Prevalence of Poor Nutrition in Knee Osteoarthritis Patients: A Hospital-Based Cohort Study in Indian Population

Purpose

Malnourished adults with knee osteoarthritis (OA) have a lower propensity for physical activities, leading to post-surgical stress and poorer clinic-functional outcomes. The study is aimed to propose an integrative screening procedure for patients and to identify a subset of patients who are undernourished or at risk of undernutrition in the Indian population.

Methods

A hospital-based cross-sectional study was conducted at a tertiary care, a university-level teaching hospital for seven months, which included knee OA patients above the age of 45 years, and the following criteria were evaluated anthropometric measurement and blood biochemical parameters and nutritional scoring system.

Results

The current study reports a high prevalence of malnutrition (69.5%) in patients with knee OA in the Indian population based on blood biochemical levels, and late presenters are associated with poor nutritional status of an individual. A single gold standard blood biochemical test, serum albumin alone, reports many malnourished individuals in the population, and the remaining blood biochemical parameters may not yield any additional information. Mini nutritional assessment, mid-arm circumference, and mid-calf circumference are poor predictors of malnutrition, and we need a revised cut-off for our group of patients.

Conclusion

In the cohort of OA Knee, the prevalence of malnutrition is high (69.5%) in the Indian population. Serum Albumin is the best parameter to detect the presence of malnutrition preoperatively, and MNS is not applicable to detect malnutrition in our subset of patients. The study recommends routinely measuring serum albumin levels in all patients to correct the nutritional abnormality preoperatively, resulting in better surgical outcomes and reduced post-operatively complications.

Level of evidence

IV.

Can patient anthropometry predict the anterior cruciate ligament footprint dimensions? - An MRI-based observational study on north Indian population

Background

Anterior Cruciate Ligament (ACL) reconstruction is one of the most common surgeries being currently done. As we usher into the era of Individualized Anatomic Reconstruction, it is very important to understand the native anatomy of ACL. We aimed to assess the ACL footprint dimensions in our patients and correlate it with anthropometric variables, which can help in preoperative decision making.

Method

A total of 143 eligible patients with suspected ACL injury presented during the study period. Out of which 92 were included in the study. Data on patient's age, sex, height, weight and body mass index (BMI) was recorded. The length and area of both the tibial and femoral footprints were measured on MRI. The footprint dimensions were correlated with the recorded anthropometric data.

Results

The ACL tibial footprint length and area, and femoral footprint length and area were found to be 13.3 ± 2.23 mm, 142.6 ± 26.16 mm2, 11.2 ± 1.97 mm, 125.8 ± 28.75 mm2 respectively. Footprint in males was significantly larger than females. A weak (ρ- 0.21 to 0.4) correlation with weight and moderate (ρ- 0.41 to 0.6) correlation with height was observed. Multivariate linear regression analysis yielded height to be the only significant predictor of footprint dimension from which predictive equations were drawn.

Conclusions

Height was found to be the most significant predictor of footprint dimensions in our patients. The predictive equations and graphs can aid in preoperative surgical decision making resulting in a more anatomical ACL reconstruction and improve the post-operative results.

Increased medial talar tilt may incite ankle pain and predispose ankle osteoarthritis after correction of severity of knee varus deformity among patients undergoing bilateral total knee arthroplasty: a prospective observation

PURPOSE

Patients with varus knee osteoarthritis usually compensate at the ankle and typically walk with hindfoot valgus alignment. As the neutral weight-bearing axis of the lower limbs is restored with Total Knee Arthroplasty (TKA), ankle and hindfoot biomechanics also acutely change. This study aims to investigate whether any ankle clinical-radiographical changes occur as a result of bilateral mechanical TKA in patients with bilateral Osteoarthritis knee at a minimum follow-up of 6 months.

METHODS

The prospective observational study included 61 patients (122 knees) undergoing simultaneous bilateral TKA (mechanical alignment). Tibio-talar angle(TTA), tibial Anterior Surface angle (TAS), lateral distal tibial angle (LDTA), talar-tilt angle (TT), anatomical talocrural angle (aTC), ground surface and distal tibial plafond angle (GP), ground surface and an upper surface of talus angle (GT)and tibial plateau and tibial plafond angle (PP) were measured on long-film radiographs to look for changes in the ankle, whereas functional assessment was done using American Foot and Ankle Society (AOFAS), Foot and Ankle Disability Index (FADI), and Forgotten Joint (FJS-12) scores. Patients were sub-grouped based on the Hip-Knee-Ankle (HKA) axis, and the effect of the severity of knee varus on the ankles after TKA was also analyzed. The minimum follow-up was 6 months.

RESULTS

A significant decrease in the tibial plateau-tibial plafond (PP), ground-tibial plafond (GP), and ground-talar dome (GT) angles was noted after TKA (p-value < 0.05). Postoperative functional parameters were comparable to the preoperative status except for FADI, which significantly improved (p-value-0.03). Sub-group analysis based on the severity of knee varus (HKA) revealed GT to be most significantly reduced (p-value-0.036), while the talar tilt (TT) increased (p-value-0.044). Functional outcomes of the ankles clinically improved with the correction of severe knee varus after TKA. At a mean follow-up of 13.2 months post-TKA, 7 out of 61 (11.4%) patients complained of post-TKA ipsilateral ankle pain.

CONCLUSION

Mechanically aligned bilateral TKA in severe varus deformity of the knee significantly decreases the GT angle but increases the varus tilt of the talus with lateral talar incongruency and under-coverage. Although the acute correction of severe knee varus deformity aligns the tibia more neutrally, resulting in an overall clinically evident improvement in ankle functional outcome, the increased varus talar tilt remains a deep concern.

LEVEL OF EVIDENCE

Prospective, observational, comparative study Level II.

Arthroscopic release and decortication provide earlier return to work with similar patient satisfaction compared to continued intensive conservative therapy for recalcitrant tennis elbow: a retrospective observational study

INTRODUCTION

Tennis elbow management has primarily been conservative over the years with over 90% of the cases being managed conservatively. Surgical intervention may be necessary only for symptomatic recalcitrant cases of tennis elbow cases. However, there are gaps in the literature when it comes to comparison of the return to pre-operative return to their work and level of activities among patients who undergo arthroscopic management and those who receive conservative management.

METHODS

A retrospective observational study was conducted to compare 23 patients receiving continued intensive conservative (CIC) management in group 1 with 24 patients undergoing arthroscopic release of the extensor carpi radialis brevis and lateral epicondyle decortication (ARD) in group 2. The study had a minimum follow-up period of 3.5 years. The researchers compared the groups in terms of return to work (RTW) at the same intensity or lower level and any changes in their previous work. Objective grip strength and patient-reported outcome measures, such as post-intervention satisfaction level (rated on a scale of 0-100) and visual analog scale (VAS) for residual elbow pain, were also compared between the two groups.

RESULTS

Return to work (RTW) occurred significantly earlier in group 2 (mean 6.13 months) compared to group 1 (mean 4.64 months), and a greater number of patients in group 2 (13/24, 54.2%) were able to return to the same of work. Although not statistically significant, the ARD group exhibited comparable patient satisfaction (p = 0.62) and visual analog scale (VAS) scores for residual elbow pain (p = 0.67). Grip strength was comparable (p = 0.084, 0.121) between the affected and unaffected sides of the bilateral upper extremities and among both groups of patients.

