Revolutionizing Back Pain Management: Is Epidural Platelet-Rich Plasma the Superior Choice Over Steroids?

Background and objective Low back discomfort is one of the main factors that restrict physical activity, and it is becoming more and more common. Surgery is the best option when all other conservative treatment methods have failed, but it is not a panacea. While local anesthetic-free and combined epidural steroid injections have been used for many years, their usefulness is limited to shorter periods. In the field of orthopedics, platelet-rich plasma (PRP) has gained widespread recognition as an adjuvant component. PRP has been applied to improve tissue repair, both soft and hard. This comparative study aimed to evaluate the potential of PRP as a therapy for low back pain (LBP). Methods We included 64 adult individuals with complaints of LBP. They were classified into two groups: group A underwent a single injection in the afflicted lumbar intervertebral disc (IVD) level with 1.5 ml of methylprednisolone, 1.5 ml 2% lidocaine, and 0.5 ml of saline under rigorous aseptic precautions; in contrast, group B was administered a single injection of 3 milliliters of autologous PRP. Patients' scores on the visual analog scale (VAS), the Modified Oswestry Disability Questionnaire (MODQ), and the Straight Leg Raising Test (SLRT) were assessed before and during therapy. Results The data gathered were subjected to statistical analysis. Statistically significant differences were found in the VAS scores between group A (methylprednisolone group) and group B (PRP group) post-one hour (6.0 ±0.74 vs. 6.92 ±0.57) and after three months (5.2 ±0.65 vs. 3.26 ±0.79). Conclusions Our study revealed gradual progressive improvement in the symptoms of patients in the PRP group as indicated by scores on SLRT, VAS, and MODQ. The results were comparable to those who received methylprednisolone injections. There was a statistically significant difference in VAS scores between the two groups, with the PRP group reporting a higher degree of pain reduction, showing that PRP is an effective alternative to epidural steroid infiltration in managing chronic LBP.

A Comprehensive Review of Current Management Trends in Medial Compartment Arthritis of the Knee Joint

Medial compartment arthritis of the knee joint presents a significant clinical challenge, with diverse management options ranging from nonsurgical interventions to various surgical procedures. This comprehensive review synthesizes current evidence on the management trends in medial compartment arthritis, highlighting both nonsurgical approaches such as physical therapy, pharmacological interventions, and intra-articular injections as well as surgical interventions, including arthroscopic debridement, high tibial osteotomy, and knee arthroplasty. Through a comparative analysis of efficacy, complication rates, and patient outcomes, this review underscores the importance of tailoring treatment strategies to individual patient characteristics and preferences. Furthermore, emerging techniques and technologies promise to advance the field, necessitating ongoing research efforts to refine treatment algorithms and establish standardized guidelines. By adopting a multidisciplinary approach and integrating evidence-based practices, clinicians can optimize the management of medial compartment arthritis and enhance patient care outcomes.

Significance of Serum Lactate Dehydrogenase as a Prognostic Marker and Outcome Predictor in Patients With Breast Cancer

Background Breast carcinoma has been the most prevalent cancer in women, with research-based evidence showing a significant rise in the incidence of cancer and related morbidity and mortality in the Indian subcontinent. The predictive value of plasmatic lactate dehydrogenase (LDH) levels has been studied in breast cancer. Numerous studies have connected high LDH values to a poor prognosis, increased risk of incidence, recurrence, and associated mortality in patients with breast carcinoma. This study aimed to assess the clinical profile of breast carcinoma and determine the correlation of serum lactate dehydrogenase levels with the stage of the disease and assessment of high-risk features using histopathology and immunohistochemistry. Methods A total of 75 patients with carcinoma breast were enrolled for this study and classified into two groups: upfront surgery and post-adjuvant therapy. Serum LDH levels were estimated a day before the surgery (baseline) and on postoperative days 1, 7, 14, and 30. The clinical tumor, node, metastasis (cTNM) staging was correlated with pathological tumor, node, metastasis TNM (pTNM) staging and immunohistochemistry findings. Results The clinical characteristics of breast cancer, serum LDH levels, and stage of the disease were collected and analyzed. A significant decreasing trend was noted in LDH values post-op days, and statistically significant higher LDH values were noted in the triple-negative group, positive lymph nodes, and positive lymphovascular invasion patients. Conclusion Regularly elevated levels or an unanticipated rise in serum LDH might indicate poor outcomes. Hence, this non-specific enzyme marker can be suggested to be used routinely to assess disease outcomes.

