Introduction: The purpose of this study is to assess the outcomes of patients that underwent single-stage revision ACL reconstruction (ACLR) with peroneus longus tendon (PLT), augmented with lateral extra-articular tenodesis (LET) using the modified Lemaire technique. Materials and methods: All the 18 patients underwent arthroscopic single-stage revision ACLR using autologous PLT with an additional modified Limier LET procedure. Patients were thoroughly assessed pre- and post-operatively by the Lachman test, the pivot shift test, and the side-to-side difference by the Rolimeter. Functional evaluation was done with the help of the Lysholm score, the IKDC subjective score, Tegner score, VAS score, MARX activity rating scale and The American Orthopaedic Foot and Ankle Society (AOFAS) score. Post-operatively, patient satisfaction, return to sport, and physical activity were also recorded. SPSS ver. 22.0 software was used. Wilcoxon test, paired and unpaired t-tests were used to compare variables. Statistical significance was determined by a two-sided p-value <0.05. Results: Regarding subjective evaluations; post-operative residual laxity, and return to sport and physical activity, all of the patients demonstrated excellent results. Post-operatively, there was significant improvement in the anterior knee laxity. According to the Marx Activity Rating Scale, the extent of sports engagement was significantly increased at 18 months following surgery (p<0.001). According to the AOFAS score (p=0.38), there were no documented significant donor site morbidities. Conclusions: Single-stage revision ACLR using PLT with an additional modified Lemaire LET procedure results in a significant reduction in residual knee laxity with good clinical outcomes and a high return to play and physical activity

Background: The standard dose (SD) of horse anti-thymocyte globulin (hATG) ATGAM (Pfizer, USA) or its biosimilar thymogam (Bharat Serum, India) for the treatment of Aplastic Anemia (AA) is 40 mg/kg/day for 4 days in combination with cyclosporine. Data on the impact of hATG dose on long-term outcomes are limited. Here, we describe our comparative experience using 25 mg/kg/day (low-dose [LD]) hATG for 4 days with SD for the treatment of AA. Methods: We retrospectively studied patients with AA (age > 12 years) who received two doses of hATG combined with cyclosporine. Among 93 AA patients who received hATG, 62 (66.7%) and 31 (33.3%) patients received LD and SD hATG with cyclosporine, respectively. Among these,seventeen(18.2%) patients also received eltrombopag with hATG and cyclosporine. Overall response rates [complete response (CR) and partial response (PR)] of LD and SD hATG groups at 3 months (50% vs. 48.4%; p = 0.88), 6 months (63.8% vs. 71.4%; p = 0.67), and 12 months (69.6% vs.79.2%; p = 0.167) were comparable. The mean (Standard Deviation) 5-year Kaplan–Meier estimate of overall survival and event-free survival was 82.1 (4.6)% and 70.9 (5.5)% for the study population. The mean (standard deviation) 5-year Kaplan–Meier estimate of overall survival and event-free survival of those who received LD hATG versus SD hATG dose was 82.9 (5·3)% versus 74.8 (10·3)% (p = 0·439), and 75.2 (6.2)% versus 61.4(11.2)% (p = 0·441). Conclusion Our study revealed that the response rates of patients with AA and LD were similar to those of patients with SD to hATG combined with cyclosporine in a real-world setting.

