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

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

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

Open Access License: CC BY-NC 4.0

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

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

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

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

Address of Correspondence

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

Abstract

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

References

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

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

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

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

Open Access License: CC BY-NC 4.0

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

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

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

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

Address of Correspondence

Dr Manit Arora,

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

E-mail: manit_arora@hotmail.com

Abstract

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

References

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25. Van der List JP, Mintz DN, DiFelice GS. The locations of anterior cruciate ligament tears in pediatric and adolescent patients: A magnetic resonance study. J Pediatr Orthop 2019;39:441-8.
26. Christino MA, Tepolt FA, Sugimoto D, Micheli LJ, Kocher MS. Revision ACL reconstruction in children and adolescents. J Pediatr Orthop 2020;40:129-34.
27. Thorolfsson B, Svantesson E, Snaebjornsson T, Sansone M, Karlsson J, Samuelsson K, et al. Adolescents have twice the revision rate of young adults after ACL reconstruction with hamstring tendon autograft: A study from the Swedish National Knee Ligament Registry. Orthop J Sports Med 2021;9:23259671211038893.

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

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

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

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

Open Access License: CC BY-NC 4.0

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

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

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

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

Address of Correspondence

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

Abstract

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

References

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

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

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

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

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

Open Access License: CC BY-NC 4.0

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

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

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

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

Address of Correspondence

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

Abstract

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

References

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

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Informed Consent: A Cornerstone of Ethical and Legal Orthopaedic Practice

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

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

Open Access License: CC BY-NC 4.0

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

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

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

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

Address of Correspondence

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

Abstract

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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