Posterior cruciate ligament injuries

                                    Dr. KS Dhillon

Anatomy and Biomechanics

The posterior cruciate ligament (PCL) length averages between 32mm and 38mm from its origin to insertion, and its cross-sectional area narrows distally [1]. The PCL is mainly made up of two bundles, namely the anterolateral bundle (ALB) and posteromedial bundle (PMB). The femoral attachment of the ALB is nearly twice as big as the tibial insertion. The ALB is more lax in full extension and tight in full flexion. This bundle comprises about 65% of the total mass of the PCL. The PMB is taught in extension and lax in flexion. 

The PCL extends from the posterior tibial plateau to the roof of the femoral notch. It is intraarticular but extra synovial. The synovial membrane covers the entire ligament except for the posterior part. The PCL femoral insertion is half-moon shaped and the PCL tibial insertion is nonplanar and rectangular in shape.

The PCL is surrounded by the anterior meniscofemoral ligament known as the Humphrey ligament and the posterior meniscofemoral ligament which is known as the Wrisberg ligament, which emerges from the lateral aspect of the medial femoral condyle and inserts distally close to the posterior horn of the lateral meniscus. Both these ligaments are only present in 49% of the knees, providing up to 71% of the posterior stability in a PCL-deficient knee, particularly between 60° and 90° of flexion [2].

The PCL is the primary restraint to posterior tibial translation on the femur and the secondary restraint to external rotation [3]. These functional roles are most when the knee is flexed to 90 degrees. When the knee is in full extension there is a minimal posterior translation with an isolated PCL lesion [3]. 

Studies show that kinematic differences increased significantly with combined PCL/posterolateral corner (PLC) lesions when compared with isolated lesions [4,5,6]. 

Mechanism of Injury

Three mechanisms have been proposed for rupture of the PCL:

1. Hyperflexion

Hyperflexion knee injury is common in sports. The individual falls on hyperflexed knee and the traumatic forces are directed proximally up the tibia which leads to posterior subluxation of the tibia and rupture of the PCL.  Nearly always an anterior isolated intrasynovial intrasubstance tear occurs and often the posteromedial bundle remains intact. The laxity is rarely greater than grade II. These lesions can heal to some extent and with time the laxity may often decrease to grade I [7].

2. Pretibial Trauma

The most common traumatic mechanism for injury to the PCL is the dashboard injury. The knee is in a flexed position and a posteriorly directed force is applied to the anterior aspect of the proximal tibia. Such an injury results in an intrasubstance tear at the level of the tibial plateau or a tibial avulsion. Severe trauma will result in damage to the meniscofemoral ligaments as well.

An anteromedial and a rotational force can cause a tear of the posterolateral corner. When the PCL and posterolateral corner is torn, the posterior instability will be greater. 

3. Hyperextension

Hyperextension injury can result in tearing of the PCL and the posterior capsule. Hyperextension can lead to dislocation of the knee and neurovascular compromise. The PCL injury is frequently a proximal disruption at the femoral attachment. 

Epidemiology

The incidence of PCL injuries in the literature varies widely and this disparity results from differences in the population of individuals examined. Miyasaka and Daniel[8] reported an incidence of 3% in the general population, whereas Fanelli and Edson [9] reported an incidence of 38% in patients with acute knee hemarthrosis in an emergency room.

There is an association between athletic injuries and `isolated' PCL injuries. The most frequent mechanism of injury in athletes is hyperflexion injury. In an emergency room setting, 56.5% of injuries are trauma-related and 32.9% are athletic-related [7]. Fanelli and Edson [9] reported that 96.5% of the PCL injuries occurred in combination with other ligamentous injuries. 

The majority of PCL tears occurred in motor vehicle and motorcycle accidents. They concluded that the incidence of PCL injuries is higher in patients with trauma as compared to patients with athletic injuries.

Most grade III PCL injuries occur with other ligament injuries (79% of cases) [10]. Isolated PCL injuries are rare and occur in 3.5% of the patients, whereas 96.5% of PCL injuries occurred in combination with other ligament injuries [9]. 

Classification

The appropriate treatment of PCL injuries remains uncertain. This is partly due to inaccurate classification of patients in follow-up studies. PCL injuries can be classified according to the structures damaged (isolated vs combined), the degree of instability, and the mechanism of injury [7]. 

• Type I- Where the PCL is stretched, laxity is less than 5mm and the tibial plateau is 5mm to 10mm anterior to the femoral condyle.
• Type II- Where the PCL is torn, MF ligaments intact, laxity is 5mm to 9mm and the tibial plateau is 0 to 5mm anterior to the femoral condyle.
• Type III-Where the PCL and MF ligaments are torn, laxity is > 10mm and tibial plateau is flush with the femoral condyle.
• Type IVA- Where there is PCL, LCL, and posterolateral injury, laxity is >12 mm and the tibial plateau is > 2mm posterior to the femoral condyle.
• Type IVB-  Where there is PCL, MCL, and posteromedial injury, laxity is >12 mm and the tibial plateau is > 2mm posterior to the femoral condyle.
• Type IVC- Where there is PCL and ACL injury, laxity is >15mm and the tibial plateau is > 5mm posterior to femoral condyle.

Grades I to III are isolated injuries and grade IV is a combined injury.

Clinical Evaluation

History

A thorough history including the mechanism of injury is useful. The chief complaint and level of activity need to be determined. Patients with acute isolated PCL tear will complain of mild swelling, pain and inability to bear weight. Patients with chronic PCL laxity complain of pain. The pain is most prevalent with long distance walking and descending stairs. The pain is predominantly felt in the retropatellar area and medial compartment of the knee. Other complaints include difficulty walking with the knee extended in mid stance. They also can have apprehension while descending stairs because they get a sense of unsteadiness or sliding of the joint when going downstairs. Athletes often complain of a decreased ability to rapidly change direction [7]. However, significant giving way of the knee or buckling that is commonly seen with an ACL deficient knee is usually not seen with an isolated PCL tears. Instability is common in patients with combined injury.

Physical examination

A physical examination for a posterior cruciate deficient knee following an acute injury must include inspection over the anterior tibia for abrasions, ecchymosis or lacerations, range of motion, gait assessment, and a neurovascular examination. 

Testing for an acute posterior cruciate ligament injury is usually difficult because of a tense hemarthrosis and pain. The most accurate test for determining a posterior cruciate rupture is the posterior drawer test at 90° of knee flexion. Following an acute injury, it is often difficult to achieve 90 degrees of knee flexion because of pain. Staubli and Jakob [11]described significant posterior translation of the tibia at 10 to 15° of flexion. The posterior tibial sag and Lachman test and reverse pivot shift tests can be useful.

Injuries to other ligamentous structures must be excluded. Examination of the ACL, collateral ligaments, and posterolateral corner must be carried out.

Slightly increased posterior translation at 30° but not 90° indicates a posterolateral injury. An isolated PLC injury increases external rotation at all angles of flexion, but this is maximal at 30°. Neurovascular examination must be carried out to exclude peroneal nerve and vascular injury.

Ancillary Tests

Radiographs are taken to rule out an avulsion fracture of the PCL at its tibial insertion. Fibular head fractures are indicative of a PLC injury. Magnetic resonance imaging (MRI) has been shown to be highly accurate in the diagnosis of a complete PCL tear. Associated collateral ligament, meniscal and chondral injuries can also be diagnosed with an MRI. A good history and physical examination is very accurate in diagnosing a PCL injury, and hence an MRI is not routinely required. 

Treatment of isolated PCL injuries

There is no controversy about the treatment of PCL avulsion fractures, which are ideally treated by open reduction and internal fixation when the fragment is large enough to be fixed with a screw. Isolated injuries of the PCL usually produce a grade I to II posterior laxity of the knee while a grade III laxity is produced by a combined PCL and posterolateral corner injuries. What is the best method of treatment of isolated PCL injuries?

An acute midsubstance tear of the PCL may heal [12] unlike ACL mid-substance injuries which do not heal. Logically such injuries should be treated conservatively. The long-term natural history of isolated PCL injuries suggests that there is no indication for surgical treatment of such injuries because the outcome of conservative treatment is good. There are no studies to show that surgical treatment is better than conservative treatment for isolated tears of the PCL. Neither is there any evidence that surgical treatment reduces the incidence of osteoarthritis of the knee after PCL injuries [13]. 

Natural history of isolated PCL injuries

One of the earlier studies of the long-term outcome of non-operatively treated isolated PCL injuries was done by Parolie and Bergfeld in 1986 [14]. They studied 25 patients who were treated conservatively for isolated PCL injuries and followed up for a mean of 6.2 years (2.2 to 16 years). They found that 80% of the patients were satisfied with their knee and 84% had returned to their previous sport, with 68% at the same level of performance and 16% at a reduced level of performance. Patients who were satisfied with their knee and had returned to sports had quadriceps strength of more than 100% of the contralateral uninvolved knee and those who were dissatisfied with their knee and not returned to sports had less than 100% strength of the quadriceps as compared to the contralateral knee. 

Selbourne et al [15] prospectively studied the natural history of acute, isolated, nonoperatively treated PCL injuries in athletically active patients. The study included 133 patients all of whom completed a yearly questionnaire for an average of 5.4 years (2.3 to 11.4 years) and 51% of the patients (68 out of 133) returned for long-term clinical and radiological examination. The functional outcome was good with a mean modified Noyes knee score of 84.2 points, a mean Lysholm score of 83.4, and a mean Tegner activity score of 5.7. The grade of laxity had no correlation with subjective functional outcome. Fifty percent of the patients returned to the same sport at the same or higher level of performance, one-third (33.3%) returned to the same sport at a lower level and one-sixth (16.6%) did not return to the same sport.

The authors concluded that ‘athletically active patients with acute isolated posterior cruciate ligament tears treated nonoperatively achieved a level of objective and subjective knee function that was independent of the grade of laxity’.

The longest follow-up study of patients with acute, isolated PCL injuries treated non-operatively was reported by Shelbourne et al in 2013 [16]. The study included 68 patients who had a subjective follow-up at a mean of 17.6 years and 44 of the patients had a subjective and objective follow-up at a mean of 14.3 years (10-21 years). The mean quadriceps strength was 97% of the contralateral side and the range of knee motion was normal in all patients. 

Fifty percent of the patients had no osteoarthritis (OA) of the knee, 30% had mild OA, 9% (4 patients) had moderate and 2% (1 patient) had severe OA of the knee at a mean follow-up of 14.3 years. The mean IKDC (International Knee Documentation Committee) and modified CKRS (modified Cincinnati Knee Rating System) subjective scores were 73.4 ± 21.7 and 81.3 ± 17.4, respectively at 17 years follow-up and the subjective scores did not correlate with the degree of PCL laxity.

The authors concluded that long-term follow-up of patients, with isolated PCL injuries treated non-operatively, shows that patients remain active, have good muscle strength, full range of knee motion and they report good subjective scores, and that the incidence of post-traumatic OA is low.

