui nous ont vu la maladie développe a la base d'ostéomyélite chronique. L'age moyen était 56.5. (38–70) 12 malades ont subi une amputation et dans l'autre l'extrémité a été gardée. La surveillance a duré à peu près 56 (24–121) mois. Parmi ces 13 malades seulement deux sont morts. Pour ces tumeurs on peut dire que l'amputation est la méthode la plus efficace.

Permissions] link. and click on the [Reprints and jbjs.org article, or locate the article citation on to use material from this order reprints or request permission Click here to Background: Although cervical spine pedicle screws have been shown to provide excellent fixation, widespread acceptance of their use is limited because of the risk of injury to the spinal cord, nerve roots, and vertebral arteries. The risks of pedicle screw insertion in the cervical spine can be mitigated by a three-dimensional appreciation of pedicle anatomy. Normative data on three-dimensional subaxial pedicle geometry from a large, young, and asymptomatic North American population are lacking. The purpose of the present study was to determine three-dimensional subaxial pedicle geometry in a large group of young volunteers and to determine level and sex-specific morphologic differences.

Infection related to surgery is a localized or systemic condition from an adverse reaction caused by the invasion of the patient's body tissues by infectious agents [1]. Risks are inherent in every surgical procedure and orthopaedic procedures are no exception. Surgical Site Infections (SSIs) are one of the most common complications following hospitalization and deep infections remain a significant cause of morbidity. These infections may cause poor wound healing or further treatment resulting in longer hospital stays and increased health care costs. However, during the 20 th century; there has been a significant reduction in the number of complications owing to improved sterile techniques, early postoperative mobilization of the patient, prophylactic anticoagulation method, enhanced implanted designs and prophylactic antibiotic use which are provided in adequate dose on the basis of the patient's Body Mass Index (BMI) and should be discontinued after wound closure [2] as prolonged use of prophylactic antibiotics are unnecessary and results in emergence of resistant bacteria strains [3] .

RATIONALE AND OBJECTIVE
Three-dimensional (3D) printed anatomic models and surgical guides have been shown to reduce operative time. The purpose of this study was to generate an economic analysis of the cost-saving potential of 3D printed anatomic models and surgical guides in orthopedic and maxillofacial surgical applications.

MATERIALS AND METHODS
A targeted literature search identified operating room cost-per-minute and studies that quantified time saved using 3D printed constructs. Studies that reported operative time differences due to 3D printed anatomic models or surgical guides were reviewed and cataloged. A mean of $62 per operating room minute (range of $22–$133 per minute) was used as the reference standard for operating room time cost. Different financial scenarios were modeled with the provided cost-per-minute of operating room time (using high, mean, and low values) and mean time saved using 3D printed constructs.

RESULTS
Seven studies using 3D printed anatomic models in surgical care demonstrated a mean 62 minutes ($3720/case saved from reduced time) of time saved, and 25 studies of 3D printed surgical guides demonstrated a mean 23 minutes time saved ($1488/case saved from reduced time). An estimated 63 models or guides per year (or 1.2/week) were predicted to be the minimum number to breakeven and account for annual fixed costs.

CONCLUSION
Based on the literature-based financial analyses, medical 3D printing appears to reduce operating room costs secondary to shortening procedure times. While resource-intensive, 3D printed constructs used in patients’ operative care provides considerable downstream value to health systems.

Purpose: Our purpose was to define the macroscopic anatomy of the infrapatellar fat pad (IFP) when viewed at arthroscopy and to document the common variations. Methods: Ninety-six consecutive patients between 8 and 50 years of age with no previous knee surgery or fat pad pathology underwent arthroscopic examination of the knee. The fat pad of each patient was observed and described regarding size, color, consistency, and the presence of lobules, villous synovium, and lingulae. Results: The macroscopic arthroscopic anatomy of the IFP was defined. Male fat pads were larger than female fat pads. Two separate parts were described-medial and lateral-with medial dominence being most typical. The specific normal anatomic appearance of each section was defined regarding size, color, consistency, and attributes. Ligamentum mucosum, as the separation limit between the sections, was found in most knees. Conclusions: The macroscopic anatomy of the IFP is described at arthroscopy performed for internal pathology of the knee. Two distinct parts were defined-medial and lateral-with medial dominance. A typical fat pad was yellow and included an infrapatellar lingula (85%), lobulation (65%), and villous synovium (65%). We found a ligamentum mucosum in 79% of cases. Clinical Relevance: Knowledge of the macroscopic anatomy of the IFP and variations will allow the accurate diagnosis of pathology of the fat pad, rather than being a diagnosis of exclusion.

