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Walkathons a unique feature of JCOrth

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Journal of Clinical Orthopaedics | Vol 3 | Issue 1 |  Jan-June 2018 | page:1 | Dr. Nicholas Antao, Dr. Ashok Shyam

Author: Dr. Nicholas Antao [1], Dr. Ashok Shyam [2, 3]

[1] Hill Way Clinic, Hill N Dale Building, 4th Floor, Hill Road, Bandra West, Mumbai – 400050
[2] Sancheti Institute for Orthopaedics and Rehablitation, Pune, India
[3] Indian Orthopaedic Research Group, Thane, India.

Address of Correspondence
Dr. Nicholas Antao
Head of Dept. of Orthopaedics, Holy Spirit Hospital, Mahakali Road, Andheri (E), Mumbai – 400093 India.
Email: narantao@gmail.com

Walkathons a unique feature of JCOrth

Journal of Clinical orthopaedics is not your regular journal with original articles and strictly online academic content. Since its inception JCOrth has been planned to be a journal with a difference. Many new features have been envisioned and added to the journal however one of the unique features is the Walkathons.

Conventionally Walkathon’s are sports events covering considerable distances. We have taken the same concept and drawn a parallel with life journeys of prominent orthopaedic surgeons across the country and world. We try and conduct interviews with them either personally or ask a close associate to conduct an interview. This gives an excellent insight into the minds of these great men. Also it gives them the opportunity to share the best of their life lessons. In the first issue, the president of BOS Dr Aseem Parikh conducted an interview with Dr K V Chaubal and the interview was one of the best pieces of insight about Chaubal Sir. The next two interviews were on Dr Shailendra Bhattacharya and Dr SM Tuli. Both interviews were conducted by their close associates and are a masterpiece to read. In the current issue we have walkathon on another great of orthopaedics, Dr Shantaram Shetty. This is one of the most detailed walkathons that we have published that touches on every important aspect of Dr Shetty’s Life. In the next issue we plan to conduct a walkathon on Life of Dr GS Kulkarni

The idea of walkathons is to preserve as much history as possible and acknowledge the great contributions to orthopaedics by these great men. We have received a lot of appreciation for the same from all the personalities that we have interviewed and also received appreciation from the readers and board of JCOrth. We will continue this tradition and hope it engages more audience

Dr Nicholas Antao
Dr Ashok Shyam.

How to Cite this article: Antao N, Shyam AK. Walkathons a unique feature of JCOrth. Journal of Clinical Orthopaedics Jan -June 2018; 3(1):1

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Digitisation of medicine: A Welcome Step?

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Vol 3 | Issue 1 |  Jan – June 2018 | Page 2-4 | Murali Poduval

Authors: Murali Poduval

[1]Tata Consultancy Services, Mumbai

Address of Correspondence
Dr Murali Poduval, MS, DNB, PGDM (Healthcare Admin)
Consultant Orthopedic Surgeon, Senior Consultant
Tata Consultancy Services, Mumbai
Email: murali.poduval@tcs.com