Persistent Pain and Purulent Discharge: A Case of Infected Bipolar Hemiarthroplasty

Prosthetic joint infection (PJI) remains a significant complication following joint arthroplasty, necessitating prompt recognition and intervention to optimize patient outcomes. This case report describes a 65-year-old male who presented with persistent pain, swelling, and purulent discharge from the right hip, three years post-bipolar hemiarthroplasty following a road traffic accident. Clinical examination revealed signs suggestive of PJI, prompting surgical intervention with total hip arthroplasty. Postoperatively, the patient experienced resolution of symptoms and satisfactory recovery. This case underscores the challenges associated with infected joint arthroplasty and highlights the importance of a multidisciplinary approach for effective management. Early diagnosis, appropriate surgical intervention, and comprehensive postoperative care are essential for minimizing morbidity associated with PJIs and optimizing patient outcomes.

A Comprehensive Review of Total Hip Arthroplasty Outcomes in Post-traumatic Hip Arthritis: Insights and Perspectives

Post-traumatic hip arthritis presents a challenging condition characterized by degenerative changes in the hip joint following traumatic injury. Total hip arthroplasty (THA) is a cornerstone in managing this condition, offering significant pain relief, functional improvement, and enhanced quality of life. This comprehensive review aims to synthesize existing literature to elucidate the outcomes of THA in post-traumatic hip arthritis, exploring factors influencing surgical success and identifying areas for further research. Key findings reveal favourable clinical outcomes associated with THA, though considerations such as patient characteristics, surgical techniques, and implant selection impact outcomes. Implications for clinical practice underscore the importance of tailored preoperative assessment and ongoing advancements in surgical approaches and implant technology. Furthermore, opportunities for future research lie in long-term durability studies, patient-reported outcomes assessment, and exploration of innovative surgical techniques. Overall, THA emerges as a promising intervention for post-traumatic hip arthritis, yet continual refinement through research and innovation remains imperative to optimize patient care in this population.

Bilateral Anterior Cruciate Ligament Reconstruction Using Gracilis and Semitendinosus Graft by Single-Staged Approach

A bilateral anterior cruciate ligament (ACL) tear is one of the rare injuries that is seen in orthopaedics practice. Although few single-staged bilateral ACL ruptures have also been documented, most bilateral ACL ruptures happen on two different occasions. Although there isn't a clear consensus, there have been accounts of both single-staged and two-staged reconstruction of bilateral ACL ruptures in the literature. This case report provides surgeons with options to consider while treating this unusual injury. A 35-year-old woman with bilateral anterior cruciate ligament injuries presented with an MRI of her left knee suggestive of a complete ACL tear with a Medial meniscus tear in the left knee, and an MRI of her right knee showed a complete ACL tear. The patient underwent arthroscopic ACL reconstruction in a single stage for both knees. Six months after her surgery, she had met all the rehabilitation goals and was cleared to resume her daily activities. The patient preoperatively had a visual analogue scale (VAS) score of 8, and postoperative assessment, her VAS score reduced to 2. ACL reconstruction in one stage and two stages were the surgical treatment modalities described in the literature. Concurrent rehabilitation of both ACL repairs is more economical, reduces hospital stay, and helps in early recovery, but it may result in severe quadriceps deconditioning. Double-staged surgeries are less demanding, with a shorter duration of surgery that can be performed by a less experienced surgeon. As single-staged bilateral ACL reconstruction is a less expensive option that reduces hospital stays and aids in early recovery for this rare patient population, it may be a great therapy option compared to two-staged bilateral ACL reconstruction.

