Unorthodox Ulnar Nerve Arborization at the Distal Metadiaphyseal Humerus: An Insight into the Neuroanatomical Oddity and its Surgical Implication

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Journal of Clinical Orthopaedics | Vol 10 | Issue 1 | January-June 2025 | page: 65-68 | Meet Ajay Mehta, Avik Kumar Naskar, Himanshu Pradeep Ganwir, Vikas Anandrao Atram

DOI: https://doi.org/10.13107/jcorth.2025.v10i01.724

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted Date: 25 March 2025, Review Date: 29 April 2025, Accepted Date: May 2025 & Published Date: 30 June 2025

Author: Meet Ajay Mehta [1], Avik Kumar Naskar [1], Himanshu Pradeep Ganwir [1], Vikas Anandrao Atram [1]

[1] Department of Orthopaedics, Indira Gandhi Government Medical College and Hospital, Nagpur, Maharashtra, India

Address of Correspondence

Dr Avik Kumar Naskar
Old Resident Hostel, IGGMC and Mayo Hospital, Nagpur – 440018, Maharashtra, India.
E-mail: avik7933@gmail.com

Abstract

Background: Anatomical variations of the ulnar nerve, particularly involving its course and branching pattern near the distal humerus, are exceedingly rare. Such anomalies may pose significant risks during surgical procedures around the elbow due to their potential for entrapment, mechanical stretch, or iatrogenic injury.
Case report: We report a case involving a 59-year-old male with a distal humerus fracture, managed surgically through a posterior paratricipital approach. Pre-operatively, there was no neurological deficit. Intraoperatively, a rare anatomical variant of the ulnar nerve was observed: It exhibited two bifurcations approximately 40 mm and 20 mm proximal to the medial epicondyle. Notably, both aberrant branches pierced the medial intermuscular septum to enter the anterior compartment. In addition, the main trunk of the ulnar nerve was tethered by a dense fascial band extending between the medial intermuscular septum and the medial epicondyle. The fracture was stabilized using bicolumnar plating.
Results: Despite meticulous dissection, the patient developed a post-operative ulnar nerve deficit, likely due to traction or compression injury to the aberrant branches. This unusual branching pattern increased the risk of intraoperative nerve compromise.
Conclusion: This case underscores the importance of considering rare ulnar nerve anatomical variations during surgical planning for distal humerus fractures. Pre-operative vigilance and careful intraoperative dissection are essential to prevent nerve injury.
Keywords: Ulnar nerve, Distal humerus fractures, Peripheral nerves, Nerve compression.

References

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How to Cite this article: Mehta MA, Naskar AK, Ganwir HP, Atram VA. Unorthodox Ulnar Nerve Arborization at the Distal Metadiaphyseal Humerus: An Insight into the Neuroanatomical Oddity and its Surgical Implication. Journal of Clinical Orthopaedics. January-June 2025;10(1):65-68.

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Physeal Sparing ACL Repair using Knotless Suture Anchor Technique for Pediatric ACL Injuries

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Journal of Clinical Orthopaedics | Vol 10 | Issue 1 | January-June 2025 | page: 57-60 | Manit Arora, Frederick Weitz

DOI: https://doi.org/10.13107/jcorth.2025.v10i01.720

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted Date: 25 Jan 2025, Review Date: 13 Feb 2025, Accepted Date: ?? 2025 & Published Date: 30 Jun 2025

Author: Manit Arora [1], Frederick Weitz [2]

[1] Department of Orthopaedics and Sports Medicine, Fortis Hospital Mohali, Punjab, India,
[2] Department of Orthopaedics, Ernst-Mortiz-Arndt-Universitat Greifswald, Pihlajalinna, Finland

Address of Correspondence

Dr Manit Arora,

Department of Orthopaedics, Fortis Hospital Mohali, Mohali – 160 022, Punjab, India.

E-mail: manit_arora@hotmail.com

Abstract

Pediatric ACL injuries are rising, and the ACL tear in an open physis is becoming more common. Traditional ACL reconstruction techniques, whether physeal sparing or transphyseal, are associated with good outcomes but carry the risk of growth arrest due to femoral and tibial bone drilling. We describe a novel technique for ACL repair in pediatric ACL patients, which prevents tibial bone drilling completely and is physeal sparing in the femur. This technique is suitable only for ACL injuries near ACL’s femoral attachment. The technique is well established and documented in adult population. For the femoral fixation Swivelock anchor screw is used. This provides a stable fixation of the ACL in femur with no risk of violating the growth plate through drilling or hardware. This should theoretically minimize the risk of growth plate arrest.
Keywords: Pediatriac, ACL, ACL injuries, Physis

References

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22. van der List JP, Vermeijden HD, Sierevelt IN, DiFelice GS, van Noort A, Kerkhoffs GM. Arthroscopic primary repair of proximal anterior cruciate ligament tears seems safe but higher level of evidence is needed: A systematic review and meta-analysis of recent literature. Knee Surg Sports Traumatol Arthrosc 2020;28:1946-57.
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25. Van der List JP, Mintz DN, DiFelice GS. The locations of anterior cruciate ligament tears in pediatric and adolescent patients: A magnetic resonance study. J Pediatr Orthop 2019;39:441-8.
26. Christino MA, Tepolt FA, Sugimoto D, Micheli LJ, Kocher MS. Revision ACL reconstruction in children and adolescents. J Pediatr Orthop 2020;40:129-34.
27. Thorolfsson B, Svantesson E, Snaebjornsson T, Sansone M, Karlsson J, Samuelsson K, et al. Adolescents have twice the revision rate of young adults after ACL reconstruction with hamstring tendon autograft: A study from the Swedish National Knee Ligament Registry. Orthop J Sports Med 2021;9:23259671211038893.

How to Cite this article: Arora M, Weitz F. Physeal Sparing ACL Repair using Knotless Suture Anchor Technique for Pediatric ACL Injuries. Journal of Clinical Orthopaedics January-June 2025;10(1):57-60.