Orthopaedics is a very technology intensive discipline. We are increasingly aware of technological improvements in the surgical sphere, the availability of more interactive navigation systems, simplified surgical tools and flexible implant choices, personalised implants, software-enabled scheduling and follow up, templating and planning tools: the list is endless and ever evolving.
Some years ago, I wrote a review entitled “Medicine as a corporate enterprise- A welcome step?” (1) In this review we investigated the pros and cons of the corporate structure that was taking over the practice of medicine. A decade later, I am writing on a topic that is taking medicine by storm, the digitisation of medicine. The digital enabling of medicine has arrived. It has invaded the workplace of not only the physician, but also the nurse, the therapist, the lab and every sphere of medical care. Digital medicine goes far beyond just technology as an instrument; it makes technology more human in its applications, potentially taking over some of the functions that were the exclusive right of a healthcare practitioner.
Healthcare has lagged behind other disciplines because of the uniqueness and complexity of clinical practice. There is tremendous variability between patients, between practitioners and between institutions. This makes it incredibly hard to reliably substitute or supplement the various aspects of decision making and planning that a clinician makes on a day-to-day basis. We have seen, over the years, the advent of EHR and EMR that have facilitated the running of large hospitals and streamlined the maintenance of patient databases whilst enabling tracking the patient’s hospital journey. Individual physician behaviour and clinical acumen is however a very different scenario.
The rapid strides in machine learning, digital learning and artificial intelligence have now started removing much of these hurdles. The unique ability of these technologies to learn tasks, reproduce them and to improve with increasing usage is leveraged in many applications. Spurred by the acquisition and availability of “big data”, decision support systems for doctors are now becoming a reality. Connectivity and accessibility in combination with predictive analytics are likely to make healthcare more efficient, cost effective, accessible and outcome oriented. In a white paper on the future of medical devices (3), IBM describes the users of medical devices as two broad groups of consumers, one is the motivated healthy individual who uses the health device to monitor and maintain health. The other group is the Chronically Monitored, suffering from chronic lifelong diseases needing monitoring. They are older and need the devices to keep going. An intermediate group is the information seeker. This group of patients has a potentially serious health risk or a condition that can be difficult to manage. The information seeker is the most efficient user of medical devices in the quest for health.(3)
The use of predictive analytics may be the ultimate enabler in the digital pathway of medicine. Predictive analytics is facilitated by the use of predictive tools to access and manipulate big data to gain insights and anticipate possible issues with increasing precision. (2) Applied to medicine, one could call it predictive medicine. The ability to integrate known disease characteristics with a specific patient’s health status to predict personalised therapy, response to treatment and to design future treatment protocols. It is a winner all the way for all the stakeholders. The patient benefits the most from better treatment, better access, decreased costs and fewer inpatient stays. The hospital benefits from better outcomes and decreased recurrent costs. The insurer benefits from the decrease in costs and better documented
outcomes.
Thus, the end user in the digital pathway may be the physician, the patient or the hospital/insurance provider. We could then envision this service as a product to enhance and optimise the delivery of healthcare across all domains. The various aspects of digital medicine include administration, telemedicine, m- Health and other technologies that may come in play in day-to-day administration and maintenance of medical care.
Telemedicine links less accessible areas to specialised medical care. In India, this is an invaluable tool to link primary and district health services to the central tertiary care teaching hospitals. This not only increases the accessibility of care but also the quality of services. It goes a long way in decreasing the overcrowding of medical services in the secondary and tertiary health care systems. Under the Digital India initiative, much is being done to bring e-health, including online consultations and follow up to the general population. Linkage of Adhaar to patient registrations is being implemented at some major hospitals. (4) These technologies that deal with medical information that is shared or transmitted electronically between individuals and sites to improve a patient’s clinical health status are termed as distance health technologies. Four distinct areas or application domains can be identified in the organisation of distance health systems which include real-time interactions, asynchronous applications which are not real time, remote patient monitoring technologies and mobile health domains. Each of these has a specific application which may overlap in usage space.(5)
Health tracking through mobile applications is used to monitor patients with chronic
illnesses. As longevity increases, the burden of chronic diseases has also increased. This brings with it a need to keep track of the patient’s wellbeing and the efficacy of a therapy administered to the patient. There is also a need to curtail rising costs of treatment and reduce re-admission rates. Mobile phones give a cheap and versatile supplement to regular hospital visits. There are a host of wearables in the market used by enthusiasts to monitor and maintain their own health. The regular check of weight, activity levels and basic health parameters have become a part of the daily routine of almost every individual with access to these technologies. These wearables powered by unique low cost sensors like accelerometers and gyroscopes are now being harnessed in the management of a number of chronic diseases. Real time and continuous monitoring are emphasised in chronic diseases like Parkinson, stroke, cardiovascular diseases and in chronic musculoskeletal ailments like back pain and osteoarthritis. Wearables coupled with mobile apps help patients take responsibility for their own treatment whilst keeping the physician updated on a regular basis of the status of the patient. Regular medication reminders and