Potpourri – Recent and relevant literature in 2017

Vol 2 | Issue 2 |  Juiy – Dec 2017 | Page 36-39 |Sunny Gugale, Parag Sancheti, Ashok K Shyam

Authors: Sunny Gugale [1], Parag Sancheti [1], Ashok K Shyam [1,2]

[1] Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra India.
[2] Indian Orthopaedic Research group, Thane, India

Address of Correspondence
Dr. Sunny Gugale
Dept of Arthroscopy, Sancheti Institute for Orthopaedics and Rehabilitation,
Pune, Maharashtra India.

Hip Arthroscopy

Hip arthroscopy is evolving and showing good outcomes in specific pathologies around the hip region in the last decade. In the current scenario the trends of utilization and its outcomes in terms of repeat hip arthroscopy as well as subsequent conversion to total hip arthroplasty was evaluated in a paper by Maradit Kremers et al [1]. Hip arthroscopy rates increased significantly over time from 3.6 per 100,000 in 2005 to 16.7 per 100,000 in 2013. As the exposure in hip arthroscopy is increasing the number of subsequent surgeries are also increasing, 2-year cumulative incidence of subsequent hip arthroscopy and THA was 11% and 10%, respectively. In long term the incidence of THA post hip arthroscopy is 35% in individuals aged 55-64 years. The indications of hip arthroscopy should be limited to femoral osteochondroplasty and labral repair which results in predictable good outcomes in young patients < 40 years of age. Elderly patients with age > 40 years operated for hip arthroscopy showed higher conversion rates to THR. This was shown by Horner NS et al [2] in their meta-analysis comprising of 16,327 patients, including 9,954 patients age 40 or older. Another Multicenter Arthroscopic Study of the Hip (MASH) Study Group by Kivlan BR et al [3] in their study of 1738 patients showed similar outcomes with Labral tear as the most common diagnosis, and most often it was addressed with repair. Briggs KK et al [4] in their commentary also mention impact of age on outcomes after hip arthroscopy. The rise in hip-preservation operations in nonarthritic patients 60 or older has been associated with encouraging improvements in patient-reported outcome scores as showsn by Ortiz-Declet V et al [6]. None the less, everything that is introduced for benefit of the patients comes with its share of complications. Fluid extravasation is a rare but potentially life-threatening complication of hip arthroscopy. Most patients require interventional management by surgery or paracentesis, but some stabilize with conservative management. Ekhtiari S et al [5] in their systematic review of 1286 patients showed 1.6% incidence of fluid extravasation (21 patients). Signs of fluid extravasation included abdominal distension, hypothermia, hypotension and metabolic acidosis. Haskins SC et al [7], in their series showed that the incidence of intra-abdominal fluid extravasation was very high about 16% in a cohort of 100 patients with none requiring any surgical intervention.

Thromboprophylaxis in Arthroscopy

The use of thromboprophylaxis to prevent clinically apparent venous thromboembolism after knee arthroscopy or casting of the lower leg is debatable topic. Various studies have been published debating the effectiveness and benefit in preventing venous thromboembolism and subsequent PE. The incidence of symptomatic venous thromboembolism after knee and hip arthroplasty is high as compared to arthroscopy. Van Adrichem RA et al [10] in their randomized controlled trial included 1543 patients, showed no significant benefit of prophylaxis with low-molecular-weight heparin for the 8 days after knee arthroscopy or during the full period of immobilization due to casting. Rebecca E. Berger et al9 also showed that the benefit of LMWH for prophylaxis must be weighed against its side effects of bleeding and inconvenience to take the dose, not all patients to receive it but selective patients. Giuseppe Lippi et al [8] showed that low molecular weight heparin is not effective for preventing venous thromboembolism, whereas thrombotic episodes may be significantly reduced using direct oral anticoagulants.

Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease

Osteoarthritis of knee and degenerative knee changes are on a rise. A degenerative meniscus lesion is a slowly developing process typically involving a horizontal cleavage in a middle-aged or older person. To relieve pain and mechanical symptoms arthroscopic debridement and partial menisectomy is being done. Muheim LLS et al [11] in their paper suggest that arthroscopic knee surgery has no added benefit compared with non-surgical management in degenerative meniscal disease. Beaufils P et al [12] also came out with the consensus that arthroscopic partial meniscectomy is not indicated in patients with non-traumatic meniscal tear typically involving a horizontal cleavage tear.

Femoroacetabular impingement and arthroscopy

Femoroacetabular impingement (FAI) as a cause of hip pain and secondary osteoarthritis has rapidly evolved since Ganz’s description in 2003. FAI is a important condition where hip arthroscopy can help to relieve impingement and prevent progression to hip arthritis in younger age group patients. Open surgical dislocation continues to play a role in the treatment of complex FAI. Nwachukwu BU et al [13] gave a predictive preoperative and diagnostic postoperative outcome scores for the substantial clinical benefit that can be used to manage patient expectations and grade outcomes, this is a useful objective criteria for defining clinical success after arthroscopic FAI treatment. Menge TJ et al [14] in their study of 10-year outcomes and hip survival following hip arthroscopy for FAI and to compare labral debridement (n=75) with labral repair (n=79) with satisfactory outcomes at 10 years. Elderly patients, hips with < 2 mm of joint space preoperatively, and patients requiring acetabular microfracture had significantly higher prevalences of THA (34%). In a systematic review with meta-analysis Kierkegaard S et al [17] showed that postoperative patient satisfaction ranged from 68% to 100% in terms of pain, activities of daily living and sport function. Anthony CA et al in their study of 1325 patients showed a complication rate of 16 (1.21%) had at least 1 complication, and 6 (0.45%) had at least 1 major complication. Bleeding resulting in transfusion was the commonest complication.

Rotator cuff tear

Rotator cuff injuries are a major cause of shoulder dysfunction in young age group. Repair of the rotator cuff to regain normal strength and function in the shoulder joint is of prime importance. Open or arthroscopic repair is indicated depending upon the training of the surgeon. Liu J et al [18] in their comparative study of arthroscopic and mini open rotator cuff repair, showed no significant difference in the outcomes a long-term follow up. Galasso O et al [19] in a cohort of 95 patients showed that when there is an irreparable supraspinatus but there is still the possibility to repair the infraspinatus and subscapularis, the arthroscopic partial cuff repair should be considered as an effective surgical option. Robinson HA et al [20] in his series of 1600 patients treated with arthroscopic rotator cuff repair reported significant improvement in functional outcomes in terms of overhead pain levels irrespective of the repair integrity at 6 months. They had 13% re-tear as confirmed by ultrasound. Yang J et al [22] in a meta-analysis compared clinical outcomes between intact and retorn rotator cuffs after arthroscopic single-row and double-row repair. Patients with a full-thickness rotator cuff retear exhibited significantly lower clinical outcome scores and strength compared with patients with an intact or partially torn rotator cuff. Audigé L et al [21] devised a structured core set of local events associated with Arthroscopic rotator cuff repair has been developed by international consensus.