Background: The standard dose (SD) of horse anti-thymocyte globulin (hATG) ATGAM (Pfizer, USA) or its biosimilar thymogam (Bharat Serum, India) for the treatment of Aplastic Anemia (AA) is 40 mg/kg/day for 4 days in combination with cyclosporine. Data on the impact of hATG dose on long-term outcomes are limited. Here, we describe our comparative experience using 25 mg/kg/day (low-dose [LD]) hATG for 4 days with SD for the treatment of AA. Methods: We retrospectively studied patients with AA (age > 12 years) who received two doses of hATG combined with cyclosporine. Among 93 AA patients who received hATG, 62 (66.7%) and 31 (33.3%) patients received LD and SD hATG with cyclosporine, respectively. Among these,seventeen(18.2%) patients also received eltrombopag with hATG and cyclosporine. Overall response rates [complete response (CR) and partial response (PR)] of LD and SD hATG groups at 3 months (50% vs. 48.4%; p = 0.88), 6 months (63.8% vs. 71.4%; p = 0.67), and 12 months (69.6% vs.79.2%; p = 0.167) were comparable. The mean (Standard Deviation) 5-year Kaplan–Meier estimate of overall survival and event-free survival was 82.1 (4.6)% and 70.9 (5.5)% for the study population. The mean (standard deviation) 5-year Kaplan–Meier estimate of overall survival and event-free survival of those who received LD hATG versus SD hATG dose was 82.9 (5·3)% versus 74.8 (10·3)% (p = 0·439), and 75.2 (6.2)% versus 61.4(11.2)% (p = 0·441). Conclusion Our study revealed that the response rates of patients with AA and LD were similar to those of patients with SD to hATG combined with cyclosporine in a real-world setting.

Background: The standard dose (SD) of horse anti-thymocyte globulin (hATG) ATGAM (Pfizer, USA) or its biosimilar thymogam (Bharat Serum, India) for the treatment of Aplastic Anemia (AA) is 40 mg/kg/day for 4 days in combination with cyclosporine. Data on the impact of hATG dose on long-term outcomes are limited. Here, we describe our comparative experience using 25 mg/kg/day (low-dose [LD]) hATG for 4 days with SD for the treatment of AA. Methods: We retrospectively studied patients with AA (age > 12 years) who received two doses of hATG combined with cyclosporine. Among 93 AA patients who received hATG, 62 (66.7%) and 31 (33.3%) patients received LD and SD hATG with cyclosporine, respectively. Among these,seventeen(18.2%) patients also received eltrombopag with hATG and cyclosporine. Overall response rates [complete response (CR) and partial response (PR)] of LD and SD hATG groups at 3 months (50% vs. 48.4%; p = 0.88), 6 months (63.8% vs. 71.4%; p = 0.67), and 12 months (69.6% vs.79.2%; p = 0.167) were comparable. The mean (Standard Deviation) 5-year Kaplan–Meier estimate of overall survival and event-free survival was 82.1 (4.6)% and 70.9 (5.5)% for the study population. The mean (standard deviation) 5-year Kaplan–Meier estimate of overall survival and event-free survival of those who received LD hATG versus SD hATG dose was 82.9 (5·3)% versus 74.8 (10·3)% (p = 0·439), and 75.2 (6.2)% versus 61.4(11.2)% (p = 0·441). Conclusion Our study revealed that the response rates of patients with AA and LD were similar to those of patients with SD to hATG combined with cyclosporine in a real-world setting.

Background: This study evaluated the outcomes of patients with refractory/relapsed Hodgkin lymphoma (RRHL) treated with a bendamustine-based regimen in combination with ifosfamide, etoposide, and vinorelbine (VIBE). Methods: Consecutive RRHL patients who were treated with the VIBE regimen were identified and studied for clinicopathologic characteristics, response to VIBE regimen, event-free survival (EFS), and feasibility of an autologous stem-cell transplant (autoSCT). Results: In total, 24 patients received the VIBE regimen, and a median of 3 cycles were administered. In this cohort, 80% of the patients had received ≥2 prior lines of therapy. The overall and complete response rates with VIBE were 79% and 42%, respectively. After a median follow-up (following VIBE regimen) of 14 months (range, 3‒76), the 3-year EFS and OS were 46% and 74%, respectively. Of the eligible patients, 92% underwent successful AutoSCT. The mean CD34+ cell count in the autograft was 5.5×106/kg (SD 2.07). Neutropenia was the commonest hematologic toxicity and it was observed in 42% of the patients. However, only 9% of the patients developed grade III/IV febrile neutropenia. Chemotherapy-induced nausea and vomiting were the second most common grade III/IV toxicities in our cohort of patients. Conclusion In this retrospective analysis, the combination regimen, VIBE, has shown good efficacy in heavily pre-treated patients with RRHL without compromising stem cell collection. These encouraging results provide a rationale for further development of this regimen.