In 2007 Patel et al [17] published a study involving 57 patients with acute isolated PCL injuries who were treated non-operatively with a mean follow-up of 6.9 years (2 to 19.3 years). Seventeen patients (29.8%) had a grade I and 41 patients (71.9%) had a grade II laxity of the PCL. The functional outcome at 7 years was good with a mean Lysholm-II knee score of 85.2 points (range 51 to 100 points) and a mean Tegner activity level of 6.6 (range 3 to 10). The Lysholm-II knee scoring system showed excellent results in 40%, good in 52%, fair in 3%, and poor in 5% of the knees. The incidence of mild medial compartment OA was 12% and moderate medial compartment OA 5% and none of the patients had severe OA.

These medium and long-term studies of the natural history of isolated PCL injuries reveal that the subjective functional outcome is good, without surgical intervention, with the majority of the patients returning to their pre-injury activity level. Are the results of PCL reconstruction better than conservative treatment?

Surgical treatment of isolated PCL injuries

Most of the published studies reporting the outcome of PCL reconstruction for isolated PCL injuries are small case series with a short follow-up, and the heterogeneity of the patients studied and the technique used makes it difficult to judge outcomes in these patients [18].

However, there are two studies that have reported the long-term outcome of PCL reconstruction in patients with isolated PCL injuries. 

Herman et al [19] studied 25 patients (22 male, 3 female) with an average age of 30.8 years who underwent single-bundle PCL reconstruction for pain and functional instability of the knee. The mean follow-up was 9.1 years (6.5 to 12.6 years). Twenty-two patients were evaluated clinically and 3 patients were provided telephone interviews.

The final mean IKDC score was 65, Lysholm score was 75 and the VAS (visual analog score) was 8. The functional scores were fair to good and were significantly better than the pre-operatively scores. The final Tegner score was 5.7. The functional results were significantly better in patients with no cartilage damage at the time of surgery and in those who underwent surgery within 1-year post-injury.

Jackson et al [20] evaluated the long-term outcome of PCL reconstruction in 26 patients after failed conservative treatment. At 10 years follow-up, the IKDC score was 87 and the Lysholm score improved from 60 to 90 postoperatively. Twenty-two patients had a radiological examination and 18% of the patients had grade II OA changes and another 18% had grade III OA changes.

A careful analysis of the subjective outcome reported by Shelbourne [12] and Patel [17] for non-operative treatment and that by Herman [19] and Jackson [20] for surgical treatment of PCL injuries appears to be very similar. 

Complications of PCL surgery

PCL injuries are rare and the indications for surgery of the PCL are limited since conservative treatment has a good outcome, therefore the number of PCL surgeries carried out by surgeons per year are small. This limited experience with such complex surgery can lead to a higher incidence of complications especially when there are vital neurovascular structures at the back of the knee. Furthermore catastrophic complications usually never get reported which can give surgeons a false sense of relative risks involved when undertaking such procedures. 

Besides the standard complications, such as those associated with anesthesia and complication of surgery such as infections and thromboembolic complications which can occur with any orthopedic procedure, there are specific complications associated with PCL surgery, some of which includes neurovascular injury, osteonecrosis, fractures, stiffness, residual laxity and anterior knee pain. 

A survey of the frequency of complications associated with arthroscopic surgical procedures of the knee reported by Salzler et al [21], where the data was obtained from the ABOS (American Board of Orthopaedic Surgery) database, showed that the complication rate was the highest for PCL surgery as compared with other arthroscopic procedures. The complication rate for PCL surgery was 20.1%, ACL surgery 9.7%, meniscal repair 7.7%, meniscectomy 2.8%, and chondroplasty 3.5%. The overall pulmonary embolism rate was 0.11% and the infection rate 0.84%. These were self-reported complication rates and the authors believe that the actual rates may be higher.

Conclusion

Posterior cruciate injuries can be caused by a variety of different mechanisms. The usual cause is trauma and sports. It is important to differentiate isolated PCL injuries from combined ligament injuries. The diagnosis can be established by a good history and good clinical examination. If the diagnosis is uncertain an MRI will be useful. It is critical to rule out neurovascular injuries in patients who have combined injuries.

Most patients with isolated PCL injuries can be treated conservatively. The mainstay of treatment is quadriceps strengthening with avoidance of active hamstring exercises. 

Medium and long-term studies of the natural history of isolated PCL injuries reveal that the subjective functional outcome is good, without surgical intervention, with the majority of the patients returning to their pre-injury activity level.

The incidence of posttraumatic OA is low after PCL injuries. The incidence of mild medial compartment OA is 12% and moderate medial compartment OA 5% and none of the patients usually develop severe OA.

A careful analysis of the subjective outcome of non-operative treatment and  surgical treatment of PCL injuries appears to be very similar. 

The complication rate following  PCL surgery is the highest as compared with other arthroscopic procedures. The reported complication rate for PCL surgery is about 20% but in actual fact may be higher.

 

 References

1. Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res. 1975 Jan-Feb;(106):216-31. doi: 10.1097/00003086-197501000-00033. PMID: 1126079.
2. Gupte CM, Bull AMJ, Thomas RD, Amis AA. The meniscofemoral ligaments: secondary restraints to the posterior drawer. Analysis of anteroposterior and rotary laxity in the intact and posterior-cruciate-deficient knee. J Bone Joint Surg [Br] 2003;85-B:765-773.
3. Castle Jr TH, Noyes FR, Grood ES. Posterior tibial subluxation of the posterior cruciate-deficient knee. Clin Orthop 1992; 284: 193-202.
4. Veltri DM, Deng XH. Torzilli PA, et al. The role of the cruciate and posterolateral ligaments in stability of the knee: a biomechanical study. Am J Sports Med 1995; 23: 436-43.
5. Noyes FR, Stowers SF, Grood ES, et al. Posterior subluxations of the medial and lateral tibiofemoral compartments: an in vitro ligament sectioning study in cadaveric knees. Am J Sports Med 1993; 21: 407-14.
6. Harner CD, Vogrin TM, Höher J, Injury to the posterolateral structures has profound effects on the function of the human posterior cruciate ligament [abstract]. Trans Orthop Res Soc 1998; 44: 47.
7. Janousek et al. Posterior Cruciate Ligament Injuries of the Knee Joint. Sports Medicine 2000, 28(6):429-41.
8. Miyasaka KC, Daniel DM. The incidence of knee ligament injuries in the general population [abstract], Am J Knee Surg 1991; 4: 3-8.
9. Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: II. Arthroscopy 1995; 11 (5): 526-9.
10. Becker EH, Watson JD, Dreese JC. Investigation of multiligamentous knee injury patterns with associated injuries presenting at a level I trauma center. J Orthop Trauma 2013;27:226-231.
11. H-U. STAUBLI, R. P. JAKOB. Posterior instability of the knee near extension. A clinical and stress radiographic analysis of acute injuries of the posterior cruciate ligament. The Bone & Joint Journal. 1990, 72(2):225-30.
12. Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg 1999; 12:209-13.
13. Dowd GSE. Reconstruction of the posterior cruciate ligament: Indications and results. J Bone Joint Surg [Br] 2004; 86-B: 480-91.
14. Parolie JM, Bergfeld JA: Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986; 14:35-38.
15. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. 1999 May-Jun; 27(3):276-83.
16. Shelbourne KD, Clark M, and Gray T. Minimum 10-Year Follow-up of Patients after an Acute, Isolated Posterior Cruciate Ligament Injury Treated Nonoperatively. Am J Sports Med July 2013 vol. 41 no. 7 1526-1533.
17. Patel DV, Allen AA, Warren RF, Wickiewicz TL, Simonian PT. The Nonoperative Treatment of Acute, Isolated (Partial or Complete) Posterior Cruciate Ligament-Deficient Knees: An Intermediate-term Follow-up Study. HSS J. 2007 Sep; 3(2): 137–146.
18. Montgomery SR, Johnson JS, McAllister DR, Petrigliano FA. Surgical management of PCL injuries: indications, techniques, and outcomes. Curr Rev Musculoskelet Med. 2013 Jun; 6(2): 115–123.
19. Hermans S, Corten K, Bellemans J. Long-term results of isolated anterolateral bundle reconstructions of the posterior cruciate ligament: a 6- to 12-year follow-up study. Am J Sports Med. Aug 2009; 37(8):1499-507.
20. Jackson WF, van der Tempel WM, Salmon LJ, Williams HA, Pinczewski LA. Endoscopically-assisted single-bundle posterior cruciate ligament reconstruction: results at minimum ten-year follow-up. J Bone Joint Surg Br. 2008 Oct; 90(10):1328-33. 
21. Salzler MJ, Miller CD, Lin A, Irrgang JJ, Harner CD. Complications Following Arthroscopic Knee Surgery. Orthopaedic Journal of Sports Medicine, September 2013 vol. 1 no. 4 suppl 2325967113S00044.

       Corruption Causes, Impact and Cures

                                            Dr. KS Dhillon

Introduction

The origin of the word corruption is from the Latin word “corruptus,” which means “corrupted”. Although the word has been widely deplored, there is no generally accepted definition of corruption. In legal terms, corruption is ‘the abuse of a trusted position in one of the branches of power (executive, legislative and judicial) or in political or other organizations with the intention of obtaining material benefit which is not legally justified for itself or for others’ [1].

Historical perspective

Corruption was labeled as a great sin in the Bible: “You shall not take a bribe, for a bribe blinds the clear-sighted and subverts the cause of the just” (Exodus 23:8).

The earliest records of corruption date back to the thirteenth century BC. Under Roman law, corruption was defined as receiving, giving, or claiming benefits in order to influence an official in connection with his work. Since corruption was so common a new law was introduced where the compensation for damage was double the value of the damage, and the perpetrator of the corrupt act lost his political rights. These laws did not help to alleviate corruption because corruption was mostly practiced by the members of the Senate and senior state officials in Rome and in the Roman provinces. 

The Christian faith in the early days condemned corruption. Despite the condemnation, corruption later reached its peak with the selling of indulgences in the Middle Ages. The selling of indulgences as well other immoral acts of the clergy were condemned by Martin Luther. 

The early feudalism in medieval Europe between the 9th and 15th centuries was familiar with various laws that punished the bribing of courts sometimes with death. In the later days of Feudalism, countries became helpless in the fight against corruption. France in 1716 established a special court that handled cases of abuse of royal finances. These abuses including embezzlement, extortion, bribery, scams, etc. were so extensive that the court was abolished and a general amnesty was introduced in 1717. From then some forms of corruption became a tradition. 

Corruption was also widespread during the time of the Spanish Inquisition. During that period the victim of the accusation could make amends with money. 

Throughout history, several intellectuals dealt with corruption or theorized about it. Machiavelli, the Renaissance political theorist, had a low opinion of republics. He considered them even more corrupt than other regimes. According to him, corruption leads to moral degradation, bad education, and bad faith.

