[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
1. Patel M, Nelson R. Genu valgum. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2024.
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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.
http://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.png00editor.jcorthhttp://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.pngeditor.jcorth2025-06-10 12:16:032025-06-21 14:02:20Correction of genu valgum deformity with femoral translation osteotomy and antegrade interlocking nail
[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
References
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2. Park KH, Cheon SH, Lee JH, Kyung HS. Incidence of venous thromboembolism using 64 channel multidetector row computed tomography-indirect venography and anti-coagulation therapy after total knee arthroplasty in Korea. Knee Surg Relat Res 2012;24:19-24.
3. Tateiwa T, Ishida T, Masaoka T, Shishido T, Takahashi Y, Onozuka A, et al. Clinical course of asymptomatic deep vein thrombosis after total knee arthroplasty in Japanese patients. J Orthop Surg (Hong Kong) 2019;27:2
4. Lee LH, Gallus A, Jindal R, Wang C, Wu CC. Incidence of venous thromboembolism in Asian populations: A systematic review. Thromb Haemost 2017;117:2243-60.
5. Gangireddy C, Rectenwald JR, Upchurch GR, Wakefield TW, Khuri S, Henderson WG, et al. Risk factors and clinical impact of postoperative symptomatic venous thromboembolism. J Vasc Surg 2007;45:335-42.e1.
6. Heit JA. Venous thromboembolism: Disease burden, outcomes and risk factors. J Thromb Haemost 2005;3:1611-7.
7. Amawi H, Arabyat RM, Al-Azzam S, AlZu’bi T, U’wais HT, Hammad AM, et al. The length of hospital stay of patients with venous thromboembolism: A cross-sectional study from Jordan. Medicina 2023;59:727.
8. MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm 2006;63 20 Suppl 6:S5-15.
9. Kahn SR. The post-thrombotic syndrome. Hematology Am Soc Hematol Educ Program 2016;2016:413-8.
10. Riga M, Altsitzioglou P, Saranteas T, Mavrogenis AF. Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery. SICOT J 2023;9:E1.
11. Glassou EN, Pedersen AB, Hansen TB. Risk of re-admission, reoperation, and mortality within 90 days of total hip and knee arthroplasty in fast-track departments in Denmark from 2005 to 2011. Acta Orthop 2014;85:493-500.
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.
13. Liew NC, Alemany GV, Angchaisuksiri P, Bang SM, Choi G, De Sila DA, et al. Asian venous thromboembolism guidelines: Updated recommendations for the prevention of venous thromboembolism. Int Angiol 2017;36:1-20.
14. The ICM-VTE Hip and Knee Delegates. Recommendations from the ICM-VTE: Hip and Knee. J Bone Joint Surg Am 2022;104 Suppl 1:180-231.
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.
17. Wong SY, Ler FL, Sultana R, Bin Abd Razak HR. What is the best prophylaxis against venous thromboembolism in Asians following total knee arthroplasty? A systematic review and network meta-analysis. Knee Surg Relat Res 2022;34:37.
18. Amarase C, Tanavalee A, Larbpaiboonpong V, Lee MC, Crawford RW, Matsubara M, et al. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 2. Mechanical venous thromboembolism prophylaxis. Knee Surg Relat Res 2021;33:20.
19. Thiengwittayaporn S, Budhiparama N, Tanavalee C, Tantavisut S, Sorial RM, Li C, et al. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 3. Pharmacological venous thromboembolism prophylaxis. Knee Surg Relat Res 2021;33:24.
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.
21. Slostad JA, Slostad B, Crusan D, Petterson T, Bailey K, Ashrani AA, et al. Impact of length of stay on hospital-associated venous thromboembolism (VTE). Blood 2018;132:1225.
22. Hu LJ, Ji B, Fan HX. Venous thromboembolism risk in rheumatoid arthritis patients: A systematic review and updated meta-analysis. Eur Rev Med Pharmacol Sci 2021;25:7005-13.
23. Omair MA, Alkhelb SA, Ezzat SE, Boudal AM, Bedaiwi MK, Almaghlouth I. Venous thromboembolism in rheumatoid arthritis: The added effect of disease activity to traditional risk factors. Open Access Rheumatol 2022;14:231-42.