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Correction of genu valgum deformity with femoral translation osteotomy and antegrade interlocking nail

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Journal of Clinical Orthopaedics | Vol 10 | Issue 1 | January-June 2025 | page: 21-25 | Sujay Kulkarni, Ruta Kulkarni, Madhura Kulkarni, Zafer Satvilkar, Shekhar Malve, Milind Kulkarni

DOI: https://doi.org/10.13107/jcorth.2025.v10i01.706

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted Date: 11 Jan 2025, Review Date: 08 Mar 2025, Accepted Date: 10 Apr 2025 & Published Date: 30 Jun 2025

Author: Sujay Kulkarni [1], Ruta Kulkarni [1], Madhura Kulkarni [1], Zafer Satvilkar [1], Shekhar Malve [1], Milind Kulkarni [1]

[1] Department of Orthopeadics, Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra, India

Address of Correspondence

Dr. Sujay Kulkarni,
Department of Orthopeadics, Post Graduate Institute of Swasthiyog Pratishthan, Station Road, Extension Area, Miraj – 416410, Maharashtra, India.
E-mail: jay2712@gmail.com

Abstract

Introduction: Genu valgum is a common deformity which is treated by almost every orthopedic surgeon. There are various methods to treat this deformity with usually satisfactory results. In adults, a femoral osteotomy is the most used method of correction of deformity. It is usually fixed by a plate. A large skin incision is required. The patient is usually kept non-weight bearing for a varying period.
We present a technique in which a minimally invasive percutaneous osteotomy is performed and fixed with an antegrade interlocking nail. The implant used is familiar, readily available, and cost-effective. Weight-bearing is started immediately, and no immobilization is necessary.
Materials and Methods: We analyzed 22 cases of genu valgum treated with this osteotomy in a single center. We performed the percutaneous osteotomy and fixation with antegrade interlocking intramedullary nail. All patients were allowed to walk with a walker and full weight bearing from the next day as pain permitted. Every patient was called for follow-up at 1, 3, and 6 months. At every follow-up, orthogonal X-rays were taken, and the range of motion (ROM) at the knee and hip was recorded.
Results: All 22 cases showed good union at the osteotomy site and full knee and hip ROM at 6 months. We had no wound complications or limb length discrepancy in any case.
Conclusion: This technique is a useful tool to add to the orthopedic surgeon’s armamentarium. It is a cost-effective and minimally invasive solution to a very common problem, using familiar implants. A comparative study is warranted to study its superiority to other techniques.
Keywords: Genu valgum, Interlocking nail, Osteotomy, Minimally invasive.

References

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11. O’Malley MP, Pareek A, Reardon PJ, Stuart MJ, Krych AJ. Distal femoral osteotomy: Lateral opening wedge technique. Arthrosc Tech 2016;5:e725-30.

How to Cite this article: Kulkarni S, Kulkarni R, Kulkarni M, Satvilkar Z, Malve S, Kulkarni M. Correction of genu valgum deformity with femoral translation osteotomy and antegrade interlocking nail. Journal of Clinical Orthopaedics January-June 2025;10(1):21-25.

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Is Pharmacological Thromboprophylaxis Truly Necessary: Predictive Factors for Venous Thromboembolic Events Post-Total Knee Arthroplasty in an Asian Population

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Journal of Clinical Orthopaedics | Vol 10 | Issue 1 | January-June 2025 | page: 14-20 | Zavier Yongxuan Lim, Lynn Thwin, Kelvin Guoping Tan

DOI: https://doi.org/10.13107/jcorth.2025.v10i01.704

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted Date: 21 Feb 2025, Review Date: 18 Mar 2025, Accepted Date: 26 April 2025 & Published Date: 30 Jun 2025

Author: Zavier Yongxuan Lim [1], Lynn Thwin [1], Kelvin Guoping Tan [1]

[1] Department of Orthopaedic Surgery, Tan Tock Seng Hospital (Singapore), 11 Jln Tan Tock Seng, Singapore 308433

Address of Correspondence

Dr. Zavier Yongxuan Lim,
Department of Orthopaedic Surgery, Tan Tock Seng Hospital (Singapore), 11 Jln Tan Tock Seng, Singapore 308433 6256 6011.
E-mail: yongxuan.lim@mohh.com.sg

Abstract

Introduction: Venous thromboembolic prophylaxis is routinely used in elective total knee arthroplasty (TKA) patients worldwide, and current guidelines vary from aspirin to low molecular weight heparin in combination with mechanical prophylaxis, and direct oral anticoagulants. This study aimed to identify predictive or protective factors for VTEs in an Asian hospital and examine the efficacy of pharmacological VTE prophylaxis.
Materials and Methods: A retrospective cohort study of 2,014 patients who underwent primary TKAs between 2017 and 2022 was performed. All patients received mechanical thromboprophylaxis postoperatively. Patients who were symptomatic were referred for radiological investigations to exclude VTE. We evaluated patient demographics, co-morbidities, and surgical parameters to establish the overall incidence of symptomatic VTEs and risk factors for VTEs.
Results: There were 23 (1.14%) incidences of symptomatic VTEs, of which 1 patient developed pulmonary embolism, and 22 deep vein thrombosis. The incidence of VTE was 0.69% (10/1449) for patients on mechanical prophylaxis only, 2.08% (9/432) for patients on aspirin, 3.67% (4/109) for patients on clexane, 0% (0/19) for patients on clopidogrel, and 0% (0/5) for patients on DOACs. Multivariate analysis revealed length of stay (P < 0.001), the need for blood transfusion (P = 0.007), choice of thromboprophylaxis (P = 0.049), and diagnosis (P = 0.048) were independent risk factors for VTE. The use of tranexamic acid did not significantly affect VTE rates in the model (P = 0.059).
Conclusion: Pharmacological thromboprophylaxis may not be required post-operative in the Asian population. The identification of risk factors in this study allows surgeons to individualise risk counselling for patients listed for elective TKAs and choose appropriate thromboprophylaxis methods.
Keywords: Knee arthroplasty, Arthroplasty, Replacement, Knee, Thromboprophylaxis, Venous thrombosis, Asians