CONCLUSION

The use of ARD for RTE (recalcitrant tennis elbow) indicates a significantly earlier return to work (RTW) at the same or lower intensity level compared to the standard CIC therapy protocol. Objective grip strength was comparable to the non-affected side and among the two groups of patients receiving two different management modalities. Comparable patient-reported satisfaction and residual lateral elbow pain were also noted among both the groups.

LEVEL OF EVIDENCE

Retrospective, comparative study, level III.

Reliability and Usefulness of YouTube as a Source of Informative Media for Arthroscopic Tennis Elbow Surgery: A Systematic Review of the Published Videos

Aims and Objectives

Over the last decade, YouTube has been extensively used as a learning tool for both physicians and patients, but the reliability of this information remains questionable. The purpose of this study was to look for the reliability and quality of videos on tennis elbow arthroscopy on YouTube.

Materials and Methods

We used three search terms on YouTube "tennis elbow arthroscopic surgery," "Arthroscopic ECRB release," and "Arthroscopic debridement for tennis elbow," and screened the first 50 videos according to popularity. The videos were included from 2009 to date. Only videos in the English language were included. Repeated videos and videos without sound were excluded. A total of 74 videos were selected for this study and reliability was checked with DISCERN and journal of the American medical association (JAMA) scores. The quality was assessed with the Global Quality Score Criteria (GQSC) score and TEARS (a novel score). Popularity was tested with the video power index (VPI). A pilot study was conducted using 20 videos to validate the TEARS score.

Results

In the pilot study, TEARS showed results in accordance with other scores used. The average number of views was 41,644.97, and the average duration was 5.03 ± 3.39 years. The mean value of DISCERN and JAMA was found to be 21.47 ± 6.28 and 1.05 ± 0.92, respectively. GQSC, TEARS, and VPI were found to be 1.70 ± 0.82, 4.17 ± 2.62, and 769,936.9 ± 6,538,851.37.

Conclusion

Most of the videos were educational and physicians were targeted. The USA was the major contributor to such videos. The reliability and quality of these videos were found to be of poor quality. The video popularity was however found to be relatively high. The inter-observer reliability was good. Based on the findings, we conclude that the videos are not reliable and could not be used for learning.

Conventional rehabilitation post-TKA achieves better knee flexion with higher resource utilization compared to application-based rehabilitation - a systematic review and meta-analysis

Background

Post-operative physiotherapy is a major component of the effectiveness of knee replacement. Adequate rehabilitation protocols are required for better functional outcomes. With the advent of smartphones and smartwatches, the use of telerehabilitation has increased recently. This study aims to compare tele rehabilitation using various mobile-based applications to conventional rehabilitation protocols.

Methods

From Jan 2000 to Jun 2022, all the RCTs from SCOPUS, EMBASE and PUBMED comparing patient-related outcome measures between the smartphone-based app and conventional rehabilitation protocols were scanned and seven studies meeting the eligibility criteria were included in this systematic review and meta-analysis. The quantitative analysis compared outcomes using the knee injury and osteoarthritis outcome score (KOOS), the knee society function score (KSFS), the active range of motion (AROM), Euro-Qol-5D-5L, and MUA. The qualitative analysis compared VAS, NRS, and Time up and go (TUG).

Results

The study shows statistically significant improvement in traditional rehabilitation over app based on KSFS score (M.D.: 6.05, p = 0.05) and AROM on long-term follow-up (12 months) (M.D.: 2.46, p = 0.02). AROM was insignificant on 3 months or less follow-up. NRS and VAS were found to be statistically better in app-based groups. No statistically significant results were seen on KOOS, Euro-Qol-5D-5L, MUA and TUG. 90 days of readmission and a number of physiotherapy visits were more in conventional groups. No difference was seen in single-leg stance and satisfaction rates.

Conclusions

The present review highlights improved early pain scores and comparable patient-reported outcome analysis at a short-term follow-up period among patients receiving mobile app-based rehabilitation. However, knee range of motion and KSFS score achieved after surgery is analysed to be better with traditional rehabilitation at the one-year end follow-up period.

Modern implants in total knee arthroplasty are more patellofemoral joint friendly compared to their traditional design: a systematic review and meta-analysis

BACKGROUND

Implant designs for total knee arthroplasties (TKA) are continuously evolving to improve outcomes and satisfaction rates after TKA. The present systematic review and meta-analysis aimed to explore the evidence in the literature regarding the outcomes of the Attune knee system over the PFC Sigma knee design and investigate the advantage of one over the other.

METHODS

A systematic review and meta-analysis of published studies till August 2021 was performed using the defined eligibility criteria. This was a systematic review of the literature published in the Cochrane Central Register of Controlled Trials (CENTRAL) Library, PUBMED, and EMBASE. The analysis included prospective and retrospective comparative trials comparing TKA by PFC sigma or Attune posterior stabilized (PS) or cruciate-retaining (CR), fixed bearing, or rotating platform systems. Patient-reported outcome measures (PROM) and postoperative patellar complications were analysed in the studies utilizing attune knee system (modern implants) to its counterpart PFC sigma (traditional implants) for TKA. Quality assessment was conducted using NIH Quality Assessment Tool for controlled intervention studies (RCTs and case-control studies).

RESULTS

This review included 3 RCTs and the rest, 10 of which were non-RCT, including 5852 patients. ATTUNE designs suggested a statistically significant improvement in KSS over PFC Sigma designs. Other PROMs such as OKS and WOMAC scores yielded comparable results between the two groups. ATTUNE knee prosthesis did not result in better knee range of motion, patient satisfaction, or radiological outcomes than the PFC design. Regarding the complications, attune knee prosthesis demonstrated favourable results over PFC Sigma for anterior knee pain and patellofemoral (PF) crepitus.

CONCLUSIONS

The present systematic review highlights better KSS and lesser chances of PF complications favouring a modern implant design over its traditional counterpart. Other patient-reported outcome analyses at a short-term follow-up period were comparable among patients undergoing total knee replacements with two different implant designs. Radiological outcomes for component positioning also suggested similar results among the two groups.

Medial Patellofemoral Ligament Tear Associated with an Intra-articular Axial Spilt Osteochondral Fracture of the Lateral Femoral Condyle: a "Knee Trap-door" Fracture

Introduction

Medial patellofemoral ligament (MPFL) prevents lateral dislocation of the patella and acts as a major stabilizer. The tear could be associated with osteochondral avulsion fractures; however, intra-articular split fractures are not seen. Here, we present one unusual case of such a presentation.

Case Report

A 16-year-old male presented with a history of recurrent patellar dislocation and inability to bear weight following the last episode. The patient was diagnosed with an MPFL tear with an unusual intra-articular femoral condyle split fracture. The case had significant improvement in functional scores post-surgery.

Conclusion

In physically active populations, twisting of the knee could result in an MPFL tear, leading to recurrent patellar dislocation. The treatment remains ligament reconstruction, open, or arthroscopic. Associated intra-articular fractures are very rare with such injuries and need to be addressed due to the high rate of non-union.

