Background
Traditionally, metallic interference screws were considered to have increased resistance to load than bio absorbable screws in anterior cruciate ligament (ACL) reconstruction. We did a comparative evaluation of biodegradable and metallic interference screws for tibial sided ACL reconstruction and also analysed complications, compared clinical outcome, did imaging study of ACL single bundle reconstruction by using titanium & newer poly–L-lactic acid (PLLA) bio absorbable screws to determine as to whether bio absorbable screw which costs double the metallic screw, is functionally better than standard metallic screws.
Methods
This is a prospective comparative study conducted among 50 patients aged between 15 and 55 years with clinical and MRI confirmation of complete ACL tear, treated arthroscopically with ACL reconstruction with either bio absorbable (group 1) or metallic (group 2) interference screw and both the groups were compared on follow up for an average duration of 12 months. Lysholm and Gillquist Knee Scoring Scale were used and outcome scores were divided into excellent, good, fair and poor.
Results
In our study 41 patients were males and 9 were females. Bio screw was used in 24 males and 6 female patients. Metallic screw was used in 17 males and 3 females. Outcome score was excellent in 26 (52 %) cases, good in 18 (36 %) cases, fair in 4 (8 %) cases, poor in 2 (4 %) cases. The mean Lysholm score in bio absorbable group was 93.13 and in metallic group was 89.70. Knee effusion was higher in bio screw group and infection rate was higher in metallic group.
Conclusions
In our study, the difference between bio absorbable screw group and metallic screw group was insignificant with regard to final patient outcome. Final osseointegration was better with bio absorbable screw, but increased cost of implant and almost same results compared to metallic screw does not make the bio absorbable screw superior to its counterpart.
Functional outcome of Arthroscopic reconstruction of single bundle anterior c...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Functional outcome of Arthroscopic reconstruction of single bundle anterior c...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Total hip arthroplasty has been an important surgical operation in orthopaedics in the 20th century. After many trails, major advancement in Total Hip Arthroplasty was made by Sir John Charnley in 1962, who introduced low friction arthroplasty. This consists of a polyethylene cup and 22.2 mm head, both components being fixed with methacrylate cement. In the following years there were many changes to this basic principle (model) of total hip arthroplasty. Patient education has become an important factor in improvement of function following total hip replacement.
Currently favored Biomaterials in total hip replacementsBhaskarBorgohain4
It was Sir John Charnley who popularized total hip replacement after his phenomenal success using PMMA cold curing bone cement to perform cemented hip replacements. His method of fixation still remains the gold standard for component fixation especially for the femoral stem. Over the years cementless or uncemented designs have come into application to avoid risk of cement related complications. Similarly metal on polyethylene articulation has been criticized for PE wear and aseptic osteolysis. This led to increasing use of ceramic head on highly cross linked PE cup articulation. Metal on metal designs came and gone due to the problem of metalosis and pseudotumors. Ceramic on ceramic articulation is reportedly best in terms of wear rates. Hybrid hip replacements are also increasing especially in younger patients of AVN. Accelerated biotechnological developments are happening in this field to improve long term outcomes and implant survival.
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts wi...CrimsonPublishersOPROJ
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts with Femoral Suspensory Fixation: A Biomechanical Study by Matthew Richard Moralle* in Crimson Publishers: Orthopedic Research and Reviews Journal
Treatment of displaced midshaft clavicle fracture with locking compression plate provides better biomechanical stability, good fracture union rates, high post-operative constant score, early pain resolution, early return to activity, high patient satisfaction rates and excellent functional outcome. These benefits of plating overweigh complications when used in specific indications like displaced with or without comminuted middle third clavicle fracture (Robinson Type 2B1, 2B2).