Intraoperative Foot Positioning During Percutaneous Calcaneal Fixation: A Technical Note

Percutaneous screw fixation is a good modality for operative management of extra-articular and some intra-articular fractures of the calcaneum amenable to closed reduction. Tongue-type calcaneal fractures with a dislocated posterior facet are usually treated with percutaneous fixation. When treating calcaneal fractures with substantial soft tissue compromise, particularly open fractures, percutaneous reduction techniques are crucial. They also provide patients with local or systemic contraindications to open reduction with a therapeutic option. We describe the intraoperative positioning of the foot using a lithotomy stirrup during percutaneous fixation of the calcaneal fractures with minimum manipulation of the foot and C-arm and consistent imaging.

Use of Endobutton for Small Avulsion Fracture of Coronoid in the Terrible Triad of the Elbow: A Case Report

The terrible triad (TT) of the elbow consists of coronoid process (CP) fracture, fracture of the radial head (RH), and posterior dislocation. Although the coronoid is an important anterior stabilizer, it is still unclear how to treat comminuted coronoid fractures. Poor fixation of the CP tends to result in posterolateral instability at the elbow joint and often in chronic instability. The ligamentous injuries also cause instability in elbow dislocations and should be suspected. There are various techniques available for coronoid fracture fixation. In this case report, we want to highlight our experience managing a 47-year-old male with posterior dislocation of the elbow after computed tomography (CT) confirmed that the patient had an RH fracture with an avulsion fracture of the coronoid. This TT of the elbow was managed with the help of an endobutton and a Herbert screw for coronoid avulsion fracture and RH fracture, respectively, through a lateral (Kocher) approach in our tertiary care hospital with satisfactory results. The use of endobutton is recommended in type 1 and type 2 coronoid fractures with no or minimal capsular attachment for good suspensory effect, and it emphasizes the possibility of associated coronoid fracture in case of posterior elbow dislocation. This case report emphasizes the fixation of even small fragments of the coronoid fracture for better stability and early mobilization. Postoperative rehabilitation involved using a hinged brace and early mobilization to avoid a stiff elbow and periodic X-rays to check the heterotopic ossification risk.

Giant Cell Tumor of Extensor Tendon Sheath in Ring Finger: A Case Report

Giant cell tumour of the tendon sheath (GCTTS) is a rare benign soft tissue tumour with no known cause. It is more prevalent in the hand than in the ankle and foot. It appears as a non-painful, perceptible enlargement. Although pre-operative imaging and fine-needle aspiration cytology (FNAC) corroborate suspicion, histology following surgical resection is used to confirm the diagnosis. Due to its rarity, a case of giant cell tumour (GCT) of the extensor tendon sheath of the left ring finger is reported here. A 39-year-old female presented with a six-month history of painless swelling over left ring finger. The swelling was spontaneous, slowly progressive and painless. On clinical examination, a 1.5 cm x 1 cm firm swelling was seen on the dorsal surface of the left ring finger extending from the distal portion of the middle phalanx to the proximal half of the distal phalanx. The swelling was well-defined, smooth, firm, and uniform in consistency. The swelling was movable sideways with no attachment to the bone when examined clinically. X-ray of the hand showed soft tissue mass without the involvement of the bone. Soft tissue mass was seen on ultrasonography. An excisional biopsy was done. Histopathology showed typical features of GCTTS. Our case is a rare example of GCTTS in a single digit of the hand. Furthermore, considering its high recurrence risk, the tumour should be totally excised. Finally, if required, the hand's function should be recreated to minimise the loss.

Surgical Repair of Achilles Tendon Rupture by Turn-O-Plasty: A Case Report

Achilles tendon rupture has been a difficult problem for surgeons, especially in older patients, since tendon strength and flexibility are significantly diminished compared to young people. The Achilles tendon endures the highest tensile stresses in the body while running, leaping, and skipping, with tensile loads up to 10 times body weight. There are many treatment options for Achilles tendon repair, including open surgery, percutaneous repair, and ultrasound therapy. Open repair has the danger of scar dehiscence owing to poor skin conditions. In contrast, small invasive operations have the risk of sural nerve damage and a higher possibility of re-rupture. The gold standard method or approach is still under question. Plantar flexion in the ankle is primarily a function of the Achilles tendon; hence, post-operative plantar flexion is a significant determinant of the desired result. We present the case of a 57-year-old male farmer suffering from a left Achilles tendon rupture due to trivial trauma. This rupture consisted of a significant defect, present in the watershed area with signs of tendinosis at the insertion of the tendon. The patient was managed surgically by turn-o-plasty and the degenerated insertion site was augmented with the help of a suture disc. This case report focuses on surgical management by turn-o-plasty for significant defects in the Achilles tendon by using a suture disc to augment the defect.