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12. Millar JS, Lawes CM, Farrington B, Andrew P, Misur P, Merriman E, et al. Incidence of venous thromboembolism after total hip, total knee and hip fracture surgery at Waitemata District Health Board following a peer-reviewed audit. N Z Med J 2020;133:52-60.
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15. Yin H. Enhanced recovery after surgery (ERAS) in postoperative lung cancer patients: A novel perioperative strategy for preventing venous thromboembolism and improving quality of life. Tohoku J Exp Med 2024;262:201-9.
16. Li S, Bercow AS, Falzone M, Kalyanaraman R, Worley MJ, Feltmate CM, et al. Risk of venous thromboembolism for ovarian cancer patients during first-line therapy after implementation of an Enhanced Recovery After Surgery (ERAS) protocol. Gynecol Oncol 2021;162:353-9.
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20. Pai FY, Chang WL, Tsai SW, Chen CF, Wu PK, Chen WM. Pharmacological thromboprophylaxis as a risk factor for early periprosthetic joint infection following primary total joint arthroplasty. Sci Rep 2022;12:10579.
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26. Salomon B, Dasa V, Krause PC, Hall L, Chapple AG. Hospital length of stay is associated with increased likelihood for venous thromboembolism after total joint arthroplasty. Arthroplast Today 2021;8:254-7.e1.
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How to Cite this article: Lim ZY, Thwin L, Tan KG. Is Pharmacological Thromboprophylaxis Truly Necessary: Predictive Factors for Venous Thromboembolic Events Post-Total Knee Arthroplasty in an Asian Population. Journal of Clinical Orthopaedics. January-June 2025;10(1):14-20.

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Informed Consent: A Cornerstone of Ethical and Legal Orthopaedic Practice

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Journal of Clinical Orthopaedics | Vol 10 | Issue 1 |  January-June 2025 | page: 1-3 | Sachin Kale, Akhil Gailot, Ashok Shyam, Sushant Srivastava, Arvind Vatkar, Ojasv Gehlot

DOI: https://doi.org/10.13107/jcorth.2025.v10i01.700

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2025; The Author(s).

Submitted Date: 20 April 2025, Review Date: 30 April 2025, Accepted Date: 16 May 2025 & Published Date: 30 Jun 2025

Author: Sachin Kale [1], Akhil Gailot [1], Ashok Shyam [3], Sushant Srivastava [1], Arvind Vatkar [2], Ojasv Gehlot [1]

[1] Department of Orthopaedics, D Y Patil Medical College and Hospital, Navi Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, MGM Medical College, Navi Mumbai, Maharashtra, India..
[3] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.

Address of Correspondence

Dr. Sachin Kale,
Department of Orthopaedics, D Y Patil Medical College and Hospital, Navi Mumbai, Maharashtra, India.
E-mail: sachinkale@gmail.com

Abstract

Informed consent is a fundamental ethical and legal requirement in orthopaedic surgery, where procedures often involve significant risk and complexity. Obtaining valid informed consent is essential for patient-centered care and medico-legal safety. This article explores the ethical imperatives, legal precedents, components of a valid consent process, challenges specific to orthopaedic practice, and strategies to improve consent quality and patient understanding. It emphasizes that consent is not just a legal formality but a crucial tool for shared decision-making and fostering trust between orthopaedic surgeons and their patients.
Keywords:

Introduction
Informed consent stands as a non-negotiable cornerstone in the practice of medicine, particularly within the realm of orthopaedic surgery. It embodies a deep respect for patient autonomy, empowering individuals to make voluntary and informed decisions about their health-care journey. Given the spectrum of orthopaedic interventions, ranging from minimally invasive techniques to intricate reconstructive surgeries with inherent risks, ensuring a robust and ethically sound consent process is paramount for legal probity, the cultivation of trust, and the promotion of collaborative decision-making.
Point-Wise Discussion

1. Ethical foundations of informed consent:
• The principle of respect for autonomy acknowledges the patient’s inherent right to make decisions concerning their own body and health care.
• Beneficence (acting in the patient’s best interest) and non-maleficence (minimizing harm) necessitate that patients understand the potential benefits and risks associated with proposed treatments.
• Justice in health care is supported by informed consent, ensuring fairness and equity in the delivery of care.

2. Legal aspects of consent in orthopaedic practice:
• The doctrine of informed consent legally mandates that orthopaedic surgeons must disclose information that a reasonable patient would deem necessary to make an informed decision about their treatment.
• Significant legal precedents, such as Canterbury v. Spence and Samira Kohli v. Dr. Prabha Manchanda (India), have been instrumental in shaping the current understanding and application of informed consent.
• Various types of consent are recognized:
• Implied consent may be assumed in emergency situations where immediate intervention is required.
• Express consent, which can be either written or verbal, is typically obtained for elective surgical procedures.
• Proxy consent is necessary when patients lack the capacity to make decisions themselves, requiring consent from legal guardians or representatives.

3. Components of valid informed consent: A valid consent process encompasses several key elements that must be present:
• Disclosure: The orthopaedic surgeon must clearly explain:
• The nature of the proposed procedure
• The expected benefits of the intervention
• The potential risks and complications, which can be significant in orthopaedic surgeries such as spinal fusions and joint arthroplasties
• Available alternatives, including non-operative management or different surgical approaches
• Post-operative expectations, including rehabilitation protocols and potential limitations.
• Understanding: The patient must genuinely comprehend the information disclosed. To facilitate understanding, orthopaedic surgeons are encouraged to use visual aids, provide information in the patient’s primary language (utilizing translators when necessary), and employ simple, lay language.
• Voluntariness: The patient’s decision to proceed with the proposed treatment must be made freely, without any form of coercion or undue influence.
• Competency: The patient must possess the mental capacity to understand the information, appreciate its relevance to their condition, and make a reasoned decision. Assessing competency can be particularly challenging in elderly and cognitively impaired patients.
• Documentation: Thorough documentation of the consent discussion, including the information provided, the patient’s questions, and their demonstrated understanding, along with the signed consent form, is essential.