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Total hip arthroplasty has been an important surgical operation in orthopaedics in the 20th century. After many trails, major advancement in Total Hip Arthroplasty was made by Sir John Charnley in 1962, who introduced low friction arthroplasty. This consists of a polyethylene cup and 22.2 mm head, both components being fixed with methacrylate cement. In the following years there were many changes to this basic principle (model) of total hip arthroplasty. Patient education has become an important factor in improvement of function following total hip replacement.
Currently favored Biomaterials in total hip replacementsBhaskarBorgohain4
It was Sir John Charnley who popularized total hip replacement after his phenomenal success using PMMA cold curing bone cement to perform cemented hip replacements. His method of fixation still remains the gold standard for component fixation especially for the femoral stem. Over the years cementless or uncemented designs have come into application to avoid risk of cement related complications. Similarly metal on polyethylene articulation has been criticized for PE wear and aseptic osteolysis. This led to increasing use of ceramic head on highly cross linked PE cup articulation. Metal on metal designs came and gone due to the problem of metalosis and pseudotumors. Ceramic on ceramic articulation is reportedly best in terms of wear rates. Hybrid hip replacements are also increasing especially in younger patients of AVN. Accelerated biotechnological developments are happening in this field to improve long term outcomes and implant survival.
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts wi...CrimsonPublishersOPROJ
Effect of Suture Tubularization on Quadruple Stranded Hamstring ACL Grafts with Femoral Suspensory Fixation: A Biomechanical Study by Matthew Richard Moralle* in Crimson Publishers: Orthopedic Research and Reviews Journal
Treatment of displaced midshaft clavicle fracture with locking compression plate provides better biomechanical stability, good fracture union rates, high post-operative constant score, early pain resolution, early return to activity, high patient satisfaction rates and excellent functional outcome. These benefits of plating overweigh complications when used in specific indications like displaced with or without comminuted middle third clavicle fracture (Robinson Type 2B1, 2B2).
Short Term Analysis of Clinical, Functional Radiological Outcome of Total Kne...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Correlation between acl injury and involvement of the anterolateral ligament ...Prof. Hesham N. Mustafa
Background:
Clinical testing has demonstrated the role of the anterolateral ligament (ALL) in controlling anterolateral laxity and knee instability at high angles of flexion. Few studies have discussed the association between an anterior cruciate ligament (ACL) injury and ALL injury, specifically after residual internal rotation and a post-ACL reconstruction positive pivot-shift that could be attributed to ALL injury. The goal of this study was to assess the correlation between ALL injury and ALL injury with concomitant ACL injury using MRI.
Material and Methods:
This was a retrospective study of 246 patients with unilateral ACL knee injuries from a database that was reexamined to identify whether ALL injuries occurred in association with ACL injuries. We excluded the postoperative reconstructed cases. The charts were reviewed on the basis of the presence or absence of diagnosed ACL injury with no regard for age or sex.
Results:
Of the 246 patients with ACL injury, there were 165 (67.1%) patients with complete tears, 55 (22.4%) with partial tears, and 26 (10.6%) with sprains. There were 176 (71.5%) patients with ALL and associated ACL injuries, whereas 70 (28.5%) did not have associated ACL injuries. There was a significant statistical relationship between ACL and ALL injuries (P<0.0001).
Conclusions:
There is high incidence of ALL tears associated with ACL injuries. Clinicians should be aware of this injury and consider the possibility of simultaneous ALL and ACL repair to prevent further knee instability.
Level of Evidence:
Level IV.
Background: Distal femur fractures make up 6 to 7% of all femur fractures. Various plating options for distal femur fracture are conventional buttress plates, fixed-angle devices, and locking plates. This study was planned to evaluate and explore locking compression plate fixation in distal end femur fractures which is expected to provide a stable fixation with minimum exposure, early mobilization, less complications and a better quality of life.
Methods: The study was conducted as prospective clinical study in 20 skeletally mature patients with x-ray evidence of distal femur fracture fulfilling inclusion and exclusion criteria, operated with distal femur LCP plating. Patients were assessed radiologically and classified according to distal femur fracture classification and outcome graded as excellent, good, fair and poor based on Lysholm Knee Score.