Full-thickness peroneus longus tendon autograft for anterior cruciate reconstruction in multi-ligament injury and revision cases: outcomes and donor site morbidity

PURPOSE

Peroneus longus tendon (PLT) autograft has been successfully used for isolated anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction cases. Being a powerful evertor and flexor of great toe, there might be associated ankle morbidity with this autograft option. However, there are only a few studies exploring whether the ankle morbidity is significant or not. This study aims to assess the functional outcomes, donor site morbidity, and ankle strength after harvesting ipsilateral peroneus longus autograft for ACL reconstruction in revision ACL and multi-ligament injury cases.

METHODS

This was a prospective case series. All of the patients were evaluated by clinical examination for knee for laxity, ankle joint stability, and using visual analog scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, and Lysholm score, preoperatively and postoperatively at two-year follow-up. Morbidity of donor ankle was assessed using American Orthopedic Foot and Ankle Society (AOFAS) score, bilateral evertors, and first ray plantarflexion strength measurement using an isometer (Innovative Design Orthopedics) at two-year follow-up.

RESULTS

Ipsilateral PLT graft was used in ten patients of revision ACL reconstruction and 27 patients of the multi-ligament knee injury. The mean length of PLT harvested (cm) was 26.2 (standard deviation 2.6, range 22-31), and mean diameter of the doubled graft (mm) was 7.9 (standard deviation 0.68, range 7.5-8.5). There was a significant improvement in VAS score for pain, Lysholm, and IKDC scores (p =  < 0.001) at two -year follow-up. There were no cases of graft failure, superficial, or deep infection. Ankle dorsiflexion(p = 0.32), ankle plantarflexion (p = 0.19), eversion strength(p = 0.6), first ray plantarflexion strength(p = 0.52), and AOFAS score(p = 0.29) were found to be comparable to the normal side in all patients.

CONCLUSIONS

Peroneus longus autograft can be considered as a potential autograft option for ACL reconstruction in multi-ligament knee injuries and revision ACL reconstruction. No significant donor site morbidity was noted at follow-up.

LEVEL OF EVIDENCE

Level IV.

The direct anterior approach without traction table: How does it compare with the posterior approach? - A prospective non-randomised trial

PURPOSE

The direct anterior approach (DAA) for total hip replacement (THR) is relatively new. It has been proved superior to other techniques concerning early functional outcomes, stability, and earlier recovery. But DAA-THR has a steeper surgical learning curve and, in its original description, needs special operating room equipment. This study aims to present clinical, functional, and radiological outcomes of DAA compared to the posterior approach (PA), performed using a routine operating table and instrumentation sets.

METHODS

Eighty patients undergoing THR were non-randomly allocated prospectively into Group 1 DAA and Group 2 PA. Visual analog scale (VAS) for pain was recorded preoperatively and at 6, 12, 24, 48, and 72 h after the surgery and at 1st and 2nd year postoperatively. Both groups' functional outcomes were evaluated pre-and postoperatively at 1st and 2nd-year follow-up with Harris hip score (HHS) and SF-12. Perioperative parameters like blood loss, length of hospital stay, duration of surgery, postoperative complications, and radiological prosthesis positioning were also compared between the two groups.

RESULTS

All patients were comparable according to their baseline demographic characteristics. DAA was found to have significantly better early HHS at one year (p = 0.001) and VAS for hip pain (p < 0.05) at 12, 24, 48, and 72 hrs postoperative period only. Clinical outcomes were comparable at the final follow-up of 2 years. Perioperative variables were also similar except the incision length, length of stay in the hospital, and average time to weight bear without walking aids which were statistically better in DAA than PA group. There was no difference in radiological prosthesis positioning. Postoperative complication rates were also comparable in the two groups.

CONCLUSION

Though technically demanding, DAA provides better early functional outcomes with comparable radiological outcomes and complication rates than the PA.Level of evidence: Non-randomized comparative trial, Level II.

Outcomes of Continued Intensive Conservative Treatment Versus Arthroscopic Extensor Carpi Radialis Brevis Release for Recalcitrant Lateral Epicondylitis: A Non-randomized Controlled Trial

INTRODUCTION

There is no consensus on treatment of recalcitrant lateral epicondylitis (RLE). This is a prospective, non-randomized, interventional study comparing pain scores and functional outcomes between arthroscopic extensor carpi radialis brevis release and continued intensive conservative treatment.

MATERIALS AND METHODS

The study compared two groups: Group 1, consisting of 25 patients undergoing continued conservative treatment for 24 months, and Group 2, consisting of 25 patients undergoing arthroscopic extensor carpi radialis brevis release with decortication (ARD). VAS (Visual Analogue Scale) score for lateral elbow pain at rest and after routine daily activities were compared at 6 weeks, 24 weeks, 12 months and 24 months. Functional outcomes were compared with grip strength, and patients reported functional outcome scores, pre-intervention and 24 months post-intervention.

RESULTS

There was a significant improvement in VAS scores for pain, functional outcome scores, and grip strength in both the groups post-intervention (P < 0.05). VAS scores for pain at rest in both the groups were significantly better after the interventions, at all follow-up durations (P < 0.001). VAS scores for pain after routine daily activities were significantly better in group 2 at 24 weeks (P = 0.002) and afterward (P < 0.001). Group 2 had significantly better functional outcome scores at 24 months (P < 0.001) though the difference in grip strength was not statistically significant (P = 0.121).

CONCLUSION

The present study shows favourable functional outcomes and pain scores of ARD compared to continued intensive conservative treatment for RLE.

LEVEL OF STUDY

II, Non-randomized comparative study.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00649-w.

No Additional Benefits of Tissue Adhesives for Skin Closure in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

This systematic review is aimed to compare the performance of tissue adhesives (TA) as an adjunct or closure method with traditional wound closure methods for cutaneous closure in arthroplasty and evaluate whether they have any added benefits in terms of decreasing wound complications and increasing postoperative patient satisfaction.

METHODS

Cochrane Library, PubMed, and EMBASE were searched until February 2021. Randomized controlled trials (RCTs) comparing outcomes of TA with emphasis on skin closure time, in-hospital stay, complication rates, cosmetic scoring systems, and patient satisfaction scores (PSS) compared to subcuticular sutures (SCS) and skin staples (ST) in arthroplasty. The quality of RCTs was assessed using the National Institutes of Health quality assessment tool.

RESULTS

Ten RCTs were included. The pooled and the subgroup analysis revealed no significant difference in the wound infection rates, discharge rates, dehiscence rates, and PSS between TA (as an adjunct or closure method) and SCS or ST. TA (as an adjunct or closure method) was significantly (P < .00001) associated with a longer time to closure compared to ST and a shorter time compared to SCS as a closure method. Length of stay was comparable in all groups.

CONCLUSION

Using TA in combination with subcuticular sutures or ST or as a cutaneous method of closure does not provide additional benefits in terms of decreased hospital stay, decreased infection rates, or wound discharge rates. The PSS and pain scores of the scars also appear to be comparable to standard wound closure methods. No clear conclusion could be drawn regarding cosmetic scoring systems, because of the paucity of data.

LEVEL OF EVIDENCE

Level I (Meta-analysis of RCTs).

Late Metastasis of Renal Cell Carcinoma in Distal Femur Treated with Knee Joint Preservation: A Case Report

Introduction

Late metastasis and recurrences after 10 years of curative treatment is a known biological behavior of renal cell carcinoma (RCC) and a long follow-up is required for the detection of metastasis. Late solitary bony metastasis is very rare. No case of a late solitary metastasis of distal femur, treated with wide local excision and reconstruction, is available in the literature. We present a case of solitary metastatic lesion of distal femur 12 years after radical nephrectomy for renal cell carcinoma in a 64-year-old male.