4. Challenges in orthopaedic surgeries: Several factors present unique challenges to obtaining informed consent in orthopaedic practice:
• Many orthopaedic procedures, such as spinal surgeries, joint replacements, and trauma surgeries, inherently carry significant risks and potential complications.
• In emergency situations, time constraints may limit the extent of the consent discussion, requiring a careful balance between providing necessary information and acting promptly.
• Obtaining valid consent from elderly and cognitively impaired patients necessitates special approaches to assess their decision-making capacity or involve legal guardians.
• Language and literacy barriers, common in diverse patient populations, require customized communication strategies and the use of interpreters to ensure genuine understanding.

5. Special considerations in orthopaedics: Certain contexts within orthopaedic surgery require specific attention to the consent process:
• In pediatric orthopaedics, obtaining assent from the child, when developmentally appropriate, in addition to consent from parents or legal guardians, is ethically important.
• Consent for anesthesia is a distinct but related process, often requiring a separate discussion and consent form, detailing the risks and benefits of the anesthetic plan.
• When involving patients in research or innovative procedures, the consent process must be exceptionally thorough, transparent, and strictly adhere to the ethical guidelines set forth by institutional ethics committees.

6. Strategies to improve the consent process: Several strategies can be implemented to enhance the quality and effectiveness of informed consent in orthopaedic practice:
• Utilizing structured consent forms that are specific to the orthopaedic procedure and clearly outline the risks, benefits, and alternatives can ensure comprehensive disclosure.
• Incorporating multimedia tools, such as videos and diagrams, can significantly improve patients’ understanding of complex surgical procedures and anatomical structures.
• Implementing consent checklists can serve as a useful reminder for surgeons to cover all essential elements of the consent discussion.
• Investing in training and simulation for residents and junior doctors on effective communication and consent-taking techniques is crucial.
• Conducting periodic audits of consent practices can help identify areas for improvement and ensure adherence to established standards.

7. The critical role of documentation: Thorough and accurate documentation is paramount in the informed consent process:
• Comprehensive records should include detailed notes on the discussions with the patient, their specific questions, and the surgeon’s assessment of their understanding.
• Electronic consent systems offer several advantages, including improved accessibility, enhanced traceability, and a reduced risk of omissions.
• In the event of litigation, properly documented informed consent serves as a crucial element of medico-legal defense.

8. Responsibilities of the surgeon and surgical team: Ensuring valid informed consent is a collaborative effort, although the primary responsibility rests with the operating surgeon:
• The operating surgeon bears the ultimate responsibility for ensuring the patient is adequately informed and has given voluntary consent.
• Effective team communication is essential, with nurses and anesthesiologists playing a supportive role in reinforcing information and addressing patient concerns.
• Re-consenting is mandatory if there is any significant change in the patient’s diagnosis or the planned surgical procedure.

9. Cultural and regional considerations in India: Within the Indian context, specific cultural and social factors influence the informed consent process:
• The influence of joint families often means that family members play a significant role in health care decision-making.
• Language diversity necessitates the availability of multilingual consent forms and access to competent interpreters.
• A potentially high degree of trust in physicians may sometimes lead patients to sign consent forms without fully comprehending the information. This places an even greater ethical obligation on the orthopaedic surgeon to ensure genuine understanding.

10. Future directions in informed consent: The field of informed consent is continually evolving:
• AI and digital consent tools have the potential to automate aspects of the consent process and tailor information delivery to individual patient needs.
• Augmented reality and 3D models can offer innovative ways to visualize complex anatomical structures and surgical procedures, enhancing patient understanding.
• Mobile health platforms can provide valuable pre- and post-operative education, supporting the consent process.
• The introduction of patient-reported understanding scores could provide a quantifiable measure of patient comprehension and satisfaction with the consent process.
Flowchart of the informed consent process:

 

Conclusion
Informed consent in orthopaedic surgery transcends a mere legal formality; it is a dynamic and continuous process of communication that lies at the heart of ethical and patient-centered care. Given the potentially significant impact of orthopaedic interventions, a comprehensive, empathetic, and individualized approach to obtaining consent is paramount. Orthopaedic surgeons must embrace their responsibility to prioritize informed consent, not only to meet legal obligations but, more importantly, to foster trust, enhance patient satisfaction, and mitigate the risk of litigation. Ongoing education, a commitment to innovation in communication strategies, and robust institutional support are essential for the continuous improvement of consent practices in modern orthopaedic care.

How to Cite this article: Kale S, Gailot A, Shyam A, Srivastava S, Vatkar A. Informed Consent: A Cornerstone of Ethical and Legal Orthopaedic Practice. Journal of Clinical Orthopaedics January-June 2025;10(1):01-03.

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Surgical Prophylaxis: Is it Always Needed in Orthopedics Practice

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Journal of Clinical Orthopaedics | Vol 9 | Issue 2 |  July-December 2024 | page: 114-117 | Swati Lalchandani, Rajesh Yadav, Rakesh Parmar, Rajesh Lalchandani, Shashikant Prakash

DOI: https://doi.org/10.13107/jcorth.2024.v09i02.688

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2024; The Author(s).

Submitted Date: 15 Jul 2024, Review Date: 10 Aug 2024, Accepted Date: 05 Oct 2024 & Published Date: 10 December 2024

Author: Swati Lalchandani [1], Rajesh Yadav [2], Rakesh Parmar [2], Rajesh Lalchandani [2], Shashikant Prakash [2]

[1] Department of Microbiology, New Delhi Pathology Clinic, New Delhi, India.
[2] Department of Orthopaedics, ESIPGIMSR, New Delhi, India.