Results: Out of 15 excellent outcome cases, 3 cases were type A1 fracture, 1 case had type A3, 2 cases had type B1 and B2 each, 5 cases had type C2 and 2 cases had type C3 fracture. 1 case with good outcome was type C3. 1 case with fair outcome was type B2. While 3 cases with poor outcome were type A1, A2 and C3.
Conclusions: The DF-LCP is an ideal implant to use for fractures of the distal femur. However, accurate positioning and fixation are required to produce satisfactory results. We recommend use of this implant in Type A and C, osteoporotic and periprosthetic fractures.
Keywords: Distal femur, DF-LCP, Lysholm score, Periprosthetic fracture
Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hams...Apollo Hospitals
In this study, we analyzed the clinical outcomes at two years following reconstruction of the anterior cruciate ligament with use of a four-strand hamstring tendon autograft in patients who had presented with a symptomatic torn anterior cruciate ligament.
Functional and radiological assessment of displaced midshaft clavicle fractures treated through open reduction and internal fixation surgery using pre-contoured locking compression plates
Internal fixation of fractures of the capitellum and trochlea - Retrospective...Apollo Hospitals
Fractures of capitellum and trochlea account for 0.5-1% of elbow fractures and 6% of distal humerus fractures. These usually occur due to axial loading of the distal humerus by forces transmitted across the joint producing a coronal shear fracture of the capitellum or the trochlea. Internal fixation is the best modality to restore articular congruity in these fractures.
“Comparative Evaluation between Physics Forceps and Conventional Extraction F...inventionjournals
:Tooth extraction procedure, although known as a minimal traumatic procedure, some sort of trauma is subjected to underlying soft and hard tissues, resulting in immediate destruction and loss of alveolar bone. Conventional extraction forceps are designed on the principle of simple machine incorporating two first-class levers, connected with a hinge. The physics forceps are the newly invented forceps. The design of physics forceps which implements a first class lever, creep, and type of force that provides a mechanical advantage, which makes it more efficient. AIM: The aim of the present study to evaluate the efficacy between the conventional extraction forceps and physics forceps in orthodontic extraction of maxillary premolars. Patients & Methods:A total of 50 healthy patients with indicated for extraction of bilateral maxillary premolar for orthodontic reasons; split mouth design (control side, test side) in a randomized manner; were included in the present study. Results:Ease of technique, buccal cortical plate fracture, fracture of tooth or root, gingival laceration, soft tissue healing was not significant. The extraction time and bleeding associated with extraction socket were significant. Post operative days 1-4 are not significant and on day 5-7 the pain on VAS score is 0. Conclusion:The results of present study suggest that, extraction using any forceps can produce predictable results and it totally depends on surgeon’s expertise in a particular technique.
A prospective observational study on comparing the outcome of patellar resurf...Dr.Avinash Rao Gundavarapu
Introduction: Total Knee Arthroplasty (TKA) has been a very successful surgery in relieving pain and restoring function in osteoarthritis. Conflicting evidence in literature exists regarding the merits of patellar resurfacing during TKA over non-resurfacing. Our aim is to evaluate and compare the difference between patellar resurfaced group and non-resurfaced group in primary TKA.
Materials and Methods: This prospective obsevational study was initiated in May 2016 conducted till April 2008 (2 years) in Yashoda Superspeciality Hospital, Hyderabad. At least 14 mm of patella was ensured to be retained after patellar cut. A total of 40 patients were allocated to receive (n=20) or not to receive patellar resurfacing (n=20) during primary TKA. The data was analyzed statistically using the Student t test. Overall patient satisfaction was recorded using the SF-36 score.