Case Report

The patient presented to us with swelling in the right distal thigh for three years with a history of radical nephrectomy for RCC 12-years back. The lesion was not responding to local radiotherapy, and chemotherapy in the form of oral pazopanib, taken before orthopedic consultation. After core biopsy, the tumor was managed by intercalary wide local excision and reconstruction using a cement block and a lateral locking plate. Post-operatively, the histopathology report confirmed the diagnosis to be a clear cell tumor, consistent with metastatic RCC. The patient is independently mobile and tumor-free 2 years after the surgery.

Conclusion

Wide resection and reconstruction of the skeletal defect remains the mainstay of the management of metastatic solitary lesion. We have presented a unique case of distal fem-oral solitary metastatic deposit from a primary RCC 12 years post radical nephrectomy treated by intercalary resection and reconstruction with bone cement-plate hybrid construct.

Plate osteosynthesis in patellar fractures: a systematic review and meta-analysis

INTRODUCTION

To perform a systematic review and assess the indications, outcomes, complications, and union rates associated with plate osteosynthesis in patellar fractures compared to tension band wiring.

METHODS

The systematic search was conducted for articles in PubMed, Embase Biomedical, Cochrane central, and LILACS databases (date of inception to July 30, 2020). Articles were included if they were randomized control trials, cohort studies, case-control studies, and case series (with more than five cases), which focused on the clinical outcomes of patients with plate osteosynthesis as a treatment for fracture of the patella and had a minimum follow-up of 3 months. All studies were assessed according to their level of evidence, the number of patients, age of patients, fracture patterns described, complications of treatment, and results summarized. Meta-analysis could only be done for two parameters (complications and reoperations) due to the paucity of data and heterogeneity of studies' limited statistical analysis. The data are presented as a review table with the key points summarized.

RESULTS

Twenty studies (seven prospective and 13 retrospective articles) identified 533 patients with 534 fractures who had undergone plate osteosynthesis for fracture of the patella. The most common fracture treated with plate osteosynthesis was 34C.

CONCLUSION

Basket plate was most commonly used for inferior pole fractures, while mesh plates were for intra-articular patella fractures. Overall plating was associated with better clinical outcomes, fewer complication rates, and high union rates compared to tension band wiring for patella fractures.

Assessment of Acetabular Component Anteversion after Total Hip Arthroplasty: Comparison of Anteroposterior and Cross-Table Lateral Radiographs with Computed Tomography Scans

Background

Several methods of measurement of anteversion of acetabular components after total hip arthroplasty (THA) have been described in the literature using plain radiographs or computed tomography (CT) scans. None of these have proved to be the gold standard. We aimed to study the correlation between the CT and radiographic methods of calculation of acetabulum anteversion.

Methods

CT scans of the pelvis, anteroposterior (AP) and cross-table lateral (CL) radiographs were obtained in 60 patients who underwent THA two weeks after surgery. Anteversion was measured using Widmer method and Liaw method on AP radiographs, and the ischiolateral method on CL radiographs. Anteversion measured on the CT scan was taken as the reference anteversion and the above measurements were analysed for correlation with the measurements on CT scan. Intraclass correlation coefficients (ICCs) were calculated for both intra- and interobserver reliability.

Results

Mean acetabular version on CL radiographs was 53.1 ± 10.7. Mean version on AP radiographs by Widmer method was 21.4 ± 3.6 and by Liaw method was 20.3 ± 4.8. Mean version on CT scans was 26.02 ± 6.8. There was a good correlation between the acetabular version on CT scans with the version on AP radiographs by Widmer method (r = 0.78, p < 0.001) and Liaw method (r = 0.87, p < 0.001). Good correlation was seen between the acetabular version on CL radiographs and CT scans (r = 0.91, p < 0.001). Also, a good correlation was observed between the acetabular version measurements on CL radiographs and AP radiographs by Widmer method (r = 0.81, p < 0.001) or Liaw method (r = 0.70, p < 0.001). Excellent inter- and intraobserver reliability were seen for all the measurements.

Conclusions

Calculation of acetabular component version on AP views as well as CL views of plain radiographs showed a strong correlation with the version measurements on CT scans. Good correlations were observed between different techniques of measurement on radiographs. Therefore, all these measurements can be valid methods for assessment of anteversion.

Limb salvage following snakebite using acute limb shortening and secondary lengthening

A case of 16-year-old boy from the remote tribal population of Uttarakhand is described, who sustained a viper snakebite. The patient after various interventions and referrals developed locoregional and systemic complications. He not only had an open tibiofibular fracture but a large bimalleolar defect over his lower limb. The wound infection with underlying osteomyelitis progressed to septic shock and failure of the conventional cross-leg flap. Computed tomography scan of the limb revealed a single patent vessel, eliminating the option of microvascular flap. Limb amputation was considered for source control; however, in an attempt to salvage the limb, the novel approach of acute limb shortening with secondary limb lengthening was performed with parental consent, an approach not previously reported in the management of snakebite injuries. Adequate infection control was achieved following removal of the osteomyelitic bone, and the defect was covered with overlapping tissue from the docked limb and a cross-thigh flap. Secondary lengthening was performed after 3 months, and following extensive surgical and rehabilitative interventions, the boy's limb was salvaged and he retains a near-normal gait. This case report entails a detailed account of how mutilating a snakebite injury could be and how unconventional techniques like acute limb shortening with secondary lengthening can be used in such injuries.

Online educational resources for orthopaedic residency-a narrative review

Purpose

Residency programs in the medical education field are considered the keystone in the development of aptitude and skills required for practice. With the worldwide current scenario of the COVID-19 pandemic, there has been a shift in the paradigm especially in the teaching of the residents from face-to-face classes to more and more online sessions. The purpose of this study is to present a compendium of knowledge-providing sites, smartphone applications (apps), YouTube channels, and podcasts that can provide better online resource management for students in the field of orthopaedics.

Methods

Search terms were used for making a list of various online resources which can be of help during orthopaedic residency. An initial list of the selected websites, smartphone apps, podcasts, and YouTube channels was made. The corresponding author with years of teaching experience and faculty for post-graduate and fellowship training programs then selected the final list.

Results

A list of 16 websites with brief points on their content and online address along with the availability of free or paid content was identified as being appropriate. A total of 39 apps available for android/apple smartphones, nine podcasts, and 11 YouTube channels were also identified as being extremely useful and have been discussed elaborately in this article.

Conclusion

Online educational tools are of immense importance in imparting adequate knowledge to an orthopaedic resident and act as an adjunct to conventional teaching methods. This article focuses on presenting various online educational resources in a simple yet concise way, which may be beneficial for the current generation of residents especially in this current time of unprecedented COVID-19 pandemic.

Good validity and reliability of forgotten joint score-12 in total knee arthroplasty in Hindi language for Indian population

PURPOSE

Commonly used patient-reported outcome measurement (PROM) tools for knee joint have a ceiling effect and may not be able to differentiate between patients achieving outcomes better than the upper limit of the score. Forgotten joint score-12 (FJS-12) is said to be free of this limitation. FJS-12 has been translated and validated in different languages. This study aims to translate and validate FJS-12 in Hindi (Hindi FJS-12).

