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Potpourri – Recent and relevant literature in 2017

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

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

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

Address of Correspondence
Dr. Sunny Gugale
Dept of Arthroscopy, Sancheti Institute for Orthopaedics and Rehabilitation,
Pune, Maharashtra India.
Email: dr.sunnygugale@gmail.com

Hip Arthroscopy

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

Thromboprophylaxis in Arthroscopy

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

Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease

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

Femoroacetabular impingement and arthroscopy

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

Rotator cuff tear

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

Special Articles

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

References

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

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

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An Atypical Complication of Osteoarthritis Knee —Non Traumatic Recurrent Haemarthrosis Knee

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Vol 2 | Issue 2 | July – Dec 2017 | Page 34-35 | Manoj Shah, Ashok K. Shyam

Authors: Manoj Shah [1], Ashok K. Shyam [2,3]

[1] Shah Fracture Orthopaedic Hospital, Malad, Mumbai, India
[2]Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
[3]Indian Orthopaedic Research Group, Thane, India.

Address of Correspondence
Dr. Manoj Shah
Shah Fracture Orthopaedic Hospital, Srinivas Apartment,
S.V. Road, Malad West, Mumbai – 400064, India
E-mail: drmanoj.shah44@gmail.com

Abstract

Recurrent synovitis is a known presentation of osteoarthritis but at times the synovium may become very vascular and patient may present with recurrent haemarthrosis. We present a case of recurrent haemarthrosis in an elderly osteoarthritis patient
Case Report: A 72 year old male with tricompartmental osteoarthritis presented four episodes of recurrent haemarthrosis within a span of 2 months. He had recently undergone angioplasty and was on anticoagulants which were stopped in consultant of cardiologist. On recurrence of haemarthrosis, an arthroscopic debridement and synovectomy was done. LOOSE PIECES OF meniscus were also removed but no bleeder was identified. Two days after arthroscopy he again developed haemarthrosis and a digital subtraction angiography was done to identify the feeder vessel. This showed moderate vascular blush around the knee with supply from both genicular branches. Trans Arterial Embolization using polyvinyl alcohol particles was done for both feeder vessels. Patient had not further episodes or haemarthrosis and continues on conservative management of osteoarthritis
Conclusion: Osteoarthritis may lead to severe vascularization of synovium which may present as recurrent haemarthrosis. Finding the cause of haemarthrosis and managing it would relieve the symptoms
Keywords: Recurrent haemarthrosis, osteoarthritis, synovectomy, embolization.

References

1. Wilson JN. Spontaneous haemarthrosis in osteoarthritis of knee–A report of five cases. Br Med J 1959;23:1327-8
2. Kawamura H., Ogata K., Miura H., Arizono T., Sugioka Y. Spontaneous hemarthrosis of the knee in the elderly: etiology and treatment. Arthroscopy. 1994;10(2):171–175.
3. Morii T., Koshino T., Suzuki K., Kobayashi A., Kurosaka T., Shimaya M. Etiology and treatment of spontaneous hemarthrosis of knee in the elderly. The Japanese Orthopaedic Association. 1990;64:p. S195.
4. Nomura E, Hiraoka H, Sakai H. Spontaneous Recurrent Hemarthrosis of the Knee: A Report of Two Cases with a Source of Bleeding Detected during Arthroscopic Surgery of the Knee Joint. Case Rep Orthop. 2016;2016:1026861.
5. DiNicolantonio JJ, D’Ascenzo F, Tomek A, Chatterjee S, Niazi AK, Biondi-Zoccai G. Clopidogrel is safer than ticagrelor in regard to bleeds: a closer look at the PLATO trial. Int J Cardiol. 2013 Oct 3;168(3):1739-44.
6. Bagla S, Rholl KS, van Breda A, Sterling KM, van Breda A. Geniculate artery embolization in the management of spontaneous recurrent hemarthrosis of the knee: case series. J Vasc Interv Radiol. 2013 Mar;24(3):439-42.
7. Weidner ZD, Hamilton WG, Smirniotopoulos J, Bagla S. Recurrent Hemarthrosis Following Knee Arthroplasty Treated with Arterial Embolization. J Arthroplasty. 2015 Nov;30(11):2004-7
8. Waldenberger P, Chemelli A, Hennerbichler A, Wick M, Freund MC, Jaschke W, Thaler M, Chemelli-Steingruber IE. Transarterial embolization for the management of hemarthrosis of the knee. Eur J Radiol. 2012 Oct;81(10):2737-40.

How to Cite this article:  Shah M, Shyam AK. An Atypical Complication of Osteoarthritis Knee —Non Traumatic Recurrent Haemarthrosis Knee. Journal of Clinical Orthopaedics July – Dec 2017; 2(2):34-35.

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Orthopaedic Complications: how to prepare ourselves for one!

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Journal of Clinical Orthopaedics | Vol 2 | Issue 2 |  July – Dec 2017 | page:1-2 | 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

Orthopaedic Complications: how to prepare ourselves for one!