Results: Of the 40 patients, 67.5% females and 32.5 % males underwent TKA. Among those who underwent resurfacement, 40% were males. 75% among the non-resurfaced group were females. Right knee was operated on 37.5% of cases. Mean operative time being 103.9 and 122.5 minutes in nonresurfaced and resurfaced cases respectively. Mean patellar thickness was 22.1mm in nonresurfaced and 23.6mm in resurfaced group. The difference in VAS score, modified HSS score, KSS scores between the two groups were statistically insignificant with p-values of 0.230, 0.0214, 0.2513 respectively at the end of two year,
but there was significant reduction of anterior knee pain in the resurfaced with p-value < 0> Conclusion: The functional outcome was not affected by whether the patella was resurfaced or nonresurfaced. There was no significant difference between the two groups with respect to the prevalence of knee-related readmission, or of subsequent patella-related surgery or patients overall satisfaction. We recommend selective patellar resurfacing at the time of primary total knee replacement.
Keywords: TKA, Patellar resurfacement, Non-resurfacement, HSS score, KSS score.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
2. Jebmh.com Original Research Article
J Evid Based Med Healthc, pISSN - 2349-2562, eISSN - 2349-2570 / Vol. 8 / Issue 18 / May. 03, 2021 Page 1259
The anterior cruciate ligament connects the femur to the
tibia and plays an important role in the stabilization of the
knee by guiding normal joint motion. Injuries to the knee
can result in a rupture of the ligament and thereby increased
joint laxity. Significant joint laxity often ends participation in
competitive sports and may, in the medium to long term,
leads to degeneration of the knee. The occurrence of ACL
injuries has increased in recent years and, diagnosis is done
by thorough clinical evaluation by clinical test such as
Anterior drawer test, lachman test, pivot shift. It is very
crucial to rule out other ligaments like posterior cruciate
ligament (PCL), lateral collateral ligament (LCL), ACL and
associated meniscus lesion while doing clinical assessment.
The MRI provides a non-invasive visualization of the ACL
and other soft tissue structure in the knee joint, any other
associated ligament injury, partial tear, chronic tear. There
are certain primary signs of injury on MRI such as Non
visualization of the ACL in its usual location, focal
interruption, angulation / nonlinearity, flattened axis of distal
ACL with poor visualization of proximal ACL. Arthroscopy is
considered one of the greatest innovations in the diagnosis
and treatment. Today, ACL reconstruction is one of the most
common procedures in orthopaedic surgery. The goals of
ACL reconstruction are to improve functional outcomes,
restore knee joint stability, and prevent subsequent damage
to the remaining intra-articular structures.1
Interference screws used in Hamstring tendon ACL graft
fixation are low profile and allow intra-articular placement
and rigid fixation, and also allow early range of motion. Till
now titanium used to be the material of choice for this
device. Titanium screws provide high initial fixation strength
and promote early integration into the bone, but, in case of
revision surgery, hardware removal may be technically
challenging, and also certain disadvantages like there is risk
of injury to the graft, loosening of the screw in posterolateral
recess, blowing out of posterior cortex, while advancing the
screw the graft can change its position. The advantages of
absorbable screws consist of reduced MRI artifacts and no
need to remove the implant, justifying the widespread use
of bio absorbable screws.2,3
Bio absorbable materials were developed to overcome
these perceived weak points, but some disadvantages like
risk of foreign body reaction, viscoelastic deformation.
Different combinations of synthetic materials have been
used: PGA (polyglycolic acid), copolymers of PGA / PLA
(polyglycolic acid / poly lactic acid), poly-p-dioxanone and
various stereoisomers of lactic acid, poly-L-lactic acid and
poly–D-lactic acid.4,5,6
Traditionally, metallic interference screws (MISs) have
afforded reliably positive clinical outcomes, prevention of
excessive laxity, and low complication rates.7
MISs promotes
early integration into bone with high initial fixation strength
and has a higher failure-load than bio absorbable
interference screws (BISs) in biomechanical studies.8
Objectives
To analyse complications, compare clinical outcome, do
imaging study of ACL single bundle reconstruction by using
titanium & newer poly–L–lactic acid (PLLA) bio absorbable
screws and assess if the bio absorbable screw which costs
double the metallic screw, is functionally better than
standard metallic screws or not, also to further assess post-
operative results of each of the above fixation methods using
Lysholm knee score.
