List of published Journal Articles

by Dr. Anurag Mittal

Aims

The aim of this study was to assess the reproducibility and validity of cross table radiographs for measuring the anteversion of the acetabular component after total hip arthroplasty (THA) and to compare it with measurements using CT scans.

Patients and Methods

A total of 29 patients who underwent THA between June 2010 and January 2016 were included. There were 17 men and 12 women. Their mean age was 43 years (26 to 65). Seven patients underwent a bilateral procedure. Thus, 36 THAs were included in the study. Lateral radiographs and CT scans were obtained post-operatively and radiographs repeated three weeks later. The anteversion of the acetabular component was measured using the method described by Woo and Morrey and the ischiolateral method described by Pulos et al and these were compared with the results obtained from CT scans.

Results

The mean anteversion was 18.35° (3° to 38°) using Woo and Morrey’s method, 51.45° (30° to 85°) using the ischiolateral method and 21.22° (2° to 48°) using CT scans. The Pearson correlation coefficient was 0.754 for Woo and Morrey’s method and 0.925 for the ischiolateral method. There was a linear correlation between the measurements using the ischiolateral method and those using CT scans. We derived a simple linear equation between the value of the CT scan and that of ischiolateral method to deduce the CT scan value from that of ischiolateral method and vice versa.

Conclusion

The anteversion of the acetabular component measured using both plain radiographic methods was consistently valid with good interobserver reproducibility, but the ischiolateral method which is independent of pelvic tilt was more accurate. As CT is costly, associated with a high dose of radiation and not readily available, the ischiolateral method can be used for assessing the anteversion of the acetabular component.

Radiofrequency ablation probes have gained popularity in arthroscopic surgeries. We report an unusual complication associated with prolonged radiofrequency use in a shoulder arthroscopy case. A 55 year old male patient suffered a second degree burn around shoulder during rotator cuff repair. Long duration of radiofrequency probe use compounded by absence of suction outlet led to high temperature fluid coming in direct contact with the surrounding skin resulting in second degree burns around the shoulder region. Burns were managed conservatively, and went on to heal with hypopigmented scar at six month follow-up. Although a safe device, caution should be maintained while using radiofrequency probe and outflow should not be allowed to come in direct contact with the surrounding skin.

Hydatid disease may develop in almost any part of the body and can be identified with a combination of clinical history, imaging findings, and serologic results; however, the diagnosis of bone hydatidosis is primarily based on radiographic Findings. Bone hydatid disease is often asymptomatic, and its diagnosis is usually made at an advanced stage when lesions have become extensive. We present a case of a 53-year-old male who presented with complains pain, swelling, discharge from his right tibia. Radiographs revealed a lytic lesion in diaphysis of tibia mimicking chronic osteomyelitis with further imaging and biopsy was suggestive of hydatid cyst. Patient opted for above knee amputation vs limb salvage.

Among the dislocations around the great toe, hallucal interphalangeal (IP) dislocation is a rare entity, with the most common being metatarsophalangeal dislocation due to its greater lever arm. We present the case of a young manual labourer with a missed hallucal IP joint dislocation with an incarcerated sesamoid, initially managed by an osteopath. After a failed attempt of closed reduction in the emergency department, we performed open reduction and reposition of sesamoid using dorsal incision and stabilized the joint with a K wire which was removed after 4 weeks. The patient was gradually mobilized and returned to his work of manual labor after 3 months without any residual pain or deformity.

Introduction: Platelet-rich plasma (PRP) is promoted nowadays as an ideal autologous biological blood-derived product. It enhances wound healing, bone healing, tendon healing and is currently being widely used.

Aims and Objectives: A prospective cohort study was conducted to assess the efficacy of autologous PRP injection and to compare it with corticosteroid injection in the treatment of plantar fasciitis (PF).