The concept of analysis of desired and expected benefits versus potential risks and costs is attributed to 18th century mathematician Daniel Bernoulli, and bears relevance even today to our practice of Orthopaedics, specifically with respect to complications.
Our huge population in India and the volume of our work helps us to examine and review a large number of patients with a spectrum of lesions. In such a wide scope of our work, one treatment does not suit all problems associated with the personality of that injury/disease. It is extremely important to be well informed and knowledgeable. Also we need to be thoroughly equipped with not only one plan, but to have ready contingency plans for any eventuality or complication. Such an approach can help us avoid problems and complications as well.
Attending conferences, clinical meetings and reading journals among other things, gives us the exposure to clinically time tested techniques from experts in the field. Their evidence based data and analysis of their volume of work, can be beneficial, when we are faced with a dilemma of what is best for our patient.
An athlete with a shoulder dislocation has to be assessed thoroughly, keeping in mind that the surgical technique used will have to support his speedy recovery to pre injury status. Non athletic person may need the same technique but his expectation of recovery may be different and less pressured. Hence the management and rehabilitation will have to be tailored to meet the needs of the patient. Where as an athlete or an insured patient may demand a top of the line modality/implant, one with lesser financial means may even want to avoid surgery and seek more conservative management. These can simplify the management and reduce serious complications.
We, as modern day clinicians are fortunate to have as a resource, modern day imaging to confirm our diagnosis. Personally, I feel content when my clinical diagnosis matches that of the radiologist. It helps remarkably to see oneself and discuss finer aspects with the radiologist. The opinion of a competent radiologist, who is well informed about the patient, can be an asset to the Orthopaedic surgeon in confirming the minute details of the pathology of the problem. Taking help of our peers while dealing with a complex case scenario is a wise thing to do [1].
So in our effort to get a proper diagnosis, we need to get a valuable history from the patient. The history must be well integrated with a detailed clinical examination and imaging. This will help us to make a proper decision and arrive at a tailor made treatment for that particular case. We must take into consideration many factors, like the personality of the injury, occupation of the patient and economic considerations, which will help with a comprehensive treatment plan.
Patient factors play a very important role, especially in terms of managing a complication. Communication is a key to preventing a small issue spiralling out of control. Communicating about risk of complications to patients before the surgery is a practice which is often recommended but seldom followed. This also with preoperative assessment for potential risk factors for complications will definitely reduce the impact of complications. Patient education as well as surgeons education about complications along with priming of the associated hospital staff both in prevention and management of complications is one of the best investment for any hospital. In current era of increased friction between patients and doctors, being aware of complications and managing them successfully needs both doctor and patient to work compassionately and not conflict with each other [2] Communication, education and an optimised infrastructure with evidence based
Most often complications can be controlled, when the procedure is done in a technically sound way by executing that particular plan for that specific patient. The theme of this issue is Complications. Complications not only result in untold misery for the patient but also add to the anxiety and stress of the surgeon. It is something we all want to avoid and keep at bay. We hope the above editorial gives some insight for the same and we request our readers to write to us their opinions and suggestions as letter to editors.
We are also glad to share that our journal is now indexed with Index Copernicus and thus now fulfils all the requirements for an indexed journal as laid by MCI. This has been achieved in a short period of one year and we would like to thanks all our authors, readers, reviewers and editorial board members for supporting the venture. We would like to extend personal gratitude to the entire Bombay orthopaedic society and all its members and look forward to their support and submissions in years to come.

We leave you now to enjoy the issue and also enjoy WIROC 2017.
Dr Nicholas Antao
Dr Ashok Shyam.

References

1. Shyam A. Wisdom of the Crowds: Extending the Domain of Medical Information to Case Banks and Online Forums. J Orthop Case Rep. 2013 Apr-Jun;3(2):1-3.
2. Gulia A. Let’s treat a Doctor as Human!!! Indian J Med Sci 2017 April – June;69 (2):1.

How to Cite this article: Antao N, Shyam AK. Orthopaedic Complications: how to prepare ourselves for one! . Journal of Clinical Orthopaedics July -Dec 2017; 2(2):1-2.

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What do you expect from WIROC 2017?

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Vol 2 | Issue 2 |  July – Dec 2017 | Page 3-4 | C J Thakkar, Harshad Argekar, Neeraj Bijlani

Authors: C J Thakkar [1], Harshad Argekar [2], Neeraj Bijlani [3].

[1] Department of Orthopaedics, Breach Candy Hospital, Mumbai, India.
[2] Department Of Orthopaedics, Lokmanya Tilak Municipal Medical College And General Hospital, Sion. Mumbai. India.
[3] OrthoTech Clinic and Sai Baba Hospital, Mumbai, India.

Address of Correspondence
Dr.Neeraj Bijlani
OrthoTech Clinic, 405, Shubham Atlanta, RC Marg, Chembur East, Mumbai 400071.
Email: drbijlani@gmail.com

Good venue? Excellent food? Sensational entertainment? Or do you expect to have good symposia, current updates & latest research?

Without a doubt, anyone spending time and money to come to Mumbai to attend WIROC will choose academics over entertainment. Satisfaction of mental curiosity over satisfaction of physical hunger, stimulation of the mind over stimulation of the senses. This is what we, the organizers believe and this is what we have attempted to achieve.
Every year WIROC has a theme, this year we have a mission! A mission to come clean on events that have previously not been discussed, to be completely honest about disasters, confess to problems faced with an aim to prevent us from facing a similar situation while treating our patients in the future. It takes a special effort to be bold enough to have thought about such a controversial theme and all credit to our president Dr C J Thakkar to have come up with this idea. In the beginning we were extremely wary of the direction we were asked to take, but soon we realized the vision seen by Dr Thakkar and we warmed up to it. This WIROC is dedicated to focusing of what can go wrong and how to avoid it.
‘Delegate becomes faculty’ is the novelty this year We are proud to say that this is the first time in WIROC history that we have asked delegates to send in cases for presentation on the podium. The delegates have a chance to be faculty. The response has been overwhelming, orthopaedic surgeons all over India and some from abroad have sent us their disasters. We have had a tough time choosing the ones which stay true to the theme and are relevant to our audience. We have managed to shortlist the best 15, all of whom will get primetime podium presentation in the plenary sessions of WIROC 2017, an honour reserved for few. Those who have not made it, due to limited availability of time, have been selected as posters. Congratulations and kudos to all those who shared their problems to update our knowledge.

Prevention of complication before they occur is what we all aim for. That gets us to the true purpose of WIROC 2017. To empower orthopaedic surgeons to avoid complications altogether. To this end “Perfection Through Protocols” is our motto. These are not just fancy words. This WIROC, The Bombay Orthopaedic Society publishes its book on Protocols. With this publication we declare our commitment to patient care. We urge all our members to follow this common format when they offer treatment to their patients. Following a protocol ensures, standardization of treatment and more importantly standardization on ‘information’ that a patient receives. It also highlights that the same condition can be treated by different ways and no treatment is perfect and devoid of complications. This standardization will go a long way in increasing patient confidence in our community. Tall promises and unrealistic expectations are the cause of most litigations. If patients are told the same facts by every doctor they meet, their expectations are then based on reality and not on misconceptions. Following a protocol in today’s day and age is the only way we can avoid legal scrutiny. We are protected if we follow norms set by a competent society and followed by its members. To this end I would encourage all members to follow the protocol in your day to day practice.
In life nothing is perfect, nothing is static. We aim to keep the Protocols dynamic, inputs from members will be incorporated in future editions, revisions and expansions will be done as per the requirement of the times. Let us all participate actively to make the protocols perfect. I sincerely thank all those who have contributed to this effort. I have named them in the last paragraph of this article

What to look forward to in WIROC 2017?

