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OBJECTIVES: Anterior cruciate ligament (ACL) rupture is a common injury and has a non-union rate of 40-100%. Important cellular events, such as fibroblast proliferation, angiogenesis and change in collagen fibril thickness in the ACL remnant, as described in other dense connective tissue, might have an implication in graft recovery following ACL reconstruction. Thus we conducted a study with an aim to characterize the ultrastructural and histological features of ruptured ACL tibial stump and correlate the same with the duration of injury. MATERIALS AND METHODS: This was a prospective observational study in which 60 ruptured human ACLs were evaluated for collagen fibril thickness, blood vessel density (per mm2) and fibroblast density (per mm2) with the help of transmission electron microscopy, immunohistochemistry via CD34 antibody staining and light microscopy (H&E staining). The findings were correlated with duration of injury. RESULTS: Fifty-four male and six female patients with a mean duration of the injury of 23.01 weeks (SD = 26.09; range 2-108 weeks) were included for the study and were divided on the basis of duration of injury as follows: Group I (≤ 6 weeks; N = 16), Group II (7-12 weeks; N = 18), Group III (13-20 weeks; N = 7), Group IV (21-50 weeks; N = 12), Group V (> 50 weeks; N = 7). A significant correlation was seen with blood vessel density (r = 0.303, p = 0.01) and fibroblast density (r = - 0.503, p = 0.001). Thickness of collagen fibril did not correlate with the duration of injury (r = 0.15, p = 0.23). The thickness of the collagen reached its peak after 50 weeks following injury, whereas highest density of blood vessel and fibroblast was seen at 12-20 weeks. Matched pair analysis revealed a significant decrease in collagen fibril thickness and an increase in fibroblast density at 7-12 weeks. CONCLUSION: Following injury to ACL, the ruptured tibial stump undergoes a series of changes at the cellular level vis-à-vis changes in collagen fibril thickness, vascular density and fibroblast density that possibly suggest an intrinsic healing response. This further may have implications on the functional outcome following ACL reconstruction with remnant preservation. LEVEL OF EVIDENCE: III.

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BACKGROUND: Proprioception is a specialized sensory modality encompassing the movement of the joint and its position in space. Reconstruction of the anterior cruciate ligament (ACL) does not always yield expected outcome, suggesting that successful reconstruction depends on not only the ultimate strength of the graft but also recovery of proprioception. Treatment delay is a significant concern in developing countries, e.g., in Asia. Thus, presence of mechanoreceptors is one of the factors having paramount importance for successful outcome. We conducted this study to identify mechanoreceptors via immunohistochemical staining and correlate their presence with duration of injury. MATERIALS AND METHODS: A total of 38 injured native ACL stumps were harvested from patients undergoing ACL reconstruction and stained with neurofilament protein stain to detect functional mechanoreceptors. RESULTS: Of the specimens, 44.7% stained positive for monoclonal antibody. No association was found between duration of injury and presence of mechanoreceptors (p = 0.897). No correlation was seen between age and side. CONCLUSIONS: No correlation was found between duration of injury and presence of viable mechanoreceptors, hence it is beneficial to preserve the native ACL stump irrespective of the time interval between injury and surgery. LEVEL OF EVIDENCE: III.