Materials and Methods: Fifty patients were included in the study and divided into two groups. Group I (25 patients) received PRP injection and Group II (25 patients) were given steroid injection. Patients were clinically assessed at different intervals. Functional outcome was evaluated on the basis of the visual analog scale (VAS) and foot and ankle ability measure (FAAM) scores. Plantar fascia thickness was assessed pre- and post-injection by ultrasound.

Results: PRP and corticosteroid injection groups at the initial visit had VAS score of 8.86 and 8.60, respectively, which was reduced to 1.52 and 3.10 at the end of 6 months. The PRP and corticosteroid injection groups at the initial visit had FAAM score of 29.2 and 30.8, respectively, which increased to 84.2 and 68.3 at the end of 6 months. After injection, the PRP group had a significant reduction (34.80%) in the thickness of plantar fascia as compared to corticosteroid group (29.54%).

Conclusion: Treatment of PF with PRP extract reduces pain and significantly increases function, exceeding the effect of steroid on long-term follow-up.

The clinical use of unicompartmental knee arthroplasty (UKA) for end stage degeneration of single knee compartment is increasing due to expanding indications and promising clinical results.

  • With an aim of improving prosthesis survivorship of UKA, the use of computer assisted technologies (CATs) such as robotics, navigation, and patient specific instrumentation has been on the rise to reduce intraoperative errors in surgical technique.
  • While CATs, especially robotics, seem to offer improvements in achieving target limb alignment and ideal component position, the evidence of its clinical efficacy to reduce revision rate is limited.
  • Future studies comparing the results of UKA done using CATs with those done with a conventional method should focus on survivorship as the primary outcome, with adequate sample size evaluated at long-term follow up while avoiding evaluation bias.

Unicompartmental knee arthroplasty (UKA) is a bone and ligament sparing alternative to total knee arthroplasty in patients with the end-stage single compartment degeneration of knee. However, despite being a successful procedure, the usage of UKA does not correlate well with its umpteen advantages, most likely due to the concerns regarding the survivability, patient selection, ideal bearing design, judicious use of advanced technology among many others. Therefore, the purpose of this study was to review and summarize the debated literature and discuss the controversies as ‘Ten Enigmas of UKA’.

Follow the four steps of learning a new technique. Nobel prize-winning physicist Richard Feynman developed four steps for adopting a new scientific approach:

  1. Choose and read about the concept you want to learn about.
  2. Pretend you are teaching the concept to a 6th grade student.
  3. Identify the gaps in your explanation and go back to the source material to better understand it.
  4. Review and simplify the concepts.

Introduction

In recent years, UKA has re-emerged as an alternative to HTO and TKA in patients of end-stage single compartment degenerative arthritis of knee when conservative treatments have been exhausted. A minimally invasive procedure, UKA, has many undeniable advantages- bone and ligament preservation, shorter operative time, less blood loss, less need of transfusions, lower perioperative co-morbidities, early rehabilitation, a larger range of motion, better proprioception, feeling of the natural knee, lower perioperative costs and better long-term functional outcomes. However, early reports of higher revision rates in UKA compared to TKA did not allow UKA to achieve its true potential. Furthermore, an associated learning curve with the requirement of accurate surgical technique and less tolerance to surgeon related errors have heralded its widespread use. The works of Murray et al. and Liddle et al. show that surgical case-volume strongly influences the rate of revision surgery. In specialized centers, where a large number of unicompartmental prosthesis implants are performed, the revision rate is comparable with those of total prostheses. Therefore, an experienced surgeon with accurate surgical technique and UKA usage of more than 20 will be able to achieve superior functional outcomes and increased implant survivorship. 

Outline of surgical technique for fixed bearing UKA.