The great philosopher, diplomat, and lawyer Sir Francis Bacon was known both for receiving and taking bribes. He reached the highest judicial position in England and during that time he was caught accepting bribes  28 times. He defended himself in parliament by saying that he accepted a bribe from both parties involved and hence the dirty money did not affect his decisions. The parliament refused to accept his arguments and sent him to jail. He, however, only spent a few days in jail since he was able to bribe the judge.

Historically although corruption has been present in society ever since, it has only garnered more attention in the recent past. Research on corruption and its negative impacts has become more common after 1995 when international institutions and countries began to be aware of this problem. Before that, the attitude of the public toward corruption was rather neutral. 

In 1998, Kaufmann and Gray from the World Bank [2] noted that:

• Bribery is widespread, especially in developing and transition countries. There are significant differences between and within regions. For example, survey responses suggest that Botswana and Chile have less bribery than many fully industrialized countries.
• Bribery has been found to increase transaction costs and it creates insecurity in the economy.
• Bribery usually leads to ineffective economic outcomes and in the long term impedes foreign and domestic investments. It misallocates talents to rent-seeking activities and distorts sectorial priorities and technology choices (for example, it creates incentives for contracting major defense projects or unnecessary infrastructure projects, but does not encourage investments in rural specialist health clinics or in preventive health care). This pushes companies “underground” (outside the formal sector), weakens the state’s ability to increase revenue, and leads to ever-increasing tax rates which are levied on fewer and fewer taxpayers, consequently diminishing the state’s ability to provide enough public goods, including the rule of law. A vicious circle of increasing corruption and underground economic activity can result.
• Bribery is unfair, as it imposes a regressive tax, which heavily burdens, in particular, commercial and service activities performed by small businesses.
• Corruption also destroys the legitimacy of the state.

Many ‘researchers and institutions including the World Bank Institute, the European Commission, the United Nations, and the EBRD have investigated corruption and its impact on macroeconomic and microeconomic indicators through various forms of corruption, as well as its connection with local customs and habits, and how it affects the everyday lives of people’ [1]. Most of the studies are mainly the analyses of the effects of corruption on various economic indicators, such as GDP growth, employment, investments, tax revenues, and foreign investments [1] or the study of various forms of corruption in relation to politics and the economic environment [1]. 

Causes of corruption

The level and extent of corruption differs from country to country. There are key common driving forces that generate it. Svensson [3] has identified what is common to all countries that are the most corrupt. They are developing countries or countries in transition and with rare exceptions low-income countries. Most of the corrupt countries have a closed economy, the influence of religion is visible (Protestant countries have far the lowest level of corruption), they have low media freedom and a relatively low level of education.

Corruption usually arises from an array of several interrelated factors, such as political factors, economic environment, professional ethics, legislation, customs, habits as well as traditions.

1. Political and economic environment

The political and economic environment has a great role to play in the phenomenon of corruption. When the economic activity in the country is heavily regulated and limited, the greater is the authority and the power of officials in decision making and this increases the possibility of corruption. In such situations, individuals are willing to pay or offer payment in order to avoid restrictions. When regulations are such that officials are given the opportunity to decide on the basis of discretion, a great potential for corruption exists.

The level of corruption is also affected by the monetary policy. A strong link between monetary policy and corruptive activity has been found. Countries with a well-regulated financial sector that do not have a lot of informal economies or black markets are less corrupt than those where the opposite is true. There is also less corruption in countries with higher economic and political freedom.

The level of efficiency of public administration determines the extent to which corruption can sprout. Such efficiency is determined by the type of regulations and permits. Ineffective and unclear regulations help to increase the level of corruption in two different ways:

• Artificially created monopoly of power enables civil servants to obtain bribes based on their superior position.
• Ineffective and unclear regulations cause inhibition and encourage people to pay bribes in order to speed up the bureaucratic procedure.

Corruption is also strongly influenced by the low salaries of public employees, who try to improve their financial position by receiving bribes. The socio-economic status of government officials also affects the phenomenon of corruption. 

Corruption arises because agencies, institutions, and governments cannot control corruption effectively due to underpaid officials, and this is especially so in developing countries, where they do not have sufficient tax revenue to properly reward the officials.

Low wages are not the only cause of corruption. The poor state of the public administration, that results from political “overcrowding” of officials is another cause of corruption. Political “overcrowding” of officials leads to loyalty prevailing over professional standards leading to corruption. 

Satisfaction with work done by officials is also an important factor that influences corruption. There is some evidence that the more officials are dissatisfied with their work or place of work, the higher the degree of corruption. The private sector has higher ethical values with higher-level satisfaction with work, than the public sector and hence is less unethical especially with regard to thefts and corruption. In principle, the salary level of civil servants affects the receipt of a bribe. The higher it is, the smaller the chance that the person will accept a bribe. On the other hand, a higher salary also strengthens the negotiating power of the official, which leads to higher bribes. Hence, it is very difficult to determine whether a higher salary will lead to less corruption. It means that the level of salary is not a decisive factor, but merely one of many causes of corruption.

The economy is largely dependent on politics and the rule of law. Individuals exploit various options for eliminating competition, and bribery is just one of the possible weapons in the struggle to obtain a job. 

The cost of a bribe is a substantial business cost, and it is an integral part of the business contract. Some believe that even if they stop giving bribery, their rivals will not, and therefore they have to bribe in order to remain competitive. They believe that bribery and misleading behavior are not crimes, they are just part of the business practice. It is also known that lubricating the bureaucratic wheel by the private sector helps to get certain things moving faster or easier.

There is no doubt that the political influence of corruption is rampant in many countries. When people at the top in politics i.e government, parties, and leading politicians are corrupt, then corruption infiltrates to all levels, and at the same time spreads among the ordinary population. In such situations, nobody trusts the institutions or the rule of law. 

Corruption is low in situations where openness and independence of the institutions are in balance and the officials are accessible. They should not be excessively exposed to private influences and should be able to make authoritative decisions, without using their power to arbitrate.

The possibility of corruption is high where the official power is poorly institutionalized and is too exposed to private influence. In such instances, the officials’ independence is reflected in excessive exploitation of their power and they can do as they please.

2. Professional ethics and legislation

Corruption emerges and spreads when there is a lack of professional ethics and there are deficient laws regulating corruption as a criminal offense. Ineffective sanctioning of corruption encourages those involved in corrupt practices to continue with such practices. It also encourages others to get involved in such practices. 

In transition countries, the lack of professional ethics is a particular issue. In some countries, ethics and professional standards change rapidly and approach that in developed countries. In some countries, the standards remain the same. In transition countries, the “softer” acts of corruption are often considered to be justifiable and acceptable. In some countries with professional ethics which manage illegal corruption well, there is nevertheless a widespread form of legal corruption.

Lack of transparency and a lack of control by supervisory institutions provides fertile grounds for corruption to flourish. Non-transparent functioning of both politics and the economy creates an atmosphere for corruption to flourish. Corruption is also affected by extensive, non-transparent, and incomplete legislations which allows for laws to be interpreted in different ways for the benefit of those who are willing to pay.

3. Customs, habits, tradition, and demography

Different countries have different views about corruption. In Europe for example, we can find two extremes; in the North where corruption is not tolerated, and in the South, corruption is an almost normal, socially acceptable phenomenon. 

Countries with a democratic past traditionally prosecute corruption, while in former socialist countries, corruption in the state apparatus was a part of their tradition. 

There are also different customs; for example in some cases, a “thank you” in the form of a gift for a service is an expression of courtesy, while elsewhere it is considered corruption. Everything is a matter of ethics and morality, and it can be very different in different areas and different countries.

Corruption apparently prospers better in countries where Islam and Orthodoxy are the main religion. 

Protestantism has been tested several times and has been found to be associated with low levels of corruption in a country. 

The least corrupt countries are those countries where the rule of law is the strongest. They were predominantly Protestant in 1900 and the most corrupt were predominantly Orthodox in the same year. There is a link between religion and corruption on one hand and respect for the rule of law on the other. The question that arises is: Why do some religions respect the rule of law more than others and control corruption?. 

A study by Melgar et al [5] titled Perception of corruption tried to find out which groups of people are more likely to pay for corruption. They found that people who think that there is a lot of corruption also perceive it so and are more willing to pay for it. It has been shown that social status and personal characteristics also play an important role in the shaping of corruption perception.

 Divorced women, unemployed individuals, people working in the private sector, and those who are self-employed are considered to be in positive correlation with the perception of corruption. The opposite applies to married individuals, full-time employees, people who frequently attend religious ceremonies, and people with at least secondary education. They perceive less corruption and are also not willing to pay. 

In all African and Asian countries, the former socialist countries, and most of the East Asian countries, people perceive more corruption than people living in other countries. Most European countries and some of the former English colonies show lower perceptions of corruption. They also found that better economic results reduce the perception of corruption, while macroeconomic instability and income inequalities have precisely the opposite effect [5]. 

High unemployment and low purchasing power increases the perception of corruption. 

Demographics is also a very important factor that affects corruption. There is evidence that a patriarchal society is more prone to corruption. There are several studies that have found that women are less corrupt than men. An influential study by the World Bank [6] of 150 countries in Europe, Africa, and Asia showed that women are more reliable and less prone to corruption.

A study by Rivas [7] also showed that women are less corrupt than men and he believed that an increase in the number of women in the labor market and in politics could help fight corruption.

 Lee and Guven [8] in a study: Engaging in corruption—the influence of cultural values and the contagion effects at the micro-level, also raised the question of whether men are more corrupt than women. Their findings support the thesis that women are less susceptible to corruption than men, and this is especially true in cultures that require men to be ambitious, competitive, and materially successful. 

In 2009, the Peruvian government decided to involve more women in the police units because women were supposed to be less corrupt than men. When 2,500 female police officers joined as traffic police officers, bribery was drastically reduced, and the people in Peru welcomed the female police officers on the streets [9].

The impact of corruption on the economy

In 1997, Tanzi and Davoodi [10] published an IMF working paper on the impact of corruption on public finances. In the working paper several important findings came to light:

• Corruption leads to an increase in public investments at the expense of private investments. There are many ways in which public expenditure can be manipulated and this is carried out by high-level officials so they can get bribes. In simple terms, it means that more government expenditures and a large budget offer more opportunities for corruption.
• Corruption redirects the public expenditure from that necessary for basic functioning and maintenance to expenditure on new pieces of equipment.
• Corruption tends to take away allotments for public expenditure from essential areas such as health and education since there is less chance of getting commissions in these areas as compared to areas where there are unnecessary projects.
• Corruption reduces the effectiveness of public investments as well as effectiveness of the infrastructure of a country.
• Corruption can also reduce tax revenues by compromising the ability of the state administration to collect taxes and fees.