METHODS
This prospective comparative study was conducted in 50
patients aged between 15 - 55 years in The Department of
Orthopaedics, Dhanwantri Hospital & Research Centre,
Jaipur from June 2017 to May 2018. The permission from
the ethical committee of the institute was taken prior to the
study. Sample size calculation was done by the following
formula.
𝑛 =
𝑍2
𝜎²
E2
Where “n” is the sample size,
E 2 Z = 2.576 for 99 % level of confidence
1.959 for 95 % level of confidence
1.645 for 90 % level of confidence
Confidence Level 95 %
SD 3.7
Standard error 1.049298
Alpha divided by 2 0.025
Z score 1.959964
Sample size 48
Table 1. Sample Size Calculation Variables
By calculation, the sample size was 48 and we took 50
patients for the study. Patients presenting with unilateral
knee complaints and history of trauma to the knee attending
the outpatient department of our hospital were evaluated by
sequential general, physical and local examination of the
knee. In a relaxed patient and in supine position, the
uninjured knee was examined first to establish ligament
excursions after which the affected knee was examined. The
following specific tests were performed for diagnosing
anterior cruciate ligament deficiency: Lachman test, anterior
drawer test, pivot shift test. Injuries to the associated
structures were assessed by performing the following clinical
tests: Valgus / Varus stress test for collateral ligament injury,
McMurray’s test and Apley grinding test for meniscal injury.
MRI was advised in suspected cases of internal derangement
of knee and cases with ACL injury were admitted for further
workup and planned for arthroscopic ACL reconstruction.
Inclusion Criteria
1) Clinically and radiologically confirmed ACL tear.
2) Patients of 15 to 55 years of age.
Exclusion Criteria
1) Chondral lesions.
BACKGROUND
3. Jebmh.com Original Research Article
J Evid Based Med Healthc, pISSN - 2349-2562, eISSN - 2349-2570 / Vol. 8 / Issue 18 / May. 03, 2021 Page 1260
2) Bilateral knee injury.
3) Infection.
4) Osteoarthritis knee with chronic ACL tear.
5) Collateral or PCL injury.
6) ACL re-tear.
7) Below 15 and above 55 yrs. age.
8) Tibial plateau injury.
Preoperative work up such as blood routine, triple
serology, coagulogram, ECG, CXR along with x-ray of the
affected knee anteroposterior (AP) & lateral views and MRI
of the affected knee was done. The range of movement and
quadriceps strength were noted pre-operatively. Quadriceps
exercises (static & dynamic) were taught to patients before
surgery. Physiotherapy department explained the post-
operative rehabilitation protocol to all the patients.
Consent
All the patients in this study were explained about the injury,
diagnosis, various management options, complication of
non-operative treatment and operative management, per-
operative & post-operative complications, donor site
morbidity, injury to surrounding structures, infection,
compartment syndrome, anaesthesia risks, post-operative
knee pain, restriction of range of motion. Consent was
obtained from all the patients who were included in this
study prior to the surgery. Patients and their attenders were
well explained about the advantages and disadvantages of
procedure. Risk benefit ratio was explained.
Study Procedure
Patients in the study were operated in supine position under
spinal anaesthesia. A pneumatic tourniquet was used.