METHODS

Hindi FJS-12 was tested for comprehensibility in a pilot study in 20 patients. This was followed by a prospective cohort study including 140 patients of bilateral total knee arthroplasty, with a minimum follow-up of 12 months. The mean age of the patients was 62.0 ± 14.5 years. There were 77 (55.2%) males and remaining were females. All patients were asked to fill up questionnaires of Hindi FJS-12, WOMAC, KSS and OKS. Hindi FJS-12 was tested for validity, reliability, responsiveness, floor effect and ceiling effect. Construct validity was expressed as the Pearson correlation coefficient. Internal consistency was expressed as Cronbach's alpha and test-retest reliability as the intra-class correlation coefficient (ICC).

RESULTS

In the pilot study, it was seen that all the questions were well answered by most of the participants. The main study showed good construct validity with Hindi FJS-12 showing moderate correlation with WOMAC, KSS and OKS (Pearson coefficients 0.45, 0.32, 0.37, respectively). Hindi FJS-12 had excellent internal consistency with Cronbach's alpha of 0.93 (95% CI 0.90, 0.97). ICC was 0.95 (95% CI 0.90, 0.99). No floor or ceiling effect was observed.

CONCLUSION

Hindi FJS-12 has high validity, reliability and reproducibility for knee function after TKA. It is devoid of floor or ceiling effect. Thus, it can be successfully used for studying knee function in the Indian population.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Acetabular and Femoral Component Positioning Using Direct Anterior Approach Versus Posterior Approach in Total Hip Arthroplasty

PURPOSE

Direct anterior approach (DAA) has recently become popular in total hip arthroplasty (THA). However, irrespective of the surgical approach used, component malposition is an important factor affecting function and complications after THA. This study aims to compare component positioning on the femoral and acetabular side between DAA and posterior approach (PA) to the hip joint. We hypothesized that the two approaches are similar in terms of component positioning.

METHODS

We prospectively studied 50 patients, matched according to age, sex, and body mass index, undergoing THA, divided non-randomly into 2 groups. Group 1 comprised 25 patients (35 hips) undergoing THA using DAA and group 2 comprised 25 patients (25 hips) undergoing THA using PA. Ten patients from group 1 had simultaneous bilateral THA. Radiological parameters studied were acetabular inclination (AI), coronal femoral stem alignment (CFA), leg length difference (LLD), acetabular cup version (AV), and femoral stem version (FV).

RESULTS

There was no significant difference in AI, CFA, LLD, AV, and FV between the two groups. Excellent to good inter and intra-observer reliability expressed in terms of intraclass correlation coefficient (ICC) was noted for all the radiographic measurements.

CONCLUSION

Both DAA and PA for THA achieve comparable radiological component positioning. DAA may not provide any advantage over PA in terms of positioning of the prosthesis.

LEVEL OF EVIDENCE

Level II, non-randomized comparative study.

Use of Osteochondral and Meniscal Allografts from Bone Cuts of Total Knee Arthroplasty for the Treatment of Tibial Plateau Malunions: A Case Series of Four Patients Showing Early Results

PURPOSE

Intra-articular malunion of tibial plateau fracture is a complex problem to treat. We are presenting outcomes of our series of patients of malunited tibial plateau fractures treated with osteo-chondro-meniscal allograft from lateral tibial plateau harvested from patients undergoing total knee arthroplasty (TKA).

METHODS

The technique was used in four patients. Preoperative computed tomography (CT) scan was used to match donor and recipient graft dimensions and to measure any malalignment. Patients were evaluated for Visual analogue Scale (VAS) for pain (scale 1-10 cm), WOMAC (Western Ontario McMaster Osteo-Arthritis Index) score, knee range of motion, and limb alignment.

RESULTS

There were three medial tibial plateau malunions and one lateral tibial plateau malunion. Articular comminution with depression was seen in all of them. One patient underwent concurrent high tibial osteotomy for the elevation of the medial tibial plateau and posterior cruciate ligament reconstruction was performed concurrently in one patient. All patients showed improvement in knee range of motion, WOMAC score, and VAS score for knee pain. Limb alignment improved in all cases. Radiologically there was consolidation of the allograft in all the cases at 6 months. The mean follow-up was 15.2 months (range 12-18 months).

CONCLUSION

Osteochondral allograft can be a good choice for reconstructing large articular cartilage defects in tibial plateau malunions. Osteo-chondro-meniscal grafts obtained during TKA can be a viable alternative for reconstructing such defects with excellent early clinical, functional, and radiological outcomes.

LEVEL OF EVIDENCE

IV.

Pie-crusting of proximal medial collateral ligament for correcting varus deformity in total knee arthroplasty

PURPOSE

Aim of this study was to compare outcomes of a newer technique of pie-crusting of the femoral origin of medial collateral ligament (MCL) with the conventional medial release, for correcting varus deformity during total knee arthroplasty. Null hypothesis was that there is no difference in clinical outcomes between these two techniques.

METHODS

All patients requiring an additional medial release after excision of osteophytes and release of deep MCL during total knee arthroplasty were allocated into two groups, alternately. Each group composed of 40 patients. Pie-crusting with a needle was done near the femoral attachment of superficial MCL in group-1, whereas the group-2 underwent classic sub-periosteal release of the tibial insertion of superficial MCL. All the patients were assessed for any laxity (more than 3 mm opening) intraoperatively or at one-year follow-up, pain score at 12 and 24 h after the surgery, Knee Society Score, Western Ontario and McMaster Universities Arthritis Index and range of motion 12 months after the surgery.

RESULTS

None of the patients showed any signs of laxity or failure at one-year follow-up. Pain scores were slightly better (not statistically significant) in the group-1. However, no differences were noted in functional outcomes scores.

CONCLUSION

Pie-crusting of superficial MCL is a safe, controlled and less invasive approach for medial soft tissue release. When knee deformity is not correctable with initial soft tissue release, this is an appropriate next surgical step. There does not appear to be a risk of over-release during the surgery or afterward.

STUDY DESIGN

Non-randomized controlled trial, Level II.

Monoarticular synovitis of knee: dealing with the dilemma

Introduction: Chronic synovitis involving a single large joint remains a diagnostic dilemma. We present 61 cases of chronic synovitis of the knee, followed prospectively for 2 years. The study focuses on the diagnosis, management, and histopathological correlation. Methods: We prospectively studied 61 patients with chronic mono-articular synovitis of the knee joint, between July 2016 and September 2017. All patients underwent plain radiographs, magnetic resonance imaging, and arthroscopic examination with synovial biopsy. Further treatment was based on findings of histopathological examination. Results: The average duration of symptoms was 7.72 ± 4.34 months. The mean age at presentation was 29.93 ± 15.56 years. Results of histopathological examination showed chronic nonspecific inflammation in 28 patients (46%), features suggesting tubercular infection in 19 patients (31%), pigmented villonodular synovitis in seven patients (11.5%), rheumatoid arthritis in three (5%) patients, acute inflammation in three (5%) patients and findings suggestive of synovial chondromatosis in one (1.5%) patient. Treatment was based on histopathological results. Intra-articular injections of methylprednisolone (80 mg depot preparation) were given to all patients with nonspecific synovitis and rheumatoid arthritis. Anti-tubercular treatment was started for patients with tubercular synovitis. Complete arthroscopic/open synovectomy followed by radiotherapy was carried out for patients with pigmented villonodular synovitis. Non-steroidal anti-inflammatory drugs are used for patients with acute on chronic inflammation. All patients had symptomatic relief and functional improvement in further follow-up. Discussion: Histopathological reporting remains the mainstay for diagnosis. The various differentials should always be kept in mind when approaching patients with chronic mono-articular synovitis. Specific treatment can be started once the diagnosis is confirmed.