Indian Journal of Orthopaedic Surgery (IJOS) is a peer-reviewed journal with reputable academics and experts as members of its Editorial Board. IJOS publishes information on basic and applied orthopaedics for a worldwide readership. It publishes original research papers, critical reviews dealing with all fields of Orthopaedicsand it addresses the international scientific community. Papers related to orthopaedic science on a worldwide basis are also considered. Special emphasis is given to issues that go beyond the traditional boundaries of anorthopaedic journal.Articles on the state-of-the art of orthopaedic surgeryin different parts of the world, the research activities and medical education in orthopaedic teaching, the role of orthopaedics in society, new findings from the frontiers of current researchare always encouraged.

Purpose: The purpose of this study was to biomechanically evaluate several configurations of the Krackow stitch and determine which configuration provided the best fixation with regard to load to failure and elongation. Type of Study: Biomechanical study. Methods: Thirty fresh-frozen porcine Achilles tendons were randomly assigned into 6 groups. For 3 of the groups, 1 suture was used (No. 5 Ethibond; Ethicon, Somerville, NJ) with 2, 4, or 6 Krackow locking loops. For the other 3 groups, 2 sutures (interlocking and at 90°) with 2, 4, or 6 Krackow locking loops were used. Data were evaluated using analysis of variance. Results: There were no statistical differences in peak load to failure and elongation among any of the 1-suture techniques regardless of the number of locking loops (2, 290 N; 4, 302 N; and 6, 298 N; standard deviation, 25.2, 9.0, and 28.6, respectively). Similarly, there were no statistical differences among any of the 2-suture techniques regardless of the number of locking loops (2, 534 N; 4, 492 N; and 6, 505 N; standard deviation, 42.0, 65.4, and 76.3, respectively). There was, however, a significant difference (P Ͻ .05) in peak load to failure between the 1-suture and the 2-suture groups. The mechanism of failure was suture rupture in all cases. Conclusions: Load to failure did increase with the addition of a second interlocking suture placed at 90°to the first. Clinical Relevance: Tendon fixation with gap formation or suture rupture is at risk of failure. This study identifies that increasing the number of sutures is more important than increasing the number of locking loops.

In this paper, we present a novel haptic technique for emulating hard surfaces with high realism; such a technique has significant potential utility in certain orthopedic surgery applications such as joint replacement surgery where the goal is to prevent incursions beyond a virtual surface during bone cutting operations. The Dynamic Physical Constraint (DPC) concept uses a unidirectional physical constraint that is actively positioned to limit movement between two manipulator links; the concept is applicable to providing virtual constraints in both 2D and 3D workspaces. Simulation results demonstrate the potential feasibility of the concept, and a prototype device was built for testing. The DPC device provides a convincing sensation of a real, hard virtual surface which can be smoothly tracked when the end effector is in contact with the surface. Incursion across the surface with the prototype was well submillimetric and within the accuracy constraints required for joint replacement applications.

Distal radius fracture often presents a metaphyseal void which is more extended in elderly, osteoporotic patients. Bone graft and bone substitutes are reported to be beneficial in maintaining metaphyseal reduction. We performed a prospective study on 52 menopausal, osteoporotic women with unstable intra-articular distal radius fractures to compare the outcome of percutaneous pinning and immobilisation in a cast for 6 weeks with that using injectable calcium phosphate bone cement (Norian Skeletal Repair System, SRS) to supplement pin and screw fixation and immobilisation in a cast for 3 weeks. All patients were reviewed 2 years (range 21-29 months) after surgery. Patients treated with SRS had better functional outcome, restoration of movement and grip strength ( p<0.001). In this group there was 1 mm loss of radial length, 3 degrees loss of radial inclination and 7 degrees loss of palmar tilt. In the control group radial length decreased 3 mm, radial inclination decreased 11 degre...