Background: This study evaluated the outcomes of patients with refractory/relapsed Hodgkin lymphoma (RRHL) treated with a bendamustine-based regimen in combination with ifosfamide, etoposide, and vinorelbine (VIBE). Methods: Consecutive RRHL patients who were treated with the VIBE regimen were identified and studied for clinicopathologic characteristics, response to VIBE regimen, event-free survival (EFS), and feasibility of an autologous stem-cell transplant (autoSCT). Results: In total, 24 patients received the VIBE regimen, and a median of 3 cycles were administered. In this cohort, 80% of the patients had received ≥2 prior lines of therapy. The overall and complete response rates with VIBE were 79% and 42%, respectively. After a median follow-up (following VIBE regimen) of 14 months (range, 3‒76), the 3-year EFS and OS were 46% and 74%, respectively. Of the eligible patients, 92% underwent successful AutoSCT. The mean CD34+ cell count in the autograft was 5.5×106/kg (SD 2.07). Neutropenia was the commonest hematologic toxicity and it was observed in 42% of the patients. However, only 9% of the patients developed grade III/IV febrile neutropenia. Chemotherapy-induced nausea and vomiting were the second most common grade III/IV toxicities in our cohort of patients. Conclusion In this retrospective analysis, the combination regimen, VIBE, has shown good efficacy in heavily pre-treated patients with RRHL without compromising stem cell collection. These encouraging results provide a rationale for further development of this regimen.

STUDY DESIGN: Cadaveric, observational study.PURPOSE: Atlantoaxial instability (AAI) is characterized by excessive movement at the C1–C2 junction between the atlas and axis. An anterior surgical approach to expose the upper cervical spine for internal fixation and bone grafting has been developed to fix AAI. Currently, no anatomic information exists on the anterior transarticular atlantoaxial screw or screw and plate fixation between C1 and C2 in the Indian population. The objective of this study is to assess the anatomic landmarks of C1–C2 vertebrae: entry point, trajectory, screw length, and safety of the procedure.OVERVIEW OF LITERATURE: Methods outlined by Magerl and Harms are the optimal approaches among the dorsal techniques. Contraindications for these techniques include aberrant location of vertebral arteries, fractures of C1–C2 posterior structures. In these cases, anterior transarticular fixation is an alternative. Several available screw insertion trajectories have been reported. Biomechanical studies have demonstrated that adequate rigidity of this fixation is comparable with posterior fusion techniques.METHODS: Direct measurements using Vernier calipers and a goniometer were recorded from 30 embalmed human cadavers. The primary parameters measured were the minimum and maximum lateral and posterior angulations of the screw in the sagittal and coronal planes, respectively, and optimum screw length, if it was placed accurately.RESULTS: The posterior and lateral angles of screw placement in the coronal and sagittal planes ranged from 16° to 30° (mean±standard deviation [SD], 23.93°±3.93°) and 8° to 17° (mean±SD, 13.3°±2.26°), respectively. The optimum screw length was 25–38 mm (mean±SD, 28.76±3.69 mm).CONCLUSIONS: If the screw was inserted without lateral angulation, the spinal canal or cord could be violated. If a longer screw was inserted with greater posterior angulation, the vertebral artery at the posterior or posterolateral aspect of the C1 superior facet could be violated. Thus, 26° and 30° of lateral and posterior angulations, respectively, are the maximum angles permissible to avoid injury of the vertebral artery and violations of the spinal canal or atlanto-occipital joint.
Anatomic Landmarks ; Atlanto-Occipital Joint ; Bone Transplantation ; Cadaver ; Humans ; Observational Study ; Spinal Canal ; Spine ; Vertebral Artery