Before harvesting the graft, diagnostic arthroscopy was
done first. In 90 degrees of knee flexion, anterolateral port
(viewing port) was made using no. 11 blade at the level of
inferior pole of patella just lateral to the patellar tendon and
knee was examined in sequential manner starting from
suprapatellar pouch, patellofemoral joint, medial gutter,
medial meniscus, intercondylar notch, lateral meniscus,
lateral gutter and finally posterolateral compartment. After
doing the diagnostic round the working anteromedial portal
was established. In all the cases ipsilateral hamstring graft
was harvested. A 3 cm oblique skin incision was made
starting 5 cm below the medial joint line and 1 cm medial to
the tibial tuberosity. The oblique incision was preferred
because it gave a wider exposure of pes anserinus and there
was less chance of injury to the infrapatellar branch of the
saphenous nerve. The notch was deepened by 2 – 3 cm
starting anteriorly on the articular surface of the
intercondylar notch 2 – 3 cm superior to the margin (notch
preparation and notchplasty). Endobutton was used on the
femoral side to fix the graft. The tibial tunnel was made with
the help of the tibial guide. With the knee in 70 – 90 degrees
of flexion, the tip of the tibial guide was placed 2 – 3 mm
anterior to the anterior horn of lateral meniscus and slightly
medial to the midline of the ACL tibial attachment area. Then
the tibial tunnel was made by reaming over the guide pin
using cannulated drill bit with diameter equal to the diameter
of the graft. After the graft had been prepared, based on the
length, the graft was quadrupled, and the loop part was
attached with endobutton. Before fixing the graft on to the
tibial side, cyclical stretching of the graft was routinely done.
Decision of tibial sided ACL fixation with metallic screw or
bio screw was decided by chit method. After the surgery the
limb was immobilized with knee brace and an antero-
posterior and lateral x-ray of the knee was taken to confirm
the placement of tunnel, endobutton and interference screw.
Intravenous antibiotics were given postoperatively for 3
days. Wound was inspected on 2nd
and 7th
post-operative
day. The sutures were removed on 12th
post-operative day.
A standard ACL rehabilitation program was started from the
post-operative day 1.
Follow Up
Patients were followed up on 2nd & 6th weeks, 6 months
and 1 year and plane x-rays of operated knee was taken in
antero-posterior & lateral view on each visit, to assess the
graft related complications. The patients who were operated
using bio absorbable screws were tagged as group 1 and
patients with metallic implant group 2. Both the groups were
given scores using Lysholm and Gillquist Knee Scoring Scale
and outcome evaluated based on following parameters:
1) Knee swelling (max. 10 - min. 0)
2) Climbing of stairs (max. 10 - min. 0)
3) Knee pain (max. 25 - min. 0)
4) Knee instability (max. 25 - min. 0)
5) Episodes of knee locking (max. 15 - min. 2)
6) Limping (max. 5 - min. 0)
7) Aided walking (max. 5 - min. 0)
8) Squatting (max. 5 - min. 0)
The above parameters were scored on the patient’s
functional ability from maximum to minimum. The maximum
score corresponds to a favourable outcome and calculated
as mentioned against each parameter. The total score was
100. The patients were categorised as Excellent if scores
were 95 – 100, good if 84 – 94, fair if 65 – 83 and poor if
scores were 64 or less. At the end of follow up, both the
groups of patients were compared by their post-operative
complications and Lysholm knee score and detailed
observation & results were formed.
Statistical Analysis
Data obtained was coded and entered into Microsoft Excel
spreadsheet. The categorical data was expressed as rate,
ratio and percentage. The continuous data was expressed
as mean ± std. deviation. A ‘P’ value of less than or equal to
0.05 was considered as statistically significant.
RESULTS
The data obtained was coded and entered into the Microsoft
excel Spread Sheet. The data was analysed and results
obtained were tabulated. In our study 41 patients were male
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and 9 patients were female and male to female Ratio was
4.6:1. Age of the patient varies from 15 to 55 years.
Minimum age was 15 years and maximum age was 55 years.
