The increasing availability of total joint replacement especially for knee and hip joints has increased their rates substantially across the globe. It is associated with increased risk of sarcopenia with loss of muscle mass and strength in the postoperative period. The supplementation of proteins along with exercises have been mainframe strategy to improve the functional ability after total knee arthroplasty and total hip arthroplasty. However, supplementation of proteins necessitates effective proteolytic digestion and conversion to amino acids for exerting substantial effects. In overcoming this challenge, supplementation with essential amino acids can be an attractive approach In this article, we review the clinical evidence with use of essential amino acids in patients undergoing TKA and THA. In the nine studies included in the review, seven assessed EAAs in TKA and two in THA. In TKA studies, improvement in muscle mass, muscle strength and functional recovery has been significant over 6 weeks postoperatively in majority of the studies. Over long term (2 years), improved recovery of rectus femoris and quadriceps had been reported. In THA as well, significant improvement in hip function and stability has been reported. Thus, EAAs in addition to the existing rehabilitation program are helpful to improve sarcopenia and enhances the recovery to perform activities of daily living. We propose from current evidence that administration of EAAs 7 to 10 days prior to planned TKA or THA and continued for 14 to 20 days in the postoperative period along with rehabilitation program is optimal in enhancing the muscle strength and help in physical functional recovery. Current evidence indicates supplementation with EAAs should be a part of routine management protocol in patients undergoing TKA or THA.

Most of the commercially available TKR implants are designed for western populations, which are known to have larger build and stature compared to Asian counterparts often leading to mismatch between resected bony surfaces and implant components. There is paucity of morphometric data of distal femur and proximal tibia in the Indian population. Thus, it becomes important to obtain anthropometric data to achieve the best stability and long-term success of implant. Intraoperative morphological measurements of 100 knees (59 female and 41 males) were done using vernier calliper during TKR. The anteroposterior (AP) and mediolateral (ML) dimensions of cross-section of the femur and tibia were noted before bony resection. The aspect ratios were calculated and compared with that of implant used (DePuy, Stryker, Maxx). We have found that Indian males have larger dimensions of distal femur as well as proximal tibia than females. There exists some degree of mismatch in patients’ dimensions and the sizes of all the three commercially available implant system as well their aspect ratios. Specific designing of implants with dimensions in accordance with the morphometric measurements of Indian population should be done. Also gender specific implant designing should be done.

this article describes a traumatic bilateral MCL avulsion in previously well-functioning total knee arthroplasty. A thorough physical examination with appropriate radiographic imaging study is required for proper evaluation and treatment of this injury, as it is associated with debilitating instability of the knee and accelerated wear and failure of the TKA.