PURPOSE: The purpose of this study was to evaluate the relative utility and benefits of free-hand 2-dimensional intraoperative ultrasound (FUS) and navigated 3-dimensional intraoperative ultrasound (NUS) as ultrasound-guided biopsy (USGB) techniques for supratentorial lesions. METHODS: All patients who underwent USGB for suspected supratentorial tumours from January 2008 to December 2017 were retrospectively analyzed. The charts and electronic medical records of these patients were studied. Demographic, surgical, and pathological variables were collected and analyzed. The study group consisted of patients who underwent either FUS or NUS for biopsy. RESULTS: A total of 125 patients (112 adults and 13 children) underwent USGB during the study period (89 FUS and 36 NUS). NUS was used more often for deep-seated lesions (58% vs. 18% for FUS, P<0.001). The mean operating time for NUS was longer than for FUS (156 minutes vs. 124 minutes, P=0.001). Representative yield was found in 97.7% of biopsies using FUS and in 100% of biopsies using NUS (diagnostic yield, 93.6% and 91.3%, respectively). The majority of lesions (89%) were high-grade gliomas or lymphomas. Postoperative complications were more common in the NUS group (8.3% vs. 1.2%), but were related to the tumour location (deep). CONCLUSION: Despite the longer operating time and higher rate of postoperative complications, NUS has the benefit of being suitable for biopsies of deep-seated supratentorial lesions, while FUS remains valuable for superficial lesions.
Adult ; Biopsy ; Electronic Health Records ; Glioma ; Humans ; Lymphoma ; Neuronavigation ; Postoperative Complications ; Retrospective Studies ; Ultrasonography

Intracapsular fracture of femoral neck is treated by anatomical reduction (preferably closed) and cannulated cancellous lag screw fixation. Malunion of these fractures have been described in the coronal plane (coxa valga or coxa vara). We reported a case of young adult patient with displaced intracapsular fracture of femoral neck that had malunited in sagittal plane with callus formation with excellent functional outcome. The radiographs revealed intracapsular fracture of femoral neck right side (Garden type 4 and Pauwel type 3). The patient was operated and closed reduction and internal fixation with three cannulated cancellous screws was performed. The postoperative radiograph revealed a loss of reduction in the lateral view. Due to this technical error, the patient was counselled for revision fixation for which he refused. At 9 months we observed union of the fracture in the displaced position by callus formation. Harris hip score at 2 years was 96 that indicate excellent functional outcome and the radiographs did not reveal any evidence of avascular necrosis of femoral head. We advised revision surgery to our patient as he had increased chances of implant failure and nonunion. However he refused the revision surgery and was continued with the suboptimal reduction. However, the fracture united and that too with callus formation, which is not a described phenomenon in neck of femur fracture.
Adult ; Bone Screws ; Femoral Neck Fractures ; diagnostic imaging ; physiopathology ; surgery ; Fracture Fixation, Internal ; Humans ; Male

OBJECTIVETo assess the interobserver agreement on Garden classification of fresh femoral neck fracture and management plan based on anteroposterior (AP) view and also assess if the addition of lateral view changes the classification and management plan.

METHODSTen orthopaedic surgeons were asked to classify 35 femoral neck fractures on AP view only and propose the management plan. Then the same films were reshown in conjunction with their lateral view after 10 days. Results were compared with respect to the classification and management plan between two groups. Interobserver agreement was calculated using Fleiss' kappa.

RESULTSThere was only a fair interobserver agreement (kappa value 0.39) on Garden classification on AP view only which improved to moderate agreement (kappa value 0.52) after adding a lateral view. While there was only a slight improvement in the interobserver agreement on the management plan on AP view only (kappa value 0.50) and AP combined with lateral views (kappa value 0.52). Supplementation of the lateral view changed the classification in 15.42% of the cases and altered the management plan in 23.14% of the cases.

CONCLUSIONWe conclude that lateral view should be obtained routinely on all patients with suspected femoral neck fracture as it definitely has a role in planning treatment of femoral neck fracture.