physiotherapy motivators are part of these solutions that are available on the cell phone application stores by the dozens. Google, Yahoo, Apple, IBM medical device manufacturers, start-ups and pharmaceuticals are all in the fray to find the perfect hardware solution and the perfect algorithm to match the solution. The magic of artificial intelligence and the promise of machine learning is creating a future sphere of immense potential. The IBM Watson project uses cognitive computing to sift through constantly updated data to assist in personalised decision making for therapeutics and development in various domains, especially cancer and drug discovery. This ever-evolving system is a benchmark for cognitive computing but the not the only one of its kind in current times. Powered by immense computing ability and accurate inputs of data which is constantly updated, such systems like Watson can generate extremely useful inputs for the clinician and the researcher. It must however be understood that the core of all machine learning is the input of accurate data. The oft quoted principle of “garbage in, garbage out” is to be kept in mind. However, we can see on the “not so far” horizon, the advent of better deep learning systems that overcome the handicap of needing to input volumes of accurately deciphered medical datasets to get meaningful output.
It is envisioned that the doctor may well become the pilot of healthcare delivery, overseeing the dashboard of data which will add to his clinical acumen and decision making power.(6) He will be empowered by the analyses provided by dedicated algorithms that he himself will help create as per his needs. He will be confident of his decisions on the strength of the data and the analyses provided to him supporting his decision. Will it take away his essential duties and replace his job of making a diagnosis and providing real time decisions on treatment? The answer is no. It is more realistic to understand that these systems would provide a doctor with an ecosystem to do what he does the best, care for the patient. He would be relieved by what is often described as “scut work” of documentation and analyses of reams of reports. (7) He would be provided with a concise dashboard of reports supplemented by real time analyses of a patient condition which would make his decision making simpler and more effective and the personalisation of therapy more efficient and predictable. He would be able to take fewer patients in his consulting hours, and each clinical visit with a patient would be a better utilisation of his time and constructive use of his abilities. With the advent of outcome based payments, and the push for better patient reported outcomes on healthcare practices, the ability to curtail costs becomes more and more complex. Efficiency and patient centricity being the essential attributes, achieving cost-accountability and efficiency becomes a difficult target to achieve. Digital medicine makes it possible to carry out Risk Based Monitoring of selected patient populations identified with specific risk factors, to enable early interventions and more predictable outcomes. The patient’s involvement in his own health is enhanced. Identification and attention to co-morbidities with the implementation of suitable lifestyle interventions can be prioritised in a phased and efficient manner. In a manner one could say this is an “incentive-based wellness programme.” The incentive being the involvement in one’s own health and fewer hospital visits with lower health costs. To be able to achieve this one needs tools that are economical and efficient, and easy to use for the physician and the patient. The era of transition of the wearable healthcare monitor to serve as a tool for this purpose has arrived with the adaptation of the mobile phone interface and smartwatches to serve these purposes. A number of tools have been developed to help clinicians predict the hospital stay and the likelihood of early discharge following joint replacement surgery. Other predictive analytic tools predict the postoperative pain and outcomes following joint replacement. Models and algorithms are being developed to determine the need for back surgery and predictors of successful outcome. We can expect these tools to become more refined and useful in the near future with the deployment of better algorithms in the rapidly developing technology sphere.
Zheng et al (8) reported on a novel online decision support system to help patients decide for knee arthroplasty. The tool enabled patients to make an informed, timely and data/evidence driven decision for surgery. The sample was small, but the tool demonstrated easy usability and high satisfaction with no technology blocks amongst the elderly populace. Olzak et al (9) have written about an artificial intelligence-based approach for reading orthopaedic trauma radiographs. The method was found over 99 percent accurate in identifying laterality and body part and over 83 percent accurate in detecting a fracture. Under similar conditions the performance was at par with two senior orthopaedic surgeons. Oh et al used a machine learning method using data from CT scans and clinical data to predict the pathological femoral fractures in patients with lung cancer. Machine learning has been used to optimise implant design (10) A large amount of interest is being created in the orthopaedic community about the application of machine learning and cognitive computing in our clinical practices. The Journal of Arthroplasty has dedicated two recent issues to technology. Stefano Bini has written an excellent review on the impact of machine learning, deep learning and cognitive computing on healthcare delivery. He has summarised beautifully that AI may be at the peak of the Gartner Hype Cycle but is unlikely to fall deep into the trough of disillusionment before coming out into enlightenment and productivity. He predicts that AI for predictive analytics and cognitive computing is going to be the new “normal”.(11) O’Donnell writes of three ways to bring augmented intelligence to the life sciences. (12) These include a sense of purpose, transparency and skill. She states that the industry suffers from a sense of information overload and that AI and cognitive capabilities would bring insights in front to enable value-based decisions. She also points out the need for a collaborative effort to use technology to help humans deliver and receive better care. This would involve training not only the system but also the user. (12)
Digital medicine is here to stay, and the future belongs to those who are willing to adapt to the change, to those who will collaborate in making this evolutionary change in the way healthcare is delivered, received and interpreted.