Actinomycotic Osteomyelitis of the Hand and Wrist Treated with Pharmacotherapy Alone: A Case Report

CASE

Primary infection by Actinomyces is uncommon because susceptibility to infection requires breakdown of the normal protective mucosal barrier. Furthermore, involvement of the upper extremity is rare. This case report presents clinical, radiological, and pathological findings in a 26-year-old patient with actinomycosis of the hand that was treated successfully by pharmacotherapy alone without any surgical debridement.

CONCLUSION

Primary actinomycoses of the hand and upper extremity present as a challenging condition. It requires a high index of clinical suspicion and histopathologic diagnosis to guide treatment, typically involving antimicrobial therapy. This case highlights the usefulness of conservative treatment with antimicrobial therapy without surgical debridement.

Correlation between anthropometric measurements and activity level on length and diameter of semitendinosus tendon autograft in knee ligament surgery: A prospective observational study

Introduction: Preoperative estimation of graft parameters can be useful while using hamstring grafts in knee ligament surgeries. Anthropometric parameters may be an easy way to predict the length and diameter of hamstring tendons. A prospective study was conducted to find the correlation between different anthropometric parameters and activity level of the patient on the length and diameter of the graft. Separate regression equations for males and females were also derived for easy prediction. Methods: Data were obtained from 95 patients who underwent arthroscopic anterior cruciate ligament reconstruction with autologous hamstring tendon graft. Variables studied were age, sex, height, weight, body mass index (BMI), thigh circumference, thigh length, Tegner activity level, diameter (double and quadruple) and length of semitendinosus tendon graft. Results: Height of the patient had strong correlation with graft length (r = 0.41, p < 0.001), double diameter (r = 0.29, p = 0.008) and quadruple diameter (r = 0.3, p = 0.006). Weight of the patients had strong positive correlation with graft length (r = 0.34, p = 0.002) and quadruple diameter (r = 0.34, p = 0.002). Thigh length was found to be positively correlating with graft length (r = 0.43, p < 0.001), double diameter (r = 0.29, p = 0.007) and quadruple diameter of graft (r = 0.34, p = 0.002). BMI and thigh circumference of the patients were not found to correlate with graft size. Male patients were found to have longer semitendinosus graft and larger double and quadruple diameter of the graft. There was no association between the Tegner activity scale and graft size. Regression equations between graft length and quadruple diameter and the anthropometric parameters are also derived. Conclusion: Height, weight and thigh length are useful anthropometric parameters in the prediction of hamstring tendon size. However, the patient’s Tegner activity level was not found to be associated with size of the hamstring tendon.

Outcomes of ketorolac versus depomedrol infiltrations for subacromial impingement syndrome: a randomized controlled trial

PURPOSE

Local subacromial infiltration with steroids is a common method of treatment of subacromial impingement syndrome. However, the use of steroids has concerns like tendon rupture, articular cartilage changes and infections. Local NSAIDs infiltration has recently been tried in literature. This study compares the effect of subacromial injections of ketorolac with steroids.

METHODS

A randomized controlled study was planned with 35 patients in each group. Patients in group-1 were infiltrated with subacromial ketorolac (60 mg with 2% lignocaine) and in group-2 with a steroid (methylprednisolone-40 mg with 2% lignocaine). A similar rehabilitation protocol was followed, and clinical outcomes were analyzed using visual analog scale (VAS) for pain and shoulder pain and disability score (SPADI) and range of motion at one-month and three-months follow-up.

RESULTS

Total data of 67 patients were analyzed, as three patients were lost to follow-up. In group 1, mean VAS improved from 7.9 [Formula: see text] 0.95 to 3.19 [Formula: see text] 0.81 (p < 0.001) and SPADI improved from 61.41 [Formula: see text] 11.86 to 28.91 [Formula: see text] 9.06 (p < 0.001) at three months, respectively. In group 2, mean VAS improved from 8.05 [Formula: see text] 0.94 to 2.9 [Formula: see text] 0.64 (p < 0.001) and SPADI improved from 63.45 [Formula: see text] 9.64 to 25.32 [Formula: see text] 6.87 (p < 0.001) at three months, respectively. However, there were no differences in functional outcomes between the groups (p = 0.21 for VAS, p = 0.16 for SPADI).

CONCLUSION

Subacromial ketorolac infiltration has an equivalent outcome as that of steroid infiltration. Ketorolac could be considered as a reasonable alternative to steroids in cases where it is contraindicated.

National Clinical Guidance for the Management of Cardiovascular Intervention in the COVID-19 Pandemic: From Bangladesh Society of Cardiovascular Interventions (BSCI)

Since the first recorded case of SARS-CoV-2 in Bangladesh on 8th March 2020, COVID-19 has spread widely through different regions of the country, resulting in a necessity to re-evaluate the delivery of cardiovascular services, particularly procedures pertaining to interventional cardiology in resource-limited settings. Given its robust capacity for human-to-human transmission and potential of being a nosocomial source of infection, the disease has specific implications on healthcare systems and health care professionals faced with performing essential cardiac procedures in patients with a suspected or confirmed diagnosis of COVID-19. The limited resources in terms of cardiac catheterization laboratories that can be designated to treat only COVID positive patients are further compounded by the additional challenges of unavailability of widespread rapid testing on-site at tertiary cardiac hospitals in Bangladesh. This document prepared for our nation by the Bangladesh Society of Cardiovascular Interventions (BSCI) is intended to serve as a clinical practice guideline for cardiovascular health care professionals, with a focus on modifying standard practice of care during the COVID-19 pandemic, in order to ensure continuation of adequate and timely treatment of cardiovascular emergencies avoiding hospital-based transmission of SARS-COV-2 among healthcare professionals and the patients. This is an evolving document based on currently available global data and is tailored to healthcare systems in Bangladesh with particular focus on, but not limited to, invasive cardiology facilities (cardiac catheterization, electrophysiology & pacing labs). This guideline is limited to the provision of cardiovascular care, and it is expected that specific targeted pharmaco-therapeutics against SARS-CoV-2 be prescribed as stipulated by the National Guidelines on Clinical Management of Corona virus Disease 2019 (COVID-19) published by the Director General of Health Services, Ministry of Health and Family Welfare of Bangladesh.