Special Articles

1. Acute native knee septic arthritis is a joint-threatening emergency. Operative treatments can be by open or arthroscopic technique. The literature to date has primarily consisted of case series and no large study has yet compared these methods. Johns BP et al [23] in their study compared open (n=43) and arthroscopic (n=123) treatment for acute native knee septic arthritis and showed that arthroscopic treatment for acute native knee septic arthritis was a more successful index procedure and required fewer total irrigation procedures compared with open treatment. Long-term postoperative range of motion was significantly greater following arthroscopic treatment.
2. Appropriate management for patients with a degenerative tear of the rotator cuff remains controversial, but operative treatment, particularly arthroscopic surgery, is increasingly being used. Carr A et al [24] in this paper compared the effectiveness of arthroscopic with open repair of the rotator cuff in a randomized study of 273 patients with 2 years post-operative evaluation by the Oxford Shoulder Score. They showed no evidence of difference in effectiveness between open and arthroscopic repair of rotator cuff tears. The rate of re-tear was high in both groups, for all sizes of tear and ages and this adversely affects the outcome.
3. Various device modalities are available for post-operative treatment following arthroscopic knee surgery; however, it remains unclear which types and duration of modality are the most effective. Gatewood CT et al [25] in their systematic review aimed to investigate the efficacy of device modalities used following arthroscopic knee surgery. They showed that cryotherapy, Neuromuscular electrical stimulation and surface electromyography are recommended for inclusion into rehabilitation protocols following arthroscopic knee surgery to assist with pain relief, recovery of muscle strength and knee function, which are all essential to accelerate recovery. Continous passive movement is not warranted in post-operative protocols following arthroscopic knee surgery because of its limited effectiveness in returning knee range of motion, extra-corporeal shock wave therapy has a doubtfull role.
4. Arthroscopic surgery of the knee is one of the most frequently performed orthopaedic procedures. One-third of these procedures are performed for meniscal injuries. Monk P et al [26] in their systematic review which includes 9 RCT’s and 8 sytematic reviews showed that No difference was found between arthroscopic meniscal debridement compared with nonoperative management as a first-line treatment strategy for patients with knee pain and a degenerative meniscal tear. Thus, more research is urgently needed to support evidence-based practice in meniscal surgery in order to reduce the numbers of ineffective interventions and support potentially beneficial surgery.
5. Clement RC et al [27], in their paper identified and quantified patient- and procedure-related risk factors for post-arthroscopic knee infections using a large database. 595,083 arthroscopic knee procedures were evaluated. Deep postoperative infections occurred at a rate of 0.22%. Superficial infections occurred at a rate of 0.29%. Tobacco use and morbid obesity were the largest risk factors for deep and superficial infections. Patients undergoing relatively complex procedures, men & diabetic patients adds to the post-operative co-morbidity group. This knowledge may allow more informed preoperative counseling, aid surgeons in patient selection, and facilitate infection prevention by targeting individuals with higher inherent risk.
6. Meniscal tears are frequently repaired during anterior cruciate ligament reconstruction. Westermann RW et al [28] in their meta-analysis of 1126 patients. There was statistically significant difference in the failure rate for all-inside meniscal repair performed concurrently with ACLR was 16% (121/744) compared with 10% (39/382) for inside-out repair. Implant irritation and device migration were the most common complications reported for all-inside repair.
7. Axillary nerve exploration is a routine procedure performed. Standard open exploration of the nerve is commonly done but it lacks exploration of the nerve in its middle course where it is known as the blind zone. Maldonado A et al [29] in their study of fresh cadaveric shoulder joint showed the feasibility to visualize all segments of the axillary nerve (including the blind zone) using this novel approach that combines the use of the standard posterior approach to the nerve with dry arthroscopic exploration.