We had the opportunity to read the interesting article by Maney et al [[1]Maney A.J. Young S.W. Frampton C.M. Age and prosthetic design as risk factors for secondary patella resurfacing.J Arthroplasty. 2020; 35: 1563-1568https://doi.org/10.1016/j.arth.2020.01.018Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar], where they have analyzed the New Zealand Joint Registry data to understand the need for patellar resurfacing. They concluded that younger age, posterior stabilized design, and a low 6-month Oxford Knee Score (OKS) were associated with secondary patellar resurfacing (SPR). Although their effort is commendable, we have certain reservations about their methodology and recommendations. Authors have mentioned that it took an average of 3.8 years after primary total knee arthroplasty, for SPR. However, the maximum follow-up of some patients included in group 2 is as low as 1 year. A longer follow-up is required for comparison. Defining surgeons as rare resurfacer if <10% of all their total knee arthroplasties (TKAs) recorded on the New Zealand Joint Registry were resurfaced, looks arbitrary. The indication for patellar resurfacing by this surgeon group has not been described, but it could clarify the characteristics of the unresurfaced patella. Most importantly, there is no description of how the unresurfaced patella was treated in group 2. There is a possibility that they did not perform patelloplasty and electrocautery denervation at all, or performed it inadequately. Our personal experience and literature suggest that patelloplasty is quite effective in reducing patellofemoral symptoms and anterior knee pain (AKP) [[2]van Jonbergen H.P. Scholtes V.A. van Kampen A. Poolman R.W. A randomised, controlled trial of circumpatellar electrocautery in total knee replacement without patellar resurfacing.J Bone Joint Surg Br. 2011; 93: 1054-1059Crossref PubMed Google Scholar]. Researchers have tried to evaluate the effect of implant designs on the need for SPR, but various factors of implant design have been overlooked. Trochlear geometry is an important part of femoral implant design, as it significantly affects the patellofemoral symptoms, including AKP [[3]Popovic N. Lemaire R. Anterior knee pain with a posterior-stabilized mobile-bearing knee prosthesis: the effect of femoral component design.J Arthroplasty. 2003; 18: 396-400Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]. Authors have failed to include important design factors, in their comparison. There is a definite role of component malrotation and joint line change in altering the patellofemoral forces, which can lead to AKP [4Berger R.A. Crossett L.S. Jacobs J.J. Rubash H.E. Malrotation causing patellofemoral complications after total knee arthroplasty.Clin Orthop Relat Res. 1998; 356: 144-153Crossref PubMed Scopus (789) Google Scholar, 5Barrack R.L. Schrader T. Bertot A.J. Wolfe M.W. Myers L. Component rotation and anterior knee pain after total knee arthroplasty.Clin Orthop Relat Res. 2001; 392: 46-55Crossref PubMed Scopus (445) Google Scholar, 6Hofmann S. Romero J. Roth-Schiffl E. Albrecht T. [Rotational malalignment of the components may cause chronic pain or early failure in total knee arthroplasty].Orthopade. 2003; 32: 469-476Crossref PubMed Scopus (120) Google Scholar, 7Bhattee G. Moonot P. Govindaswamy R. Pope A. Fiddian N. Harvey A. Does malrotation of components correlate with patient dissatisfaction following secondary patellar resurfacing?.Knee. 2014; 21: 247-251Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 8Incavo S.J. Wild J.J. Coughlin K.M. Beynnon B.D. Early revision for component malrotation in total knee arthroplasty.Clin Orthop Relat Res. 2007; 458: 131-136Crossref PubMed Scopus (108) Google Scholar]. Exclusion of these factors in the current study makes it vulnerable to bias. Authors mention that the patients of group 2 had a lower 6-month post-primary TKA OKS than group 1 and the mean OKS was higher after SPR than after the primary TKA. However, they had only 35.5% and 19.8% of group 2 available for the above-mentioned OKS comparisons. This questions the significance of the conclusion that a low 6-month OKS is associated with SPR, and that SPR improves OKS at 6 months. A study of Trent and Wales Registry found that SPR produces a satisfactory outcome in only 2 of every 5 patients [[9]Thomas C. Patel V. Mallick E. Esler C. Ashford R.U. The outcome of secondary resurfacing of the patella following total knee arthroplasty: results from the Trent and Wales Arthroplasty Register.Knee. 2018; 25: 146-152https://doi.org/10.1016/j.knee.2017.10.004Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,[10]Toro-Ibarguen A.N. Navarro-Arribas R. Pretell-Mazzini J. Prada-Cañizares A.C. Jara-Sánchez F. Secondary patellar resurfacing as a rescue procedure for persistent anterior knee pain after primary total knee arthroplasty: do our patients really improve?.J Arthroplasty. 2016; 31: 1539-1543https://doi.org/10.1016/j.arth.2016.01.001Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. In a meta-analysis of 7075 cases, no significant differences were found between the resurfacing and nonresurfacing groups with regard to the incidence of AKP and a higher rate of reoperations was observed in the nonresurfacing group [[11]Pavlou G. Meyer C. Leonidou A. As-Sultany M. West R. Tsiridis E. Patellar resurfacing in total knee arthroplasty: does design matter? A meta-analysis of 7075 cases.J Bone Joint Surg Am. 2011; 93: 1301-1309https://doi.org/10.2106/JBJS.J.00594Crossref PubMed Scopus (94) Google Scholar]. A meta-analysis of 7 high-quality studies showed no advantage for resurfacing the patella with regard to AKP [[12]He J.Y. Jiang L.S. Dai L.Y. Is patellar resurfacing superior than nonresurfacing in total knee arthroplasty? A meta-analysis of randomized trials.Knee. 2011; 18: 137-144Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar]. In summary, we understand that this study has inherent limitations of a retrospective study but a strong recommendation favoring patellar resurfacing in all young patients and patients receiving posterior stabilized TKA seems unwarranted. Download .jpg (.81 MB) Help with files Conflict of Interest Statement for Kumar Download .jpg (.73 MB) Help with files Conflict of Interest Statement for Anand Download .jpg (.66 MB) Help with files Conflict of Interest Statement for Yadav Age and Prosthetic Design as Risk Factors for Secondary Patella ResurfacingThe Journal of ArthroplastyVol. 35Issue 6PreviewSelectively resurfacing the patella based on a patient’s risk of secondary patella resurfacing (SPR) may be the optimal strategy for primary total knee arthroplasty (TKA). However, exactly which factors increase the risk of SPR is unknown. Utilizing New Zealand Joint Registry data, we investigated the following: (1) What patient and surgical factors are more prevalent among TKA patients who received SPR compared to those who did not? and (2) What is the difference in Oxford Knee Scores (OKS) between those who receive SPR and those who do not? Full-Text PDF Reply to Letter to the Editor on “Age and Prosthetic Design as Risk Factors for Secondary Patella Resurfacing”The Journal of ArthroplastyVol. 35Issue 10PreviewWe thank Doctors Anand, Yadav, and Kumar for their interest in our paper and their thoughtful letter. We respectfully disagree with almost all of the points they raised. Full-Text PDF