24. Lin SY, Chang YL, Yeh HC, Lin CL, Kao CH. Blood transfusion and risk of venous thromboembolism: A population-based cohort study. Thromb Haemost 2020;120:156-67.
25. Cai J, Ribkoff J, Olson S, Raghunathan V, Al-Samkari H, DeLoughery TG, et al. The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients. Eur J Haematol 2020;104:79-87.
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.
27. Xu H, Zhang S, Xie J, Lei Y, Cao G, Chen G, et al. A nested case-control study on the risk factors of deep vein thrombosis for Chinese after total joint arthroplasty. J Orthop Surg Res 2019;14:188.
28. Klatsky AL, Armstrong MA, Poggi J. Risk of pulmonary embolism and/or deep venous thrombosis in Asian-Americans. Am J Cardiol 2000;85:1334-7.
29. White RH. The epidemiology of venous thromboembolism. Circulation 2003;107 23 Suppl 1:I4-8.
30. Klatsky AL, Baer D. What protects Asians from venous thromboembolism? Am J Med 2004;116:493-5.
31. Stein PD, Matta F. Epidemiology and incidence: The scope of the problem and risk factors for development of venous thromboembolism. Clin Chest Med 2010;31:611-28.
32. Jadaon MM. Epidemiology of prothrombin G20210A mutation in the Mediterranean Region. Mediterr J Hematol Infect Dis 2011;3:e2011054.
33. Tay K, Bin Abd Razak HR, Tan AH. Obesity and Venous Thromboembolism in Total Knee Arthroplasty Patients in an Asian Population. J Arthroplasty 2016;31:2880-3.
34. Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. J Bone Joint Surg Br 2007;89:316-22.
35. Shohat N, Ludwick L, Sherman MB, Fillingham Y, Parvizi J. Using machine learning to predict venous thromboembolism and major bleeding events following total joint arthroplasty. Sci Rep 2023;13:2197.
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.
http://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.png00editor.jcorthhttp://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.pngeditor.jcorth2025-06-10 11:59:272025-06-21 14:01:25Is Pharmacological Thromboprophylaxis Truly Necessary: Predictive Factors for Venous Thromboembolic Events Post-Total Knee Arthroplasty in an Asian Population
[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.
http://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.png00editor.jcorthhttp://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.pngeditor.jcorth2025-06-10 10:47:362025-06-21 14:00:31Informed Consent: A Cornerstone of Ethical and Legal Orthopaedic Practice
[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
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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.
http://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.png00editor.jcorthhttp://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.pngeditor.jcorth2024-12-10 17:20:362025-04-25 05:30:04Surgical Prophylaxis: Is it Always Needed in Orthopedics Practice
[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.
http://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.png00editor.jcorthhttp://jcorth.com/wp-content/uploads/2016/10/BOS-LOGO.pngeditor.jcorth2024-12-10 17:14:252025-04-25 05:29:57Musculoskeletal Tissue Retrieval from Deceased Donors in India: Protocols and Challenges
[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.
Correction of genu valgum deformity with femoral translation osteotomy and antegrade interlocking nail
/in Vol 10 | Issue 1 | January-June 2025 /by editor.jcorthJournal 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
1. Patel M, Nelson R. Genu valgum. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2024.
2. Vaishya R, Shah M, Agarwal AK, Vijay V. Growth modulation by hemi epiphysiodesis using eight-plate in Genu valgum in Paediatric population. J Clin Orthop Trauma 2018;9:327-33.
3. Salenius P, Vankka E. The development of the tibiofemoral angle in children. J Bone Joint Surg Am 1975;57:259-61.
4. Heath CH, Staheli LT. Normal limits of knee angle in white children–genu varum and genu valgum. J Pediatr Orthop 1993;13:259-62.
5. Boero S, Michelis MB, Riganti S. Use of the eight-plate for angular correction of knee deformities due to idiopathic and pathologic physis: Initiating treatment according to etiology. J Child Orthop 2011;5:209-16.