1. Maradit Kremers et al, Trends in Utilization and Outcomes of Hip Arthroscopy in the United States Between 2005 and 2013. J Arthroplasty. 2017 Mar;32(3):750-755.
2. Horner NS1, Ekhtiari S, et al Hip Arthroscopy in Patients Age 40 or Older: A Systematic Review. Arthroscopy. 2017 Feb;33(2):464-475.e3.
3. Kivlan BR, Nho SJ et al, Multicenter Outcomes After Hip Arthroscopy: Epidemiology (MASH Study Group). What Are We Seeing in the Office, and Who Are We Choosing to Treat? Am J Orthop (Belle Mead NJ). 2017 Jan/Feb;46(1):35-41.
4. Briggs KK, Editorial Commentary: 40 the New 30? Maybe Not for the Hip. Arthroscopy. 2017 Feb;33(2):476.
5. Ekhtiari S, Haldane CE Fluid Extravasation in Hip Arthroscopy: A Systematic Review. Arthroscopy. 2017 Apr;33(4):873-880.
6. Ortiz-Declet V, Domb BG. Editorial Commentary: Hip Arthroscopy-Safe, Effective, and Still Improving in Older Nonarthritic Patients. Arthroscopy. 2016 Dec;32(12):2511-2512.
7. Haskins SC1, Desai NA Diagnosis of Intraabdominal Fluid Extravasation After Hip Arthroscopy with Point-of-Care Ultrasonography Can Identify Patients at an Increased Risk for Postoperative Pain. Anesth Analg. 2017 Mar;124(3):791-799.
8. Lippi G, Cervellin G. Thromboprophylaxis after Knee Arthroscopy: Out of the Maze? Trends Pharmacol Sci. 2017 May;38(5):425-426.
9. Berger RE, Pai M. Thromboprophylaxis after Knee Arthroscopy. N Engl J Med. 2017 Feb 9;376(6):580-583.
10. Van Adrichem RA, Nemeth B, Algra A et al. Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting. N Engl J Med. 2017 Feb 9;376(6):515-525.
11. Muheim LLS1, Senn O et al, Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease. Acta Orthop. 2017 Oct;88(5):550-555.
12. Beaufils P1, Becker R Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc. 2017 Feb;25(2):335-346.
13. Nwachukwu BU1, Chang B et al, Defining the “Substantial Clinical Benefit” After Arthroscopic Treatment of Femoroacetabular Impingement. Am J Sports Med. 2017 May;45(6):1297-1303.
14. Menge TJ1, Briggs KK et al, Survivorship and Outcomes 10 Years Following Hip Arthroscopy for Femoroacetabular Impingement: Labral Debridement Compared with Labral Repair. J Bone Joint Surg Am. 2017 Jun 21;99(12):997-1004.
15. Nepple JJ1, Clohisy JC Evolution of Femoroacetabular Impingement Treatment: The ANCHOR Experience. Am J Orthop (Belle Mead NJ). 2017 Jan/Feb;46(1):28-34.
16. Anthony CA1, Pugely AJ et al, Complications and Risk Factors for Morbidity in Elective Hip Arthroscopy: A Review of 1325 Cases. Am J Orthop (Belle Mead NJ). 2017 Jan/Feb;46(1):E1-E9.
17. Kierkegaard S et al, Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a systematic review with meta-analysis. Br J Sports Med. 2017 Apr;51(7):572-579.
18. Liu J, Fan L et al, Comparison of clinical outcomes in all-arthroscopic versus mini-open repair of rotator cuff tears: A randomized clinical trial. Medicine (Baltimore). 2017 Mar;96(11):e6322.
19. Galasso O, Riccelli DA et al, Quality of Life and Functional Results of Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears. Arthroscopy. 2017 Feb;33(2):261-268.
20. Robinson HA, Lam PH et al, The effect of rotator cuff repair on early overhead shoulder function: a study in 1600 consecutive rotator cuff repairs. J Shoulder Elbow Surg. 2017 Jan;26(1):20-29.
21. Audigé L, Flury M et al, Complications associated with arthroscopic rotator cuff tear repair: definition of a core event set by Delphi consensus process. J Shoulder Elbow Surg. 2016 Dec;25(12):1907-1917.
22. Yang J Jr, Robbins M et al, The Clinical Effect of a Rotator Cuff Retear: A Meta-analysis of Arthroscopic Single-Row and Double-Row Repairs. Am J Sports Med. 2017 Mar;45(3):733-741.
23. Johns BP, Loewenthal MR et al, Open Compared with Arthroscopic Treatment of Acute Septic Arthritis of the Native Knee. J Bone Joint Surg Am. 2017 Mar 15;99(6):499-505.
24. Carr A, Cooper C et al Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial. Bone Joint J. 2017 Jan;99-B(1):107-115.
25. Gatewood CT, Tran AA et al, The efficacy of post-operative devices following knee arthroscopic surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2017 Feb;25(2):501-516.
26. Monk P1, Garfjeld Roberts P The Urgent Need for Evidence in Arthroscopic Meniscal Surgery. Am J Sports Med. 2017 Mar;45(4):965-973.
27. Clement RC1, Haddix KP et al, Risk Factors for Infection After Knee Arthroscopy: Analysis of 595,083 Cases From 3 United States Databases. Arthroscopy. 2016 Dec;32(12):2556-2561.
28. Westermann RW1, Duchman KR et al, All-Inside Versus Inside-Out Meniscal Repair With Concurrent Anterior Cruciate Ligament Reconstruction: A Meta-regression Analysis. Am J Sports Med. 2017 Mar;45(3):719-724.
29. Maldonado AA1, Spinner RJ et al, Arthroscopic-assisted exploration of the axillary nerve through a posterior open approach: A novel technique. J Plast Reconstr Aesthet Surg. 2017 May;70(5):625-627.