Acknowledgements
I would like to acknowledge the active insights and inputs of my colleague Dr Sanjay M Kimbahune, Senior Scientist, Embedded Systems and Robotics, Tata Consultancy Services , Mumbai, in preparation of this manuscript.

References

1. Poduval M, Poduval J., (2008), Medicine as a Corporate Enterprise: A Welcome Step? In: Medicine, Mental Health, Science, Religion, and Well-being (A.R. Singh and S.A. Singh eds.), MSM, 6, Jan – Dec 2008, p157-174.
2. Elton J, Ural A. “Predictive Medicine Depends On Analytics.” Harvard Business Review. (2014) Oct 14;:1–4. Available from: https://hbr.org/2014/10/predictivemedicine- depends-on-analytics . Accessed on July 24 2018.
3 Fraser H, Kwon Y, Neuer M. “The future of connected health devices”. IBM Global Business Services Executive Report. 2011 Mar pp. 1–20. Available from: https:// www- 935.ibm.com/services/us/gbs/thoughtleadership/ibv-connected-healthdevices. html . Accessed 24 July 2018.
4. http://www.digitalindia.gov.in/rural accessed on 30.07.2018
5. Schaffer JL,Rasmussen PA, Faiman MR. The Emergence of Distance Health Technologies. J Arthroplasty.; 2018 Aug 1;33(8):2345–51.
6. Woodson J., “Decades Ago, Pilots Learned to “Fly by Instruments.” Doctors need to do the same”. Harvard Business Review (2018) Mar 15;:1–5. Available from:
https://hbr.org/2018/03/decades-ago-pilots-learned-to-fly-by-instruments-doctorsneed- to- do-the-same accessed 24.07.2018
7. BUSH J. “How AI Is Taking the Scut Work Out of Health Care” Harvard Business Review (2018) Mar 5;:1–4. Available from: https://hbr.org/2018/03/how-ai-is- takingthe-
scut-work-out-of-health-care
8. Zheng, H., Rosal, M. C., Li, W., Borg, A., Yang, W., Ayers, D. C., & Franklin, P. D. (2018). A Web-Based Treatment Decision Support Tool for Patients With Advanced Knee Arthritis: Evaluation of User Interface and Content Design. JMIR Human Factors, 5(2), e17.
9. Olczak, J., Fahlberg, N., Maki, A., Razavian, A. S., Jilert, A., Stark, A., … Gordon, M. (2017). Artificial intelligence for analyzing orthopedic trauma radiographs: Deep learning algorithms—are they on par with humans for diagnosing fractures? Acta Orthopaedica, 88(6), 581–586.
10. Cilla M, Borgiani E, Martınez J, Duda GN, Checa S (2017) Machine learning techniques for the optimization of joint replacements: Application to a short-stem hip implant. PLoS ONE 12(9): e0183755.
11) Bini, Stefano A. : Artificial Intelligence, Machine Learning, Deep Learning, and Cognitive Computing: What Do These Terms Mean and How Will They Impact Health Care? The Journal of Arthroplasty , 33(8), 2358 – 2361.
12. O’Donnell L, Three Principles to bring augmented intelligence to life sciences ; Watson Health Perspectives , available at https://www.ibm.com/blogs/watson-health/ three-principles-for-bringing-ai-to-life-sciences/ accessed 24/08/2018

How to Cite this article: Poduval M. Digitisation of medicine: A welcome step? Journal of Clinical Orthopaedics Jan -June 2018; 3(1):2-4

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A Malunited Fibula with raised Lateral Malleolus treated Surgically by Fibular Osteotomy and Plating

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Vol 3 | Issue 2 |  July-Dec 2018 | Page 54-55 | HR Jhunjhunwala.

Authors: HR Jhunjhunwala [1].

[1] Department of Orthopaedics, Bombay Hospital Postgraduate Institute of Medical Sciences, Marine Lines, Mumbai, India.

Address of Correspondence
Dr. HR Jhunjhunwala,
Department of Orthopaedics, Bombay Hospital Postgraduate Institute of Medical Sciences, Marine Lines, Mumbai, India.
Email: drhrj2@gmail.com

Abstract

Isolated fibular fractures are often considered innocuous and treated conservatively. They may malunited and predispose the ankle to severe twisting injuries. We present one such case where the patient presented with twisting injury to the ankle. Radiograph revealed a malunited fibula which was high riding. To prevent future such episodes, fibula was pulled down by doing an osteotomy and was stabilised with a plate. The union was uneventful and at final follow up pf two years the patient is symptom free
Keywords: malunited fibula, Osteotomy

References

1. Sakaki MH, Matsumura BAR, Dotta TDAG, et al. Epidemiologic study of ankle fractures in a tertiary hospital. Acta Orto Bras. 2014;22(2):90-93.
2. Thur CK, Edgren G, Jansson KÅ, et al. Epidemiology of adult ankle fractures in Sweden between 1987 and 2004: a population-based study of 91,410 Swedish inpatients. Acta Orthop. 2012;83(3):276-281.
3. McPhail SM, Dunstan J, Canning J, et al. Life impact of ankle fractures: Qualitative analysis of patient and clinician experiences. BMC Musculoskeletal Disorders. 2012;13:224.
4. Hosea TM, Carey CC, Harrer MF. The gender issue: Epidemiology of ankle injuries in athletes who participate in basketball. Clin Orthop Relat Res. 2000;(372):45-49.
5. Helfet DL, Haas NP, Schatzker J, et al. AO Philosophy and Principles of Fracture Management-Its Evolution and Evaluation. J Bone Joint Surg Am, 2003;85(6):1156-1160 .
6. Van Wensen RJA, van den Bekerom MPJ, Marti RK, et al. Reconstructive osteotomy of fibular malunion: review of the literature. Strategies in Trauma and Limb Reconstruction. 2011;6(2):51-57.
7. Zhenhua F, Waizy H, Ming X, et al. Lateral malleolus hook plate for comminuted Weber A and B fractures: A retrospective study. Indian J Orthop. 2013;47(4): 364–369.
8. Buscharino B, MorettiRG, Hungria JOS, et al. Biomechanical Study: Resistance Comparison of Posterior Antiglide Plate and Lateral Plate on Synthetic Bone Models Simulating Danis-Weber B Malleolar Fractures. Rev Bras Ortop. 2013;48(3):221-227.