6. Jelinek EM, Bittersohl B, Martiny F, Scharfstädt A, Krauspe R, Westhoff B. The 8-plate versus physeal stapling for temporary hemiepiphyseodesis correcting genu valgum and genu varum: A retrospective analysis of thirty five patients. Int Orthop 2012;36:599-605.
7. Blount WP, Clarke GR. Control of bone growth by epiphyseal stapling; a preliminary report. J Bone Joint Surg Am 1949;31a:464-78.
8. Ismailidis P, Schmid C, Werner J, Nüesch C, Mündermann A, Pagenstert G, et al. Distal femoral osteotomy for the valgus knee: Indications, complications, clinical and radiological outcome. Arch Orthop Trauma Surg 2023;143:6147-57.
9. Chahla J, Mitchell JJ, Liechti DJ, Moatshe G, Menge TJ, Dean CS, et al. Opening- and closing-wedge distal femoral osteotomy: A systematic review of outcomes for isolated lateral compartment osteoarthritis. Orthop J Sports Med 2016;4:2325967116649901.
10. Wylie JD, Jones DL, Hartley MK, Kapron AL, Krych AJ, Aoki SK, et al. Distal femoral osteotomy for the valgus knee: Medial closing wedge versus lateral opening wedge: A systematic review. Arthroscopy 2016;32:2141-7.
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.
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Is Pharmacological Thromboprophylaxis Truly Necessary: Predictive Factors for Venous Thromboembolic Events Post-Total Knee Arthroplasty in an Asian Population
/in Vol 10 | Issue 1 | January-June 2025 /by editor.jcorthJournal 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
References
1. Healy WL, Della Valle CJ, Iorio R, Berend KR, Cushner FD, Dalury DF, et al. Complications of total knee arthroplasty: Standardized list and definitions of the knee society. Clin Orthop Relat Res 2013;471:215-20.
2. Park KH, Cheon SH, Lee JH, Kyung HS. Incidence of venous thromboembolism using 64 channel multidetector row computed tomography-indirect venography and anti-coagulation therapy after total knee arthroplasty in Korea. Knee Surg Relat Res 2012;24:19-24.
3. Tateiwa T, Ishida T, Masaoka T, Shishido T, Takahashi Y, Onozuka A, et al. Clinical course of asymptomatic deep vein thrombosis after total knee arthroplasty in Japanese patients. J Orthop Surg (Hong Kong) 2019;27:2
4. Lee LH, Gallus A, Jindal R, Wang C, Wu CC. Incidence of venous thromboembolism in Asian populations: A systematic review. Thromb Haemost 2017;117:2243-60.
5. Gangireddy C, Rectenwald JR, Upchurch GR, Wakefield TW, Khuri S, Henderson WG, et al. Risk factors and clinical impact of postoperative symptomatic venous thromboembolism. J Vasc Surg 2007;45:335-42.e1.
6. Heit JA. Venous thromboembolism: Disease burden, outcomes and risk factors. J Thromb Haemost 2005;3:1611-7.
7. Amawi H, Arabyat RM, Al-Azzam S, AlZu’bi T, U’wais HT, Hammad AM, et al. The length of hospital stay of patients with venous thromboembolism: A cross-sectional study from Jordan. Medicina 2023;59:727.
8. MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm 2006;63 20 Suppl 6:S5-15.
9. Kahn SR. The post-thrombotic syndrome. Hematology Am Soc Hematol Educ Program 2016;2016:413-8.
10. Riga M, Altsitzioglou P, Saranteas T, Mavrogenis AF. Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery. SICOT J 2023;9:E1.
11. Glassou EN, Pedersen AB, Hansen TB. Risk of re-admission, reoperation, and mortality within 90 days of total hip and knee arthroplasty in fast-track departments in Denmark from 2005 to 2011. Acta Orthop 2014;85:493-500.
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.
13. Liew NC, Alemany GV, Angchaisuksiri P, Bang SM, Choi G, De Sila DA, et al. Asian venous thromboembolism guidelines: Updated recommendations for the prevention of venous thromboembolism. Int Angiol 2017;36:1-20.
14. The ICM-VTE Hip and Knee Delegates. Recommendations from the ICM-VTE: Hip and Knee. J Bone Joint Surg Am 2022;104 Suppl 1:180-231.