This year the Veterans Surgeons Forum and the Young Surgeons Forum is back. We have dynamic speakers, Dr Ram Chaddha & Dr Vishal Kundnani respectively. A chance for us to see the experienced senior and the promising newcomer present their experience & research. The Katrak Orator Dr Joseph Dias is a giant in hand surgery. The KT Dholakia Lecture will be delivered by Dr Christopher Evans on the burning topic of improving bone healing. This year we have invited the Gujarat Orthopaedic Association to conduct a trauma symposium which will give us a glimpse into the strides taken by our neighbor in the orthopaedic field. The Masalawala best paper session features the top 6 papers from each subspecialty, a truly high-class research effort by the presenters. This year we have 4 sessions dedicated to free papers. The efforts of our members will bear fruit when they get to present their work to their peers. We have introduced new speakers and conveners this year in an attempt to empower the new generation who will eventually carry the torch of future WIROC events. I am sure all will do great justice to the responsibility given. We have a very interesting role-playing session where common OPD scenarios enacted will show us a way to deal with difficult patients & bad news. The Orthopaedic Quiz – where orthopaedic surgeons will also get a chance to pit their general knowledge against a professional quizmaster and prove, we are brains as well as brawns. All in all, you can look forward to a well-rounded academic program with new features and pathbreaking activities.

Well how about A Good venue? Excellent food? Sensational entertainment?

Don’t worry we have chosen The Hotel Grand Hyatt Santacruz for its central location making travel easier and known for its scrumptious food, arguably perhaps the best among the big conference venues in Mumbai. For your entertainment, we have our own colleagues performing to foot tapping numbers on the 1st day (Friday). The grand banquet on Saturday features the singer with Bollywood blockbuster hits like “Pareshaan”, “Balam Pichkari”, “Daru Desi”, “Lat Lag Gayi”, Baby Ko Bass Pasand Hai” this Diva has done it all. The most Adorable and Lovable, the young, the gorgeous the immensely talented, the one and only Shalmali Kholgade.
We have taken great care to ensure that your WIROC experience is diverse and unique. Where you get the best of academics, best of knowledge, best of entertainment and the best of what Bombay Orthopaedic Society has to offer.

WIROC Live Transmission

For the first time in history of WIROC we will be doing a live transmission of proceedings of WIROC. This transmission will be available online to global audience and any orthopaedic surgeon anywhere in the world can register to enjoy the webcast of sessions in Hall A. This provides an unique opportunity for our speakers to present their work to global audience and also increases the outreach of BOS manifolds. The proceedings will also be made available later on OrthoTV. We thank our members Dr Neeraj Bijlani and Dr Ashok Shyam for co-ordinating the live transmission.

My sincere thanks to the contributors to the BOS Protocols Dr C J Thakkar Dr S S Bawa, Dr Sudhir Sharan, Dr Rajendra Chandak Dr Gautam Zaveri, Dr Arjun Dhawle, Dr Uday Pawar, Dr Sanjay Dhar, Dr Nikhil Shetty, Dr Prashant Agrawal and the Association of Pelvi-Acetabular Surgeons and to our special advisor and guide Dr Vikas Agashe
I, Dr Harshad Argekar, Dr Neeraj Bijlani and our President Dr C J Thakkar welcome you to WIROC 2017 and hope you make it a part of your protocol to attend this conference year after year.

Thank you
Dr C J Thakkar (President BOS)
Dr Harshad Argekar (Organising Secretary WIROC 2017)
Dr Neeraj Bijlani (Organising Secretary WIROC 2017)

References

1. Dabezies EJ and D’Ambrosia RD. Treatment of the multiply injured patient: plans for treatment and problems of major trauma. Instructional course lectures 1984; 33: 242-52.
2. Hoff WS, Reilly PM, Rotondo MF, DiGiacomo JC, and Schwab CW. The importance of the command-physician in trauma resuscitation. The Journal of trauma 1997; 43: 772-7.
3. Lu WH, Kolkman K, Seger M, and Sugrue M. An evaluation of trauma team response in a major trauma hospital in 100 patients with predominantly minor injuries. The Australian and New Zealand journal of surgery 2000; 70: 329-32.
4. Simons R, Eliopoulos V, Laflamme D, and Brown DR. Impact on process of trauma care delivery 1 year after the introduction of a trauma program in a provincial trauma center. The Journal of trauma 1999; 46: 811-5; discussion 815-6.
5. Initial Management of Open Fractures .(Book Chapter) S. Rajasekaran et al. Rockwood and Green’s Fractures in Adults. Eight Edition . Vol 1 :353-396.
6. Pollak AN. Timing of debridement of open fractures. The Journal of the American Academy of Orthopaedic Surgeons 2006; 14: S48-51.
7. Carsenti-Etesse H, Doyon F, Desplaces N, and et al. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis 1999; 18: 315-323.
8. Kreder HJ and Armstrong P. The significance of perioperative cultures in open pediatric lower-extremity fractures. Clinical orthopaedics and related research 1994: 206-12.
9. Lee J. Efficacy of cultures in the management of open fractures. Clinical orthopaedics and related research 1997: 71-5.
10. Patzakis MJ. Orthopedics-epitomes of progress: The use of antibiotics in open fractures. The Western journal of medicine 1979; 130: 62.
11. Edwards CC, Simmons SC, Browner BD, and Weigel MC. Severe open tibial fractures. Results treating 202 injuries with external fixation. Clinical orthopaedics and related research 1988: 98-115.
12. Emami A, Mjoberg B, Ragnarsson B, and Larsson S. Changing epidemiology of tibial shaft fractures. 513 cases compared between 1971-1975 and 1986-1990. Acta Orthop Scand 1996; 67: 557-561
13. Rajasekaran S and Giannoudis PV. Open injuries of the lower extremity: issues and unknown frontiers. Injury 2012; 43: 1783-4
14. Gustilo RB. Management of infected fractures. Instructional course lectures 1982; 31: 18-29.
15. Rajasekaran S, Naresh Babu J, Dheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, and Rajasabapathy S. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. The Journal of bone and joint surgery. British volume 2006; 88: 1351-60.
16. Rajasekaran S and Sabapathy SR. A philosophy of care of open injuries based on the Ganga hospital score. Injury 2007; 38: 137-46.

How to Cite this article: Thakkar C J, Argekar H, Bijlani N. What do you expect from WIROC 2017?. Journal of Clinical Orthopaedics July-Dec 2017; 2(2):3-4.