The main question is what is Trunnionosis and what do we need to know as a surgeon. So trunnionosis is basically metallosis. It is the generation of metallic debris from a combination of motion at head on neck junction and an electrochemical corrosion [1,2]. Trunnion is part of the femoral stem where head gets engaged [1]; Corrosion of this part is called Trunnionosis. Taper is the slotted part of head which fits into trunnion of stem; corrosion of this part is called Taperosis (Figure 1).

Achieving adequate dorsiflexion in neglected clubfoot cases remains challenging. On a close observation of the Ponseti method, we have now made certain modifications from the standard Ponseti protocol. This has helped us improve functional results, as well as reduce the number of casts in this walking-age group. From March 2011 onward, we managed 62 neglected clubfeet in 41 patients with the modified protocol. All these patients were treated with serial weekly above-knee casts. The feet were assessed by Dimeglio and Pirani scorings, which were done every week. These children were closely monitored and followed up at regular intervals for any signs of relapses. The mean age group was 3.1 years (1.1–12 years). The mean follow-up period for these feet was 3 years (1.2–4 years). Mean Dimeglio score before treatment was 15.9, and after treatment it was 0.52. Mean Pirani score before treatment was 4.21 and after treatment it was 0.03. The average number of casts before tenotomy with our modified method was 6.9. Percutaneous tenotomy was done in all the cases. The mean dorsiflexion achieved at the end of treatment was 21.3° (15°–40°). Our modified Ponseti technique is a very effective and reproducible method for correction of neglected clubfeet. We feel that an extensive soft tissue surgery may not be required for neglected clubfeet even up to the age of 10 years.

Total knee Arthroplasty is the most common and successful surgery world wide. Foundation of TKA is based on three pillars soft tissue balancing, bone cuts and cementing. All these factors are equally important and mistake at any level will lead to failure. We here would like to add the fourth pillar 'Joint line Restoration' for successful TKA.

Total knee and hip replacement have been very successful surgeries and the indications for these are extending daily. We are presenting the case of an adult female who was crippled due to severe deformity of her hip and knee joints and had her life improved tremendously after the surgery. However, the post-operative range of flexion and hip stability were not as good as those following primary hip replacement in joints that had not been ankylosed. Nevertheless, with proper planning and meticulous surgery, it is possible to provide stable and mobile joints to the patients and make their life way better. We suggest that all such patients should be given the option of replacement and few anticipated complications and outcome somewhat inferior to non-ankylosed joints, should not deprive them of the opportunity to make their lives self-reliant.

ABSTRACT Avascular necrosis (AVN) of tibial condyles is an uncommon cause of joint degeneration and it may mimic osteoarthritis. The differentiation between spontaneous and secondary osteonecrosis is important for appropriate management. We present here a case of spontaneous avascular necrosis of the medial tibial condyle causing sudden increase in pain; localization to the medial tibial condyle near joint line with exacerbation on weightbearing and varus deformity. We also aim to recapitulate briefly various types and currently available treatment options. In the present case, considering advanced stage of AVN and associated degenerative changes, total knee replacement (TKR) was performed successfully with good outcomes. How to cite this article Yadav S, Yadav CS, Kumar N, Kumar A. Every Knee is not Osteoarthritic, Spontaneous Avascular Necrosis of the Medial Tibial Condyle. J Postgrad Med Edu Res 2016;50(1):33-35.