Background: Neuromodulation for relief of chronic back has been accepted as a treatment of choice because of its cost effectiveness
while the technology has evolved to recruit new targets for stimulation and minimally invasive techniques. Dorsal root
ganglion (DRG) is one such new target and wireless stimulation is an advancement in neuromodulation.
Objective: Review of Dorsal root ganglion stimulation (DRGS) as an alternative neuromodulation technique to conventional
spinal cord stimulation (SCS). DRGS by a novel, minimally invasive wireless technology in the management of chronic back pain
and leg pain following failed back surgery.
Material and Methods: Animal experiments have demonstrated DRG as sensory gateway with unique properties of electrical
conduction. Its location in the neural foramina and lack of cerebrospinal fluid dynamics promise a stable delivery of stimulation.
Refined implant designs have improved access to the DRG and prospective multicenter studies have demonstrated utility
of DRGS in providing a long lasting relief in chronic pain syndromes. A recent pilot study using our minimally invasive device
activated by a wireless system (Stimwave Technologies) reported its safety and feasibility.
Results: DRGS provided more than 50% relief in multicenter studies by conventional apparatus with risks of CSF leak (8%) and
wound infection (10%). Motor stimulation in 11% and loss of stimulation in 4% were observed. Wireless DRGS in our pilot study
was safe and took an average time of 10 minutes to complete the procedure. Overall pain reduction was close to 60%. From the
implantation to the explant (45 days) no adverse events were noted. Results from our other ongoing studies are awaited.
Conclusion: Chronic pain is challenging at all frequencies of stimulation and with the currently available targets and technologies.
DRGS by a novel miniature stimulation system with wireless operational capabilities is a feasible approach to minimize the
adverse events and to improve the acceptability of the available neuromodulation methods.

Keywords: primary total knee arthroplasty total knee replacement systematic review satisfaction dissatisfaction a b s t r a c t Background: Dissatisfaction following total knee arthroplasty (TKA) is common. Approximately 20% of patients report dissatisfaction following primary TKA. This systematic literature review explores key factors affecting patient dissatisfaction following TKA. Methods: Six literature databases published between 2005 and 1 January 2016 were searched using 3 key search phrases. Papers were included if the study investigated patient dissatisfaction in primary unilateral or bilateral TKA. Information from each article was categorized to the domains of socioeconomic , preoperative, intraoperative, and postoperative factors affecting patient dissatisfaction. Results: This review found that patient dissatisfaction pertains to several key factors. Patient expectations prior to surgery, the degree of improvement in knee function, and pain relief following surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic and surgical domains. Conclusion: Identifying who may be dissatisfied after their TKA is mystifying; however, we note several strategies that target factors whereby an association exists. Further research is needed to better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully appreciated and strategies employed to target them.

Amputation is one of the oldest surgical procedure and a good amputation results in optimal functional outcome by providing healthy residual limb. Advances in prosthetics has enabled amputee with diverse options and better functionality. There is also decrease in the overall burden of amputation as a result of better treatment of causative disorders and proper limb salvage techniques. Complications, however, pose challenges in regain of necessary functions and include an array of disorders related to the procedure, technique and other factors. An understanding of common and practical complications is helpful in their anticipation and relevant prohibitive measures. Apart from it, a comprehensive study that highlights pattern of amputations and related complications provides database for preventive and management strategy. A total of 69 cases of extremity amputations were included within a defined period of Jan 2011 to June 2016. Relevant demographic data were noted along with other details amputation and complications. An attempt is also made for co-morbidities associated in cases with complications. Males (88.40%) and lower extremity (66.66%) were involved more commonly than females and upper extremity. Below knee was commonest (50.72%) lower and below elbow along with digital amputations were commonest (15.94% each) upper extremity amputations. The significant complication that required increased hospital stay or additional procedures were noted in 34 (49.27%) cases. Delayed wound healing, wound dehiscence, painful neuroma, stiffness, exposed bone and phantom pain were some of major complication noted in the study. A brief notes on patient characteristics has been attributed to the nature of trauma, co-morbidities and substance abuse among the complicated cases. The early recognition of complication and prompt management goes a long way in abetment of agony and discomfort of patient affecting overall outcome. Introduction Amputation is one of the oldest surgical intervention and staged procedure for variety of indications compromising the vitality of limb and at times life [1]. It is to be considered as a reconstructive procedure and is not mere removal of useless body part. The level and underlying culprit causes are of little concern now as advances in prosthetics has given us diversity and functionality that was akin to fiction in the past. Amputation aims to restore function and better results are met with team efforts. Apart from patient, doctor and prosthetist, moral support of family and close ones and at times psychological support is also critical for the optimal outcome [2]. The knowledge of common risk factor and types of amputations as well as complications helps clinician better anticipate and prevent those.