How to Cite this article: Jhunjhunwala HR. A Malunited Fibula with raised Lateral Malleolus treated surgically by Fibular Osteotomy and Plating. Journal of Clinical Orthopaedics July-Dec 2018; 3(2):54-55.

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Reconstruction of Ankle Mortise following Resection of Giant Cell Tumor of Distal Fibula

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Vol 3 | Issue 2 |  July-Dec 2018 | Page 51-53 | Dinesh Chidambaram, Prakash Sengottaiyan, Karthikeyan Chinnaswami.

Authors: Dinesh Chidambaram [1], Prakash Sengottaiyan [2], Karthikeyan Chinnaswami [1].

[1] Dept of Orthopaedic Surgery, Royal Care Superspeciality Hospital, Neelambur, Coimbatore, Tamilnadu, India
[2] Dept of Plastic Surgery, Royal Care Superspeciality Hospital, Coimbatore, India

Address of Correspondence
Dr. Dinesh Chidambaram,
Royal Care Superspeciality Hospital, Neelambur, Coimbatore, Tamilnadu, India
Email: dineshchidambaram75@gmail.com

Abstract

Introduction: Giant cell tumor commonly occurs in the age group of 20-40 years with the commonest predilection around the knee joint. This case is presented here for its rare occurence in the distal fibula and its unique management.
Case report: 25 year old male patient presented with complaints of pain and swelling over the outer aspect of left ankle for one year. On examination there was a diffuse swelling over distal third fibula with classical egg shell cracking consistency. Imaging with X ray, Computed tomography (CT) and Magnetic resonance imaging (MRI) revealed eccentric, expansile, lytic lesion with cortical breech. Thus a preoperative diagnosis of Giant Cell tumor(GCT) was made. Chest X ray and CT Chest were normal. Trucut Biopsy revealed features suggestive of Giant Cell Tumor. Locally aggressive tumor in an expendable bone warrants resection of distal fibula to prevent recurrence, which compromises ankle stability. So we did wide resection of the distal fibula and reconstruction of the ankle mortise with ipsilateral proximal fibula. Biceps femoris tendon and fibular collateral ligament were secured with suture anchor to lateral proximal tibia to avoid knee instability. Excision biopsy revealed giant cell tumor with margins free of tumor invasion. At one year follow up, there is no recurrence locally and patient walks without any support with normal knee and ankle range of movements . There is no lateral opening of knee joint on varus stress test with knee in 30 degree flexion. Mean musculoskeletal tumor society (MSTS) score was 100%.
Conclusion: Giant cell tumor involving distal fibula is very rare. Owing to high recurrence rate, resection of tumour in toto and to enable the patient with good ankle stability, reconstruction of ankle mortise with ipsilateral proximal fibula is an appropriate mode of management especially in young patients.
Keywords: GCT, Distal Fibula, Resection and Reconstruction with Proximal Fibula

References

1. Puri A, Agarwal MG. Current concepts in bone and soft tissue tumours.Chapter 6 page 53 – 54.
2. Mirra JM. Giant Cell Tumours. Mirra JM (Ed), Bone Tumours.Clinical Radiologic and Pathologic correlations, Vol 2. Philadelphia: Lea and Febiger; 1989, pp 942.
3. Jones RB, Ishikawa SN, Richardson EG, Murphy GA. Effect of distal fibular resection on ankle laxity. Foot and Ankle International 2001;22:590–3.
4. Zhao S-C, Zhang C-Q, Zhang C-L. Reconstruction of lateral knee joint stability following resection of proximal fibula tumors. Experimental and Therapeutic Medicine. 2014;7(2):405-410. doi:10.3892/etm.2013.1429.
5. Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstruction procedures after surgical treatment of tumors of the musculoskeletal system. Clinical Orthopaedics and Related Research 1993;286(1):241–6.
6. Sung HW, Kuo DP, Shu WP, Chai YB, Liu CC, Li SM. Giant cell tumor of bone: Analysis of two hundred and eight cases in Chinese patients. J Bone Joint Surg Am. 1982;64:755–61
7. Campanacci M. Giant cell tumor. In: Gaggi A, editor. Bone and soft-tissue tumors. Bologna, Italy: Springer-Verlag; 1990. pp. 17–53.
8. Vaishya R, Kapoor C, Golwala P, Agarwal AK, Vijay V. A Rare Giant Cell Tumor of the Distal Fibula and its Management. Muacevic A, Adler JR, eds. Cureus. 2016;8(7):e666. doi:10.7759/cureus.666.
9. Leibner ED, Ad-El D, Liebergali M, Ofiram E, London E, Peyser A. Lateral malleolar reconstruction after distal fibular resection. A case report. Journal of Bone and Joint Surgery American Volume 2005;87:878–82.
10. Capanna R, van Horn JR, Biagini R, Ruggieri P, Bettelli G, Campanacci M. Reconstruction after resection of the distal fibula for bone tumor. Acta Ortho-paedica Scandinavica 1986;57:290–4.
11. Khodamorad Jamshidi, Farid Najd Mazhar, Zahra Masdari. Reconstruction of distal fibula with osteoarticular allograft after tumor resection.official journal of the European society of foot and ankle surgeons 2013 19;1: 31 – 35.
12. Carrell WB. Transplantation of the fibula in the same leg. Journal of Bone and Joint Surgery 1938;20:627–34.
13. Malawer MM. Surgical management of aggressive and malignant tumors of the proximal fibula. Clinical Orthopaedics and Related Research 1984;186:172–81.