Background: Synovial chondromatosis is a rare, benign condition characterized by proliferation of synovial lining and metaplasia.The disease is usually mono articular and commonly involves knee joint, but it can also occur in shoulder, elbow, hip, ankle and wrist joints.A review of the literature produced 30 case reports of synovial chondromatosis of the wrist with only five cases showing recurrence (5/30, 17%).Because of its low prevalence and nonspecific symptoms, it can present diagnostic difficulties and lead to a delay in treatment.Case: We report a 6 month follow up case of a 29 year old right hand dominant male who presented with complaint of pain and swelling in right wrist joints of four months duration.Plain X-ray revealed lytic lesion at distal end of right ulna with multiple radio opaque deposits.MRI and FNAC were in favour of Synovial chondromatosis.Patient underwent synovectomy and excision of calcific lesion through a dorsoulnar approach and a separate incision over radial styloid under general anaesthesia.Histopathology confirmed the diagnosis of Synovial chondromatosis.Patient had no recurrence till last follow up (6 Month). Conclusion:Synovial chondromatosis of wrist joint is extremely rare.A close coordination between the clinician, radiologist and pathologist is essential for accurate diagnosis and management.

Background: Gentle passive manipulation and casting by the Ponseti method have become the preferred method of treatment of clubfoot presenting at an early age. However, very few studies are available in literature on the use of Ponseti method in older children. We conducted this study to find the efficacy of Ponseti method in treating neglected clubfoot, which is a major disabler of children in developing countries. Materials and Methods: 41 clubfeet in 30 patients, presenting after the walking age were evaluated to determine whether the Ponseti method is effective in treating neglected clubfoot. This is a prospective study. Pirani and Dimeglio scoring were done for all the feet before each casting to monitor the correction of deformity. Quantitative variables were expressed as mean ± standard deviation and compared between preoperative and postoperative followup using the paired t -test. Also, the relation between the Pirani and Dimeglio score, and age at presentation with the number of casts required was evaluated using Pearson’s correlation coefficient. No improvement in Dimeglio or Ponseti score after 3 successive cast was regarded as failure of conservative management in our study. Results: The mean age at presentation was 3.02 years (range 1.1–10.3 years). The mean followup was 2.6 years (range 2–3.9 years). The mean number of casts applied to achieve final correction were 12.8 casts (range 8–18 casts). The mean time of immobilization in cast was 3.6 months. The mean Dimeglio score before treatment was 15.9 and after treatment were 2.07. The mean Pirani score was 5.41 before treatment and 0.12 after treatment. All feet (100%) achieved painless plantigrade feet without any extensive soft tissue surgery. 7 feet (17%) recurred in our average followup of 2.6 years. Conclusions: Painless, supple, plantigrade, and cosmetically acceptable feet were achieved in neglected clubfeet without any extensive surgery. A fair trial of conservative Ponseti method should be tried before resorting to extensive soft tissue procedure.

Background: Fractures of lateral condyle of humerus in pediatric age group, the most common being distal humerus epiphyseal injury, are commonly associated with delayed presentation to terminal health care providers. Reasons accounted might be at every level, right from the patient to the physician. In the backdrop of existing disputed treatment strategy operative v/s non-operative treatment of fractures having more than 3-week duration of injury, same were treated by open reduction and k wire fixation using ulnar peg graft. Final functional result was evaluated with longest follow up of over 1 year. Materials and Methods: Twenty children having fracture of lateral condyle of humerus with duration of trauma more than 3 week were included in the prospective study. Age ranged from 5 years to 15 years. Average age was 8 years. Among the 20 patients, 8 were male and 12 were female. Average time of presentation was after 5 weeks of injury. Seven patients had milch type 1 injury and 13 patients had milch type II injury. All patients were treated by open reduction and internal fixation using k wires and ulnar peg graft. The follow-up period was over 1 year. Result: Results were evaluated using radiograph, and functional results were evaluated using the Liverpool elbow scoring system. In the present series, all fractures united with 92% excellent, 5% good, and 3% poor results. Poor results were associated with greater displacement of fracture, prior repeated attempts of close reduction, and history of massage. Conclusion: Being an epiphyseal injury and a common occurrence, fracture of lateral condyle of humerus in pediatric age group are commonly maltreated, with error contributed right from parents to even physician. Common reasons of delayed presentation are ignorance on parents′ side, malpractice by some bone-setters, poorly done radiograph, inaccurate radiographic interpretation by the physician, and poor selection of treatment methods.