Visceral Adiposity Index Score is the Better Predictor of Clinical and Coronary Angiographic Severity Assessment than Other Adiposity Indices in Patients with Acute Coronary Syndrome

Acute coronary syndrome (ACS) is one of the leading causes of death throughout the world and obesity especially visceral adiposity is one of the important concerns globally due to its huge impact on coronary artery disease particularly on ACS. There are several traditional methods like BMI, WC, WHR, WHtR etc. but none of these can measure visceral fat accurately. In this regard visceral adiposity index (VAI) is a novel sex specific index which has significant correlation with visceral adiposity and can express the distribution as well as function of visceral fat precisely. This cross sectional study was done in the Cardiology Department of National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from August 2015 to July 2016 to compare the VAI with other adiposity indices for clinical and coronary angiographic severity assessment in patients with acute coronary syndrome. A total of 200 patients (Case 100 patients of ACS and Control 100 patients of non ACS) were included. Afterward clinical, biochemical, echocardiographic and coronary artery angiographic indexes determined by Gensini score were acquired. Adiposity indices like BMI, Waist and Hip circumference, Waist Hip and Waist Height ratio (WHR, WHtR) and finally VAI were calculated using appropriate formula. Patient with ACS had more severe form of clinical features like severe chest pain & shortness of breath (p=0.001), pulse, BP, abnormal precordial findings, BMI, WC, WHR, WHtR, HC, VAI (p=0.001) and angiographic severity (p=0.001) than non ACS group. Multivariate binary logistic regression analysis for clinical and coronary angiographic severity assessment (GS>36) by adiposity indices showed VAI was the better predictor of clinical and coronary angiographic severity assessment with OR's being 5.61 than others. An ROC curve was plotted for each adiposity indices for clinical and coronary angiographic severity assessment showed VAI to have the maximal AUC. A VAI of OR-5.61 was provided as the cutoff value which had a sensitivity of 73.3% and specificity of 76.6% (AUROC=0.839, CI-0.760-0.918, p<0.001) which indicates better than other adiposity indices in patients under study. VAI is an excellent, simple, noninvasive tool to detect the visceral adipose mass & was markedly associated with the clinical and coronary angiographic severity assessment in patients with ACS.

Penetrating spine injury bisecting thoracic spinal canal with no significant neurological deficits-The midline cord syndrome

Introduction

In India, the incidence of penetrating spine injury (PSI) is increasing because of the increased use of advanced ballistics (missile PSI) among military personnel and sophisticated tools and construction instruments like nail-guns or drills (non-missile PSI) among civilians. These injuries are associated with a risk of neurological damage, central nervous system infections, vascular injury, dural tear followed by CSF leakage, and spinal instability.

Case presentation

A 35-year-old male presented with a non-missile PSI with retained iron nail bisecting his dorsal spinal cord, without any motor deficits. Patient presented with only left lower limb proprioceptive loss and L1-L3 paresthesia. Nail removal was done on emergent basis without any further neurological damage.

Discussion

To the best of our knowledge, this presentation of a non-missile PSI and has not been previously reported. The specific clinical presentation of this distinct type of injury to the midline structures of the spinal cord is hence named "midline cord syndrome".

Association of Prolonged QTc Dispersion with Diastolic Dysfunction of the Left Ventricle in Patients with Non ST Segment Elevation Myocardial Infarction

Diastolic function usually declines before systolic function, and this precedes clinical signs in patients with acute coronary syndrome. Therefore, diagnosis of diastolic dysfunction is very important for early diagnosis, follow-up, treatment, and prognostic evaluation in heart failure with preserved ejection fraction (HFpEF) patients. The main objective of the study was to find out association between prolonged QTc dispersion and left ventricular diastolic dysfunction in Non ST Segment Elevation Myocardial Infarction (NSTEMI) patients in HFpEF. This cross sectional analytical study was conducted in the Department of Cardiology and 60 patients were included as study population from August 2015 to July 2016. Then the study population was divided into two groups, each group consisted of 30 patients. NSTEMI patients with prolonged QTc dispersion treated as Group I and NSTEMI patients with normal QTc dispersion treated as Group II. The study shows 20.0% vs. 26.6% patients had detected as Grade I in Group I and Group II respectively with statistically insignificant association (p=0.16). On the contrary, 30.0% vs. 13.4% patients had detected as Grade II in Group I and Group II respectively with statistically significant association (p=0.001). Again, 40.0% vs. 10.0% patients had detected as Grade III in Group I and Group II respectively with statistically significant association (p=0.001). QTc dispersion was found sequentially significant increased (p=0.007) among 3 grades of LVDD (63.6±4.9 vs. 79.4±8.6 vs. 98.2±28.8). QTc dispersion in surface ECG which is a cheap, non-invasive, easily available tool can help us predicting left ventricular diastolic dysfunction in patients with NSTEMI.

Comparison between retrograde and transeptal approach in radiofrequency catheter ablation of left accessory pathways

To study a series of patients submitted to radiofrequency catheter ablation (RFA) of left accessory pathways (AP) using the transeptal approach (TSA) as compared to the conventional retrograde arterial approach (RAA). Sixty consecutive patients (44 male; mean age of 35.60±11.63 years) with 60 left APs (39 overt and 21 concealed) underwent catheter ablation using the TS method (30 patients) and the RAA method (30 patients) in an alternate fashion. The analysis was performed according to the intention-to-treat principle. The transeptal puncture was successfully performed in 29 patients (96%). This access allowed primary success in the ablation in all the patients without any complication. When we compared this approach with the RAA there was no difference as regards the primary success (p=0.103), fluoroscopy time (p=0.565) and total time (p=0.1917). Three patients in the RAA group presented a vascular complication. The TSA allowed shorter ablation times (p=0.006) and smaller number of radiofrequency applications (p=0.042) as compared to the conventional RAA. The patients who had unsuccessful ablation in the first session in each approach underwent with the opposite technique (cross-over), with a final ablation success rate of 100%.The TS and RA approaches showed similar efficacy and safety for the ablation of left accessory pathways. The TSA allowed shorter ablation times and smaller number of radiofrequency applications. When the techniques were used in a complementary fashion, they increased the final efficacy of the ablation.

Association between elevated B-type Natriuretic Peptide levels with extent of coronary artery disease in patients with unstable angina and NSTEMI

The study was undertaken to find out the correlation of elevated B-type Natriuretic Peptide (BNP) levels with the severity of coronary artery disease in patients with unstable angina and NSTEMI. This cross sectional analytical study was carried out in the department of cardiology, National Institute of Cardiovascular Diseases, Dhaka during a period of August 2011 to June 2012. A total of 100 consecutive patients with unstable angina and NSTEMI undergoing coronary angiography were included in the study. BNP assay was done by Architect system, a chemo luminescent microparticle immunoassay (CMIA). CAG was done by conventional method within 14 days of index hospital admission. Study patients were divided into two groups on the basis of BNP levels. In Group I, BNP Levels were ≤80pg/ml and in Group II, BNP levels were elevated >80pg/ml. with 50 patients in each group. Angiographic severity of CAD was assessed by vessel score and Friesinger score. Vessel score showed single vessel was involved in 21(47.7%) patients while multi vessel in 23(52.3%) patients was found in Group I. On the contrary 11(22.4%) single vessel patients and 38(77.6%) multivessel patients were found in Group II. There was significant association between vessel involvement (p=0.01). Friesinger score revealed that less severe CAD was found in 22(44%) patients and significant severe CAD in 28(56.0%) patients in Group I. On the contrary 7(14.0%) less severe CAD patients and 43(86.0%) severe CAD patients were found in Group II. There was significant difference between severity of CAD among the study groups (p=0.01). There was linear correlation between BNP pg/ml and coronary artery disease severity in terms of Vessel score (r=0.38, p=0.01) and Friesinger score (r=0.51, p=0.01). The present study concluded that increased BNP level >80pg/ml was significantly associated with the presence and severity of CAD in patient with UA and NSTEMI.