The influence of corruption on the economy was also studied by Tanzi and Davoodi [10]. The influence of corruption on the economy occurs through several means:

• Through the effect of corruption on businesses. The impact of corruption on a business to a large extent depends on the size of the company. Large companies are better protected in environments that are prone to corruption. They can avoid taxes more easily and their size protects them from petty corruption. They are also often politically protected. The survival of small and middle-sized companies, regardless of their economic importance, is much more difficult than the survival of large companies.
• Through the effect of corruption on investments. Corruption affects total investments, the size, and form of investments by foreign investors, and the size of public investments. It also affects the quality of investment decisions and investment projects.
• Through the effect of corruption on public spending. Corruption has a negative impact on public spending, especially on education and health. There is a strong correlation between corruption and military expenditure. When there is corruption the military expenditure is higher. Higher military expenditure reduces economic growth. 
• Through the effect of corruption on taxes: Because of corruption, fewer taxes are levied than would otherwise be, since some of the taxes go into the pockets of corrupt tax officials. In corrupt countries, there are also frequent tax relieves selective taxes and various types of progressive taxes. Hence, there will be much less money in the country. Therefore corruption, through the country’s fiscal deficit, will affect economic growth.

A study by Smarzynska and Wei [11] on the effects of corruption on the size and composition of investments showed that corrupt countries are less attractive for investors. If they do invest, they often enter the market with a joint venture with local partners who usually understand or control matters of the home country better. The local partner can also help foreigners with the acquisition of local licenses and permits as well as negotiate with the bureaucratic labyrinths at a lower cost. 

Corruption also affects employment for various reasons, because the job does not go to the most qualified or suitable person, but goes to the one who is ready to pay for it in some form or another. 

Corruption also affects the total investments, the size and composition of foreign investments, and the size of public investments. Corruption also affects the effectiveness of investment decisions and projects. When there is corruption, investments are smaller, because investors are aware that they will have to bribe the officials or even give them a profit share for a successful implementation of a business. Because of these increased costs, the investors are usually not keen to invest.

Wei [12] made a projection which predicted that if corruption in Bangladesh could be brought to the level of corruption in Singapore then the growth rate of GDP per capita in Bangladesh could increase by 1.8% per year between 1960 and 1985 and the average per capita income could have been more than 50% higher. The Philippines could have raised their investments in relation to GDP by as much as 6.6% (which means a significant increase in the investments) if the level of corruption could be brought down to that of Singapore. 

Wei [12] also notes that in order to reduce the corruption level to that of Singapore in countries such as India, Ghana, Kenya, Turkey, Sri Lanka, Colombia, and Mexico, the salaries of officials have to be increased by 400—900% which is unlikely to be possible. He goes on to say that if there was such a hike in salaries, a new form of corruption would arise when people would be prepared to pay a bribe to get these well-paid jobs.

The effectiveness of various financial assistance programs is reduced when there is corruption because the money is lost along the way and does not reach the intended target. Furthermore, the financial benefits deriving from corruption cannot be taxed because they are hidden. The state hence loses part of the income from the taxes due to corruption. 

The European Commission in its 2014 report noted that corruption alone cost the EU economy EUR 120 billion per year, which is just a little less than the annual budget of the European Union [13]. According to the European Commissioner for Home Affairs, Cecilia Malstotröm, corruption in Europe is mainly present in public procurement, financing of political parties, and health care [13].

According to the United Nations, Afghanistan’s cost of corruption in 2012 was estimated to be $ 3.9 billion. 

According to Transparency International, Suharto, the former leader of Indonesia, embezzled between $15 and $35 billion. Embezzlements by Mobutu in Zaire, Ferdinand Marcos in the Philippines, and Abacha in Nigeria have been estimated to amount to $5 billion [14]. 

According to a World Bank survey, $1 billion in bribes is paid annually in both the rich and developing countries [15]. This actually means that even the developed countries are not immune to corruption. Political corruption is present in large infrastructure projects. 

Bađun [29] studied the relationship between political corruption and public investment in Croatia. They found that countries with high public investment have bigger political corruption. According to Badun, Croatia's infrastructure is in a bad state despite a high share of public capital expenditure in their GDP. The existence of huge allocations for public investment in the presence of weak control mechanisms provides plenty of opportunities for political corruption. 

There is a strong relationship between the degree of corruption and the emergence of the shadow economy. When there is a high degree of corruption, the level of the shadow economy is also higher. There is a link between low quality of institutions, the holders of the rule of law, and the shadow economy. When the law is weak, higher is the degree of corruption and level of shadow economy. Higher the degree of corruption, lower is the economic development as measured by GDP per capita. Hence, corruption affects the economic development of countries.

A devastating combination of widespread state intervention and subsidies in the absence of a strong institutional framework and lack of control of public finances and lack of effective anti-trust legislation promotes corruption. There is no clear evidence that private monopolies are more effective and less corrupt than the public ones. Public procurement is the breeding ground of corruption. 

Failure to respect copyright and intellectual property has a damaging effect on the global economy. This is obvious in corrupt countries. The economic damage can amount to billions of dollars when there is a failure to respect copyright and intellectual property.

Year after year the perception of corruption is increasing. Despite all the anti-corruption initiatives and anti-corruption moves, people still do not hesitate to accept and offer a bribe. The individuals who give bribes are becoming more innovative. They adapt to the situation and their innovations in paying bribes and hiding them are becoming more visible. The negative effects of corruption are the same all over the world. It reduces both foreign direct and domestic investments and increases inequality and poverty. Corruption increases the number of renter seekers in the economy and it also distorts and exploits public investments as well as reduces public revenues.

Remedial Measures

Corruption exists in all countries but it is more widespread in low-income countries. This is not because people in poor countries are more corruptible than in rich countries. It is because conditions in poor countries are more conducive for corruption to flourish. Bribery and graft are crimes of calculation. When the benefits are large, chances of getting caught are small, and penalties are light, then many people will succumb to corruption.

Low-income countries usually have highly regulated economies with large monopoly rents. Accountability is usually weak, political competition and civil liberties are often restricted. Laws and principles of ethics are poorly developed and legal institutions charged with enforcing them are ill-prepared to address the task. Watchdog organizations are not well developed and are often suppressed. The discretionary powers of administrators are extensive, with poorly defined rules and regulations which makes the situation worse [17] Given these constraints, what can be done to redress the situation?

The pessimist says nothing can be done. There are, however, others with more optimistic views. The more optimistic people point out that there are developing countries in the world, such as Chile and Botswana that, at present, have less bribery than many industrialized countries. They also point out that developing economies like Singapore, Hong Kong, and China have been able to transform themselves from being very corrupt to relatively clean within a reasonably short period of time [17].

Some ideas and suggestions of the optimistic groups to fight corruption include [17]: 

(i) Leadership: There are many authors, including Professor Syed Hussein Alatas of Malaysia, a noted authority on corruption, who are of the view that the leadership in a country has a key role to play in fighting corruption [18].

Asians traditionally hold their leaders and those in authority in high regard and esteem. Top leaders are expected to set a good example with respect to honesty, integrity, and capacity for hard work. Fighting corruption involves taking difficult decisions, hence the leadership must display firmness, political will, and commitment to carry out reforms that are required. Honest and dedicated leaders are necessary to counter corruption. 

(ii) Credibility: For success in the drive against corruption, the offenders on the demand and supply side of a corrupt deal have to be convinced that the government is serious about fighting corruption. There have been suggestions that some well-known corrupt people in the country should be publicly tried and punished.

In several Asian countries, some highly publicized trials and convictions of important officials and businessmen on charges of corruption have taken place.

(iii) Involving people: People should be involved in campaigns to eradicate corruption. Publicity campaigns to create greater awareness of the adverse effects of corruption can be useful. There should be clear and unequivocal official pronouncements by the authorities on the desirability to bring corruption under control. 

Help and cooperation of ordinary citizens, who have a lot of first-hand experience with corruption, should be solicited for the successful launch of anti-corruption drives. People will extend their full cooperation once they are convinced that a sincere and genuine effort to combat corruption is underway. Providing opportunities for people to express their views on such matters will bring forth an outpouring of information, ideas, and suggestions.

 (iv) Responsible press: A responsible press can go a long way to help fight corruption. Secretiveness helps politicians and public officials to get away with corruption. A responsible press can gather, analyze, organize, present, and disseminate information which is vital to create greater public awareness as well as to provide the momentum for undertaking reforms necessary to overcome corruption. A responsible and investigative press can play an important role in exposing misconduct as well as in serving as a watchdog to reduce corruption. It can also prevent the spread of corruption. The power of the press to limit misconduct and improper behavior should not be underestimated.

(v) Oversight bodies: There are mixed views on the effectiveness of anti-corruption oversight or watchdog bodies. In some situations, the views have been useful. The Independent Commission Against Corruption in Hong Kong, China, and similar institutions in other countries such as

Botswana, Chile, Malaysia, and Singapore have apparently done a good job. According to surveys and interviews of public officials and members of civil society organizations, many respondents do not believe that these organizations have done a good job to reduce corruption. 

For such bodies to be effective, they have to be created in an environment where leaders are honest and civil servants are insulated from political interference. Better incentives have also to be provided to discourage corruption. Oversight bodies are often misused for political gain which renders these oversight bodies useless.

Conclusion

Corruption is a symptom of deep-seated economic, political, and institutional weaknesses and shortcomings in a country. To tackle corruption the underlying causes must be addressed. Root causes of corruption must be tackled by undertaking economic, political, and institutional reforms. 

Anti-corruption enforcement measures such as a strengthened police force oversight bodies and more efficient courts will not be sufficient to tackle corruption without making serious efforts to address the fundamental causes of corruption. 

Corruption is prevalent where there are other forms of institutional weaknesses, such as bureaucratic red tape, political instability, and weak legislative and judicial systems. Corruption and such institutional weaknesses are usually linked together and they feed upon each other. Getting rid of corruption helps a country to overcome institutional weaknesses, and reducing institutional weaknesses helps to curb corruption.

Undertaking reforms (both economic and political) by reducing institutional weaknesses offers the best hope of overcoming corruption. Reforms will not make corruption disappear but reforms will bring it under control so that adverse consequences can be minimized so that the country can progress to become a modern, developed nation [17]. 