Address of Correspondence

Dr. Rakesh Parmar,
Senior Resident, Department of Orthopaedics, ESIPGIMSR, New Delhi, India.
E-mail: rksdoc@gmail.com

Abstract

Objectives: The objectives of this study were to assess the need for antibiotic prophylaxis in soft-tissue surgeries of short duration without usage of implant in the field of orthopedics.
Methods: A prospective and comparative randomized study was performed on 100 cases with clean elective surgical procedure of short duration <⅟2 h. Data were analyzed for development of surgical site infection (SSI) in clean elective soft-tissue procedures of short duration.
Results: In our carefully selected cohort of patients of clean soft-tissue surgeries of less than half hour duration without involving the use of implant, two groups were made based on block randomization technique, one of which got a shot of pre-operative antibiotic prophylaxis and other did not. Mean patient age was 36.1 years (04 month-66 years). In both groups at all age levels, no infection was found. In the group which received antibiotic 80.8% were female and 19.2% were male, and in the antibiotic not given group had 61.5% female and 38.5% male. Therefore, it is evident that antibiotics did not provide clinical or statistical protection against SSI in clean elective soft-tissue procedures of short duration.
Conclusion: We suggest stratification of use of antibiotic prophylaxis, that is, antibiotic prophylaxis is required for surgeries of longer duration involving placement of implants but not required in surgeries of short duration which do not involve placement of implants in the field of orthopedics.
Keywords: Surgical Prophylaxis, Surgical site infection, Orthopaedics Practice

References

1. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32.
2. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) hospital infection control practices advisory committee. Am J Infect Control 1999;27:97-132; quiz 133-4, discussion 96.
3. Curcio D, Cane A, Fernández F, Correa J. Surgical site infection in elective clean and clean-contaminated surgeries in developing countries. Int J Infect Dis 2019;80:34-45.
4. Page CP, Bohnen JM, Fletcher JR, McManus AT, Solomkin JS, Wittmann DH. Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical care. Arch Surg 1993;128:79-88.
5. Bratzler DW. The surgical infection prevention and surgical care improvement projects: Promises and pitfalls. Am Surg 2006;72:1010-6; discussion 1021-30, 1133-48.
6. Meehan J, Jamali AA, Nguyen H. Prophylactic antibiotics in hip and knee arthroplasty. J Bone Joint Surg Am 2009;91:2480-90.
7. Knight R, Charbonneau P, Ratzer E, Zeren F, Haun W, Clark J. Prophylactic antibiotics are not indicated in clean general surgery cases. Am J Surg 2001;182:682-6.
8. Li K, Sambare TD, Jiang SY, Shearer EJ, Douglass NP, Kamal RN. Effectiveness of preoperative antibiotics in preventing surgical site infection after common soft tissue procedures of the hand. Clin Orthop Relat Res 2018;476:664-73.
9. Ansari SA, Saddique M, Azim WA. Antibiotic prophylaxis in clean surgery. Biomedica 2005;21:121-4.
10. Olix ML, Klug TJ, Coleman CR, Smith WS. Prophylactic penicillin and streptomycin in elective operations on bones, joints and tendons. Surg Forum 1960;10:818-9.
11. Pavel A, Smith RL, Ballard A, Larsen IJ. Prophylactic antibiotics in clean orthopedics surgery. J Bone Joint Surg Am 1974;56:777-82.
12. Pavel A, Smith RL, Ballard A, Larson IJ. Prophylactic antibiotics in elective orthopedic surgery: A prospective study of 1,591 cases. South Med J 1977;70 (Suppl 1):50-5.
13. Burnakis TG. Surgical antimicrobial prophylaxis: Principles and guidelines. Pharmacotherapy 1984;4:248-71.
14. Dickemore C, Green R, Jolley W, Green D. Prophylactic Antibiotics in Clean Forefoot Surgery: Are They Necessary? Ch. 19.4; 2002. p. 228-30.
15. Tosti R, Fowler J, Dwyer J, Maltenfort M, Thoder JJ, Ilyas AM. Is antibiotic prophylaxis necessary in elective soft tissue hand surgery? Orthopedics 2012;35:e829-33.
16. Ansari SA, Saddique M, Azim WA. Antibiotic prophylaxis in clean surgery. Biomedica 2005;21:121-4.

How to Cite this article: Lalchandani S, Yadav R, Parmar R, Lalchandani R, Prakash S. Surgical Prophylaxis: Is it Always Needed in Orthopaedics Practice. Journal of Clinical Orthopaedics Jul-dec 2024;9(2):114-117.

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Musculoskeletal Tissue Retrieval from Deceased Donors in India: Protocols and Challenges

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Journal of Clinical Orthopaedics | Vol 9 | Issue 2 |  July-December 2024 | page: 109-113 | Damini Shah, Prasad Bhagunde, Nihar Modi

DOI: https://doi.org/10.13107/jcorth.2024.v09i02.686

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2024; The Author(s).

Submitted Date: 14 Aug 2024, Review Date: 27 Aug 2024, Accepted Date: 14 Oct 2024 & Published Date: 10 Dec 2024

Author: Damini Shah [1], Prasad Bhagunde [2, 3, 4, 5], Nihar Modi [2, 4, 6]

[1] Novo Tissue Bank and Research Centre, Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, Sona Medical Centre, Mumbai, Maharashtra, India.
[3] Department of Orthopaedics, Saifee Hospital, Mumbai, Maharashtra, India.
[4] Department of Orthopaedics, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India.
[5] Department of Orthopaedics, Breach Candy Hospital Trust, Mumbai, Maharashtra, India.
[6] Department of Orthopaedics, Criticare Asia Multispeciality Hospital and Research Centre, Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Damini Shah,
Assistant Director of Operations, Novo Tissue Bank and Research Centre, Mumbai, Maharashtra, India.
E-mail: daminirshah@gmail.com