ABSTRACT Background Association of tuberculosis and total hip joint replacement (THR) is described with or without antitubercular treatment (ATT) cover but total knee arthroplasty (TKA) in early disease in single-stage is uncommonly reported. We wish to share our clinical experience in such a case. Case description A 22-year-old male presented with pain and swelling of left knee for 7 months. It was drained at local health facility with sinus development. Tuberculosis was diagnosed by clinic-radiological evaluation and ATT was started. Sinus healed but disabling pain and knee stiffness with flexion deformity persisted. Radiographs revealed destructive osteoarticular arthritis with periarticular osteopenia. Debridement followed by TKA in single-stage was done with posterior-stabilized implant. Postoperative period was uneventful. Histopathological analysis confirmed chronic granulomatous synovitis with caseation necrosis suggestive of mycobacterial infection. After 1-year, ATT was discontinued and patient was disease-free. Clinical relevance Single-stage prosthetic knee joint arthroplasty can be safely performed under adequate ATT coverage in early disease provided response to medical treatment is good. Patient counseling regarding compliance with ATT and postoperative protocol is important in ensuring success. How to cite this article Yadav S, Yadav CS, Kumar N, Kumar A. Total Knee Arthroplasty in a Case of Tuberculosis Knee in Healing Stage: Is it Safe? J Postgrad Med Edu Res 2015;49(3): 139-142.

Complications involving the extensor mechanism after TKA are potentially disastrous. We are reporting a case of patellar tendon rupture from tibial tuberosity following total knee arthroplasty. We managed it by direct repair with fiberwire using Krackow suture technique without augmentation. Our long term result has been very encouraging. Our method is a safe and better method of management of patellar tendon avulsion following TKA when it happens without any tissue loss.

We report a case of fracture of tibial polyethylene post fracture from base in a 56 year old lady 10 years from posterior stabilized total knee arthroplasty following trivial trauma. There have been signs of wear at the base especially anteriorly. After revision of tibial polyethylene component patient developed complete relief of symptom.

AIM:Thigh pain following tourniquet application is a common complaint in early post operative period following total knee arthroplasty.METHOD:Post operative Thigh pain was evaluated in 30 consecutive simultaneous bilateral total knee arthroplasty patients between July 2013 and January 2014. Patient thigh pain was evaluated with the VAS score. The scale was applied on first, second, third day & second and six weeks after surgery.RESULT:There were statistically significant difference in VAS score in non-tourniquet group on first, second, third post operative day. We did not find statistically significant difference at Second and Six weeks post operatively.CONCLUSION:This Randomized trial demonstrates that non-tourniquet use in TKA has less early postoperative pain and leads to better recovery.

Today, total knee arthroplasty (TKA) is one the most commonly performed surgeries worldwide. The purpose of this article is to review the appearance of normal post-TKA roentgenographs and describe the correct sequence for their interpretation. It is unwise to depend solely on patients' symptoms when diagnosing TKA complications because serial radiographs can foresee failures well before they manifest clinically. Ideal post-TKA radiographs comprise whole lower extremity anteroposterior and lateral views taken under weight bearing conditions along with a skyline view of the patellofemoral joint. Among other things, weight bearing exposes the true alignment, ligamentous laxity and polyethylene wear. On the basis of follow-up of our TKA cases, we have drawn up a protocol for assessing postoperative X-ray films after TKAs. Following the proposed sequence, surgeon can easily decide how to proceed with follow-up and foresee complications. Careful interpretation of postoperative radiographs after TKA is essential to careful monitoring of patients and implant survival.

BACKGROUND:Stable trochanteric femur fractures can be treated successfully with conventional implants such as sliding hip screw, cephalomedullary nails, angular blade plates. However comminuted and unstable inter or subtrochanteric fractures with or without osteoporosis are challenging & prone to complications. The PF-LCP is a new implant that allows angular stability by creating fixed angle block for treatment of complex, comminuted proximal femoral fractures. METHOD:We reviewed 30 patients with unstable inter or subtrochanteric fractures, which were stabilized with PF-LCP. Mean age of patient was 65 years, and average operative time was 80 min. Patients were followed up for a period of 3 years (June 2010-June 2013). Patients were examined regularly at 3 weekly interval for signs of union (radiological & clinical), varus collapse (neck-shaft angle), limb shortening, and hardware failure. RESULT:All patients showed signs of union at an average of 9 weeks (8-10 weeks), with minimum varus collapse (<10°), & no limb shortening and hardware failure. Results were analysed using IOWA (Larson) hip scoring. Average IOWA hip score was 77.5. CONCLUSION:PF-LCP represents a feasible alternative for treatment of unstable inter- or subtrochanteric fractures.