 Reference

1. Štefan Šumah. Corruption, Causes and Consequences. Trade and Global Market at https://www.intechopen.com/books/trade-and-global-market/corruption-causes-and-consequences.
2. Gray CW and Kaufmann D. Corruption and Development - Finance & Development - March 1998 at https://www.imf.org/external/pubs/ft/fandd/1998/03/pdf/gray.pdf
3. Svensson J. Eight questions about corruption. Journal of Economic Perspectives—Volume 19, Number 3—Summer 2005—Pages 19–42.
4. Eugen Dimant* and Guglielmo Tosato. CAUSES AND EFFECTS OF CORRUPTION: WHAT HAS PAST DECADE’S EMPIRICAL RESEARCH TAUGHT US? A SURVEY. Journal of Economic Surveys(2018) Vol. 32, No. 2, pp. 335–356.
5. Melgar et al. The perception of corruption. International Journal of Public Opinion Research. 2009, Vol. 22 No. 1.
6. Dollar D, Fisman R, Gatti R. Are women really the “fairer” sex? Corruption and women in government. Journal of Economic Behavior & Organization. 2001;46(4):423-429.
7. Rivas MF. An experiment on corruption and gender. Bulletin of Economic Research. 2013;65(1):10-42. 
8. Lee WS, Guven C. Engaging in corruption: The influence of cultural values and contagion effects at the microlevel. Journal of Economic Psychology. 2013;39:287-300.
9. Karim S. Madame Officer. 2011. Available from: http://www.americasquarterly.org/node/2802.
10. Tanzi V, Davoodi H. Corruption, public investment, and growth. IMF Working Paper 97/139. Washington: International Monetary Fund; 1997.
11. Smarzynska BK, Wei SJ. Corruption and Composition of Foreign Direct Investment: Firm-Level Evidence. Vol. 7969. Cambridge, MA: National Bureau of Economic Research; 2000. 
12. Wei SJ. Corruption in Economic Transition and Development: Grease or Sand? Geneva: United Nations Economic Commission for Europe; 2001.
13. EU Commission. Report from the Commission to the Council and the European Parliament – EU Anti-corruption Report. 2014. Available from: https://ec.europa.eu/home-affairs/sites/homeaffairs/files/e-library/documents/policies/organized-crime-and-human-trafficking/corruption/docs/acr_2014_en.pdf.
14. The Guardian. Suharto, Marcos and Mobutu Head Corruption Table with $50 bn Scams. 2004. Available from: http://www.theguardian.com/world/2004/mar/26/indonesia.
15. The World Bank. The Cost of Corruptions. 2004. Available from: http://go.worldbank.org/LJA29GHA80.
16. Bađun M. The relationship between political corruption and public investment-the case of Croatia. Društvena istraživanja. 2011;20(2):295-316.
17. U Myint. CORRUPTION: CAUSES, CONSEQUENCES AND CURES. Asia-Pacific Development Journal. Vol. 7, No. 2, December 2000.
18. Alatas, Hussein S., 1999. Corruption and the Destiny of Asia. Malaysia : Prentice Hall ; Singapore : Simon & Schuster.

               Chondromalacia Patella

                 

                                        DR KS Dhillon

Introduction

Chondromalacia is an affliction of the hyaline cartilage of the articular surfaces of the bone. There is softening and then subsequent tearing, fissuring, erosion, and degeneration of hyaline cartilage. Chondromalacia can occur in any synovial joint. It is, however, most commonly seen in the patellofemoral joint. In the patellofemoral joint, it is called chondromalacia patella, patellofemoral syndrome, or runner's knee. The articular surface of the patella is covered with hyaline cartilage and it articulates with the hyaline cartilage on the femoral groove (trochlear groove). 

Chondromalacia can result from direct trauma, patellar dislocation, chronic patellar instability/subluxation, patella alta, quadriceps imbalance, synovial plicae, and iatrogenic injections of medication. 

Etiology

A common cause of microtrauma leading to wear and tear resulting in chondromalacia patella is lateral subluxation or lateral positioning of the patella. It is more commonly seen in females who have a larger Q angle. 

The Q angle measures the pull of the quadriceps muscle relative to the pull of the patella tendon on the patella.  A normal angle is 17 degrees in women and 14 degrees in men. It is measured by drawing a line from the center of the anterior iliac spine to the center of the patella (quadriceps pull) and a second line from the mid-portion of the patella to the tibial tubercle (patella tendon pull). An abnormally high Q angle indicates lateral pull of the patella in the trochlear groove of the femur which leads to articular cartilage wear and tear [1].

The patella alignment in the vertical plane can also be abnormal. A high riding patella (patella alta) and a low riding patella (patella baja) have also been implicated as a cause of chondromalacia.

Chondromalacia can also result from injuries, immobilization, and surgical procedures that lead to quadriceps atrophy. Quadriceps atropy causes micro-trauma which is created by the decreased pull of the quadriceps muscle on the patella [1].

Lateral synovial plicas have also been implicated in the pathogenesis of chondromalacia patella. Patellofemoral stress caused by sporting activities, repeated stair climbing, and kneeling can contribute to the development of chondromalacia.

Iatrogenic injection of chondrotoxic medications into a joint can lead to chondromalacia patella. Intra-articular injections of bupivacaine and high doses or frequent intra-articular injections of corticosteroid are known to lead to softening and/or articular cartilage dysfunction [1]. 

Pes planus can cause an increased valgus orientation of the knee leading to increased lateral wear of the patellofemoral joint. High-heel shoes can increase stresses on the patellofemoral joint leading to chondromalacia [1].

Epidemiology

Chondromalacia patella is more common in women as compared to men. This is attributed to the presence of increased Q angles in women. There is no known hormonal cause of variation. Active young adults who participate in running sports and workers who have increased patellofemoral stress due to repeated stair climbing and/or kneeling have a higher incidence of chondromalacia.

About 20% of individuals with patellofemoral pain have chondromalacia patella. About 80% of patients with lower limb joint pain have patellofemoral pain [2]. 

History and Physical Examination

The chief complaint of patients with chondromalacia patella is anterior knee pain. The pain is aggravated by activities that increase the stress on the patellofemoral joint. These activities include stair climbing, squatting, kneeling, and running. 

There are several other causes of anterior knee pain. These include patellar tendonitis, infrapatellar fat pad syndrome (Hoffa disease), patellar instability, bi-partite patella, osteochondritis dessicans of the patellofemoral joint, patella alta, patella baja, and synovial plica.

The major symptom of chondromalacia is diffuse pain in the peripatellar or retropatellar area of the knee. The onset of pain is usually insidious and typically vague in nature. The pain is aggravated by daily activities such as going up and downstairs, prolonged sitting with knee bent, squatting, and kneeling.

Physical exam can show quadriceps muscle atrophy, signs of patella maltracking, lateral subluxation of patella or loss of medial patellar mobility, 

increased femoral anteversion or tibial external rotation, positive patellar apprehension test, palpable crepitus, pain with compression of the patella with knee range of motion, or resisted knee extension. 

The Clark’s test specifically evaluates the knee for chondromalacia. This test is performed by compressing the patella into the femoral trochlea and having the patient contract his/her quadriceps muscle. This pulls the patella through the groove and causes anterior knee pain in patients with chondromalacia.

Imaging

Radiographs

Three views of radiographs are recommended namely the AP, lateral, and Merchant’s view. The radiographs can show a shallow sulcus, patella alta/baja, and lateral patella tilt.

CT scan

CT scans are of not much use for the diagnosis of chondromalacia. CT scans can show patellofemoral alignment, fractures, trochlear geometry, and limb torsion.

MRI

MRI is the modality of choice for assessing patellar cartilage.

T1 sequence is a poor sequence for cartilage and surface irregularity and subtle signal change may not be apparent. Areas of hypointensity may be seen in cartilage. Subchondral reactive bone marrow edema pattern (low signal) may be seen.

T2/PD sequences are the best sequences for assessing cartilage. Most patients with chondromalacia patellae will have focally increased signal in the cartilage or focal contour defects in the cartilage surface. Abnormal cartilage is usually of high signal compared to normal cartilage. The findings can range from a subtle increase in signal to complete loss of cartilage. 

The modified Outerbridge grading of chondromalacia is divided into four grades based on T2/PD sequences. 

Grade I: focal areas of hyperintensity with normal contour. 

Grade II: blister-like swelling/fraying of articular cartilage extending to surface.

Grade III: partial-thickness cartilage loss with focal ulceration.

Grade IV: full-thickness cartilage loss with underlying reactive changes in the bone. 

Treatment

Nonoperative

In many individuals with chondromalacia patellae, the symptoms are self-limiting. The treatment is primarily nonsurgical. Conservative therapeutic interventions include the following:

• Isometric quadriceps strengthening and stretching exercises: Restoration of good quadriceps strength and function is important in achieving good recovery [3].

• Stretching exercises. Hamstring, quadriceps, calf, lateral hip, and thigh stretching exercises can be useful.

• Temporary modification of activity. Avoid activities that compress the

patella against the femur with force. This will include avoiding going up and downstairs and hills, deep knee bends, kneeling, step-aerobics, and high-impact aerobics. Do not wear high-heeled shoes. Do not do exercises sitting on the edge of a table and lifting leg weights

• Patellar taping. An elastic knee support that has a central opening cut out for the kneecap can help reduce pain.

• Foot orthoses. Orthotics which decrease pronation of the foot can be useful.

• Non-steroidal anti-inflammatory drugs are more effective than steroids.

Surgical treatment

Surgical management is indicated when there is a failure to respond to nonoperative management. Studies show that up to 20% of athletes fail to improve adequately with conservative treatment [4]. Surgical intervention often produces variable results. 

There are 2 approaches to surgical treatment of chondromalacia:

1.Treatment directed at malalignment and other abnormalities of the extensor mechanism and the patellofemoral joint. 

Treatment directed at malalignment and other abnormalities of the extensor mechanism and the patellofemoral joint include:

• Lateral retinacular release-- This is indicated when there is a tight lateral retinacular capsule, loose medial capsule and there is lateral patellar tilt. This can be carried out by open arthrotomy or arthroscopically. The majority of studies, however, show that over 80% of patients with chronic patellofemoral pain respond initially to lateral release of the patella but with increasing time there is a diminishing long-term benefit [4].
• Patellar realignment surgery- This is indicated when there is patellar malalignment. The following techniques can be used: Maquet anterior tubercle elevation, Fulkerson anterior-medialization for increased Q angle and patella instability, Elmslie-Trillat osteotomy, and medial patellofemoral reconstruction.

2.Treatment of the diseased cartilage.

 Arthroscopic debridement of the cartilage is usually carried out for Outerbridge grade 2-3 chondromalacia of the patellofemoral joint. Krüger et al [5] carried out a retrospective study of 161 patients who had undergone arthroscopic operation for chondromalacia of the knee joint. The average follow-up was 40 (range 10-72) months. They found that patients with severe articular cartilage lesions who had undergone articular lavage alone showed significantly poorer results. Generally, younger patients showed better results than older patients. According to the authors, the literature shows that aggressive subchondral abrasion in severely degenerated knees does not provide any benefits to the patient. They found that almost every second patient suffering from grade 4 chondromalacia complained of recurrent pain 1 year postoperatively. One of every 6 patients received a knee joint prosthesis within the 1st year after debridement surgery. 

Price et al [6] in a series involving cases of post-traumatic chondromalacia patellae found that arthroscopic shaving and lavage generally provided only partial relief of symptoms, and few patients showed improvement beyond 2 years from the date of injury.

Federico et al [7] found that patients with traumatic chondromalacia patellae had 57.9% good or excellent results with joint debridement, and the patients with atraumatic cases had 41.1% good or excellent results with surgery, indicating that many patients who were improved by the surgery still had functional limitations.