How to Cite this article: Dinesh C, Sengottaiyan P, Chinnaswami K. Reconstruction of ankle mortise following resection of giant cell tumor of distal fibula. Journal of Clinical Orthopaedics July-Dec 2018; 3(2):51-53.

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Three Stitch technique for Humerus Nailing

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Vol 3 | Issue 2 |  July-Dec 2018 | Page 48-50 | Sachin Kale, Vaibhav Koli, Prakash Samant, Sanjay Dhar, Sandeep Deore, Gaurav Kanade.

Authors: Sachin Kale [1], Vaibhav Koli [1], Prakash Samant [1], Sanjay Dhar [1], Sandeep Deore [1], Gaurav Kanade [1].

[1] Department of Orthopaedic surgery, Dr. D.Y. Patil medical college, Nerul,Navi Mumbai.

Address of Correspondence
Dr. Vaibhav Koli,
Department of Orthopaedics, Dr. D.Y. Patil medical college, Nerul,Navi Mumbai.
E-mail id: vaibhavkoli08@gmail.com

Abstract

Intramedullary nailing for humerus diaphyseal fractures is associated with a quite a number of complications like violation of rotator cuff, soft tissue injury around the shoulder and elbow. The purpose of this article is to describe a simple three stitch technique for intramedullary humerus nailing which aims at avoiding most of the common complications encountered during and after humerus nailing. One year follow up of all the patients have shown good to excellent results and favorable functional outcomes.
Keywords: humerus diaphyseal fractures, antegrade humerus nailing, three stitch technique

References

1. Rose SH, Melton LJ, Morrey BF, Ilstrup DM & Riggs BL (1982) Epidemiological features of humeral fractures. Clin Orthop 168: 24–30.
2. Sarmiento A, Waddellle JP, Latta LL. Diaphyseal humeral fractures: treatment options. Instr Course Lect 2002;51:257-69.
3. Zuckerman JD, Koval KJ. Fractures of the shaft of the humerus. Chap 15, In Rockwood and Green Fractures in Adults. 4th ed. Philadelphia, PA: JB Lippincott 1996:p. 1025-51
4. Farragos AF, Schemitsch EH, McKee MD. Complicationsof intramedullary nailing for fractures of the humeral shaft: a review. J Orthop Trauma. 1999;13:258-67. doi:10.1302/0301- 620X.90B1. 19215.
5. Lögters TT, Wild M, Windolf J, Linhart W. Axillary nerve palsy after retrograde humeral nailing: clinical confirmation of an anatomical fear. Arch Orthop Trauma Surg 2008;128:1431-5
6. Cheng HR, Lin J. Prospective randomized comparative study of antegrade and retrograde locked nailing for middle humeral shaft fracture. J Trauma. 2008;65:94-102.
7. Sarmiento A, Kinman P, Galvin E. Functional bracing of fractures of the shaft of the humerus. JBJS (Am) 1977; 59- A.596-601
8. RG McCormack, D. Brien, RE Buckley, MD McKee, J Powell, EH Schemitsch. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective randomised trial. JBJS (Br) 2000; 82-B: 336-9
9. Christos Garnavos.Diaphyseal humeral fractures and intramedullary nailing: Can we improve outcomes. Indian Journal of Orthopaedics | May 2011 | Vol. 45 | Issue 3,Pg 208-213
10. Stern PJ, Mattingly DA, Pomeroy DL, Zenni EJ Jr, Kreig JK. Intramedullary fixation of humeral shaft fractures. J Bone Joint Surg Am 1984;66:639-46.
11. Evans PD, Conboy VB, Evans EJ. The Seidel humeral lockingnail: an anatomical study of the complications from locking screws. Injury 1993;24:175-6.
12. Garnavos C. Intramedullary nailing for humeral shaft fractures: the misunderstood poor relative. Current Orthop 2001; 15:68-75.
13. Kolonja A, Vecsei N, Mousani M, Marlovits S, Machold W, Vecsei V. Radial nerve injury after anterograde and retrograde locked intramedullary nailing of humerus. A clinical and anatomical study. Osteo Trauma Care 2002;10:192-6.