  1. Exposure: a) Skin incision, b) Arthrotomy c) Dissection.
  2. Tibial cut: a) Coronal alignment, b) Tibial slope, c) Resection level, d) Vertical cut.
  3. Distal femur cut: a) Spacer block method, b) Gap check.
  4. Femur sizing and final femoral preparation: a) Posterior rasping, b) Femur size determination and finishing guide placement, c) Final preparation, d) Femoral trial test., e) Flexion-extension gap check.
  5. Tibia sizing and preparation.
  6. Periarticular injection and Trial test.
  7. Cementation and Implantation: a) Tibia cementation, b) Femur cementation, c) Final assessment and implantation.
  8. Periarticular injection and Wound closure.

Background: Closed intramedullary (IM) nailing among various modalities is one of the commonest sought out procedure in current practice for management of femoral-diaphyseal fractures (FDF) following trauma. However, it has some limitations like prolonged procedural duration, high radiation exposure and a steep learning curve. Therefore, with limited resources in odd hours and at a high patient turnover center like ours where closed reduction can be a challenge, we adopted a modified mini-open technique which can overcome the limitations of closed reduction technique.

Objective: To compare the closed IM nailing and mini-open technique in FDF in terms of radiation exposure, surgical duration, radiological and functional outcome.

Materials and Methods: A total of 100 patients (118 femurs) with FDF (AO 32A1-B2) operated in odd-hours (20:00–06:00 hrs. GMT +5.30) with closed (Group I, n=62) or mini-open (Group II, n=56) IM nailing technique between September 2018 to December 2019 with a minimum follow up of 12 months were included in this study. The outcomes were measured using Thoresen scoring system and statistical analysis were performed using paired t-test and χ2 -test.

Results: The overall mean patient age was 37.5 years (18-74 years). The mean surgical duration, c-arm shoots and radiological union time were 71.5 minutes, 21 shoots and 16 weeks, respectively for group I and 47.5 minutes, 5.4 shoots and 18 weeks for group II. There was significant difference between the two groups in mean surgical duration (p<0.05) and c-arm shoots (p<0.05). However, there was no statistical significant difference between time for union, rate of union, functional results and incidence of superficial or deep infection between the two groups.

Conclusion: Our study shows that the mini-open technique has the advantage of less radiation and short surgical duration with similar functional outcomes when compared to closed IM nailing technique. In conclusion, mini-open technique is a safer alternative in patients with FDF at high-volume centers and in odd-hours when the available resources are limited.

Introduction: Total hip arthroplasty (THA) is a successful procedure; however, its longevity depends mainly on accurate component position, among many other factors. Multiple plain radiographic methods; cross table radiographic method, modified Budin method, projected neck-shaft angle method, and trans lateral decubitus view method using Ogata-Goldsand formula, have been described in literature for measurement of femoral stem version (FSV) but none have been proved to be as accurate as CT scan method. The purpose of this paper is to review these multiple methods and also determine validity and accuracy of the modified Budin method in the Indian population.

Material and methods: A literature search for the different methods described for FSV measurement was performed and these methods were reviewed. In addition, for validation of modified Budin method in Indian population, 36 THAs were performed by senior author and data was collected prospectively. A posteroanterior radiograph with patient sitting in 90 degrees hip flexion and 30 degrees of abduction was taken 3 weeks and 6 weeks after surgery for calculating the femoral version using modified Budin method. At 6 weeks, a CT scan was also done for version measurement. Intra and interobserver reliability, and reproducibility of radiographic FSV measurement, and the correlation between CT scan and radiographic FSV measurement were statistically calculated.

Results: All the reviewed studies demonstrated that their method is comparable to CT method for FSV measurement, except FSV measured on cross table radiographic view. However, there are only one or two studies of every method described except for modified Budin method. The mean FSV in our prospective case series using ‘modified Budin’ method was 11.6° which was comparable to the mean of CT scan version measurement (12.3°).The mean difference was 0.7° which was statistically insignificant (p value >0.05). There was high intra-class correlation coefficient (ICC) in radiographic femoral version for both intra- and inter-observer reliability.

Conclusion: Multiple methods have been described and validated in literature, however, the ‘modified Budin’ view have proved multiple times to have excellent reliability and validity for easy measurement of FSV.