Transient Hypertension in a case of Congenital Pseudarthrosis of Tibia treated with Ring Fixator: A Case Report

Introduction

Congenital pseudarthrosis of tibia is an uncommon condition leading to gradually progressive deformity, shortening of the limb and disability. The condition is notorious for failure of treatment and need of multiple operations. A combination of open reduction, thorough excision of abnormal tissue at the pseudarthrosis site, intramedullary nailing, ring fixator application, and distraction to achieve bone equalization has proved successful.

Case Report

A case of congenital pseudarthrosis of the left tibia and fibula associated with neurofibromatosis treated by open reduction, intramedullary nailing, ring fixator application, and distraction at corticotomy to cause compression at the pseudarthrosis site and limb length equalization is being reported due to uncommon occurrence of transient hypertension in the child as a complication of ring fixator.

Conclusion

Transient hypertension is a rare complication seen in children after application of ring fixator. Its diagnosis and control require proper perioperative assessment of child regarding blood pressure (BP), monitoring of BP during distraction period and period of application of ring fixator, and its treatment under care of pediatrician.

Functional Analysis of Fracture Patella Managed with Tension Band Wiring

Background: Fracture patella accounts for around 1% of all skeletal fractures. It is basically of 2 types: displaced fracture and un displaced fracture. It mainly occurs due to direct blows to the knee joint such as car accidents, injuries, or direct falls on the ground with bent knees. Management of these fractures varies from cylindrical cast application to surgical management for displaced fractures. This study focuses on the functional evaluation of fracture patella managed with tension band wiring. Materials and Methods: 17 patients with displaced transverse patella fracture managed with tension band wiring were included in the study. An interventional study was performed in AVBRH hospital Wardha between 2017-2019. Operated patients were followed up at one month, two months, and three months for functional assessment. On every follow-up, x-ray was taken to assess the union and implant positioning. Observations and Results: 41.47 were the mean age (in years) of patients participating in the study. In the study, 17 patients participated, 13 were males (76.47%) and 4 were females (23.53%). Comminuted and oblique fractures were excluded from the study. Out of 17 patients at final follow up, 70.58% patients had excellent results, 29.42 percent had good results, and no patient had a poor functional outcome. Conclusion: Tension band wiring of fracture patella yields better fun outcomes outcome and an inexpensive method of managing fractured patella. Early knee mobilization and knee range of motion exercises should be started to avoid quadriceps muscle wasting.

Risk factors for progression of paroxysmal to persistent atrial fibrillation following successful PV isolation

Background

Progression from paroxysmal (PAF) to persistent atrial fibrillation (PerAF) following effective PV isolation (PVI) has important clinical implications, as it is relevant for subsequent management of the arrhythmia.

Objective

We evaluated risk factors responsible for progression of PAF to PerAF following successful PVI.

Methods

Consecutive AF patients that received their first catheter ablation as well as the first redo at our center were identified (n=1352). Patients were included in group 1 if the diagnosis was PAF at both first and redo procedure (PAF to PAF) and group 2 if PAF at index progressed to PerAF at redo. All patients received PVI plus isolation of LA posterior wall and SVC at the first procedure.

Results

A total of 822 patients remained as PAF at redo, whereas 530 (39%) progressed from PAF to PerAF. Clinical characteristics of the study population are presented in table 1. In multivariate analysis, BMI (OR 1.02, 1.01–1.04, p=0.04), hypertension (1.4, 1.08–1.8, p=0.01), heart failure (1.67, 1.03–2.69, p=0.03), LA size (2.75, 2.29–3.31, p<0.001) were independent predictors of progression of PAF to PerAF. Data on serum-transthyretin level was available for 37 and 48 patients in group 1 and 2 respectively. It was <18 mg/dL (normal) in 33 (68.7%) patients in group 2 vs 6 (16.2%) in group 1 (p<0.001).