In our study 38 patients had right knee ACL tear in which 23
(76.7 %) were operated with bio screws and 15 with metallic
screws. The 12 patients having left knee ACL tear, 7 (23.3
%) were operated with bio screws and 5 with metallic
screws. In the study 35 patients had ACL insufficiency due
to renal tubular acidosis (RTA), 11 patients had injury due
to sports i.e., cricket, football, kabaddi. 4 patients had
trauma by other means i.e. hit by object, self-fall. In our
study 41 patients were males and 9 patients were females,
out of that bio screws were used in 24 male patients and 6
female patients. Metallic screw was used in 17 male patients
and 3 female patients. Mean age group for bio-screws was
28.40 with std. deviation of 9. 287. Mean age group for
metallic screw was 35. 30 with std. deviation of 7. 320.
Complication
Tibial Sided Fixation Device
Percentage
Bioabsorbable
Screw
Metallic
Interference
Screw breakage Nil Nil 0 %
Graft damage Nil Nil 0 %
Knee effusion 3 0 6 %
Infection 2 1 4 %
Graft failure Nil 1 2 %
Total 5 2 10 %
Table 2. Complications of Implant
Bio Screw Group Metallic Screw Group
Lysholm
Score (Grade)
Frequency %
Valid
%
Frequency %
Valid
%
Excellent 19 63.3 63.3 7 35.0 35.0
Good 8 26.7 26.7 10 50.0 50.0
Fair 3 10.0 10.0 1 5.0 5.0
Poor 0 00.0 00.0 2 10.0 10.0
Total 30 100.0 100.0 20 100.0 100.0
Table 3. Statistical Analysis of Two Fixation Methods
N Minimum Maximum Mean
Std.
Deviation
Age (yrs) 30 17 46 28.40 9.287
Time since injury
(months)
30 1 12 6.57 2.861
Lysholm score (value) 30 80 97 93.13 4.614
Follow up (months) 30 8 16 11.57 1.995
Table 4. Descriptive Statistics for Bio Screw Fixation Device
N Minimum Maximum Mean
Std.
Deviation
Age (yrs) 20 18 49 35.30 7.320
Time since injury
(months)
20 2 12 7.40 3.050
Lysholm score (value) 20 64 97 89.70 10.408
Follow up (months) 20 7 15 11.55 2.373
Table 5. Descriptive Statistics for
Metallic Screw Fixation Device
Fixation
Device
N df Mean
Std.
Deviation
T-Value P-Value
Lysholm
score
(value)
Bio screw 30
48
93.13 4.614
1.37 0.18
Metallic
screw
20 89.70 10.408
Table 6. Group Statistics
The interval between injury and surgery ranged from
date of injury to 1 year with maximum patients (42 %)
getting operated within 4 to 6 months. The most common
presenting symptom was knee pain and instability in the
series. The other less common presenting symptoms were
locking of the knee and knee pain with instability. Total
number of cases according to fixation device–bio screw was
used in 30 patients and metallic screw was used in 20
patients in total.
Complications were divided into intraoperative and
postoperative. No patient had intraoperative complication;
two patients had developed superficial infection which was
managed with IV antibiotics. One patient had developed
deep infection which was managed with IV antibiotics
followed by wound debridement. Wound healed completely
after 10 days. Three patients had developed knee effusion
in which bio screw was used. Effusion had subsided at
repeated follow up. One patient had graft failure at 9th
month follow up in which metallic screw was used.
Arthroscopic debridement done in this patient and revision
ACL reconstruction was done. On tibial side fixation, rate of
complication was higher in bio absorbable screw then
metallic screw. Knee effusion was higher in bio screw group
and infection rate was higher in metallic group. Outcome
according to Lysholm score in the present series was
excellent in 26 (52 %) cases, good in 18 (36 %) cases, fair
in 4 (8 %) cases, poor in 2 (4 %) cases because of infection
in one patient and graft failure in one.