How to Cite this article: Kale S, Koli V, Samant P, Dhar S, Deore S, Kanade G. Three Stitch technique for humerus nailing. Journal of Clinical Orthopaedics July-Dec 2018; 3(2):48-50.

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Surgical treatment of Posterior Malleolus Fracture

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Vol 3 | Issue 2 |  July-Dec 2018 | Page 44-47 | Nicholas Antao, K.S. Kushalappa, Rajesh Hingwe, Ashish Upadhyay.

Authors: Nicholas Antao [1], K.S. Kushalappa [1], Rajesh Hingwe [1], Ashish Upadhyay [1].

[1] Department of Orthopaedic surgery, Holy Spirit Hospital, Mumbai, Maharashtra

Address of Correspondence
Dr. Nicholas Antao,
Dept. of Orthopaedics, Holy Spirit Hospital, Mahakali Road, Andheri (E), Mumbai – 400093 India.
Email: narantao@gmail.com

Abstract

Introduction: Posterior malleolus fractures mostly occur in association with fractures of other malleoli. The current recommendation is fixation based on the size of the fragment.
Materials & Methods: A retrospective study of 30 cases of posterior malleolus was conducted. There were 4 cases in type 1, 8 cases in Type 2, 7 cases in type 3, 10 cases in Type 4 and Type 5 there was one case. Type 1 were not operated, and type 5 were left alone in POP cast for 6 weeks. Type 2, 3 and 4 were operated either by cannulated cancellous screw by trans-Achilles approach, when the fragment was less than 20% of the surface area in 6 cases. When the surface exceeded 15% , those cases were treated with osteosynthesis by posterolateral approach using a buttress plate principle.
Results: Good results were seen in all cases except one which develop post-operative infection and had early arthritis.
Conclusion: Radiological studies are essential to plan, and posterolateral approach provides a good exposure for management of posterior malleolar fractures
Keywords: Posterior malleolar fracture, fixation, 3D CT scan

References

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How to Cite this article: Antao N, Kushalappa KS, Hingwe R, Upadhyay A. Surgical treatment of posterior malleolus fracture. Journal of Clinical Orthopaedics July -Dec 2018; 3(2):44-47.

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Prevalence of Nerve Injuries in Lower Limb following Total Joint Replacement Surgery, and Management

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Vol 3 | Issue 2 |  July-Dec 2018 | Page 36-43 | Kunal Ajitkumar Shah, Mohan M Desai.

Authors: Kunal Ajitkumar Shah [1], Mohan M Desai [1].

[1] Department of Orthopaedics, KEM Hospital, Parel Mumbai

Address of Correspondence
Dr. Mohan Desai,
Department of Orthopaedics, KEM Hospital, Parel Mumbai
Email: md1964@gmail.com

Abstract

Nerve injuries during lower limb joint replacement are uncommon but serious complications. Review of this condition is sparse in literature. The present review aims to collate the current literature and provide an overview of the subject. Subclinical cases are quite common and preoperative counseling would be helpful. In case the nerve injury occurs, assurance and counselling helps. Since, the prognosis is not uniform and depends on multiple factors, it is best to try and avoid these iatrogenic injuries. A good surgeon knows how to manage his complications, but the best surgeon knows how to avoid them!
Keywords: Nerve injuries, knee arthroplasty, hip arthroplasty, iatrogenic

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How to Cite this article: Shah K, Desai M. Prevalence of Nerve Injuries in Lower Limb following Total Joint Replacement Surgery, and Management. Journal of Clinical Orthopaedics July-Dec 2018; 3(2):36-43.

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Orthobiologics-Today

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Vol 3 | Issue 2 |  July-Dec 2018 | Page 30-35 | Ramesh K Sen, Manuj Aggarwal.

Authors: Ramesh K Sen [1], Manuj Aggarwal [1].