Conclusion

In our patients, after successful PVI, progression of PAF to PerAF was mediated by independent risk factors such as high BMI, heart failure, hypertension, larger LA size and lower LVEF.

Funding Acknowledgement

Type of funding source: None

Extended Pulmonary Vein Isolation: is it sufficient to achieve long-term sinus rhythm in octogenarian women with atrial fibrillation?

Background

Atrial fibrillation (AF) is a disease of the elderly and women typically present with AF at an older age than men do. Moreover, they tend to experience more symptoms and post-ablation recurrences, have worse quality of life and increased risk of stroke and mortality.

Objective

We evaluated long-term efficacy of our standard ablation approach of extended pulmonary vein isolation (PVI) in octogenarian women undergoing their first AF ablation.

Methods

Consecutive female AF patients aged ≥80 years receiving their first catheter ablation at our center were included in the analysis. Our standard ablation approach at the first procedure includes PVI + empirical isolation of left atrial posterior wall (LAPW) and superior vena cava (SVC). Complete abolition of all potentials rather than decrease in amplitudes was the procedural end point. Patients were prospectively monitored at regular intervals for 3 years after the index procedure with event recorders, 12-lead ECG, cardiology evaluation at office visits and 7-day Holter monitoring.

Results

A total of 194 patients with mean age of 84.2±1.4 years were included in the analysis. Of the 194, 120 (61.8%) had non-paroxysmal AF. All received PVI+ isolation of LAPW and SVC. Acute procedural success was achieved in 100% of cases.

At 3 years of follow-up, 24 (12.4%) patients remained in sinus rhythm; 22 on- and 2 off-antiarrhythmic drugs (AAD). All of the 23 patients had paroxysmal AF as their initial diagnosis.

Of the 170 patients experiencing recurrence, 147 underwent repeat ablation. PV/PW/SVC reconnection was noted in only 6 (4.1%) patients at redo. Triggers originating from non-PV sites were targeted for ablation in all. At 1.5 years after the repeat procedure, 136 (92.5%) patients were in sinus rhythm; 131 off-AAD and 5 patients on-AAD.

Conclusion

Extended PVI including isolation of posterior wall and SVC was not sufficient to maintain long-term sinus rhythm in majority of octogenarian women, regardless of AF type. Moreover, non-PV triggers rather than PV reconnection was the major cause of recurrence in this subset of AF population.

Funding Acknowledgement

Type of funding source: None

Risk factors and effective ablation strategy in patients presenting with left atrial flutter with no previous ablation for atrial fibrillation

Background

A typical left atrial flutter (LAFL) may occur as a proarrhythmic complication of ablation for atrial fibrillation (AF).

Objective

We evaluated the risk factors and the best ablation strategy for LAFL in patients with no prior AF ablation.

Methods

Consecutive patients undergoing first catheter ablation for AFL with no prior procedure for AF were included in this prospective analysis. Based on the ablation strategy, patients were divided into, Group 1: PVI+ Flutter ablation (ablation of re-entry circuits) and Group 2: PVI+ Non-PV trigger ablation (targeting areas of focal activity as triggers). 3-D mapping of the LA was performed during tachycardia to identify the reentrant circuit.

PV isolation was performed in all patients. In group 1, ablation line was chosen to transect the area critical for the circuit (roof and mitral line). In group 2, ectopic beats arising from extra-PV foci detected by isoproterenol challenge were ablated. Off-drug success rate was assessed in all.

Results

A total of 92 and 90 patients were included in group 1 and 2 respectively. Baseline characteristics are provided in table 1. Pre-existent LA scar was detected in 91.3% and 90% of patients in group 1 and 2 respectively.

At 2 years of follow-up, 11/92 (12%) from group 1 and 60/90 (66.7%) from group 2 remained arrhythmia-free off-drugs (p<0.001). In the multivariate analysis, PVI +flutter ablation was detected to be associated with significantly high risk of recurrence [HR: 3.92 (95% CI: 2.52–6.1, p<0.001)]

Conclusion

In this series of patients presenting with LAFL with no earlier AF ablations, pre-existent left atrial scar was detected in majority of cases and PVI+ non-PV trigger ablation provided significantly better success rate than PVI+ flutter ablation.

Funding Acknowledgement

Type of funding source: None