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.

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Tuberculosis (TB) of synovial sheath of tendon is uncommon, it is a severe form of extrapulmonary TB, diagnosis is obvious on clinical grounds in later stages, but is always confirmed by histopathology. Here, we are presenting a case of a 50-year-old female, who presented to us with gradual increasing swelling in her left hand and wrist and numbness over left thenar eminence. The patient was successfully treated with debulking operation and anti-tubercular drugs. Tubercular tenosynovitis of wrist and hand is a severe form of extrapulmonary TB. Intraoperatively, the presence of rice body or melon seed bodies is pathognomonic for confirming the diagnosis. Early diagnosis and intervention give good prognosis.

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BACKGROUND: Blood transfusion is the cornerstone of therapy for many serious ailments, surgical and trauma patients. Patients undergoing orthopedic surgeries as elective procedure or emergency orthopedic surgery for trauma often experience excessive blood loss- requiring transfusions. However, preoperative placement of blood requests frequently overshoots the actual need resulting in unnecessary crossmatching, which can be reduced by formulating maximum surgical blood ordering schedule (MSBOS). It is a table of elective surgical procedures, which lists the number of units of blood routinely cross-matched pre-operatively. OBJECTIVE: The objective of this study is to audit the blood utilization in orthopedic surgeries so that unnecessary cross-matching, wastage of blood bank resources, and financial losses to the patients could be reduced. MATERIALS AND METHODS: A retrospective study was carried out in our tertiary care hospital over a period of 6 months to determine the utilization of blood during different orthopedic procedures and to recommend an appropriate blood ordering schedule. The data collected include patient's requests, patient's transfused, type of surgical procedure, number of units crossmatched and transfused, crossmatch to transfusion ratio (CTR) and transfusion indices (TI's); according to them, MSBOS was proposed. RESULTS: A total of 478 units of blood were crossmatched for 273 patients and only 243 units were transfused to 183 patients. About 50.8% of the crossmatched units and 67% of the total patients were transfused. Seven out of the thirteen procedures had a CTR higher than 2, low TI ≤0.5 and blood utilization ≤50%. Fracture forearm and unilateral total knee replacement have the transfusion probability of ≤30%, so implementation of type and screen policy was recommended for these two procedures. CONCLUSIONS: MSBOS based on the past blood utilization records for different surgeries and keeping patients variables in consideration wherever required would provide an efficient way of blood utilization and appropriate management of blood bank resources.

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Cysts are very common lesions around the knee although they seldom cause complications. Peripheral neuropathy caused by these structures most commonly occurs by compression of the common peroneal nerve and its branches, at the level of the fibular neck. We report a case of a 44-year-old male admitted to the emergency department with complaints of right foot drop and numbness on the lateral side of the right leg caused by an extraneural synovial cyst compressing the peroneal nerve. Ultrasonography and magnetic resonance aided on the diagnosis. The cyst was removed surgically. Three months after the procedure, the patient was without complaints, with full motor and sensory function.

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INTRODUCTION AND AIM: Clubfoot is usually diagnosed immediately after birth; hence, most of the surgeons believes in an early initiation of treatment. Thus, our study was aimed to assess the efficacy of Ponseti technique in correcting congenital talipes equinovarus deformity of foot, to determine the type of clubfoot best suited for this technique and to find the lacunae and disadvantages of Ponseti technique, if any. MATERIALS AND METHODS: It was a prospective study of 50 cases with 76 feet of clubfoot in tertiary level hospital from September 2012 to October 2016. All these cases included were classical clubfoot deformities (idiopathic clubfoot), excluding syndromic and complicated cases with previous failed operative treatment. Children were evaluated by Pirani severity scoring system. All the patients were treated by Ponseti technique of corrective casting and achilles tenotomy. RESULTS: In the present study, about 84% of patients had good results, 4% had fair results, and 12% of patients had poor results showing failure with Ponseti technique. Overall, 88% of the patients presented with satisfactory results. Overall, mean Pirani score for all the feet was 5.01. There were thirty complications among all the patients, constituting 39% of total feet. CONCLUSION: The observations of the present study clearly showed that age at initial presentation, quality (mobility) of foot and Pirani score at presentation directly affects final results. Ponseti technique for the treatment of clubfoot is a simple and effective which is suitable in the Indian subcontinent as it is economical.

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We present the case of a 55-year-old female who sustained avulsion of anterior cruciate ligament (ACL) from its tibial attachment while undergoing unicompartmental knee replacement (UKR). The fibers of ACL were intact. Realizing the paramount importance of ACL in a knee undergoing UKR, we promptly performed a primary repair of the ACL and continued with the surgery in the same sitting. At the latest follow-up, the patient is doing well both clinically and functionally and has no antero-posterior or varus-valgus laxity. We discuss the cause for ACL avulsion during UKR and precautions to avoid it.

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INTRODUCTION: Intertrochanteric fractures (ITF) are of intense interest globally. These fractures are most frequently operated type having the highest postoperative fatality rates and hence have become a serious health resource issue. AIM: The aim of this study is to assess the risk factors and their effect on the outcome of intertrochanteric fractures treated by sliding hip screw fixation. SETTINGS AND DESIGN: This is a retrospective and prospective observational study of all the intertrochanteric fractures treated by sliding hip screw fixation at our institute between January 2013 to August 2015. MATERIALS AND METHODS: A total of 78 intertrochanteric fractures have met the inclusion criteria proposed for the study. Preoperative and intraoperative risk factors were assessed for all the cases and treated by sliding hip screw. The Radiological outcome was assessed after a minimum follow-up of 3 months for all the cases. RESULTS: When comparing all the preoperative and intraoperative variables independently with the outcome, P value was found to be statistically significant only in displacement, reverse obliquity, inadequate lateral wall thickness, and reduction. We devised a scoring system to assess the risk outcome in the treatment of trochanteric fractures based on local fracture factors. Least score of zero and a maximum score of eight was seen in the study participants. CONCLUSION: Trochantric severity score is a useful tool to assess the outcome of management of intertrochanteric fractures. Sliding hip screw may not be an ideal implant for, trochantric fractures with inadequate lateral wall thickness (failure rate of 63%), reverse oblique type of trochanter fractures (failure rates of 50%), and displaced comminuted fractures (failure rate of 13%).

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Avascular necrosis can develop secondary to a traumatic or atraumatic interruption of blood supply to a bony region. We present an unusual case of femoral head osteonecrosis in a patient who concomitantly suffered a complete delamination injury to the articular surface and ultimately underwent progressive degenerative changes in the femoral head requiring total hip arthroplasty (THA). A 57-year-old man without significant medical comorbidities presented for orthopedic evaluation in the outpatient setting complaining of left hip pain. The patient reported a slip and fall onto his left hip 4 months prior with no preexisting discomfort. Since then, the progressively worsening pain has centered on the left groin with radiation into the lateral aspect of the hip. Physical examination is negative for focal deficits, but provocative maneuvers for intra-articular pathology were positive. X-rays demonstrated mild degenerative changes while magnetic resonance imaging (MRI) showed a complete delamination injury to the articular surface with associated femoral head collapse. Nonoperative treatment failed to provide pain relief, and so the patient ultimately underwent surgical intervention. Treatment consisted of left uncemented THA with cable augmentation. Postoperatively, the patient was monitored with periodic follow-ups while undergoing postsurgical rehabilitation. Interval improvement was demonstrated and patient overall did well.

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