The literature has shown that anterior cruciate ligament (ACL) tear rates vary by gender, by sport, and in response to injury-reduction training programs. However, there is no consensus as to the magnitudes of these tear rates or their variations as a function of these variables. For example, the female-male ACL tear ratio has been reported to be as high as 9:1. Our purpose was to apply meta-analysis to the entire applicable literature to generate accurate estimates of the true incidences of ACL tear as a function of gender, sport, and injury-reduction training. Methods: A PubMed literature search was done to identify all studies dealing with ACL tear incidence. Bibliographic cross-referencing was done to identify additional articles. Meta-analytic principles were applied to generate ACL incidences as a function of gender, sport, and prior injury-reduction training. Results: Female-male ACL tear incidences ratios were as follows: basketball, 3.5; soccer, 2.67; lacrosse, 1.18; and Alpine skiing, 1.0. The collegiate soccer tear rate was 0.32 for female subjects and 0.12 for male subjects. For basketball, the rates were 0.29 and 0.08, respectively. The rate for recreational Alpine skiers was 0.63, and that for experts was 0.03, with no gender variance. The two volleyball studies had no ACL tears. Training reduced the ACL tear incidence in soccer by 0.24 but did not reduce it at all in basketball. Conclusions: Female subjects had a roughly 3 times greater incidence of ACL tears in soccer and basketball versus male subjects. Injury-reduction programs were effective for soccer but not basketball. Recreational Alpine skiers had the highest incidences of ACL tear, whereas expert Alpine skiers had the lowest incidences. Volleyball may in fact be a low-risk sport rather than a high-risk sport. Alpine skiers and lacrosse players had no gender difference for ACL tear rate. Year-round female athletes who play soccer and basketball have an ACL tear rate of approximately 5%. Level of Evidence: Level IV, therapeutic case series.

We carried out a blinded prospective randomised controlled trial comparing 2-octylcyanoacrylate (OCA), subcuticular suture (monocryl) and skin staples for skin closure following total hip and total knee arthroplasty. We included 102 hip replacements and 85 of the knee.OCA was associated with less wound discharge in the first 24 hours for both the hip and the knee. However, with total knee replacement there was a trend for a more prolonged wound discharge with OCA. With total hip replacement there was no significant difference between the groups for either early or late complications. Closure of the wound with skin staples was significantly faster than with OCA or suture. There was no significant difference in the length of stay in hospital, Hollander wound evaluation score (cosmesis) or patient satisfaction between the groups at six weeks for either hips or knees. We consider that skin staples are the skin closure of choice for both hip and knee replacements.

Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.