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Management of Infected Non – Unions

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Vol 2 | Issue 2 |  July – Dec 2017 | Page 25-31 | John Mukhopadhaya

Authors: John Mukhopadhaya [1]

[1]Department of Orthopaedics and Joint Replacement, Paras HMRI Hospital, Patna, Bihar, India.

Address of Correspondence
Dr. John Mukhopadhaya
Department of Orthopaedics and Joint Replacement,
Paras HMRI Hospital, Patna, Bihar, India.
Email: mukhoj@gmail.com

Abstract

Infected nonunions are difficult problems to tackle. The treatment is often multistaged and involves high expenses and has major impact on both patient as well as surgeons. Understanding of the basics of infected non-union including etiopathology, diagnostic criteria and management algorithms is helpful in successfully managing this complication. This article provides a basic overview of infected nonunions along with new methods of management including Masquelet technique and techniques of managing bone gaps
Keywords: infected non-union, diagnosis, management

References

1. Brinker MR, Hanus BD, Sen M, O’Connor DP. The devastating effects of tibial nonunion on health-related quality of life. J Bone Joint Surg Am. 2013 Dec 18;95(24):2170-6.
2. Struijs PA, Poolman RW, Bhandari M. Infected nonunion of the long bones. J Orthop Trauma. 2007 Aug;21(7):507-11.
3. Chaudhary MM. Infected nonunion of tibia. Indian J Orthop. 2017 May-Jun;51(3):256-268.
4. Tetsworth K, Cierny G 3rd. Osteomyelitis debridement techniques. Clin Orthop Relat Res. 1999 Mar;(360):87-96.
5. Shyam AK, Sancheti PK, Patel SK, Rocha S, Pradhan C, Patil A. Use of antibiotic cement-impregnated intramedullary nail in treatment of infected non-union of long bones. Indian J Orthop. 2009 Oct;43(4):396-402.
6. Bhatia C, Tiwari AK, Sharma SB, Thalanki S, Rai A. Role of Antibiotic Cement Coated Nailing in Infected Nonunion of Tibia. Malays Orthop J. 2017 Mar;11(1):6-11.
7. Pradhan C, Patil A, Puram C, Attarde D, Sancheti P, Shyam A. Can antibiotic impregnated cement nail achieve both infection control and bony union in infected diaphyseal femoral non-unions? Injury. 2017 Aug;48 Suppl 2:S66-S71.
8. Putnis S, Khan WS, Wong JM. Negative pressure wound therapy – a review of its uses in orthopaedic trauma. Open Orthop J. 2014 Jun 27;8:142-7.
9. Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou R. Masquelet technique for the treatment of bone defects: tips-tricks and future directions. Injury. 2011 Jun;42(6):591-8.
10. Patwardhan S, Shyam AK, Mody RA, Sancheti PK, Mehta R, Agrawat H. Reconstruction of bone defects after osteomyelitis with nonvascularized fibular graft: a retrospective study in twenty-six children. J Bone Joint Surg Am. 2013 May 1;95(9):e56, S1.
11. Yin P, Ji Q, Li T, Li J, Li Z, Liu J, Wang G, Wang S, Zhang L, Mao Z, Tang P. A Systematic Review and Meta-Analysis of Ilizarov Methods in the Treatment of Infected Nonunion of Tibia and Femur. PLoS One. 2015 Nov 3;10(11):e0141973
12. Mukhopadhaya J, Raj M. Distraction osteogenesis using combined locking plate and Ilizarov fixator in the treatment of bone defect: A report of 2 cases. Indian J Orthop. 2017 Mar-Apr;51(2):222-228.
13. Dhillon MS, Rajasekharan S, Sancheti P. Status of road safety and injury burden: India. J Orthop Trauma. 2014;28 Suppl 1:S43-4.

How to Cite this article:  Mukhopadhaya J. Management of Infected Non-unions. Journal of Clinical Orthopaedics July-Dec 2017; 2(2):25-31

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Acute Osteomyelitis and Septic Arthritis in Children – Current Concepts in Diagnosis and Management

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Vol 2 | Issue 2 |  July – Dec 2017 | Page 16- 24 | Chintan Doshi, Kailash Sarathy, Alaric Aroojis

Authors: Chintan Doshi [1], Kailash Sarathy [1], Alaric Aroojis [1]

[1] Dept of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, India.

Address of Correspondence
Dr. Alaric Aroojis
Department Of Paediatric Orthopedics,
Bai Jerbai Wadia Hospital For Children,
Parel, Mumbai – 400012, Maharashtra, India
Email : aaroojis@gmail.com

Abstract

Acute osteomyelitis and septic arthritis are the most common cause of morbidity in childhood. These occur more commonly in children upto 5 years of age. The most common organism responsible is Staphylococcus aureus, however, many other organisms are also known to cause osteoarticular infections in children. These infective conditions demand a prompt diagnosis and management, as any delay can lead to joint destruction, instability, deformity and significant limb length discrepancy. Thus early diagnosis and prompt management are of importance to achieve optimal goals. The clinical presentation of a child with osteoarticular infection is typical; with presence of fever, swelling and inability to move the affected extremity. However, sometimes the typical clinical findings are missing. Therefore it is important to follow a specific clinical, laboratory and imaging work-up to reach a definitive diagnosis. Following appropriate diagnosis, the further management protocol should be followed, with appropriate choice and dose of antibiotics and surgical debridement as required. The aim of this review article is to discuss the current concepts in acute osteomyelitis and septic arthritis in children. This article discusses the recent literature on etiological organisms, pathophysiology, current trends in investigations and management of osteoarticular infections in children.
Keywords : Acute osteomyelitis, Septic arthritis, Osteoarticular Infection.