How to Cite this article:  Gugale S, Sancheti PK, Shyam AK. Recent Trends in Arthroscopy. Journal of Clinical Orthopaedics July-Dec 2017; 2(2):36-39.

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Perspective on Orthopaedic Research and Publication in India

Volume 1 | Issue 1 |  July – Dec 2016 | Page 3-4 | Ashok K Shyam, Parag K Sancheti

Authors: Ashok K Shyam [1,2], Parag K Sancheti [1]

[1] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India.
[2] Indian Orthopaedic Research Group, Thane, India.

Address of Correspondence
Dr Ashok Shyam
A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane [W],Maharashtra, India.

Medical Research can be broadly divided into two, clinical research and academic research. Clinical research includes studies that are directly or indirectly funded/conducted by the pharmaceutical companies or the industry. The academic research pertains to research done by surgeons/clinicians at universities, institutes or at individual level. Academic Research and publication are the main source of enriching the medical subjects. This is especially true for surgical subjects like orthopaedics where industry sponsored studies may tend to be biased towards their specific products. Textbooks and reviews are synthesis of these academic research studies that are published in peer reviewed Journals. This knowledge base is in constant state of flux with new information adding to or overwriting the old concepts and principles. This requires constant addition of new academic studies to literature and thus the need to support and conduct such research. There is a huge need to promote academic orthopaedic research in India. India as a country, has orthopaedic challenges that are specific to its population. We see cases of osteomyelitis, infections like tuberculosis, delayed fracture presentations and revision cases that are not seen in the western world. The world literature is sparse on these diseases and we can’t rely on it to provide us guidelines to manage these cases. The socio-economic and cultural views of our patients also vary a lot and many a times we have to come up with innovative plans to face the challenges of individual patients. The best way would be for us will be to publish our data and make it available for systematic reviews and create our own body of literature that will provide relevant guidelines for our own problems [1]. If every surgeon from India publishes his or her orthopaedic knowledge to a common pool, we would be able to draw patient specific conclusions from this pool of knowledge. We can learn from experiences of our colleagues and will be better equipped to provide optimal treatment to our patients. Although this dream will take long time, infrastructure planning and a huge dedicated network, we believe the process has already begun. Journal of Clinical Orthopaedics is a glowing example of such an initiative from the oldest and one of the most academically strong orthopaedic body in the country. Academic orthopaedic research in India is surely improving but at a very slow pace. There are many reasons for this ‘research apathy’ but the main reasons are lack of training in principles of research and publication, lack of support and guidance and lack of platforms to present and publish. The authors should realise that research should be focussed on patients needs and core principles of research methodology have to be followed. Every publications should exhibit high clinical quality and ethical standards. In orthopaedics, most of the areas have shades of grey as far as decision making is concerned. The available options vary from conservative to surgical methods but every option has its own place with its own set of indications and contraindications. The main aim of orthopaedic research is to specify and refine these indications, contraindications, advantages, disadvantages, limitations and complications of these treatment options. This can only be achieved when we are able to collect and collate our data, interpret it scientifically, subject it to peer review and publish it. A high standard of ethics and publication has to be maintained but this is easier said than done. Although this may not be true for most published article, many articles that are published today are simply for the sake of publication. There are lot of poor conducted studies and poorly written articles that are published. Plagiarism is a special issue that needs spread of more awareness and understanding among the authors [2,3 ]. One of