Abstract

Musculoskeletal tissue donation from deceased donors plays a crucial role in advancing orthopedic and reconstructive surgeries, providing an alternative to autografts and synthetic implants. Despite its clinical significance, the adoption of tissue donation in India remains limited due to challenges such as low public awareness, cultural barriers, and infrastructural constraints. This study analyzes 16 cases of musculoskeletal tissue retrieval conducted in Mumbai between 2022 and 2023, highlighting procedural protocols, ethical considerations, and logistical challenges. The analysis underscores the importance of timely retrieval, adherence to regulatory frameworks like the Transplantation of Human Organs and Tissues Act (THOTA) 1994, and stringent quality assurance measures to ensure the safety and efficacy of allografts. Results demonstrate a high success rate, with over 98% of retrieved tissues meeting bioburden and structural integrity standards. The paper advocates for standardized protocols, improved public awareness, and enhanced training for healthcare professionals to advance tissue donation practices in India. This effort is pivotal for addressing unmet medical needs and fostering a compassionate healthcare system.
Keywords: Allografts, Musculoskeletal tissue donation, Tissue Banking, Orthobiologics, Reconstructive surgeries

References

1. India orthopedic procedures count by segments and forecast to 2030. (2024, June 14). Market Research Reports & Consulting | GlobalData UK Ltd.
2. (2011) The Transplantation of Human Organs and Tissues Act, 1994. Gazette of India, Ext., Pt. II, S. 1.
3. Guidelines for Tissue Banking (2021) rottosottokem.in. Available at: https://rottosottokem.in/downloads/SOTTO%20Tissue%20Guidelines.pdf.
4. Morales Pedraza, J., Lobo Gajiwala, A. and Martinez Pardo, M.E. (2010) ‘A review of the International Atomic Energy Agency (IAEA) international standards for tissue banks’, Cell and Tissue Banking, 13(1), pp. 15–25. doi:10.1007/s10561-010-9215-3.
5. Nather, A. et al. (2018) ‘Tissue banking in Asia Pacific region: Past, present and future’, Cell and Tissue Banking, 19(2), pp. 229–240. doi:10.1007/s10561-018-9697-y.
6. Yusof, N., Shamsudin, A. R., Mohamad, H., Hassan, A., Yong, A. C., & Rahman, M. N. F. A. (2005). BIOBURDEN ESTIMATION IN RELATION TO TISSUE PRODUCT QUALITY AND RADIATION DOSE VALIDATION. In Elsevier eBooks. https://doi.org/10.1533/9781845690779.5.319

How to Cite this article: Shah D, Bhagunde P, Modi N. Musculoskeletal Tissue Retrieval from Deceased Donors in India: Protocols and Challenges. Journal of Clinical Orthopaedics July-December 2024;9(2):109-113.

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Tackling Post-TKR Complications: Achilles Allografts in Extensor Mechanism Reconstruction

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Journal of Clinical Orthopaedics | Vol 9 | Issue 2 |  July-December 2024 | page: 105-108 | Prasad Bhagunde, Damini Shah, Nihar Modi

DOI: https://doi.org/10.13107/jcorth.2024.v09i02.684

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2024; The Author(s).

Submitted Date: 10 Sep 2024, Review Date: 02 Oct 2024, Accepted Date: 22 Oct 2024 & Published Date: 10 Dec 2024

Author: Prasad Bhagunde [1, 2, 3, 4], Damini Shah [5], Nihar Modi [1, 3, 6]

[1] Department of Orthopaedics, Sona Medical Centre, Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, Saifee Hospital, Mumbai, Maharashtra, India.
[3] Department of Orthopaedics, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India.
[4] Department of Orthopaedics, Breach Candy Hospital Trust, Mumbai, Maharashtra, India.
[5] Novo Tissue Bank and Research Centre, Mumbai, Maharashtra, India.
[6] Department of Orthopaedics, Criticare Asia Multispeciality Hospital and Research Centre, Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Prasad Bhagunde,
Director, Sona Medical Centre, Mumbai, Maharashtra, India.
E-mail: prasadbhagunde27@gmail.com

Abstract

Revolutionizing post-TKR care, novel use of Achilles tendon allografts emerge as a game-changer for displaced extensor mechanism, tackling one of the most challenging complications of total knee replacement. By restoring active knee extension and preventing lateral patellar subluxation, this technique empowers patients with improved mobility and independence.
The study included three patients with persistent patellar instability and malalignment were treated with a lateral retinacular release and Achilles tendon allograft fixation around the quadriceps mechanism. At 12 months, functional outcomes improved significantly: the Kujala score increased from 50 to 85, Knee Society Score (KSS) from 60 to 90, and Tegner Activity Level from 2 to 6. Postoperative imaging confirmed successful graft incorporation and alignment correction.
This technique, combining soft-tissue release with robust Achilles tendon allograft reconstruction, offers a promising solution for complex post-TKR patellar maltracking, highlighting the strength and adaptability of the Achilles tendon in restoring knee dynamics.
Overcoming the limitations of autografts and other traditional methods, this novel approach offers unmatched strength and adaptability while addressing critical surgical complexities. Despite potential challenges like stiffness and availability, the outcomes highlight enhanced function, stability, and patient satisfaction. With its innovative approach and tailored rehabilitation protocols, this procedure sets a new benchmark in orthopedic reconstructive surgery, combining precision and patient-centric care to redefine recovery.
Keywords: Quadriceps displacement, extensor mechanism repair, achilles tendon allograft, post-TKR complications