References

1. Gutierrez K. Bone and joint infection in children. Pediatr Clin N Am 2005;52(3):779-794.
2. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis. J Bone Joint Surg Br. 2012;94(5):584-95.
3. Yeo A, Ramachandran M. Acute haematogenous osteomyelitis in children. BMJ. 2014;20;348.
4. Malcius D, Trumpulyte G, Barauskas V, Kilda A. Two decades of acute hematogenous osteomyelitis in children: are there any changes?. Pediatr Surg Int. 2005;21(5):356-9.
5. Gillespie WJ. The epidemiology of acute haematogenous osteomyelitis of childhood. Int J Epidemiol. 1985;14(4):600-6.
6. Godley DR. Managing musculoskeletal infections in children in the era of increasing bacterial resistance. JAAPA. 2015;28(4):24-9.
7. Arnold SR, Elias D, Buckingham SC, Thomas ED, Novais E, Arkader A, Howard C. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. 2006;26(6):703-8.
8. García-Arias M, Balsa A, Mola EM. Septic arthritis. Best Pract Res Clin Rheumatol. 2011;25(3):407-21.
9. Gutierrez K. Bone and joint infections in children. Pediatr Clin North Am. 2005;52(3):779-94.
10. Laupland KB, Davies HD, Low DE, Schwartz B, Green K, McGeer A, Ontario Group A Streptococcal Study Group. Invasive group A streptococcal disease in children and association with varicella-zoster virus infection. Pediatrics 2000;105(5):e60-.
11. Morrissy RT, Haynes DW. Acute hematogenous osteomyelitis: a model with trauma as an etiology. J Pediatr Orthop. 1989;9(4):447-56.
12. Floyed RL, Steele RW. Culture-negative osteomyelitis. Pediatr Infect Dis J. 2003;22(8):731-6.
13. Davidson D, Letts M, Khoshhal K. Pelvic osteomyelitis in children: a comparison of decades from 1980–1989 with 1990–2001. J Pediatr Orthop. 2003;23(4):514-21.
14. Krogstad P, Smith AL: Osteomyelitis and septic arthritis, in Feigin RD, Cherry JD (eds): Textbook of Pediatric Infectious Diseases, 4th ed. Philadelphia: WB Saunders, 1998, vol 1, pp 683-704.
15. Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg. 2001;9(3):166-75.
16. Copley LA. Pediatric musculoskeletal infection: trends and antibiotic recommendations. J Am Acad Orthop Surg. 2009;17(10):618-26.
17. Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL. Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am. 2007;89(7):1517-23.
18. Stott NS. Review article: Paediatric bone and joint infection. J Orthop Surg. 2001;9(1):83-90.
19. Unkila-Kallio L, Kallio MJ, Peltola H, Eskola J. Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics. 1994;93(1):59-62.
20. Chou AC, Mahadev A. The use of C-reactive protein as a guide for transitioning to oral antibiotics in pediatric osteoarticular infections. J Pediatr Orthop. 2016;36(2):173-7.
21. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: An evidence-based probability algorithm. Pediatrics. 1999;104(3):713.
22. Caird MS, Flynn JM, Leung YL, Millman JE, Joann GD, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. J Bone Joint Surg Am. 2006;88(6):1251-7.
23. Rosenfeld S, Bernstein DT, Daram S, Dawson J, Zhang W. Predicting the presence of adjacent infections in septic arthritis in children. J Pediatr Orthop. 2016;36(1):70-4.
24. Maharajan K, Patro DK, Menon J, Hariharan AP, Parija SC, Poduval M, Thimmaiah S. Serum Procalcitonin is a sensitive and specific marker in the diagnosis of septic arthritis and acute osteomyelitis. J Orthop Surg Res. 2013;8(1):19.
25. Gené A, García-García JJ, Sala P, Sierra M, Huguet R. Enhanced culture detection of Kingella kingae, a pathogen of increasing clinical importance in pediatrics. The Pediatric infectious disease journal. 2004;23(9):886-8.
26. Gibbons SD, Barton T, Greenberg DE, Jo CH, Copley LA. Microbiological Culture Methods for Pediatric Musculoskeletal Infection. J Bone Joint Surg Am. 2015;97(6):441-9.
27. Song KM, Boatright KC, Drassler J, Strom MS, Nilsson WB, Bevan W, Burns JL. The use of polymerase chain reaction for the detection and speciation of bacterial bone and joint infection in children. J Pediatr Orthop. 2009;29(2):182-8.
28. Choe H, Inaba Y, Kobayashi N, Aoki C, Machida J, Nakamura N, Okuzumi S, Saito T. Use of real-time polymerase chain reaction for the diagnosis of infection and differentiation between gram-positive and gram-negative septic arthritis in children. J Pediatr Orthop. 2013;33(3):28-33.
29. Peltola H, Kallio MJ, Unkila-Kallio L. Reduced incidence of septic arthritis in children by Haemophilus influenzae type-b vaccination. J Bone Joint Surg Br. 1998;80(3):471-3.
30. Laine JC, Denning JR, Riccio AI, Jo C, Joglar JM, Wimberly RL. The use of ultrasound in the management of septic arthritis of the hip. J Pediatr Orthop B. 2015;24(2):95-8.
31. Jaramillo D, Treves ST, Kasser JR, Harper M, Sundel R, Laor T. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. Am J Roentgenol. 1995;165(2):399-403.
32. Browne LP, Mason EO, Kaplan SL, Cassady CI, Krishnamurthy R, Guillerman RP. Optimal imaging strategy for community-acquired Staphylococcus aureus musculoskeletal infections in children. Pediatric radiology. 2008;38(8):841-7.
33. Kan JH, Young RS, Yu C, Hernanz-Schulman M. Clinical impact of gadolinium in the MRI diagnosis of musculoskeletal infection in children. Pediatr Radiol. 2010;40(7):1197-205.
34. Peltola H, Pääkkönen M, Kallio P, Kallio MJ, Osteomyelitis-Septic Arthritis Study Group. Short-versus long-term antimicrobial treatment for acute hematogenous osteomyelitis of childhood: prospective, randomized trial on 131 culture-positive cases. The Pediatric infectious disease journal. 2010;29(12):1123-8.
35. Jagodzinski NA, Kanwar R, Graham K, Bache CE. Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children. J Pediatr Orthop. 2009;29(5):518-25.
36. Frank AL, Marcinak JF, Mangat PD, Tjhio JT, Kelkar S, Schreckenberger PC, Quinn JP. Clindamycin treatment of methicillin-resistant Staphylococcus aureus infections in children. The Pediatric infectious disease journal. 2002;21(6):530-4.
37. Buxton RA, Moran M. Septic arthritis of the hip in the infant and young child. Current Orthopaedics. 2003;17(6):458-64.