[1] Institute of orthopaedics, Max hospital Mohali, India

Address of Correspondence
Dr. Ramesh Sen,
Institute of orthopaedics, Max hospital Mohali, India
Email: senramesh@rediffmail.com

Abstract

Orthobiologics is a newer science that has biologic-based therapies for treatment of various hip, knee, ankle and shoulder pathologies. It involve biological sources which promote and accelerate bone and soft tissue healing and based on theoretical advantages in focal chondral defect, osteoarthritis, AVN hip, plantar fasciitis and various tendinopathies. Strong evidence which support the use of biologic agent such as hyaluronic acid, platelet rich plasma bone marrow aspirate concentrate, largely remain absent from the literature. This article review the existing literature on most commonly employed biologic agent for the different knee, hip, and ankle pathologies. There was a lack of clinical evidence for various treatment strategies; therefore we suggest that there is a need for comparative studies in future.
Keywords: Orthobiologics, Hyaluronic acid, platelet rich plasma, Bone marrow aspirate concentrate; Adipose derived stem cells, Osteoarthritis

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How to Cite this article: Sen RK, Aggarwal M. Orthobiologics-Today. Journal of Clinical Orthopaedics Jan-June 2018; 3(2):30-35.

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Simultaneous Bilateral Total Knee Replacement – Current Evidence Based Management Strategy

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Vol 3 | Issue 2 |  July-Dec 2018 | Page 22-29 | Abhishek Patil, Nandan Rao.

Authors: Abhishek Patil [1], Nandan Rao [2].

[1] Department of Joint Replacement and Orthopaedics, Sahyadri Superspeciality Hospital Hadapsar, Pune, Maharashtra, India
[2] Department of Orthopaedics Reliance Hospital, Navi Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Abhishek Patil, Sahyadri Superspeciality Hospital, Survey number 163, Bhosale nagar, Pune-Solapur road, Hadapsar, Pune. 411028
Email- abhipatortho@gmail.com

Abstract

With an ever-increasing geriatric population and associated knee arthritis; the number of patients requiring total knee arthroplasty continues to rise. In India 94% of patients with Kellegren-Lawrence grade 3 or 4 arthritis have bilateral arthritis. As such bilateral knee arthroplasty offers the convenience of single surgery, concomitant recovery and rehab of both knees and significant cost savings. However traditionally simultaneous bilateral knee replacement has been associated with higher mortality- both in hospital and after discharge extending up to 1 year and higher morbidity due to cardio-pulmonary complications, deep vein thrombosis, pulmonary embolism and higher rates of readmissions. With modern day surgical refinements and improved anesthetic practices; recent studies have reported results and complications at par with unilateral and staged bilateral total knee arthroplasty. However controversies do remain over the applicability of doing simultaneous bilateral knee arthroplasty. Ethical considerations and rarity of complications have made it difficult to conduct adequately powered randomized trials to justify or refute the practice of simultaneous bilateral knee arthroplasty. This review tries to amalgamate the views of recent literature to give the present status and best practices in simultaneous bilateral total knee arthroplasty.
Keywords: Total knee arthroplasty, bilateral total knee arthroplasty, bilateral knee replacement, knee arthritis, knee arthroplasty, knee replacement.

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Pediatric ACL in Sports, Prognosis, Decision Making and Outcomes of Management

/in , /by

Vol 3 | Issue 2 |  July-Dec 2018 | Page 16-21 | Reha N. Tandoğan, Metin Polat.

Authors: Reha N. Tandoğan[1], Metin Polat [2].

[1] ankaya Orthopedics, Ankara, Turkey,
[2] Orthopedic Surgeon, Cankaya Orthopedics, Ankara, Turkey

Address of Correspondence
Dr. Reha N. Tandogan,
Cinnahcaddesi 51/4 Cankaya Ankara, Turkey
Email: rtandogan@ortoklinik.com

Abstract

Anterior cruciate ligament (ACL) injuries in pediatric & adolescent patients may occur as tibial eminence fractures, mid-substance ligament injuries and peel-off injuries of the femoral insertion site. ACL injuries in adolescents nearing skeletal maturity may be treated as adults without risk of deformity or leg length discrepancy. Treatment of ACL injuries children with wide open physes and substantial remaining growth are controversial. Disappointing functional results and an increased prevalence of secondary meniscal and cartilage damage with conservative management have led to an increased utilization of surgical treatment in these children. ACL reconstruction with soft tissue grafts and physeal sparing techniques are considered the gold standard of surgical management. Primary repair combined with healing enhancement techniques for femoral peel-off injuries with minimal damage to the body of the ACL can be used in select cases. The rates of growth disturbance after ACL surgery remain low with modern techniques and are usually clinically insignificant. However, a higher rate of failure and need for revision has been reported in pediatric & adolescent ACL injuries compared to adults. The risk of failure increases in patients with allografts and who return to high risk impact sports.
Keywords: Paediatric ACL tEAR, Physeal sparing techniques, repair

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How to Cite this article: Tandoğan R N, Polat M. Pediatric ACL in sports, prognosis, decision making and outcomes of management. Journal of Clinical Orthopaedics July-Dec 2018;3(2):16-21.

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