References

1. Ferri, R., Digennaro, V., Panciera, A., Bulzacki Bogucki, B. D., Cecchin, D., Manzetti, M., Brunello, M., & Faldini, C. (2023). Management of patella maltracking after total knee arthroplasty: a systematic review. In Musculoskeletal Surgery (Vol. 107, Issue 2, pp. 143–157). Springer Nature. https://doi.org/10.1007/s12306-022-00764-9
2. de Franco, C., de Matteo, V., Lenzi, M., Marano, E., Festa, E., Bernasconi, A., Smeraglia, F., & Balato, G. (2022). The active knee extension after extensor mechanism reconstruction using allograft is not influenced by “early mobilization”: a systematic review and meta-analysis. In Journal of Orthopaedic Surgery and Research (Vol. 17, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s13018-022-03049-w
3. Hoang, V., Anthony, T., Quattrocelli, M., Farina, E., Meter, J., & Lattermann, C. (2023). Quadriceps Tendon Reconstruction With Achilles Tendon Bone Block Allograft. Arthroscopy Techniques, 12(1), e45–e52. https://doi.org/10.1016/j.eats.2022.08.056
4. Kunze, K. N., Burnett, R. A., Shinsako, K. K., Bush-Joseph, C. A., Cole, B. J., & Chahla, J. (2019). Trapezoidal Achilles Tendon Allograft Plug for Revision Quadriceps Tendon Repair With a Large Tendon Defect. Arthroscopy Techniques, 8(9), e1031–e1036. https://doi.org/10.1016/j.eats.2019.05.015

How to Cite this article: Bhagunde P, Shah D, Modi N. Tackling Post-TKR Complications: Achilles Allografts in Extensor Mechanism Reconstruction. Journal of Clinical Orthopaedics July-December 2024;9(2):105-108.

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The Promise of Kinematic Alignment in TKA: Game-changer or Gimmick?

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Journal of Clinical Orthopaedics | Vol 9 | Issue 2 |  July-December 2024 | page: 100-104 | Abhishek Nighot, Niharika Virkar

DOI: https://doi.org/10.13107/jcorth.2024.v09i02.682

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2024; The Author(s).

Submitted Date: 20 Aug 2024, Review Date: 05 Sep 2024, Accepted Date: 12 Sep 2024 & Published Date: 10 Dec 2024

Author: Abhishek Nighot [1], Niharika Virkar [2]

[1] Department of Orthopaedics, Hip and Knee Arthroplasty Unit, SAANVI Orthopaedics, Mumbai, Maharashtra, India.
[2] Department of Hand and Microsurgery, Pinnacle Hospital, Thane, Maharashtra, India.

Address of Correspondence

Dr. Abhishek Nighot,
Department of Orthopaedics, SICOT Fellow in Hip and Knee Arthroplasty, SAANVI Orthopaedics, Mumbai, Maharashtra, India.
E-mail: abhisheknighot43@gmail.com

Abstract

Introduction: Total knee arthroplasty (TKA) is a proven solution for end-stage knee arthritis, yet traditional mechanical alignment (MA), which aims for a neutral mechanical axis, leaves up to 20% of patients dissatisfied postoperatively. Kinematic alignment (KA) has emerged as an alternative, focusing on restoring the patient’s native anatomy and joint line orientation, achieving balance without extensive soft-tissue releases.
Methods: This article examines the principles of KA and compares it with MA regarding safety, outcomes, and biomechanical balance through a literature review comprising various retrospective studies, randomized controlled trials, and systemic reviews. KA relies on the patient’s unique femoral morphology to guide bone cuts, achieving natural alignment and ligament balance. Evidence suggests that KA offers comparable if not superior, functional outcomes, with higher Oxford knee scores and forgotten joint scores while maintaining similar implant survivorship. Studies also show KA leads to better compartmental balance, reduced knee adduction moments, and more natural gait mechanics. The compartmental pressure alignment knee classification highlights KA’s ability to balance the knee across various lower limb phenotypes.
Conclusion: Although KA shows promise, challenges remain. Concerns about tibial varus have been addressed, with studies confirming no compromise in implant stability or survival. However, long-term data are needed to validate KA’s durability and define its role for specific patient groups.
This article provides a comprehensive overview of KA’s benefits and limitations, offering guidance for surgeons seeking evidence-based alignment strategies. It underscores KA’s potential as a personalized approach in TKA, bridging gaps in satisfaction and functional outcomes while maintaining safety.
Keywords: Kinematic alignment, mechanical alignment, arthroplasty, osteoarthritis.

References

1. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: Who is satisfied and who is not? Clin Orthop Relat Res 2010;468:57-63.
2. Griffin FM, Insall JN, Scuderi GR. Accuracy of soft tissue balancing in total knee arthroplasty. J Arthroplasty 2000;15:970-3.
3. Rivière C, Iranpour F, Auvinet E, Aframian A, Asare K, Harris S, et al. Mechanical alignment technique for TKA: Are there intrinsic technical limitations? Orthop Traumatol Surg Res 2017;103:1057-67.
4. Beckers G, Meneghini RM, Hirschmann MT, Kostretzis L, Kiss MO, Vendittoli PA. Ten flaws of systematic mechanical alignment total knee arthroplasty. J Arthroplasty 2024;39:591-9.
5. Bellemans J, Colyn W, Vandenneucker H, Victor J. The Chitranjan Ranawat award: Is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 2012;470:45-53.
6. Rivière C, Harman C, Boughton O, Cobb J. The kinematic alignment technique for total knee arthroplasty. In: Rivière C, Vendittoli PA, editors. Personalized Hip and Knee Joint Replacement. Ch. 16. Cham, CH: Springer; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565753
7. Roth JD, Howell SM, Hull ML. Native knee laxities at 0°, 45°, and 90° of flexion and their relationship to the goal of the gap-balancing alignment method of total knee arthroplasty. J Bone Joint Surg Am 2015;97:1678-84.
8. Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG. A randomised controlled trial of kinematically and mechanically aligned total knee replacements: Two-year clinical results. Bone Joint J 2014;96-B:907-13.
9. Calliess T, Bauer K, Stukenborg-Colsman C, Windhagen H, Budde S, Ettinger M. PSI kinematic versus non-PSI mechanical alignment in total knee arthroplasty: A prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 2017;25:1743-8.
10. Howell SM, Shelton TJ, Hull Ml. Implant survival and function ten years after kinematically aligned total knee arthroplasty. J Arthroplasty 2018;33:3678-84.
11. Howell SM, Akhtar M, Nedopil AJ, Hull ML. Reoperation, implant survival, and clinical outcome after kinematically aligned total knee arthroplasty: A concise clinical follow-up at 16 years. J Arthroplasty 2024;39:695-700.
12. Van Essen J, Stevens J, Dowsey MM, Choong PF, Babazadeh S. Kinematic alignment results in clinically similar outcomes to mechanical alignment: Systematic review and meta-analysis. Knee 2023;40:24-41.
13. Laende EK, Richardson CG, Dunbar MJ. A randomized controlled trial of tibial component migration with kinematic alignment using patient-specific instrumentation versus mechanical alignment using computer-assisted surgery in total knee arthroplasty. Bone Joint J 2019;101-B:929-40.
14. Matsumoto T, Takayama K, Ishida K, Hayashi S, Hashimoto S, Kuroda R. Radiological and clinical comparison of kinematically versus mechanically aligned total knee arthroplasty. Bone Joint J 2017;99-B:640-6. Erratum in: Bone Joint J 2021;103-B:1641.
15. Niki Y, Nagura T, Nagai K, Kobayashi S, Harato K. Kinematically aligned total knee arthroplasty reduces knee adduction moment more than mechanically aligned total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2018;26:1629-35.
16. MacDessi SJ, Griffiths-Jones W, Harris IA, Bellemans J, Chen DB. Coronal plane alignment of the knee (CPAK) classification. Bone Joint J 2021;103-B:329-37.