Some surgeons have resorted to patellofemoral arthroplasty and others to patellectomy for treatment of advanced chondromalacia of the patella. The clinical outcome after patellectomy is not good with one study showing only 29% of soldiers recovering to a fully fit category after patellectomy [8].

Patellectomy has its own set of problems, which include loss of extension power and increased risk of arthritis in the tibiofemoral compartment. It is hardly carried out nowadays.

Patellofemoral arthroplasty (PFA) is sometimes carried out in patients with severe isolated patellofemoral osteochondropathy not responding to nonoperative measures. The main contraindications for arthroplasty are uncorrected maltracking of the patella, uncorrected tibiofemoral malalignment, and other compartmental diseases. Success rates of PFA vary from 42% to 90% [9,10,11,12]. The published data is limited and the indications for surgery are varied in these studies and this could possibly explain the diversity of these success rates [13].

Other treatments

There are some newer techniques for the treatment of chondromalacia patellae, such as chondrocyte transplant and cartilage transplant. A definite conclusion cannot be drawn on the effectiveness of these techniques in the treatment of chondromalacia because the patients undergoing such treatment have not been followed up for a sufficient length of time [14]. 

Prognosis

Pain from chondromalacia usually disappears with time. Recovery can occur in a month. Sometimes it takes years before it disappears. Teenagers usually achieve long-term recovery because their bones are still growing, and their symptoms generally disappears once they reach adulthood.[15]

Reference

1. Habusta SF, Coffey R, Ponnarasu S, et al. Chondromalacia Patella at https://www.ncbi.nlm.nih.gov/books/NBK459195/#_NBK459195_pubdet_.
2. Glaviano et al. DEMOGRAPHIC AND EPIDEMIOLOGICAL TRENDS IN PATELLOFEMORAL PAIN. The International Journal of Sports Physical Therapy | Volume 10, Number 3 | June 2015. 
3. Natri A, Kannus P, Järvinen M. Which factors predict the long-term outcome in chronic patellofemoral pain syndrome? A 7-yr prospective follow-up study. Med Sci Sports Exerc. 1998 Nov;30(11):1572-7. doi: 10.1097/00005768-199811000-00003. PMID: 9813868.
4. Perry JD. Sports medicine: the clinical spectrum of injury. In: Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, editors. Rheumatology 3rd ed. St Louis, MO: Mosby, Inc;2003. p 749.
5. Krüger T, Wohlrab D, Birke A, Hein W. Results of arthroscopic joint debridement in different stages of chondromalacia of the knee joint. Arch Orthop Trauma Surg. 2000;120(5-6):338-42. doi: 10.1007/s004020050478. PMID: 10853909.
6. Price AJ, Jones J, Allum R. Chronic traumatic anterior knee pain. Injury 2000;31:373-8.
7. Federico DJ, Reider B. Results of isolated patellar debridement for patellofemoral pain in patients with normal patellar alignment. Am J Sports Med 1997;25:663-669.
8. Pailthorpe CA, Milner S, Sims MM. Is patellectomy compatible with an army career? J R Army Med Corps 1991;137(2):76-9.
9. Cartier P, Sanouiller JL, Khefacha A (2005) Long-term results with the first patellofemoral prosthesis. Clin Orthop Relat Res 436:47–54.
10. Kooijman HJ, Driessen AP, van Horn JR (2003) Long-term results of patellofemoral arthroplasty. A report of 56 arthroplasties with 17 years of follow-up. J Bone Jt Surg 85(6):836–840.
11. Leadbetter WB, Ragland PS, Mont MA (2005) The appropriate use of patellofemoral arthroplasty: an analysis of reported indications, contraindications, and failures. Clin Orthop Relat Res 436:91–99
12. Leadbetter WB, Seyler TM, Ragland PS, Mont MA (2006) Indications, contraindications, and pitfalls of patellofemoral arthroplasty. J Bone Jt Surg Am 88(Suppl 4):122–137.
13. van Wagenberg JM, Speigner B, Gosens T, de Waal Malefijt J. Midterm clinical results of the Autocentric II patellofemoral prosthesis. Int Orthop. 2009 Dec;33(6):1603-8. doi: 10.1007/s00264-009-0719-z. Epub 2009 Feb 18. PMID: 19224212; PMCID: PMC2899175.
14. Adrian Roberts. Chondromalacia Patellae at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/384485/chondromalacia_patellae.pdf.
15. Mouzopoulos G, Borbon C, Siebold R. Patellar chondral defects: a review of a challenging entity. Knee Surg Sports Traumatol Arthrosc. 2011 Dec;19(12):1990-2001.

Ivermectin for Prevention and Treatment of COVID-19 Infection

          Ivermectin for Prevention and Treatment of COVID-19 Infection

                                                 Dr. KS Dhillon

Ivermectin oral tablet is used to treat infections of parasites. These include parasitic infections of our intestinal tract, skin, and eyes. It is also available as a topical cream and topical lotion. Ivermectin oral tablet is available as the brand-name drug Stromectol. 

Ivermectin tablet works by binding to parts inside the parasite. It eventually paralyzes and kills off the parasite, and it also stops adult parasites from making larvae for some time. This results in the eradication of the parasitic infection. 

In recent years several groups have shown, in-vitro, that ivermectin has anti-viral activity against a broad range of viruses [1]. Due to its in vitro antiviral activity against a broad range of viruses, it has been used off-label for the treatment of some viral diseases. 

Several studies have reported antiviral effects of ivermectin on RNA viruses such as dengue, Zika, yellow fever, West Nile, Hendra, Newcastle, Venezuelan equine encephalitis, chikungunya, Semliki Forest, Sindbis, Avian influenza A, Porcine Reproductive and Respiratory Syndrome, Human immunodeficiency virus type 1, and severe acute respiratory syndrome coronavirus 2. There are also some studies that show antiviral effects of ivermectin against DNA viruses such as Equine herpes type 1, BK polyomavirus, pseudorabies, porcine circovirus 2, and bovine herpesvirus 1.

Ivermectin has been found to have antiviral action against the SARS-CoV-2 clinical isolate in vitro. A single dose of ivermectin is able to control viral replication within 24–48 hours by inhibiting IMPα/β1-mediated nuclear import of viral proteins [1].

Ivermectin has an established safety profile for human use [2,3,4] and is FDA-approved for several parasitic infections [2,4]. Recent reviews and meta-analyses indicate that high-dose ivermectin has comparable safety as the standard low-dose treatment [5]. There, however, is not enough evidence to make conclusions about the safety profile in pregnancy.

Many drugs with anti-inflammatory, antiviral, and immunomodulatory properties are currently used in the treatment of COVID-19. Unfortunately, none of them can provide a complete cure [6]. One of the drugs whose effectiveness has been and is being investigated in the treatment of  COVID-19 is ivermectin.

Up to February 2021, the Pan American Health Organization (PAHO) identified twenty-two ivermectin randomized clinical trials through a rapid review of current available literature [7]. In these studies, there is considerable heterogeneity in the population receiving ivermectin, with studies administering it to family contacts of confirmed COVID-19 cases as a prophylactic measure [8], other studies using ivermectin for treatment of mild and moderate disease [9], and even in patients who are hospitalized with severe disease [10]. 

Kim et al [11] recently published a systematic review and network meta-analysis that compared the efficacy and safety of pharmacological interventions for COVID-19 in hospitalized patients. The review included 110 studies (78 published and 38 unpublished) with 40 randomized clinical trials and 70 observational studies. Based on the observational data, they found that high-dose intravenous immunoglobulin, tocilizumab, and ivermectin were associated with a reduced mortality rate in critically ill patients. They also found that none of the analyzed drugs were significantly associated with increased non-cardiac serious adverse events compared to standard care.

Kow et al [12] carried out a meta-analysis to study the association between the use of ivermectin and mortality in patients with COVID-19. The study included 6 randomized controlled trials with a total of 658 patients who were randomized to receive ivermectin and 597 patients randomized in the control group who did not receive ivermectin. The meta-analysis showed significantly reduced odds of mortality with the use of ivermectin among patients with COVID-19 relative to non-use of ivermectin. The estimated effect of ivermectin indicated mortality benefits.

Rajter et al [13] carried out a study that showed that the use of Ivermectin is associated with lower mortality in hospitalized patients with coronavirus disease. Their study included 280 patients, 173 treated were treated with ivermectin and 107 without ivermectin. Most patients in both groups also received hydroxychloroquine, azithromycin, or both. Univariate analysis showed lower mortality in the ivermectin group. Mortality also was lower among ivermectin-treated patients with severe pulmonary involvement. No significant differences were found in extubation rates or length of stay. After multivariate adjustment for confounders and mortality risks, the mortality difference remained significant. Mortality was significantly lower in the ivermectin group. 

Okumus et al [14] carried out a study to evaluate the effectiveness and safety of adding ivermectin to treatment in patients with severe COVID-19.

It was a prospective, randomized, controlled, single-blind phase 3 multicenter clinical trial to assess the effectiveness and safety of ivermectin use in the treatment of patients without mutation. All patients in the study had severe COVID19 pneumonia. Ivermectin 200 mcg/kg/day for 5 days in the form of a solution prepared for enteral use was given to the study group in addition to the reference treatment protocol of hydroxychloroquine, favipiravir, and azithromycin. Patients in the control group were given only reference treatment with 3 other drugs without ivermectin. The study showed that ivermectin provided an increase in clinical recovery, improvement in prognostic laboratory parameters, and a decrease in mortality rates even when used in patients with severe COVID-19. The authors were of the opinion that ivermectin should be considered as an alternative drug that can be used in the treatment of COVID-19 disease or as an additional option to existing protocols.

Shoumann et al [15] carried out a randomized clinical trial to study the use of ivermectin for chemoprophylaxis for covid-19 infection. This was a  prospective interventional randomized open label-controlled study. Two arms were designed according to the use of ivermectin. In the ivermectin arm, contacts of a patient with covid infection received ivermectin on the day of the diagnosis of their index case. The nonintervention group received no ivermectin. Both groups were followed up for two weeks to look for symptoms suggestive of COVID-19.

In the Ivermectin group, there were 203 contacts (to 52 index cases). In the nonintervention group, there were 101 contacts (to 24 index cases). Fifteen contacts (7.4%) developed COVID-19 in the ivermectin arm as compared to 59 (58.4%) in the nonintervention arm. The authors concluded that Ivermectin is suggested to be a promising, effective, and safe chemoprophylactic drug in the management of COVID-19.

Bryant et al [16] carried out a systematic review and meta-analysis to assess the efficacy of ivermectin treatment and/or prophylaxis among people with, or at high risk of covid-19 infection. They searched bibliographic databases up to February 2021. Their study included 21 RCTs involving 2741 participants. Meta-analysis of 13 trials found that ivermectin reduced the risk of death compared with no ivermectin. The evidence was of low to moderate certainty. Low-certainty evidence found that ivermectin prophylaxis reduced covid-19 infection by an average of 86%.