DISCUSSION
Metal interference screws were first described in ACL
reconstruction surgery and bio absorbable interference
screws were developed to overcome some weak points
related to their ferromagnetic quality and the difficulty in
removal during revision surgery.9
There are some
disadvantages of bio-screw, like, higher chance to break
during surgery and may also lead to inflammatory reactions
which may lead to knee effusion. As for the specific measures
taken into account to assess clinical results obtained by the
procedure using the two different materials, all the studies10,11
presenting range of motion of the knee did not show
significant differences between two groups at long-term
follow-up.
Our study tries to give clinically relevant evidence
analysing imaging assessment and complication and
comparing clinical outcome of the metallic and bio
absorbable screws for single bundle ACL reconstruction to
assess whether bio absorbable screws are more effective or
as effective as standard metallic screws despite being more
recent and costlier.
In our study lysholm knee score was higher in bio
absorbable groups with maximum follow up of up to 12
months. The mean lysholm score in bio absorbable group
was 93.13 and in metallic group the mean lysholm score was
89.70. On the other hand, McGuire et al.12
reported that
measured clinical outcome by Tagner activity level was
better with bio absorbable screw group than the
counterpart, though the sample size was small in his study.
Tunnel widening, considered as an inflammatory
reaction to the implanted screw mediated by inflammatory
cytokines.13
Tunnel widening was observed more with bio
absorbable screws compared with metallic interference
screws.14,15,16
The final outcome achieved by the patients did
not seem to be ultimately affected by a wider diameter of
the tunnel measured at MRI assessment. In our study, till
the end of follow up, none of the patients showed tunnel
widening on MRI or any clinical signs of the same.
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McGuire et al.12
suggested that screw breakage was
another complication which can be prevented by an
additional 0.125 mm to the core diameter of 7 mm screw, it
increases the strength of the screw. Cases were having graft
damage due to wrong technique while applying torque.
In our study, complications were divided into intra-
operative (graft damage, screw breakage), and
postoperative (graft failure, infections, knee effusion). The
student t-test with unequal variance was computed to
analyse the significance of difference between mean score
of the groups. The t-value was 1.37 and P-value was 0.18.
The P-value in analysis was greater than alpha (P > 0.05),
implying there is no strong evidence against null hypothesis.
It shows that difference in complication between bio and
metallic screw was not significant, but bio absorbable screw
group are slightly more commonly associated with intra and
postoperative complications. In particular, we considered
remarkable how screw breakages were associated only with
procedures using bio absorbable screws, which may suggest
a lower intrinsic mechanical resistance of this class of device.
However, screw breakages occurred more frequently in the
early studies, and only when screws > 7 mm in diameter
were used.12,14,17-20
Likewise, no overall significant
differences in incidence could be found regarding infections
and graft failure, but there was a slight increase in the risk
of effusion in the bio absorbable screw groups.
Moisala et al.17
reported that due to difference in the
mechanical properties of Bio and metallic screw, bio
absorbable screw puts a negative effect on graft healing,
that’s why graft failure is more common with bio absorbable
screw. In our study graft failure was reported in one case in
which metallic interference screw were used.
Finally, we evaluated the methodological quality of the
studies using Coleman methodological score,21
a validated
score already adopted by authors reviewing the literature
published about many orthopaedic techniques and
disorders2-5
and the average score 74 / 100 suggests good
methodological quality. Indeed, most of the studies included
in this systematic review were prospective randomized
controlled trials, providing conclusions supported by a solid
level of evidence because of protocol and study design.
CONCLUSIONS
In our study, the difference between bio absorbable screw
group and metallic screw group was insignificant with regard
to final patient outcome. Final osseointegration was better
with bio absorbable screw, but increased cost of implant and
almost same results compared to metallic screw does not
make the bio absorbable screw superior to its counterpart.
Data sharing statement provided by the authors is available with the
full text of this article at jebmh.com.
Financial or other competing interests: None.
Disclosure forms provided by the authors are available with the full
text of this article at jebmh.com.
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