OBJECTIVES:To assess the proportion and pattern of injury of the anterolateral ligament (ALL) and the Kaplan fibre (KF) complex in knees with anterior cruciate ligament (ACL) injuries on MRI using three-dimensional (3D) proton density (PD) sequences.METHODS:A total of 88 patients having ACL injury were included in this cross-sectional study. 3D PD sequences were used to assess injury of ALL and the KF complex and were graded on a scale of 0 to 3. MR images were evaluated by two radiologists. Interobserver agreement was determined using Cohen Kappa.RESULTS:Femoral, meniscal, and tibial portions of ALL were visualized in 90.9%, 92%, and 94.3% of the study subjects, respectively. Proximal and distal KF were visualized in 92% and 93.2% of patients, respectively. Injury to ALL and KF was seen in 63.6% and 17% of the patients, respectively. Excellent interobserver agreement was noted for the identification and grading of ALL and KF complex injuries.CONCLUSIONS:Oblique reformatted 3DPD MRI reliably detect ALC; however, ALL injury is better characterized than KF injury using this sequence.ADVANCES IN KNOWLEDGE:Given the potential role of anterolateral complex (ALC) in maintaining the rotational stability of the knee, ALC assessment using the 3D PD sequences and their oblique reformatted images should be incorporated as routine review area of the knee MRI, particularly in the setting of ACL tear.

Free flap procedure provides an overall success rate of 97%, which decreases to 85% in hypercoagulable states. COVID-19, as a pro-thrombotic disorder, therefore seems detrimental to free flap survival. We encountered a case of unique pattern of free flap partial failure in a young male who underwent extremity reconstruction. The patient was diagnosed as COVID-19 positive on the 3rd day post-reconstruction. The flap survived well for the first 7 days post-operatively, but gradually the skin got necrosed and the subcutaneous fat layer was preserved when debriding. To our knowledge, this is the only case in which the skin of the free flap of a COVID-19 positive patient was necrosed almost entirely subsequently, while the subcutaneous fat was relatively preserved.

A patent vascular tree within the flap and anastomosis are quintessential for the success of a microvascular free flap. Any thrombus or vasoconstriction severely affects the blood flow in the flap. Intraoperative ischemia time also plays a major role in the flap. Various clinical and objective methods have been designed that help in the postoperative monitoring and timely intervention to reverse an impending free flap failure by identifying the cause. Here, we discuss an interesting scenario about a free flap showing signs of flap failure (clinical and objective) during the immediate postoperative period up to 16 hours, but later on survived completely without active intervention.

Introduction:Bicondylar Conjoint Hoffa fractures, where both the fractured femoral condyles joined by the bony bridge at intercondylar notch, are extremely rare with only 7 cases reported so far in the literature. We present a first case of such fracture along with patellar fracture dislocation where a fractured fragment was incarcerated between the femoral condyles.Case Presentation:18 years old boy after road side accident presented with knee swelling and pain. Computed tomography revealed this rare combination of the fractures and was appropriately managed.Conclusion:High index of suspicion in trauma victims with described mechanism of injury like in this report is needed to not miss the Hoffa fracture and to differentiate conjoint variety from bicondylar unconjoint and deciding appropriate surgical. Non- contrast computed tomography NCCT is a must to look for fracture geometry and associated fractures.

Background: The Bundled Payment for Care Improvement initiative is a program designed by Center for Medicare and Medicaid Services in an attempt to increase the value of care delivered to Medicare recipients by rewarding providers who can deliver more cost-efficient, high-value care. This article reports the results of a coordinated care redesign program in an independent, medium-sized private-practice orthopedic group. Methods: A committee of stakeholders worked to redesign care protocols for patients receiving upper and lower joint replacement procedures. These protocols included preoperative, intraoperative, and postoperative care. Baseline metrics for post-acute care and readmissions were compared to the same metrics after initiating care redesign. Results: Incidence of discharge to inpatient facilities decreased as did length of stay at these facilities. Home health utilization and readmission rates were lowered. Average cost of the 90-day episodes decreased to a statistically significant degree. Conclusions: These initial results indicate that coordinated care redesign in the private practice setting can yield higher value care with decreased utilization of high-cost care, particularly in the post-acute period.

The elbow joint is an inherently stable joint and 2nd most commonly dislocated joint in adults. The most common mechanism of injury is indirect by fall on an outstretched hand. The most common type is posterolateral dislocation. Simultaneous bilateral elbow dislocation with the distal end of the radius and radial head fracture is an unusual case, probably the first case with this type of injury. Very few cases of bilateral elbow dislocation are reported in the literature. Our aim is to report this case to know the sequence of mechanisms of injury and their management.