The systematic review and meta-analysis were done using rigorous Cochrane methods. Evidence was assessed using the GRADE approach which judges the certainty of the evidence.

The authors concluded that the apparent safety and low cost of the drug suggest that ivermectin could have an impact on the SARS-CoV-2 pandemic globally. Ivermectin is not a new and experimental drug with safety concerns; it is a WHO ‘essential medicine’ usually used for the treatment of other diseases.

López-Medina et al [17] carried out a randomized clinical trial to determine whether ivermectin is efficacious in the treatment for mild COVID-19. In this double-blind, randomized trial a total of 476 adult patients with mild disease and symptoms for 7 days or fewer (at home or hospitalized) were enrolled

between July 15 and November 30, 2020, and followed up through December 21, 2020. The patients were randomized to receive ivermectin, 300 μg/kg of body weight per day for 5 days (n = 200) or placebo (n = 200).

The median time to resolution of symptoms was 10 days in the ivermectin group compared with 12 days in the placebo group. By day 21, 82% in the ivermectin group and 79% in the placebo group had resolved symptoms. The authors concluded that among adults with mild COVID-19, a 5-day course of ivermectin, compared with placebo, did not significantly improve the time to resolution of symptoms. They said that their findings do not support the use of ivermectin for the treatment of mild COVID-19.

Despite the presence of several randomized clinical trials which show the effectiveness of Ivermectin in the treatment and prophylaxis of covid-19, WHO in its latest 2021 guidelines does not recommend the use of ivermectin for the treatment of covid-19 infections. According to WHO the current evidence on the use of ivermectin to treat COVID-19 patients is inconclusive. WHO recommends that the drug only be used within clinical trials. The WHO panel did not look at the use of ivermectin to prevent COVID-19. 

WHO strongly recommends the use of systemic corticosteroids for severe or critically ill COVID-19 patients. WHO does not recommend the use of remdesivir, hydroxychloroquine, and lopinavir/ritonavir for treatment of covid-19.  WHO provides conditional recommendation for the use of low-dose anticoagulants in hospitalized covid-19 patients. 

The WHO decision was based on the following factors. Their panel found that for most key outcomes, including mortality, mechanical ventilation, hospital admission, duration of hospitalization, and viral clearance, the evidence was of very low certainty. The evidence was rated as very low certainty mainly because of very serious imprecision for most outcomes: the aggregate data had wide confidence intervals and/or very few events. There were also concerns related to the risk of bias for some outcomes, specifically lack of blinding, lack of trial pre-registration, and lack of outcome reporting for one trial that did not report mechanical ventilation despite pre-specifying it in their protocol (publication bias) [18].

There has been some criticism of the WHO analysis [19]. According to the critics, the WHO analysis contains many flaws [19]: 

• Of the 58 studies (29 RCTs) available in the literature, WHO only included 16 in their analysis.
• They excluded all 14 prophylaxis studies (4 RCTs).
• There was no protocol for data exclusion.
• Trials included in the original UNITAID search protocol were excluded.
• They excluded all epidemiological evidence, although WHO has considered such evidence in the past.
• They combine early treatment and late treatment studies and do not provide heterogeneity information. Early treatment is more successful, so pooling late treatment studies will obscure the effectiveness of early treatment. They chose not to do subgroup analysis by disease severity across trials, although treatment delay is clearly a critical factor in COVID-19 treatment, the analysis is easily done, and it is well known that the studies for ivermectin and many other treatments clearly show greater effectiveness for early treatment.
• WHO downgraded the quality of trials compared to the UNITAID systematic review team and a separate international expert guideline group that has long worked with the WHO.
• They disregarded their own guidelines that stipulate quality assessments should be upgraded when there is evidence of a large magnitude effect (which there is), and when there is evidence of a dose-response relationship (which there is). They claim there is no dose-response relationship, while the UNITAID systematic review team found a clear relationship.
• Their risk of bias assessments does not match the actual risk of bias in studies. There is a clear treatment delay-response relationship and very late stage treatment is not expected to be as effective as early treatment. Much higher quality studies were classified as high risk of bias.
• Although WHO's analysis is called a "living guideline", it is rarely updated and very out of date. As of May 14, 2021, four of the missing RCTs are known to WHO and labeled "RCTs pending data extraction" [COVID-NMA]. 
• A single person served as Methods Chair, member of the Guidance Support Collaboration Committee, and member of the Living Systematic Review/NMA team.
• Public statements from people involved in the WHO analysis suggest substantial bias. For example, a co-chair reportedly said that "the data available was sparse and likely based on chance". The data is comprehensive, and we estimate the probability that an ineffective treatment generated results as positive as observed to be 1 in 9 trillion (p = 0.00000000000011). The clinical team lead refers to their analysis of ivermectin as "fighting this overuse of unproven therapies ... without evidence of efficacy", despite the extensive evidence of efficacy from the 58 studies by 519 scientists with 18,776 patients. People involved may be more favorable to the late-stage treatment of COVID-19, for example, the co-chair recommended treating severe COVID-19 with remdesivir.

It is not true that there is no evidence for the use of ivermectin in the prevention and treatment of covid-19 infections. There is evidence but the evidence is apparently weak.

In conclusion, research related to ivermectin use in COVID-19 has several limitations but the evidence continues to grow [20,21]. The use of ivermectin for prophylaxis or treatment for COVID-19 should be done based on trustable evidence, without conflicts of interest, with proven safety and efficacy in patient-consented, ethically approved, randomized clinical trials [22]. There remains a need for large randomized clinical trials to prove the efficacy of ivermectin in the prevention and treatment of covid-19 infections.

Reference

1. Leon Calya, Julian D.Druce, Mike G.Catton, David A.Jans, Kylie M.Wagstaff. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Research. Volume 178, June 2020, 104787.
2. A. Gonzalez Canga, et al. The pharmacokinetics and interactions of ivermectin in humans--a mini-review AAPS J., 10 (1) (2008), pp. 42-46.
3. D.A. Jans, A.J. Martin, K.M. Wagstaff. Inhibitors of nuclear transport Curr. Opin. Cell Biol., 58 (2019), pp. 50-60.
4. D. Buonfrate, et al. Multiple-dose versus single-dose ivermectin for Strongyloides stercoralis infection (Strong Treat 1 to 4): a multicentre, open-label, phase 3, randomised controlled superiority trial Lancet Infect. Dis., 19 (11) (2019), pp. 1181-1190.
5. Navarro M, Camprubí D, Requena-Méndez A, Buonfrate D, Giorli G, Kamgno J, Gardon J, Boussinesq M, Muñoz J, Krolewiecki A. Safety of high-dose ivermectin: a systematic review and meta-analysis. J Antimicrob Chemother. 2020 Apr 1;75(4):827-834. doi: 10.1093/jac/dkz524. PMID: 31960060.
6. Jean SS, Lee PI, Husueh PR. Treatment options for COVID-19: the reality and challenges. J Microbiol Immunol Infect. 2020;53(3): 436–43.
7. PAHO. Ongoing living update of COVID-19 therapeutic options: summary of evidence, 2021. Available: https://iris.paho.org/bitstream/handle/10665.2/52719/PAHOIMSEIHCOVID-19200030_eng.pdf?sequence=17&isAllowed=y.
8. Clinical Trial. Prophylactic ivermectin in COVID-19 contacts.. Available: https://clinicaltrials.gov/ct2/show/NCT04422561.
9. Clinical Trial. Clinical trial of ivermectin plus doxycycline for the treatment of confirmed Covid-19 infection. Available: https://clinicaltrials.gov/ct2/show/NCT04523831.
10. Hashim HA, Maulood MF, Rasheed AM. Controlled randomized clinical trial on using ivermectin with doxycycline for treating COVID-19 patients in Baghdad, Iraq. medRxiv 2020:2020.10.26.20219345.
11. Kim MS, An MH, Kim WJ, et al. Comparative efficacy and safety of pharmacological interventions for the treatment of COVID-19: a systematic review and network meta-analysis. PLoS Med 2020;17:e1003501. doi:10.1371/journal.pmed.1003501 pmid:http://www.ncbi.nlm.nih.gov/pubmed/33378357.
12. Kow CS, Merchant HA, Mustafa ZU, Hasan SS. The association between the use of ivermectin and mortality in patients with COVID-19: a meta-analysis [published online ahead of print, 2021 Mar 29]. Pharmacol Rep. 2021;1-7. doi:10.1007/s43440-021-00245-z.
13. Rajter JC, Sherman MS, Fatteh N, Vogel F, Sacks J, Rajter JJ. Use of Ivermectin Is Associated With Lower Mortality in Hospitalized Patients With Coronavirus Disease 2019: The Ivermectin in COVID Nineteen Study. Chest. 2021;159(1):85-92. doi:10.1016/j. chest.2020.10.009.
14. Nurullah Okumus, Nese Demirtürk, Rıza Aytac et al. Evaluation of the effectiveness and safety of adding ivermectin to treatment in severe COVID-19 patients. BMC Infectious Diseases (2021) 21:411.
15. Waheed M Shoumann, Abdelmonem Awad Hegazy, Ramadan M Nafae et al. Use of Ivermectin as a Potential Chemoprophylaxis for COVID-19 in Egypt: A Randomized Clinical Trial. Journal of Clinical and Diagnostic Research. 2021 Feb, Vol-15(2): OC27-OC32.
16. Andrew Bryant, Theresa A Lawrie, Therese Dowswell, Edmund Fordham, Scott Mitchell, Sarah Hill and Tony Tham. Ivermectin for Prevention and Treatment of COVID-19 Infection: a Systematic Review and Meta-analysis. Research square at https://assets.researchsquare.com/files/rs-317485/v1/611bf808-b0eb-4a9a-b877-6d6cc8f79d54.pdf.
17. Eduardo López-Medina et al. Effect of Ivermectin on Time to Resolution of Symptoms Among Adults With Mild COVID-19. A Randomized Clinical Trial. JAMA. 2021;325(14):1426-1435. doi:10.1001/jama.2021.3071.
18. WHO Therapeutics and COVID-19 living guideline at https://app.magicapp.org/#/guideline/5058/section/67421.
19. Ivermectin for COVID-19: real-time meta-analysis of 58 studies at https://ivmmeta.com/.
20. Chaccour C, Casellas A, Blanco-Di Matteo A, et al. The effect of early treatment with ivermectin on viral load, symptoms and humoral response in patients with non-severe COVID-19: a pilot, double-blind, placebo-controlled, randomized clinical trial. EClinicalMedicine 2021;32:100720.doi:10.1016/j.eclinm.2020.100720.
21. Hill A, Abdulamir A, Ahmed S. Meta-Analysis of randomized trials of ivermectin to treat SARS-CoV-2 infection. Research square 2021.doi:10.21203/rs.3.rs-148845/v1.
22. Garegnani LI, Madrid E, Meza NMisleading clinical evidence and systematic reviews on ivermectin for COVID-19BMJ Evidence-Based Medicine Published Online First: 22 April 2021. doi: 10.1136/bmjebm-2021-111678.

