Nishit Bhatnagar

Maniar RN, et al. Clin Orthop Surg. 2021 Mar;13:e43. https://doi.org/10.4055/cios20130

Background High-flex posterior stabilised rotating platform (PSRP) implant was introduced to provide for deep knee flexion. Few short-term results have been reported, but there are no long-term outcomes reported. Methods We prospectively followed 48 patients (53 knees) implanted with one such design. Inclusion criteria for implantation were patients with good pre-operative flexion and wishing to perform activities requiring deep knee flexion post-operatively, with femorotibial varus angle < 15° and having good flexion stability at trialling stage. Previously, we reported their outcomes at 2–6 years (FU-1). We now report their functional and radiological results at a minimum follow-up of 10 years (FU-2) in 39 patients (43 knees); 5 patients having died and 4 lost to follow-up. Results The mean pre-operative flexion of 124° improved to 130° at FU-1 and to 134° at FU-2. Flexion of 130° or more was seen in 59.6% knees at FU-1 and 74.42% knees at FU-2. At FU-2 mean Knee score was 90.5 and Function score was 67.8. Incidence of patellofemoral symptoms increased from 7.7% at FU-1 to 11.36% at FU-2. There were no cases of bearing spin out, osteolysis or revision surgeries. Conclusion At a minimum 10-year follow-up, high-flexion PSRP design in selected patients yielded 100% survival. We recorded good knee flexion and knee society scores, with no case of spin out, implant loosening, osteolysis or revision surgery. Although deep knee flexion improved at longer follow-up, its use in ADL had reduced due to other age-related factors. There was increased incidence of patellofemoral symptoms.

Update: This article was updated on June 11, 2021, because of an error. The acknowledgment was not included. The note should read: The authors would like to thank Dr. Rajesh N Maniar for allowing us to report his case and his guidance. An erratum (JBJS Case Connect. 2021;11[2]:e20.00354ER) has been published for this article. Case: A 72-year-old man with bilateral knee osteoarthritis treated elsewhere with bilateral intraarticular stem cell injections (SCIs) presented to us 2 months later with signs of infection in his left knee. Aspiration culture grew fungus Penicillium sp. First-stage total knee arthroplasty (TKA) included thorough joint debridement, lavage, standard bone cuts, and insertion of antibiotic-impregnated cement spacer. Second stage included spacer removal and final implantation. At the 1.5-year follow-up, he has a satisfactory clinical outcome without evidence of infection. Conclusion: As far as we know, this is the first reported case of infective fungal arthritis secondary to intraarticular SCI successfully managed by a staged primary TKA.

Maniar RN, et al. Clin Orthop Surg. 2020 Nov;13:e40. https://doi.org/10.4055/cios20147

Introduction The commonly recognized causes of post-operative neurological deterioration in spinal tuberculosis are inadequate decompression, damage to vascular supply of the spinal cord, and multi-drug resistant organisms. There are no known cases of syringomyelia developing after surgical decompression of spinal tuberculosis. Case presentation A teenage girl presented with rapid onset quadriparesis secondary to a tubercular epidural abscess extending from C4-T8. The neurological status deteriorated to quadriplegia immediately following decompression by hemilaminectomy at C7 and T7 levels. Investigations into the cause of neurological deterioration revealed syrinx formation at T5–9 levels. The patient had partial motor and sensory recovery in the first 3 weeks post-operatively. Tubercular infection was treated with a 1-year course of multi-drug anti-tubercular therapy. However, there was no further neurological improvement at 2 years follow-up. Discussion Syringomyelia in tuberculosis has been associated with tubercular meningitis, intradural tuberculomas, and post-surgical vascular insult. None of these were implicated as the cause of syrinx formation in this case. We hypothesize that the rapid evolution of epidural abscess in an intact vertebral column led to an acute “epidural compartment syndrome”, which caused ischemic damage to the spinal cord. Compression caused by the epidural abscess was relieved by surgical decompression, allowing the central canal to dilate and expand into the softened spinal parenchyma, hence leading to syrinx formation.

Case: A patient who underwent first-stage revision procedure elsewhere for prosthetic joint infection (PJI) of the knee with Kocuria rosea presented to us 9 months after the index surgery, with persistent infection. First-stage revision surgery was repeated and Mycobacterium wolinskyi, a rare rapidly growing nontuberculous mycobacterium (RGM), was isolated from samples obtained by sonication of the cement spacer. After a prolonged antibiotic course, definitive implantation surgery was done. One-year postimplantation, patient remains infection free. Conclusions: This is only the second known case of knee PJI caused by M. wolinskyi. This case highlights the possibility of RGM getting masked by other organisms.

Background: Chronic plantar fasciitis is often a difficult to treat entity and platelet-rich plasma (PRP) is an upcoming modality instead of steroid in chronic cases of plantar fasciitis resistant to traditional non-operative management. Methods: Sixty patients with chronic plantar fasciitis were prospectively randomised into 2 groups and treated with either a single injection of 3 cc PRP or 40 mg DepoMedrol (Cortisone) injection and followed for a year. Immediately prior to PRP or cortisone injection American Orthopedic Foot and Ankle Society (AOFAS) hind foot scoring was done for all patients. These scores were repeated at 6 weeks, 6 months and 12 months. Results: Six weeks evaluation of AOFAS after PRP and corticosteroid administration, the mean visual analogue scale (VAS Score) showed a significant increase in corticosteroid group (4.2) as compared to PRP group (5.8). But, the PRP group (1.8) showed significant improvement in mean VAS scores as compared to Steroid group (3.4) after a year of the treatment. Similarly, the AOFAS score improved significantly in the steroid group (64.4) at 6wks as compared to the PRP group (52.2) but at 12 months however, the PRP group sustained its effect with a mean AOFAS score of 92.2 while in the steroid group, the score dropped to a mean of 78.4. Conclusions: PRP was more effective than steroid for the long term treatment of chronic plantar fasciitis. Level of Evidence: Level I, prospective randomized comparative series.

Spontaneous osteonecrosis of the knee affects the medial femoral condyle in patients above 55 years of age. Many reports and studies are available from western countries. But there is a gross paucity of literature on spontaneous osteonecrosis of the knee (SPONK) in the Indian subcontinent, either it is under-reported or detected at a later stage. The aim of our study was to detect SPONK in Indian population and describe its characteristics, treatment, and outcome.

Background: Multimodal periarticular cocktail injection (MPCI) containing local anesthetics, adrenaline, and anti-inflammatory agents such as NSAIDS have been promising in terms of quick functional recovery. This study evaluates the efficiency of steroid as a component of MPCI in knee arthroplasty.Methods: This is a prospective, double-blind, RCT where 36 patients with osteoarthritis were included and randomized to receive MPCI either with steroid or without steroid. Pain was evaluated by visual analogue scale (VAS) at preoperative and postoperatively at rest, and during activity. The range of motion of the knee was looked for in a similar way. The amount of NSAIDs and the duration of NSAID usage were noted till the last follow-up.Results: Both non-steroid and steroid groups were similar with regard to VAS at rest and during activity, or range of motion, at all postoperative observations. The postoperative knee society knee score in the steroid group improved significantly as compared to that in non-steroid group at the one-month (84.1±13.1 and 65.9±12.1; pConclusions: The Study validates usage of steroid in MPCI due to faster rehabilitation and less consumption of NSAIDs and no additional risk of post-operative complications.

Bhatnagar N, et al. J Bone Metab. 2017 May;24(2):135-139. https://doi.org/10.11005/jbm.2017.24.2.135