Cardiac contractility modulation device-new hope for refractory heart failure patients

A large number of patients with advanced heart failure (HF) are refractory to optimal standard medical therapy. This has given rise to development and testing of a host of new device based therapies. One recent and potentially broadly applicable treatment under investigation is cardiac contractility modulation (CCM) electrical signals. The CCM signals are relatively high-voltage electrical impulses applied to the myocardium during the absolute refractory period. These signals do not initiate a new contraction or modify activation sequence as is the case with other therapies such as cardiac resynchronization therapy. Rather, CCM signals are intended to enhance systolic function of the failing myocardium. A device similar to a pacemaker is typically implanted in the right pectoral region. Three standard pacemaker leads are placed intravenously. One right arterial lead is used to sense atrial activity, and two right ventricular leads are used to sense ventricular activity and deliver the CCM pulse trains. The electrodes of the ventricular leads are placed on the right ventricular septum at least 2cm apart. In contrast to a Pacemaker and defibrillator the system is designed to modulate the strength of contraction of the heart muscle rather than the rhythm. Application of CCM signals to the failing heart is associated with improved gene expression which ultimately causes LV global, cellular and biochemical remodeling as a result improved LV systolic function.

Ad-hoc percutaneous coronary intervention and staged percutaneous coronary intervention

Percutaneous coronary intervention (PCI) is a catheter based procedure where a catheter system is introduced through a systemic artery under local anesthesia in a stenotic coronary artery by controlled inflation of a distensible balloon. At early period, PCI was done in a separate session following coronary angiogram (Staged PCI) and it was more costly and hospital stay was long. As the expertization and laboratory facilities improved, the health care providers think about cost, hospital stay and patient convenience. So, to reduce the cost and patient preferred more PCI being done immediately following diagnostic catheterization (Ad-hoc PCI). Subsequently this Ad-hoc procedure becomes popular and now most of the PCI are Ad-hoc PCI worldwide. Rate of combined procedure (Ad-hoc) progressively increased from 54% in 1990 to 88% in 2000 with a significant decrease in rate of complications. In the initial study of Ad-hoc PCI suggested that Ad-hoc PCI should be done in selected group of patients as there was some potential risk factors (e.g. Multivessel diseases, unstable angina, aortic valve disease, and recent infarction or thrombolytic therapy) for Ad-hoc procedure and some (e.g. Older age, multivessel PTCA and complex lesion PTCA) for staged procedure. But recent studies showed that no significant difference in respect of safety and efficacy between Ad-hoc and staged PCI. Previous studies, in the era of balloon angioplasty from 1985 to 1995, Haraphonges et al. (1988), Rozenman et al. (1995) and Kimmel et al. (1997) suggested that an ad hoc approach is safe, with potentially more complications in patients with unstable angina pectoris or other high-risk factors. However, these reports have been limited to observational studies representing single institution experiences with small samples and inclusion of patients who underwent emergency PCI procedures. In Bangladesh a prospective observational study was done among 120 patients to compare the outcome of Ad-hoc and staged PCI and high angiographic, procedural and clinical success rate with minimum complications were observed in Ad-hoc PCI in comparison to Staged PCI.

Synthesis and DNA cleavage activity of a novel bleomycin A(5) glycoconjugate

[structure in text] To explore the possibility of modifying bleomycin in a fashion that could alter its physiological distribution in a therapeutic setting, a new analogue of bleomycin has been prepared. This analogue is intended to target the asialoglycoprotein receptor on liver cells. Critically, despite the large C-substituent, the bleomycin conjugate was found to degrade DNA in the same fashion as bleomycin A(5) itself, and with only modestly decreased efficiency.

Traumatic rupture of diaphragm

Traumatic diaphragmatic rupture remains a diagnostic challenge, and associated injuries determine the outcome in those diagnosed early, whereas that of latent cases is dependent on the consequence of the diaphragmatic rupture: namely, the diaphragmatic hernia. To analyze the clinical and radiologic features and the therapeutic implications, we reviewed 980 patients reported in the English-language literature. This injury affects predominantly males (male:female = 4:1) in the third decade of life, and is often caused by blunt trauma (75%). There were 1,000 injuries, of which 685 (68.5%) were left-sided, 242 (24.2%) right-sided, 15 (1.5%) bilateral, and 9 (0.9%) pericardial ruptures; 49 cases were unclassified. Chest (43.9%) and splenic (37.6%) trauma were the most common associated injuries. The diagnosis was made preoperatively in 43.5% of cases, whereas in 41.3% it was made at exploration or at autopsy and on the remaining 14.6% of the cases the diagnosis was delayed. The mortality was 17% in those in whom acute diagnosis was made, and the majority of the morbidity in the group that underwent operation was due to pulmonary complications. Uniform diagnosis depends on a high index of suspicion, careful scrutiny of the chest roentgenogram in patients with thoracoabdominal or polytrauma, and meticulous inspection of the diaphragm when operating for concurrent injuries. Repeated evaluation for days after injury is necessary to discern injury in patients not requiring laparotomy. Acute diaphragmatic injuries are best approached through the abdomen, as more than 89% of patients with this injury have an associated intraabdominal injury. Patients with diaphragmatic rupture presenting in the latent phase have adhesion between the herniated abdominal and intrathoracic organs, and thus the rupture is best approached via a thoracotomy.

Topical urea in dermatology

For years research has been conducted to find a cutaneous moisturizer that is effective, easily available and relatively inexpensive urea, as a atopical agent, is all of this and is also a mild keratolytic. A trial was conducted over 200 patients suffering from a variety of disorders that were selected and using urea topically as urea 10 (10%), urea-20 lotion (20%), Urea-HC (with hydrocartisanl). The agent was applied twice daily for a maximum period of 8 weeks. Results indicate that urea is an effective moisturizer and in promotes the penetration of hydrocelisone into the skin.

Repair of burns of the scrotum using a gracilis myocutaneous flap

An unusual case of isolated burns of the scrotum reconstructed by a unilateral gracilis myocutaneous flap is reported because of its clinical rarity.

Diphenhydramine in Orientals and Caucasians

The kinetics and psychomotor effects of diphenhydramine were investigated in Orientals and Caucasians. Each of 5 Oriental and 5 Caucasian young adults received on 1 of 3 occasions diphenhydramine 50 mg/70 kg body weight either intravenously or orally, or placebo. Plasma levels of diphenhydramine were measured hourly for 8 hr at each session. Tests of subjective sedation and psychomotor performance were performed at hourly intervals. The results showed that after both intravenous and oral diphenhydramine, at all times Orientals had plasma levels approximately half those of Caucasians. With the assumption of linear kinetics and a 1-compartment open model, analysis of the data showed that the volume of distribution (VD) and plasma clearance (Cl) but not plasma half-life (t 1/2) were higher in Orientals than Caucasians: [VD = 480 +/- 24 (SEM) and 292 +/- 36 1/70 kg; Cl = 79 +/- 7 and 51 +/- 7 1/70 kg/hr; t 1/2 = 4.1 +/- 0.4 and 4.3 +/- 0.4 hr]. Unbound diphenhydramine in fresh plasma was higher in Orientals than Caucasians [24.0 +/- 1.9% (SEM) and 14.8 +/- 1.5%] and probably explains the increased VD in Orientals. Orientals had significantly less sedation and deterioration in psychomotor performance.