                Talus dislocations

                                     DR KS Dhillon

Anatomy of the talus

The talus is the second largest tarsal bone, and it is situated posteriorly in the hindfoot between the tibia and the calcaneus. Two-thirds of the talar surface is covered with articular cartilage and it has a tenuous blood supply. It has 5 articular surfaces and there are no muscles or tendons attached to it. The talus has 3 parts, namely the head, neck, and body. There are two processes on the talus (the lateral and posterior process).

The talus has seven articular surfaces.

Superiorly the talus through the talar dome forms the mortise joint of the ankle with the tibia, medial and lateral malleoli.

Inferoposteriorly there is a large oblique facet that is concave which articulates with the calcaneus to form the talocalcaneal joint.

Anteroinferiorly there are two facets that articulate with the calcaneus to form part of the talocalcaneonavicular joint. The talar head articulates anteriorly with the navicular to form the talonavicular joint.

Blood supply is provided by the posterior tibial artery into the medial side of body and sinus, anterior tibial artery/dorsalis pedis artery into head and neck, and peroneal artery into the lateral side of the body and sinus. 

Robust peritalar ligaments provide stability to the talus. These include:

• Anterior talofibular ligament
• Posterior talofibular ligament
• Talocalcaneal ligaments
• Tarsal sinus ligaments
• Cervical ligament
• Talocalcaneal interosseous ligament
• Deltoid ligament
• Anterior tibiotalar ligament
• Posterior superficial tibiotalar ligament
• Posterior deep tibiotalar ligament
• Dorsal talonavicular ligament

Talus dislocation

There several types of talar dislocation given its multiple articulations. These include tibiotalar dislocation, subtalar dislocation, total talar dislocation, and talonavicular dislocation.

1.Total talar dislocation.

Total talar dislocation is also known as extrusion of the talus or pan-talar dislocation. It involves a tri-articular dislocation of the talus at the tibiotalar, talonavicular, and subtalar joints.  Most injuries are compound.

It usually occurs due to a high‐energy impact to an inverted, plantar‐flexed foot resulting from a fall from height or from a motor vehicle accident.

Total dislocation of the talus is a rare injury and it accounts for only 0.06% of all dislocations and only 2% of talar injuries [1]. 

Limited blood supply and numerous articulations of the talus along with the fact that the injuries are frequently open, make the treatment of total talar dislocation difficult. Such injuries are often associated with complications such as avascular necrosis (AVN), infection, and osteoarthritis [2]. 

In patients with close dislocation, a close reduction is carried out under GA and if the reduction is stable a cast is applied for 6 weeks. If the reduction is not stable percutaneous pinning can be carried out to maintain the talus in its position. If a close reduction is not successful, open reduction is carried out.

In patients with open dislocation, wound irrigation, debridement, and temporary internal or external stabilization of the ankle is carried out.

If the talus is lost and cannot be found, tibiocalcaneal fusion and fibular graft is a surgical option.

Primary talectomy is not recommended. All attempts must be made to preserve the talus even in patients with total extrusion of the talus with significant contamination.

Besides the total dislocation of the talus, neurovascular, capsular, and ligamentous injuries and pressure necrosis are early concomitant injuries.  Late complications include AVN, infection, and post-traumatic degenerative arthritis. Post-traumatic osteoarthritis can occur after several years. 

Incidence of AVN after total dislocation of the talus varies between 24% [3] and 88% [4]. The incidence of posttraumatic osteoarthritis (PT) varies between 10% [3] and 44% [4].

Open talar dislocations are often complicated by soft‑tissue infection. The incidence of infection ranges from 11.5% to 38% [5,6]. Infection rate as high as 88.9% has been reported in the older days [7]. Over the years, infection rates have been brought down through improvement of staged procedures for wound care and soft‑tissue management and adapted antibiotherapy.

2.Subtalar Dislocation

Subtalar dislocations are also known as peritalar dislocations. Subtalar dislocation is a rare injury that accounts for 1%–2% of all dislocations. In subtalar dislocations, there is a separation of the talonavicular and talocalcaneal articulations. These dislocations are commonly caused by falls from height, motor vehicle crashes, and twisting leg injuries. The dislocations are divided into anterior, posterior, medial, and lateral types based on the direction in which the distal part of the foot moves in relation to the talus. The most common type is medial dislocation which results from an inversion injury. A medial dislocation occurs in about 71.5 % of the patients, lateral in 26.0%, posterior in 1.6%, and anterior in about 0.8% of the patients [8]. Most of the dislocations are close. An open dislocation occurs in about 22.5% of the patients [8]. Sometimes subtalar dislocations are associated with fractures of the navicular, calcaneus, and talus. Additional bony injury is seen in about 61.4% of the patients [8].

During the physical examination, the neurovascular status must be carefully assessed. Subtalar dislocations are treated with closed reduction under sedation. In about 14% of the patients close reduction is unsuccessful. If close reduction fails, immediate open reduction should be carried out. After reduction of the dislocation, X-rays and if necessary computed tomography scan should be performed to evaluate the alignment of the bones and evaluate the presence of fractures.

The overall outcome of treatment of subtalar dislocations is good in 52.3%, fair in 25.2%, and poor in 22.5% of the patients.

The most frequent late complications following subtalar dislocations include pain, decreased motion, subtalar instability, and degenerative joint disease [9,10]. Other complications that have been reported include avascular necrosis of the talus, RSD (reflex sympathetic dystrophy), and recurrent dislocation [11]. Some authors have reported no AVN following subtalar dislocations [11,12] while others have reported a low incidence of 4% to 6% [9,10]. In patients with severe open fracture-dislocations of the subtalar joint a high incidence of 33% has been reported [13].

About 80% of patients with subtalar dislocation show significant restriction of motion and about 30% show roentgenographic evidence of arthritis [14].

3.Talonavicular Dislocation

Isolated dislocation of the talonavicular joint is a rare injury. These injuries are caused by severe adduction or abduction force applied to the forefoot. 

A medially or laterally directed force applied to the foot causes dislocation of the talonavicular joint without dislocation of the subtalar joint. The calcaneum along with the remaining foot swivels on the intact interosseous talocalcaneal ligament. The dislocation can be medial or lateral depending on the direction of the force applied to the foot. Medial dislocation is more common than a lateral dislocation.

The dislocation is treated by close reduction and cast immobilization. If close reduction fails, an open reduction is carried out, and if the reduction is not stable, internal fixation with K-wires can be done. The leg is immobilized with a cast. 

4.Tibiotalar dislocation

The tibiotalar joint is formed by the tibia, fibula, and talus. Stability is provided by the strong medial (deltoid) and lateral ligaments.

Tibiotalar dislocation is also known as talocrural or ankle dislocation. Tibiotalar dislocations without associated fractures are very uncommon. More than 50% of these dislocations are posteromedial and 25% are pure posterior dislocations [15]. The majority of dislocations are open injuries. On rare occasions, the dislocation can be anterior/anterolateral, medial, or lateral.

The usual mechanism of injury is a fall on a fully plantarflexed foot. The fall forces the talus into a position posterior to the tibia. Other causes of dislocation include motor vehicle accidents and sporting injuries. 

Most cases of closed tibiotalar dislocations can be treated by close reduction under sedation and cast immobilization for 6 to 9 weeks [15].  Open injuries are treated with thorough wound lavage and débridement followed by reduction of the dislocation, stabilization with K-wires if necessary, repair of ligaments and capsule, and immobilization in a slab followed by casting.

The overall prognosis for tibiotalar dislocations is favorable. The majority of patients are asymptomatic following appropriate treatment [16]. Those who are symptomatic (primarily female) complain of ankle stiffness. Ankle instability is rare. Closed dislocations are associated with fewer symptoms as compared to open dislocations. Some of the prognostic factors that are associated with worse outcomes include advanced age, presence of vascular injury, delay in reduction, and inferior tibiofibular ligament injury [16].  Late complications reported include stiffness, degenerative changes, joint instability, and capsular calcification [17]. 

The incidence of posttraumatic osteoarthritis is about 25% and it often occurs in patients with open dislocations [18]. 

Conclusion

There several types of talar dislocation given its multiple articulations. These include tibiotalar dislocation, subtalar dislocation, total talar dislocation, and talonavicular dislocation. Most of the time these dislocations result from falls from a height. Other causes include motor vehicle accidents and sports injuries. 

The injuries can be open or close. Open dislocations are treated with wound debridement. The dislocation can be treated with close reduction. If close reduction fails open reduction can be carried out. If the reduction is stable the limb is immobilized with a cast for 6 to 8 weeks. If the reduction is not stable then the fragments can be stabilized with k-wires or external fixation.

The complications include loss of motion, instability, AVN, and posttraumatic arthritis. Generally, the clinical outcome is good. Open dislocations can result in poorer outcomes.

Reference

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11. F. Rivera, C. Bertone, E. Crainz, P Maniscalco and M. Filisio. Peritalar dislocation: three case reports and literature review. J Orthopaed Traumatol (2003) 4:39–44.
12. Wang HY, Wang BB, Huang M, Wu XT. Treatment of closed subtalar joint dislocation: A case report and literature review. Chin J Traumatol. 2020;23(6):367-371. doi:10.1016/j.cjtee.2020.08.008
13. Goldner JL, Poletti SC, Gates HS 3rd, Richardson WJ. Severe open subtalar dislocations. Long-term results. J Bone Joint Surg Am. 1995 Jul;77(7):1075-9. doi: 10.2106/00004623-199507000-00015. PMID: 7608231.
14. Heppenstall RB, Farahvar H, Balderston R, Lotke P. Evaluation and management of subtalar dislocations. J Trauma. 1980 Jun;20(6):494-7. doi: 10.1097/00005373-198006000-00011. PMID: 7373681.
15. Grotz et al. Open Tibiotalar Dislocation Without Associated Fracture in a 7-Year-Old Girl. A Case Report & Literature Review. Am J Orthop. 2008;37(6): E116-E118.
16. Wight L, Owen D, Goldbloom D, Knupp M. Pure Ankle Dislocation: A systematic review of the literature and estimation of incidence. Injury. 2017 Oct;48(10):2027-2034. 
17. Wang YT, Wu XT, Chen H. Pure closed posteromedial dislocation of the tibiotalar joint without fracture. Orthop Surg. 2013 Aug;5(3):214-8.
18. Elisé S, Maynou C, Mestdagh H, Forgeois P, Labourdette P. Les luxations tibio-astragaliennes pures. A propos de 16 observations [Simple tibiotalar luxation. Apropos of 16 cases]. Acta Orthop Belg. 1998 Mar;64(1):25-34. French. PMID: 9586247.