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CONTEXT: Dexmedetomidine, a highly selective alpha-2 agonist has been used as an adjuvant analgesic in vascular, bariatric, and thoracic surgery. We assessed the efficacy of intravenous dexmedetomidine as an analgesic adjunct to local anesthetic infiltration for control of postoperative pain in arthroscopic knee surgery. SETTINGS AND DESIGN: This was a randomized control study performed in a Tertiary Care Hospital. MATERIALS AND METHODS: Forty-five adult patients scheduled for anterior/posterior cruciate ligament reconstruction were randomized into three groups. Group B (bupivacaine group) received bupivacaine intraarticularly and normal saline by the intravenous route. Group D (dexmedetomidine group) received Intravenous dexmedetomidine and normal saline intraarticularly. Group BD (bupivacaine + dexmedetomidine group) received a combination of intravenous dexmedetomidine and intraarticular bupivacaine. Patient's cardiorespiratory parameters, time to first rescue, total rescue analgesic consumption in first 24 h, visual analog scale for pain were assessed. STATISTICAL ANALYSIS: The data were analyzed using analysis of variance and Chi-square test. RESULTS: The time to first request for rescue analgesia was significantly prolonged in Group D and Group BD patients (P < 0.05) compared to Group B. Total rescue analgesic consumption was least in Group BD. Group D and Group BD patients had lower heart rate and systolic and diastolic blood pressure values. CONCLUSION: Intravenous dexmedetomidine in combination with intraarticular bupivacaine decreased perioperative analgesic requirement in patients undergoing arthroscopic knee surgery. However, monitoring and vigilance are essential if dexmedetomidine is used as part of a multimodal analgesic regimen in view of its hemodynamic side effects.

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Intra-articular ganglion cysts of the knee joint are rare and most frequently are an incidental finding on MRI and arthroscopy. Most of the previous studies have reported a single ganglion cyst in the knee. There have been previous reports of more than one cyst in the same knee but not in the same structure within the knee. We are reporting a case of dual ACL (anterior cruciate ligament) ganglion cysts one of which was missed on radiological examination but later detected during arthroscopy. To the best of our knowledge, no such case has been reported in the indexed English literature till date.

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BACKGROUND: Management of early stages of osteonecrosis aims to prevent the collapse of the femoral head by attempts at restoring the vascularity of femoral head. Bone marrow-derived mononuclear cells with their angiogenic and osteogenic properties appear to have the potential to halt the disease process when injected intralesionally following core decompression. MATERIALS AND METHODS: Forty patients (60 hips) with stage I, II or III (ARCO system) osteonecrosis of femoral head were treated by either core decompression and isolated mononuclear cells (group A) or core decompression and unprocessed bone marrow injection (group B). The patients were followed up clinically and radiologically for a minimum of 2 years. The functional outcome was assessed in terms of Harris hip score, and disease progression was assessed radiologically by comparing the preoperative and follow-up MRI at the end of 2 years. RESULTS: On 2-year follow-up, there was considerable improvement in the hip function as measured by the Harris hip score in both the groups (p = 0.031). On MRI, there was a decrease in the size of the lesion in group A (p = 0.03). Three of 30 hips (10.0 %) in group B required total hip replacement. CONCLUSIONS: Implantation of autologous bone marrow stem cells in avascular necrosis of femoral head is a safe and effective procedure and has better outcome than bone marrow for early stage of avascular necrosis of femoral head.

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BACKGROUND & OBJECTIVES: The discrimination between the Staphylococcus epidermidis colonizing the deep seated indwelling devices and those which are mere commensals has always been a challenge for the clinical microbiologist. This study was aimed to characterize the S. epidermidis isolates obtained from device related infection for their phenotypic and molecular markers of virulence and to see whether these markers can be used to differentiate the pathogenic S. epidermidis from the commensals. METHODS: Fifty five S. epidermidis isolates from various device related infections such as endophthalmitis following intra-ocular lens (IOL) implantation, intravascular (IV) catheter related sepsis and orthopaedic implant infections, were studied for slime production, biotyping, antibiotic sensitivity; and mec A and ica positivity by the recommended procedures. RESULTS: Twenty three (41.8%) isolates were multi-drug resistant, 26 (65.2%) were slime producers, 30 (54.5%) were adherent, 23 (41.8%) possessed the intercellular adhesin (ica) gene, and 28 (50.9%) harboured the mec A gene. Biotypes I and III were the commonest, most members of which were multi- drug resistant. Twenty two (73.3%) of the 30 adherent bacteria were slime producers as opposed to only 4 (16%) of the 25 non-adherent bacteria (P<0.001). A vast majority i.e. 21 (91.3%) of the 23 ica positive organisms were adherent to artificial surfaces in contrast to only 9 (28.1%) of the 32 non-ica positive organisms (P<0.001). Twenty (86.9%) of the 23 ica positive bacteria were slime producers, as opposed to only 6 (18.7%) of the 32 ica negative bacteria (P<0.001). Of the 23 multi-drug resistant isolates, 19 (82.6%) carried the mec A gene. INTERPRETATION & CONCLUSIONS: The present findings showed that ica AB and mec A were the two important virulence markers of S. epidermidis in implant infections and slime was responsible for the sessile mode of attachment on the devices.