How to Cite this article: Doshi C, Sarathy K, Aroojis A. Acute Osteomyelitis And Septic Arthritis In Children – Current Concepts In Diagnosis And Management. Journal of Clinical Orthopaedics July-Dec 2017; 2(2): 16-24

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Changing paradigms in the management of Open Injuries

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Vol 2 | Issue 2 | July – Dec 2017 | Page 5-10 | Dheenadhayalan Jayaramaraju, Sivakumar SP, Raja Bhaskara Kanakeshwar, Devendra Agraharam, Ramesh Perumal, Arun Kamal C, Rajasekaran Shanmuganathan

Authors: Dheenadhayalan Jayaramaraju [1], Sivakumar SP [1], Raja Bhaskara Kanakeshwar [1], Devendra Agraharam [1], Ramesh Perumal [1], Arun Kamal C [1], Rajasekaran Shanmuganathan [1]

[1] Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, Coimbatore, Tamil Nadu

Address of Correspondence
Dr Raja Bhaskara Kanakeshwar
Ganga Hospital, Coimbatore
Email : rajalibra299@gmail.com

Abstract

Open injuries still pose a major problem as they are prone to higher rates of infection and non-union and are usually associated with life threatening polytrauma. Nowadays, specialized trauma centres and a multimodal team approach have shown to give superior results in the outcome following open injuries. Early aggressive wound debridement followed by early fracture stabilization with early wound closure to achieve bone and soft tissue healing are important components as nowadays we focus on the ‘Era of functional restoration’. Serum Lactate is a widely used biochemical marker to assess the adequacy of tissue resuscitation and the Ganga Hospital Open Injury score (GHOIS) has a higher specificity towards limb salvage and also gives guidelines regarding timing and type of soft tissue reconstruction. A combined ‘Orthoplastic’ approach in the management of open injuries and adherence to the ‘revised reconstruction ladder’ with regarding to wound coverage has shown to a favourable outcome.
Keywords : Open fractures, Debridement, Serum lactate, Ganga Hospital Open Injury score.

References

1. Dabezies EJ and D’Ambrosia RD. Treatment of the multiply injured patient: plans for treatment and problems of major trauma. Instructional course lectures 1984; 33: 242-52.
2. Hoff WS, Reilly PM, Rotondo MF, DiGiacomo JC, and Schwab CW. The importance of the command-physician in trauma resuscitation. The Journal of trauma 1997; 43: 772-7.
3. Lu WH, Kolkman K, Seger M, and Sugrue M. An evaluation of trauma team response in a major trauma hospital in 100 patients with predominantly minor injuries. The Australian and New Zealand journal of surgery 2000; 70: 329-32.
4. Simons R, Eliopoulos V, Laflamme D, and Brown DR. Impact on process of trauma care delivery 1 year after the introduction of a trauma program in a provincial trauma center. The Journal of trauma 1999; 46: 811-5; discussion 815-6.
5. Initial Management of Open Fractures .(Book Chapter) S. Rajasekaran et al. Rockwood and Green’s Fractures in Adults. Eight Edition . Vol 1 :353-396.
6. Pollak AN. Timing of debridement of open fractures. The Journal of the American Academy of Orthopaedic Surgeons 2006; 14: S48-51.
7. Carsenti-Etesse H, Doyon F, Desplaces N, and et al. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis 1999; 18: 315-323.
8. Kreder HJ and Armstrong P. The significance of perioperative cultures in open pediatric lower-extremity fractures. Clinical orthopaedics and related research 1994: 206-12.
9. Lee J. Efficacy of cultures in the management of open fractures. Clinical orthopaedics and related research 1997: 71-5.
10. Patzakis MJ. Orthopedics-epitomes of progress: The use of antibiotics in open fractures. The Western journal of medicine 1979; 130: 62.
11. Edwards CC, Simmons SC, Browner BD, and Weigel MC. Severe open tibial fractures. Results treating 202 injuries with external fixation. Clinical orthopaedics and related research 1988: 98-115.
12. Emami A, Mjoberg B, Ragnarsson B, and Larsson S. Changing epidemiology of tibial shaft fractures. 513 cases compared between 1971-1975 and 1986-1990. Acta Orthop Scand 1996; 67: 557-561
13. Rajasekaran S and Giannoudis PV. Open injuries of the lower extremity: issues and unknown frontiers. Injury 2012; 43: 1783-4
14. Gustilo RB. Management of infected fractures. Instructional course lectures 1982; 31: 18-29.
15. Rajasekaran S, Naresh Babu J, Dheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, and Rajasabapathy S. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. The Journal of bone and joint surgery. British volume 2006; 88: 1351-60.
16. Rajasekaran S and Sabapathy SR. A philosophy of care of open injuries based on the Ganga hospital score. Injury 2007; 38: 137-46.

How to Cite this article: Dheenadhayalan J, Sivakumar SP, Kanakeshwar RB, Agraharam D, Perumal R, Arun KC, Rajasekaran S. Changing paradigms in the management of Open Injuries. Journal of Clinical Orthopaedics July-Dec 2017; 2(2): 5-10.

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Prosthetic Joint Infection – How to Deal with it Rationally

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Vol 2 | Issue 2 |  July – Dec 2017 | Page 11-15 | Shantanu Patil, Anshu Shekhar, Sachin Tapasvi

Authors: Shantanu Patil [1], Anshu Shekhar [2], Sachin Tapasvi [2].

[1] Department of Translational Medicine and Research, Kattankulathur Campus, SRM University, India.
[2] The Orthopedic Speciality Clinic, Pune, India.

Address of Correspondence
Dr Shantanu Patil
Department of Translational Medicine and Research,
Kattankulathur Campus, SRM University, India
Email: shantanusp@gmail.com

Abstract

Prosthetic Joint Infection is a devastating complication both for the patient and the surgeon. It depends on many factors including patient factors, surgeon factors, surgery set up. The most important factor in management of PJI is to take care of all modifiable factors that can bring down the rate of infection. One of the critical steps is in prevention of surgical site infections and raising awareness among the surgeons and patients about the role of various screening procedures and avoiding indiscriminate antibiotic abuse. Management option includes one stage or two stage exchange arthroplasty, but the success rates are less than 90%. At times salvage surgeries like fusion, excision arthroplasty or amputation may also be needed. The present article overviews the prevention and management of PJI
Keywords: Prosthetic Joint Infection, arthroplasty, revision, salvage