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.
17. Wong SY, Ler FL, Sultana R, Bin Abd Razak HR. What is the best prophylaxis against venous thromboembolism in Asians following total knee arthroplasty? A systematic review and network meta-analysis. Knee Surg Relat Res 2022;34:37.
18. Amarase C, Tanavalee A, Larbpaiboonpong V, Lee MC, Crawford RW, Matsubara M, et al. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 2. Mechanical venous thromboembolism prophylaxis. Knee Surg Relat Res 2021;33:20.
19. Thiengwittayaporn S, Budhiparama N, Tanavalee C, Tantavisut S, Sorial RM, Li C, et al. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 3. Pharmacological venous thromboembolism prophylaxis. Knee Surg Relat Res 2021;33:24.
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.
21. Slostad JA, Slostad B, Crusan D, Petterson T, Bailey K, Ashrani AA, et al. Impact of length of stay on hospital-associated venous thromboembolism (VTE). Blood 2018;132:1225.
22. Hu LJ, Ji B, Fan HX. Venous thromboembolism risk in rheumatoid arthritis patients: A systematic review and updated meta-analysis. Eur Rev Med Pharmacol Sci 2021;25:7005-13.
23. Omair MA, Alkhelb SA, Ezzat SE, Boudal AM, Bedaiwi MK, Almaghlouth I. Venous thromboembolism in rheumatoid arthritis: The added effect of disease activity to traditional risk factors. Open Access Rheumatol 2022;14:231-42.
24. Lin SY, Chang YL, Yeh HC, Lin CL, Kao CH. Blood transfusion and risk of venous thromboembolism: A population-based cohort study. Thromb Haemost 2020;120:156-67.
25. Cai J, Ribkoff J, Olson S, Raghunathan V, Al-Samkari H, DeLoughery TG, et al. The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients. Eur J Haematol 2020;104:79-87.
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.
27. Xu H, Zhang S, Xie J, Lei Y, Cao G, Chen G, et al. A nested case-control study on the risk factors of deep vein thrombosis for Chinese after total joint arthroplasty. J Orthop Surg Res 2019;14:188.
28. Klatsky AL, Armstrong MA, Poggi J. Risk of pulmonary embolism and/or deep venous thrombosis in Asian-Americans. Am J Cardiol 2000;85:1334-7.
29. White RH. The epidemiology of venous thromboembolism. Circulation 2003;107 23 Suppl 1:I4-8.
30. Klatsky AL, Baer D. What protects Asians from venous thromboembolism? Am J Med 2004;116:493-5.
31. Stein PD, Matta F. Epidemiology and incidence: The scope of the problem and risk factors for development of venous thromboembolism. Clin Chest Med 2010;31:611-28.
32. Jadaon MM. Epidemiology of prothrombin G20210A mutation in the Mediterranean Region. Mediterr J Hematol Infect Dis 2011;3:e2011054.
33. Tay K, Bin Abd Razak HR, Tan AH. Obesity and Venous Thromboembolism in Total Knee Arthroplasty Patients in an Asian Population. J Arthroplasty 2016;31:2880-3.
34. Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. J Bone Joint Surg Br 2007;89:316-22.
35. Shohat N, Ludwick L, Sherman MB, Fillingham Y, Parvizi J. Using machine learning to predict venous thromboembolism and major bleeding events following total joint arthroplasty. Sci Rep 2023;13:2197.
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Informed Consent: A Cornerstone of Ethical and Legal Orthopaedic Practice
/in Vol 10 | Issue 1 | January-June 2025 /by editor.jcorthJournal 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.
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Surgical Prophylaxis: Is it Always Needed in Orthopedics Practice
/in Vol 9 | Issue 2 | July - Dec 2024 /by editor.jcorthJournal 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
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Musculoskeletal Tissue Retrieval from Deceased Donors in India: Protocols and Challenges
/in Vol 9 | Issue 2 | July - Dec 2024 /by editor.jcorthJournal 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
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Tackling Post-TKR Complications: Achilles Allografts in Extensor Mechanism Reconstruction
/in Vol 9 | Issue 2 | July - Dec 2024 /by editor.jcorthJournal 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
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