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PURPOSE: To compare magnetic resonance (MR) arthrography and arthroscopy as a means of assessing the severity of labral tear in anterior glenohumeral instability. METHODS: 52 patients presenting with traumatic recurrent anterior shoulder instability were evaluated using MR arthrography; 30 shoulders with a labroligamentous lesion were treated with arthroscopic Bankart repair. Their MR arthrographic images were interpreted by 3 senior musculoskeletal radiologists, and a radiological diagnosis was reached by consensus. The sensitivity and positive predictive values of MR arthrography for detecting a labral tear were determined. Agreement between MR arthrography and arthroscopy in terms of the width and depth of the labral tear was analysed. RESULTS: On arthroscopy, a labroligamentous lesion (Bankart lesion and its variants) was present in all the 30 shoulders. Agreement between the MR arthrography and arthroscopy in terms of the width and depth of the labral tears was good. CONCLUSION: MR arthrography is an accurate means of assessing the severity of anterior labroligamentous lesions and yields a good correlation with arthroscopy.

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A total of 32 Staphylococcus epidermidis isolates from indwelling device-related infections such as endophthalmitis following intraocular lens (IOL) implantation, intravenous catheter-related sepsis and orthopaedic implant infections, were studied for slime production and adherence to artificial surfaces. Of these, 21 (65.6%) isolates were slime positive by the Congo Red agar method and 24 (75%) were adherent to artificial surfaces by the quantitative slime test. The majority (19 out of 24; 79.1%) of the adherent bacteria were slime producers. Antibody to slime raised in rabbits was able to inhibit the adherence of all 24 bacteria designated as adherent by our quantitative test. It seems that slime is indispensable for the sessile mode of attachment, leading further to the development of biofilms on the indwelling devices.

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The aim of our study was to evaluate clinical, radiological and functional outcomes of selected cases of percutaneous fixation of scaphoid fractures via a dorsal approach. Percutaneous fixation by dorsal approach was done in 32 patients (mean age 32.2 years) involving both fresh and late scaphoid fracture presentations (mean 17 days). Fourteen cases of B1 type, ten cases of B2 and eight cases of C type (Herbert's classification) were treated. The patients were prospectively followed up clinically and radiologically for a minimum follow-up of 14 months (mean 16 months), and functional outcome and complications were assessed. All fractures united over an average of nine weeks. There was no avascular necrosis or screw cutout with preservation of wrist movement and grip strength. There were no injuries to any at risk anatomical structures. Percutaneous fixation of scaphoid fractures through dorsal approach gives good clinical and functional outcome in acute and chronic scaphoid fractures of B1, B2 and C types (Herbert's classification).