ISSN: 2319-7706 Volume 9 Number 10 (2020) Journal homepage: http://www.ijcmas.com Osteoarticular (spinal and extra spinal) tuberculosis consist of1% to 5% of all cases of tuberculosis and 10% to 18% of EPTB. The diagnosis of osteoarticular tuberculosis is often delayed due to insidious onset, lack of constitutional and pulmonary involvement, lack of awareness, or due to lack of characteristic early radiographic findings. The purpose of this analysis is to provide an update on the diagnostic and therapeutic recommendations for osteoarticular TB. In this retrospective study, laboratory and hospital records were collected, evaluated and analyzed for all the patients with suspected osteoarticular TB. Data collection was done during the period of 3 years from 2017 to 2020, from the CBNAAT center, AIIMS Patna with suspected sample for confirmation of TB. Out of 62 suspected patients tested, 9 (14.52%) were detected positive by CB NAAT test for osteoarticular TB. Among these 9osteoarticularTB cases 4 (44.44%) were Rifampicin sensitive, 4 (44.44%) were Rifampicin resistant and 1 (11.11%) case was indeterminate for Rifampicin. 62suspects were identified having mean age at the presentation was33.72 years with age ranges from 4 to 71 years, male to female ratio was 1.8:1 (40:22). The manifestations were articular (arthritis or arthralgia in 54 cases, comprises as41were monoarthritis, 9 were oligoarthritis and 4 with polyarthralgia) followed by tenosynovitis (n=13) and tuberculous osteomyelitis (n=3). 2 patients were detected with disseminated TB. Most common clinical symptoms were pain (n=48), followed by swelling of the involved site (n=14). 27 (43.54%) patients presented with fever whereas previous history of TB was shown in8 patients. 13 (20.96%) patients were associated with concurrent pulmonary TB. 8 (12.9%) patients had lymph node enlargement. A definite diagnosis of osteoarticular TB was made in 9 (14.51%) patients and rest 53 (85.48%) are probable TB patients. Manifestations of osteoarticular TB occurs at any age but in this study most common age group affected were in between 10 to 30years.Tenosynovitis and/or oligoarthritis may be a presenting manifestation but chronic monoarthritis is the most common presentation. The diagnosis of osteoarticular TB should not be discourage in the absence of fever. This study makes aware about the burden of osteoarticular tuberculosis cases and higher risk of development of multidrug resistant (MDR) osteoarticular TB. Thus early diagnosis of MDR in osteoarticular TB and start of specific antitubercular therapy help into get an earlier and better outcome. K e y w o r d s Arthritis, Osteoarticular Tuberculosis, CBNAAT, Rifampicin resistant tuberculosis, MDRTB Accepted: 15 September 2020

We read the article “Postoperative single shot Epidural Fentanyl and Bupivacaine for postoperative Analgesia after Lumbar Decompression: A Prospective, Double-Blind Randomized Study” by Alican et al1 and wish to appraise the author with certain valid points for further insight and deliberation. 1. How was it made feasible and possible to recruit patients at the clinic of a senior, highly experienced spine consultant and he performed all surgical procedures when it is a multicenter study.1 2. Opiods have been shown to provide excellent postoperative pain control1 but it is otherwise reported in the literature too.2 3. What was the rationale of passing epidural catheter 10 cm cephalad to the most rostral decompressed level and how were the outcome variables matched for patients who underwent, dural level nerve root decompressions? 4. 4.3% of infection rate and that too requiring additional surgery is to be taken into consideration on a serial note. How was the time between transfer back to the ward from the recovery room standardized and matched as this time duration can affect the postoperative outcome variables measured?

Irreparable rotator cuff tears are common conditions seen by shoulder surgeons, characterized by a torn and retracted tendon associated with muscle atrophy and impaired mobility. Direct fixation of the torn tendon is not possible due to the retracted tendon and lack of healing potential which result in poor outcome. Several treatment options are viable but correct indication is mandatory for a good result, pain improvement, and restoration of shoulder function. Patient can be treated either with a conservative program or surgically when necessary, by different available modalities like arthroscopic debridement, partial reconstruction, subacromial spacer, tendon transfer, and shoulder replacement with reverse prosthesis. The aim of this study was to review literature to give an overview of the available possible solutions, with indications and expected outcomes.