Trotz entscheidender Erkenntnisse über Biomechanik und Funktion des Handgelenks der letzten Jahre sieht sich der traumatologisch tätige Arzt nach wie vor mit einer Vielzahl posttraumatischer Spätschäden an diesem Gelenk konfrontiert. Neben der früher führenden Rettungsoperation, der Totalarthrodese des Handgelenks, stehen heute differenziertere Behandlungsverfahren zur Verfügung. Teilarthrodesen basieren auf dem Prinzip, den Karpus zu stabilisieren, zerstörte Gelenkflächen auszuschalten und in den noch erhaltenen Gelenkabschnitten eine Restbeweglichkeit aufrecht zu erhalten. Sie können unter Beachtung der Pathobiomechanik am Handgelenk für eine zunehmende Zahl von Indikationen mit Erfolg eingesetzt werden. Für den Patienten resultiert ein besseres funktionelles Ergebnis als bei Panarthrodesen und eine höhere Stabilität und längere Beschwerdefreiheit als bei Endoprothesen oder Arthroplastiken. Dennoch sind Untersuchungen zur Verbesserung der Ergebnisse und Wertigkeit einzelner Teilfusionen im Vergleich zu anderen Verfahren zu fordern und zu erwarten. Despite the important observations that have been made concerning biomechanics and function of the wrist joint in recent years, the surgeon is still confronted with a huge number of delayed posttraumatic disorders of this joint. In the past, total wrist fusion was the leading salvage procedure, whereas today several salvage procedures are available to solve these problems. Partial wrist fusions are supposed to stabilize the carpus, immobilize destroyed articulating surfaces while allowing motion in the unharmed parts of the wrist. Acknowledging pathobiomechanical laws, they have been used for a growing number of indications with a large benefit. The patients profit of better functional results than can be observed in patients with total arthrodesis of the wrist. Furthermore, partial wrist fusion provides a more stable situation and the absence of pain for a longer period of time. However, further studies evaluating the clinical outcome of these salvage procedures are necessary and to be expected in the near future.

Using meta-analysis we compared the survival and clinical outcomes of cemented and uncemented techniques in primary total knee replacement. We reviewed randomised controlled trials and observational studies comparing cemented and uncemented fixation. Our primary outcome was survival of the implant free of aseptic loosening. Our secondary outcome was joint function as measured by the Knee Society score. We identified 15 studies that met our final eligibility criteria. The combined odds ratio for failure of the implant due to aseptic loosening for the uncemented group was 4.2 (95% confidence interval (CI) 2.7 to 6.5) (p < 0.0001). Subgroup analysis of data only from randomised controlled trials showed no differences between the groups for odds of aseptic loosening (odds ratio 1.9, 95% CI 0.55 to 6.40, p = 0.314). The weighted mean difference for the Knee Society score was 0.005 (95% CI -0.26 to 0.26) (p = 0.972).

This study is based on the technique of minimally-invasive osteosynthesis using Titanium elastic nails (TENS) in OTA Type a midclavicular fractures with displacement or shortening more than 2 cm. The aim of the study was the evaluation of the operative technique and post-operative outcome after fixation of displaced midclavicular fractures with TENS. The study was carried out on 21 cases at, Bangalore medical College and research Institute for a period of 1 year. The mean age of all patients was 29 ± 11.25 years.All cases were treated with open reduction. Clinical union was seen at 7.8 ± 3.2 weeks (range 6-12 weeks) in all cases and the mean time for radiological union 19.8 ± 16.47 weeks (range 12-24 weeks). The functional outcome was measured using DASH and Constant Shoulder score. Results of our study showed that the Titanium Elastic Nail is an excellent implant for achieving reduction and union middle one third clavicular fractures with minimal surgical exposure during fixation and implant removal, minimal complications, and early rehabilitation.

Introduction: Vocal polyps and nodules are benign lesions of vocal cords. These lesions have significant influence on quality of life of patients. Mainly these lesions present as hoarse-ness of voice with vocal demand and abuse as significant precipitating factor. Objective of the study was to analyze clinical and demographic profile and VHI-10 of patients with vocal cord polyps and nodules. Material and Methods: A total of 50 patients with clinical diagnosis of vocal polyp or nodule were studied. All cases were analyzed clinically. History, laryngeal examination (Indirect laryngoscope and fibro-optic laryngoscopy) and patient self reporting questionnaire (VHI-10) was taken from every patient. Results: Total 50 cases with Male: Female ratio of 1.5:1 were analyzed. Age of patients ranged from 14 to 65 years and majority of patients with vocal polyps and nodules presented in 4 th decade. Voice demanding profession was presented in 46% of cases. Apart from voice demanding profession, other form of voice abuse, smoking and laryngopharyngeal reflux disease were other predisposing factors in 54%, 30% and 34% of patients respectively. Vocal polyps and nodules were roughly in equal ratio 26:24. Over all mean (+ SD) of VHI-10 was 11.16+6.68. In male, it was 10.2+5.91 and in female, it was 12.60+7.63. Conclusion: Vocal polyps and nodules are benign lesions of vocal cords with male predominance and voice demand/abuse acts as significant precipitating factor and have a significant impact on patients quality of life.