How to Cite this article: Nighot A, Virkar N. The Promise of Kinematic Alignment in TKA: Game- Changer or Gimmick? Journal of Clinical Orthopaedics July-December 2024;9(2):100-104.

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Evaluation of Functional and Radiological Outcome of Total Knee Replacement Surgery in Obese V/S Non-obese Patients

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Journal of Clinical Orthopaedics | Vol 9 | Issue 2 |  July-December 2024 | page: 95-99 | Ashish S Phadnis, Saurabh S Ranjalkar, Vijay Kumar, Prathamesh Sangare, Shashank Gabhe

DOI: https://doi.org/10.13107/jcorth.2024.v09i02.680

Open Access License: CC BY-NC 4.0

Copyright Statement: Copyright © 2024; The Author(s).

Submitted Date: 16 Aug 2024, Review Date: 27 Sep 2024, Accepted Date: 12 Oct 2024 & Published Date: 10 Dec 2024

Author: Ashish S Phadnis [1], Saurabh S Ranjalkar [2], Vijay Kumar [3], Prathamesh Sangare [2], Shashank Gabhe [4]

[1] Department of Orthopaedic Surgery, Jupiter Hospital Thane, Maharashtra, India,
[2] Department of Orthopaedic Surgery, HBT Trauma Hospital, Jogeshwari (E), Mumbai, Maharashtra, India,
[3] Department of Orthopaedic Surgery, ESIC hospital and Dental College, Rohini West, Delhi, India,
[4] Dr Gabhe’s Bones and Joints Clinic, Thane, Maharashtra, India

Address of Correspondence

Dr. Saurabh S Ranjalkar,
Department of Orthopaedic Surgery, HBT Trauma Hospital, Jogeshwari(E), Mumbai, Maharashtra, India
E-mail: saurabh.ranjalkar93@gmail.com

Abstract

Introduction: Primary total knee replacement (TKR) is one of the most commonly performed orthopedic procedures. With the increasing prevalence of obesity and advancing age of the population, it is imperative to know whether the obese patients have inferior or equivalent outcomes as opposed to non-obese patients. Hence, this study was planned to learn the functional and radiological outcomes of TKR surgery in obese and non-obese patients.
Materials and Methods: This prospective observational study included 64 adult patients 32 obese (body mass index [BMI] >30) and 32 non-obese (BMI <30) operated for TKR surgery. Functional outcome was assessed by patient-reported outcome measures using Oxford knee score (OKS) and short form-12 (SF-12) quality of life questionnaires at 6 weeks postoperatively. Radiological outcomes were assessed using pre- and post-operative radiograph and bilateral lower limb scanogram.
Results: On comparing the mean hospital stay, that of obese patients was 8.16 days and that of non-obese patients was 6.72 days (significant). The OKS improved from 14.19 to 37.44 in the obese group and from 14.75 to 38.59 in non-obese group. In obese patients, the physical component of SF-12 score improved from 23.92 to 53.6 postoperatively, and that in non-obese patients went from 27.29 to 53.08. The mean mental component of SF-12 score improved from 48.59 to 56.37 postoperatively in obese patients, in non-obese patients it improved from 53.02 to 57.94 postoperatively (significant). Hip-knee-ankle axis in obese patients on the right side improved from 171.18° to 176.82° (significant), left side from 171.31° to 176.71° whereas in non-obese patients right side from 171.89° to 176.94°, left side from 171.82° to 176.66°. Comorbidities were seen more in obese patients (diabetes 21 of 32 cases, hypertension 17 of 32 cases) than in non-obese patients (diabetes 12 of 32 cases, hypertension 16 of 32 cases). Superficial surgical site infection (SSI) in about 3 of 32 obese patients, whereas no SSI was found in non-obese patients.
Conclusion: The present study assesses the patients’ perception of their outcomes which are important in clinical decision-making. There was no significant difference found in patient perceived parameters, functional and radiological outcomes at end of 6 months following TKR surgery in both obese and non-obese patients.
Keywords: Total knee replacement, body mass index, obese.

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How to Cite this article: Phadnis AS, Ranjalkar SS, Kumar V, Sangare P, Gabhe S. Evaluation of Functional and Radiological Outcome of Total Knee Replacement Surgery in Obese V/S Non-obese Patients. Journal of Clinical Orthopaedics July-December 2024;9(2):95-99.

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