Ollier disease (Spranger type I) is a rare bone disease that is characterized by multiple enchondromatosis with a typical asymmetrical distribution and confined to the appendicular skeleton. The pathogenesis of enchondromatosis is not clearly understood. Recently, heterozygous mutations of PTHR1, IDH1 (most common), and/or IDH2 genes have been suggested by various authors as genetic aberrations. Genomic copy number alterations and mutations controlling many vital pathways are responsible for the pathogenesis of Ollier disease. A comprehensive description of all genetic events in Ollier disease is presented in this article. Clinically, Ollier disease has a wide variety of presentations. This article describes the plethora of clinical features, both common and rare, associated with Ollier disease. Multiple enchondromas are most commonly seen in phalanges and metacarpals. Radiologically, Ollier disease presents with asymmetrical osteolytic lesions with well-defined, sclerotic margins. In this article, various radiological features of Ollier disease, including radiographs, computed tomography, and magnetic resonance imaging, are also discussed. Gross pathology, cytological, and histological features of both Ollier disease and its malignant transformation are outlined. Although treatment is conservative in most cases, different possible treatment options for difficult cases are discussed. In the literature, there is a paucity of data about the disease, including diagnosis, management, prognostication, and rehabilitation, necessitating a comprehensive review to further define all of the possible domains related to this disease.

Background: Total shoulder arthroplasty (TSA) is commonly used to treat glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Recently, reverse shoulder arthroplasty (RSA) has been used for GHOA patients who are elderly or have eccentric glenoid wear. We evaluated patients with GHOA scheduled to have TSA but who were changed to RSA because of intraoperative difficulties with the glenoid component or instability and compared them with a cohort that underwent TSA to determine if the groups had similar outcomes.Methods: We identified 24 consecutive GHOA patients who underwent RSA and matched them to 96 patients who underwent TSA. Glenoid wear and rotator cuff musculature were assessed with preoperative computed tomography scans. Direct hospital costs of the procedure were collected.Results: Postoperative American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and range of motion were similar between the 2 groups. Five TSA patients had radiographic glenoid loosening, whereas no RSA patients did. Neither group required a revision. One RSA patient required surgery for treatment of a periprosthetic fracture. RSA was $7274 more costly than TSA, related mainly to implant cost.Conclusions: Patients with GHOA who were converted intraoperatively to RSA because of improper seating of the glenoid trial or persistent posterior subluxation had outcomes comparable to those of a similar group of patients in whom TSA was performed. At midterm follow-up, TSA is associated with lower cost than RSA. The higher rate of radiographic loosening in the TSA group warrants longer follow-up to assess revision costs. In cases in which a TSA cannot be performed with confidence, RSA is a reasonable alternative. (C) 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.

Radial head and coronoid fractures without posterior dislocation of the elbow have not been recorded in the literature. There is no literature documenting the combined fractures of the radial head, capitellum and coronoid process together in the same elbow. This is a case report highlighting this combination of fractures in a 30 year old patient treated with open reduction and internal fixation of all three fractures. The patient was followed up for 28 months and had a good range of motion of the elbow without any instability. Thus such a triad with no ligamentous injuries could depict a bony variant of terrible triad and a mechanism for such an injury has also been explained.

Outcomes for a RSP to treat either a previous operated shoulder (revision procedure) was compared to a primary RSP. Twenty primary RSP (6M, 14F) for an irreparable rotator cuff tear (IRCT) with glenohumeral arthritis /anterior superior arch deficiency and 31 revision RSP (10M, 21F) (previous rotator or cuff surgery, hemi or total shoulder arthroplasty) were evaluated at an average of 24 months postoperatively. Mean age at the time of RSP was 72.3 for primaries 67.2 for revisions. Assessment with pre- and postoperatively SF-36, SST, ASES scores, physical exam, satisfaction surveys, and radiographs was performed. Primary RSP improvements /Revision RSP improvements were: 9.4 sf-36 PCS/ 6.3 sf-36 PCS, 1.8 SST/ 1.6 SST,31.8ASES / 17.5ASES (p Primary RSP provides predictable improvements in pain and function with minimal complications. Revision RSP has a higher complication rate and improvements in pain and function are less reliable. Conventional shoulder arthroplasty for patients with IRCT with gle-nohumeral arthritis/anterior superior arch deficiency has resulted in adequate pain relief but functional improvement has not been predictable. Thus, the initial operative selection for these patients must consider the effect of a failed reconstructive attempt on patient outcomes.

&NA; There has been renewed interest in a semiconstrained total shoulder replacement for patients with arthritis and an irreparable rotator cuff tear. Traditional methods of hemiarthroplasty or glenohumeral arthrodesis do not provide enough improvement in shoulder function to meet patient expectations. This article discusses the design rational, surgical technique, and early results of a custom reverse total shoulder replacement.