References

1. Anseth SD, Pulido PA, Adelson WS, Patil S, Sandwell JC and Colwell CW, Jr. Fifteen-year to twenty-year results of cementless Harris-Galante porous femoral and Harris-Galante porous I and II acetabular components. J Arthroplasty. 2010; 25: 687-91.
2. Patil S, McCauley JC, Pulido P and Colwell Jr CW. How do knee implants perform past the second decade? Nineteen-to 25-year followup of the press-fit condylar design TKA. Clinical Orthopaedics and Related Research®. 2015; 473: 135-40.
3. Aggarwal VK, Rasouli MR and Parvizi J. Periprosthetic joint infection: Current concept. Indian Journal of Orthopaedics. 2013; 47: 10-7.
4. Bozic KJ, Kurtz SM, Lau E, et al. The Epidemiology of Revision Total Knee Arthroplasty in the United States. Clinical Orthopaedics and Related Research®. 2010; 468: 45-51.
5. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP and Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009; 91: 128-33.
6. Lenguerrand E, Whitehouse MR, Beswick AD, Jones SA, Porter ML and Blom* AW. Revision for prosthetic joint infection following hip arthroplasty. Bone and Joint Research. 2017; 6: 391-8.
7. Springer BD, Cahue S, Etkin CD, Lewallen DG and McGrory BJ. Infection burden in total hip and knee arthroplasties: an international registry-based perspective. Arthroplasty Today. 2017; 3: 137-40.
8. Zhu M, Ravi S, Frampton C, Luey C and Young S. New Zealand Joint Registry data underestimates the rate of prosthetic joint infection. Acta Orthop. 2016; 87: 346-50.
9. Witso E. The rate of prosthetic joint infection is underestimated in the arthroplasty registers. Acta Orthop. 2015; 86: 277-8.
10. Gundtoft PH, Overgaard S, Schonheyder HC, Moller JK, Kjaersgaard-Andersen P and Pedersen AB. The “true” incidence of surgically treated deep prosthetic joint infection after 32,896 primary total hip arthroplasties: a prospective cohort study. Acta Orthop. 2015; 86: 326-34.
11. Kurtz SM, Lau E, Watson H, Schmier JK and Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012; 27: 61-5.e1.
12. Laura Matsen Ko M, Javad Parvizi, MD, FRCS. Diagnosis of Periprosthetic Infection Novel Developments. Orthop Clin N Am 2016; 47: 1-9.
13. Parvizi J, Gehrke T and Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone & Joint Journal. 2013; 95-B: 1450-2.
14. Mahmud T, Lyons MC, Naudie DD, MacDonald SJ and McCalden RW. Assessing the Gold Standard: A Review of 253 Two-Stage Revisions for Infected TKA. Clinical Orthopaedics and Related Research. 2012; 470: 2730-6.
15. Million M, Bellevegue L, Labussiere AS, et al. Culture-negative prosthetic joint arthritis related to Coxiella burnetii. The American journal of medicine. 2014; 127: 786.e7-.e10.
16. Pavoni GL, Giannella M, Falcone M, et al. Conservative medical therapy of prosthetic joint infections: retrospective analysis of an 8-year experience. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2004; 10: 831-7.
17. Castelli CC, Gotti V and Ferrari R. Two-stage treatment of infected total knee arthroplasty: two to thirteen year experience using an articulating preformed spacer. Int Orthop. 2014; 38: 405-12.
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20. Qasim SN, Swann A and Ashford R. The DAIR (debridement, antibiotics and implant retention) procedure for infected total knee replacement – a literature review. SICOT-J. 2017; 3: 2.
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24. Parvizi J, Shohat N and Gehrke T. Prevention of periprosthetic joint infection: new guidelines. Bone Joint J. 2017; 99-b: 3-10.
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How to Cite this article: Patil S, Shekhar A, Tapasvi S. Prosthetic Joint Infection – How to deal with it Rationally. Journal of Clinical Orthopaedics July-Dec 2017; 2(2):11-15

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Changing Trends in Fracture Fixation

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Volume 2 | Issue 1 |  Jan – June 2017 | Page 2-3 | Sudhir Babhukar

Authors: Sudhir Babhukar [1]

[1] Sushrut Hospital, Research Centre and Post Graduate Institute of Orthopaedics, Nagpur.

Address of Correspondence

Dr. Sudhir Babhulkar
Emeritus Prof. of Orthopaedics Indira Gandhi Medical College, Nagpur. Director Sushrut Hospital, Research Centre and Post Graduate Institute of Orthopaedics, Nagpur.
Email: sudhirbabhulkar@gmail.com