the causes of recent increase in these malpractices is the Medical Council of India (MCI) directive where publications are made necessary for promotions and appointments in medical colleges. The MCI had laid down the rule with good intention of promoting research and publication, but there was no training and infrastructure provided for research. Surgeons were simply expected to produce papers when they haven’t conducted a single project in years except probably participate in thesis of their students. This not only led to increase in unethical practices and publication of poor articles but also led to growth of predatory Journals that promised rapid publication for a fees [4]. Other issues like peer review frauds, duplicate publications, salami slicing and ghost authorships are also on rise in recent years. A clear picture of these can be obtained from the websites like ‘retraction watch’ [5] and other such sentinel websites. The solution for these issues is urgent dissemination of information regarding adverse effects of such malpractices and also education about correct and ethical practices. Journals like Journal of Clinical Orthopaedics can play a very important role in changing this scenario. Reviews and articles based on research methodology and publications will help in spreading the correct information. Also the academic weight and stature of Bombay Orthopaedic Society will definitely increase the impact of these articles manifold. We believe this situation will change with focussed efforts and with the new breed of clinician scientists showing interest in academic research the future looks much brighter. In addition there are more opportunities arising due to change in policies of academic bodies, who are now offering assistance for research and publications. In developed countries, academic research is done through co-operation of three entities namely the universities, government and the industry. Although this co-operation still does not exist in India (as far as orthopaedics is concerned), there has been increased recognition for academic research by the government and universities. Academic bodies like Bombay Orthopaedic Society (BOS), Indian Orthopaedic Association, Indian Orthopaedic Research Group (IORG) etc are showing great interest in this area. There are number of research methodology courses and workshops held in the country to train the surgeons in the art of research and publications. Many of these organisations also provide funds and resources for academic research projects. IORG has started many clinician initiated speciality journals including the popular Journal of Orthopaedic Case Reports [6]. Recent launch of projects like ‘Trauma Registry’ will help in creating a network of Academic Surgeons coming together to do research that will have great impact. BOS has its own ongoing research projects and most noted of them is the project on tuberculosis which will definitely have path breaking impact. The BOS journal, ‘Journal of Clinical Orthopaedics’ (JCORTH) will provide platform for many Indian surgeons to publish their work. It is also a great step in initiating postgraduate students and trainees in the habit of reading and publishing. The outreach of JCORTH would be exceptional and it will definitely contribute immensely in improving the research and publication scenario in the country.  The future of Orthopaedic research and publication looks promising but there is definitely a need for improved awareness and education and also need for platforms to publish and present the research. We have to remain cautious and careful about the malpractices and aim to maintain high standard of ethics in our research and publications.


1. Jain AK. Research in orthopaedics: A necessity. Indian J Orthop 2009;43:315-7
2. Poduval M. Plagiarism- Cut it at the roots. Journal of Orthopaedic Case Reports. 2015 Jan-Mar;5(1):3–4.
3. Shyam AK. Insights from a Personal Journey in field of Orthopaedic Research and Publications. J Orthop Case Rep. 2015 Jan-Mar;5(1):1-2.
4. Shyam AK. Predatory Journals: What are they? J Orthop Case Rep. 2015 Oct-Dec;5(4):1-2.
5. Retraction Watch – Tracking retractions as a window into the scientific process.
6.Shyam AK, Shetty GM. Resurrection of the Case Report! J Orthop Case Rep. 2011 Oct-Dec;1(1):1-2.

How to Cite this article: Shyam AK, Sancheti PK. Perspective on Orthopaedic Research and Publication in India. Journal of  Clinical Orthopaedics July – Dec 2016; 1(1):3-4.

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