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OBJECTIVES: To assess the efficacy and safety of digastric trochanteric flip osteotomy technique in the management of acetabular fractures and to evaluate surgical outcome in terms of fracture reduction, femoral head viability of selected acetabular fractures treated operatively using a digastric trochanteric flip osteotomy and a modified Kocher­Langenbeck approach with surgical dislocation of the femoral head. DESIGN: Prospective. PATIENTS: Eighteen patients predominantly with combined transverse and posterior wall fractures or multifragmentary posterior wall fractures. OUTCOME EVALUATION: Clinical and radiographic analysis after a minimum 18 months follow-up. Methods A single modified approach involving digastric trochanteric flip osteotomy and a modified Kocher­Langenbeck approach with anterior (n = 14) or posterior (n = 4) surgical dislocation of the femoral head, was done for one or more of following reasons: intra-articular assessment of reduction in fractures with comminution, marginal impaction and involvement of the anterior column, removal of intra-articular fragments, and confirmation of extra-articular screw placement. RESULTS: At a mean follow-up of 26 months (18­40 months), the 17 patients presented with a good to excellent clinical result according to the d'Aubigné score. In all subjects, anatomical reduction was achieved during surgery. The osteotomy site healed at an average of 7 weeks and all the patients recovered abductor strength at 12 weeks. One avascular necrosis occurred in a case of posterior column plus wall fracture (who presented to us after 3 weeks). No heterotopic ossification interfering with hip function was found. CONCLUSION: This technique gives good exposure (especially in posterior wall, dome area, posterior fracture-dislocation with intra-articular fragments/femoral head fractures and T-fractures), preservation of abductor strength (which may be lost with excessive retraction of abductors to see dome area in classical posterior approach), reliable healing of osteotomy (in contrast to conventional trochanteric osteotomy) without risking the vascularity of femoral head.

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We describe a patient with a large subarticular cystic lesion in the proximal tibia developed following traumatic avulsion of PCL. There was a demonstrable communication between the cyst and the joint cavity and ingrowth of the synovial tissue was the most probable pathogenetic mechanism for the development of the cyst. We recommend that the post-traumatic cyst must be kept as a differential diagnosis in a patient presenting with cystic lesion around a joint, especially if there is a history of significant trauma in recent past.

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PURPOSE: To investigate the harmful effects of a single episode of intra-articular bleeding on articular cartilage of rabbit knees using scanning electron microscopy. METHODS: Autologous blood was injected into the right knee joints of 18 New Zealand white rabbits. Surface and cellular damages were examined by the scanning electron microscope (n=9) and light microscope (n=34), respectively. The injected right knees were then compared with the corresponding control left knees at one, 3, and 6 weeks after the blood injection. RESULTS: The articular surface of the injected knees turned uniformly rough with multiple pits after one week. Maximal changes with elevations and depressions were observed at 3 weeks. These changes reversed at 6 weeks with the irregularities smoothing out. A similar pattern of transient cartilage damage was noted histologically. CONCLUSION: Both scanning electron microscopic and light microscopic findings suggest that a single episode of intra-articular bleeding leads to articular cartilage damage but this appears to be reversible. Our findings of transient damage to the articular cartilage suggest that there is no need for intra-articular evacuation and washout following an acute episode of haemarthrosis.

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Vascular malformations involving the muscles around the knee can be a cause of knee pain. We studied ten such cases. All underwent magnetic resonance (MR) imaging which confirmed the diagnosis. Eight cases underwent wide surgical excision of the lesion, histology of which showed a vascular malformation with predominantly venous element. There was no recurrence in any of the operated cases at the last follow-up. We believe that most of these lesions can be treated successfully by careful preoperative planning aided by MR imaging and a wide-open excision of the lesion.

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All the described tests for the detection of anterior cruciate ligament (ACL) tear are passive tests. For obese or muscular built patients these tests are cumbersome and often unsuitable. We describe for the first time a new method, the 'Delhi active test', by which a torn ACL can be detected irrespective of the size or build of the patient. The results of this test are reproducible and the diagnostic accuracy is comparable with other tests. We suggest that the 'Delhi active test' be used as one of the routine clinical methods to detect the torn ACL.

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Desmoplastic fibroma is a rare benign tumour of bone. Diagnosis is not easy and is often made by excluding other tumours. Histopathological diagnosis of this tumour is also sometimes not easy. The treatment modalities for this tumour are non-uniform and often controversial. In the present case surgical options were left aside because the patient did not consent to surgery, so radiotherapy was used, with success at 3-year follow-up. This case is presented here along with a review of relevant literature.

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