Internal fixation requires a sound understanding of the principles and techniques of the use of implants. Proper understanding of mechanical and biological aspects of fracture repair is key to selection of implant for the treatment of a particular fracture. Fracture fixation is guided by results of various laboratory researches and is related to cellular biology, vascular physiology, biomechanics and our observation and experience from clinical practice. Due respect should be given to microcirculation of bone and soft tissues which is equally important while considering the internal fixation of fractures. One major factor for non-healing of fractures has been the association of the motion at the fracture site during the process of healing after internal fixation causing instability. In cases of internal fixation, this will affect the choice of implant and its principle of application.
Kuntscher first developed the technique of intramedullary nailing as early as 1939. Kuntscher’s work was marked by his extensive knowledge, his wealth of ideas and his understanding of the biological process of bone healing, which are impressively, documented in his monograph ‘The problem of consolidation and intramedullary nailing’. His contributions in this field include flexible intramedullary reamers, distraction device, intramedullary saw, and the detensor, which was the first type of interlocking nail. Kuntscher’s original nail was hollow, slotted; cloverleaf shaped and became progressively popular all over the world.
During the last 20-25 years interlocking nailing has been the golden standard in the treatment of diaphyseal long bone fractures. In 1972 Klemm and Schellmann from Frankfurt and Maine developed the first version of Interlocking nail. Subsequently at CTO Strasbourg around 1974-76 Grosse and Kempf modified, developed and improved the original nailing interlocking system. Lot of changes has occurred in this methodology of nailing-interlocking fixation. Second-generation Reconstruction nail, Gamma nail, PFN and very recent third generation telescoping locking nails are some recent newer modifications.
The treatment of open injuries during the course of fracture treatment dictate the use of methods believed to reduce the risk of complications, including urgent or emergent treatment and thorough debridement of wound and stabilisation by various methods of fracture stabilization, which includes markedly improved external fixators and intramedullary (IM) devices. External fixation devices were used as early as 1840 by Malgaigne to hold a fracture tibia in position and in 1843 a clamp to approximate fractures of the patella. Lambotte in 1907 is also credited with the use of monolateral system with threaded pins, which looks like the AO fixator. However the method failed to gain widespread acceptance till Hoffmann from Switzerland published his series in 1938 with good results. Today it is one of the best methods of fixation for open fractures especially grade III B and C. With the development of VAC system the prognosis of open injuries have improved. Another significant development in this area was the Ilizarov’s technique of ring fixators, which has revolutionized the treatment of infected nonunion and reconstruction of comminuted intra-articular fractures.
Stable reconstruction of the fractured bone minimizes the load to be carried by the implant. Stability of the fixation is therefore a critical parameter with respect to implant fatigue and corrosion. Fracture fixation once achieved should produce absolute quietness of fracture by way of stable or biological fixation. This was the basis of AO principles, the group formed in 1958 that promoted the treatment by internal fixation. However their principles are changing and they have moved from rigid fixation to biological fixation & stable fixation allowing micromotion. Stability in internal fixation is used to describe the degree of immobility of the fracture fragments. Stable fracture fixation (Osteosynthesis, term coined by Lambotte) means a fixation with little displacement. A special condition is described by the term absolute stability. This defines complete absence of relative displacement between fracture surfaces. Within the same fracture surfaces, areas of absolute and of relative stability may be present simultaneously. Over the years there has been a major change in the philosophy of the AO/ASIF group. It is now preferred to have a stable biologic fixation than a rigid fixation.
The principles of Biological Fixation may be summarized as: Repositioning and realigning by manipulation at a distance to the fracture site, preserving soft tissue attachments, leaving comminuted fragments out of the mechanical construct while preserving their blood supply, using low elastic modulus, biocompatible material, decreasing contact between the bone and the implant and limiting operative exposure when possible. The degree of stability achieved has a determining effect upon the amount of the load borne by the implant used for fixation. The load carried by the implant is critical with respect to possible fatigue failures and /or to fretting corrosion.
Today with the development of key-hole & minimally invasive surgery, arthroscopically assisted fracture reduction, reconstruction of articular surface & fixation is very much in vogue, especially for distal radius, tibial plateau and plafond fractures. The principle of indirect reduction has been developed lately for fracture fixation. The technique of plating as well as plate design has been modified. The AO principles, techniques and implants have changed considerably over the time. There is a shift of emphasis from mechanical to biological aspect of internal fixation with great emphasis being placed on the preservation of blood supply to the bones & soft tissues. Less Invasive Stabilisation System (LISS) and Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) represents a new generation of plates and principles, which act as internal fixators, minimising any surgical insult to the bone and approach related soft tissue damage.
Similarly, there have been lot of developments for the easy and safe technique of closed nailing and interlocking of femur, tibia and other bones. Use of ultrasound for control of passage of guide wire by closed technique is one of the latest developments. Ultrasound and Doppler studies are used for assessing the fracture healing. The technique studies the morphology of callus and neo-vascularisation to predict the progress of fracture healing. The test is non-invasive, cheap and easily accessible. Minimally invasive surgery and computer-aided techniques will influence future developments in the fracture management.
With the increase in the medicolegal issues related to the field of medicine, especially in orthopedics, there is no specific single method of treatment available, for a particular fracture/injury. Major changes are taking place around the world concerning fracture treatment. Change cannot be avoided and will, sooner or later, arrive. The specialty of orthopedics in particular has grown by leaps and bounds in the last 50 years, thanks to the modern day pandemics – road traffic accidents. From a neglected specialty that dealt with deformity, osteomyelitis and low energy trauma, it has become a specialty of demand and glamour, ever growing with quantum leaps. Improved metallurgy, asepsis, intensive care facilities, anesthesia, imaging and diagnostic methodology has allowed us to progress faster.

How to Cite this article: Babhulkar S. Changing Trends in Fracture Fixation. Journal of Clinical Orthopaedics Jan – June 2017; 2(1):2-3.

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Journal of Clinical Orthopaedics – an academic venture of Bombay Orthopaedic Society

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bos-cover-page-july-dec-2016

Journal of Clinical Orthopaedics | Vol 2 | Issue 1 |  Jan – June 2017 | 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

Journal of Clinical Orthopaedics – an academic venture of Bombay Orthopaedic Society

Bombay Orthopaedic Society (BOS) has always been in forefront of academics and education. Academic courses and content of BOS have always been known for high quality and providing best education to the new generation of orthopaedic surgeon has been the central aim of BOS right from its inception decades ago. Taking ahead the same tradition, BOS had taken the decision of starting its own journal named Journal of Clinical Orthopaedics. This is the second issue of the Journal and the entire editorial team is proud to present it to our readers
As is the hallmark of all BOS activities, high quality content is hallmark of Journal of Clinical Orthopaedics (JCO). In this issue we have guest editorial by Dr Sudhir Babhulkar and a perspective article by Dr Shantaram Shetty. Dr GS Kulkarni, Dr Ashok Rajgopal, Dr Ramesh Sen, Dr Raju Vaishya and many more have contributed excellent review articles. Also the issue contains the usual potpourri features that includes, foot and ankle, arthroscopy, paediatric orthopaedics and tuberculosis. Lastly but most importantly the issue contains interview of Dr Sailendra Bhattacharya, the living legend of Orthopaedics. Thus the content of the issue is contributed by the best in orthopaedics from across the country and although the issue was delayed by a month, we could cover the shortcoming by providing excellent quality articles for our readers.
The format of JCO will continue to evolve in coming years, but the goal will always be to bring the best reading material which has balance of both experience and evidence based content. The focus would be to bring practically useful content which can be applied to day to day practice. We would like to request our readers to please submit clinically relevant articles, original research, case series, case reports and technical notes to JCO. The Journal has an excellent website and online article submission system which is simple to use and keep record of all your submissions. Preparation of JCO issue for WIROC 2017 is in full swing and we are hopeful to get articles from many more of our readers.
We thank our authors and editorial board members for their contributions to the journal. We look forward to making JCO a world recognised indexed journal and we solicit support from all of our readers

Regards
Dr Nicholas Antao – Editor JCO
Dr Ashok Shyam – Associate Editor JCO.

How to Cite this article: Antao N, Shyam AK. Journal of Clinical Orthopaedics – an academic venture of Bombay Orthopaedic Society . Journal of Clinical Orthopaedics Jan – June 2017; 2(1):1.

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