Multi-drug resistant tuberculous spondylitis: A review of the literature

Vol 2 | Issue 2 |  Juiy – Dec 2017 | Page 32-33 | Vikas Agashe

Authors: Vikas Agashe [1]

[1]P.D.Hinduja Hospital & Research Centre, , Mumbai, India.

Address of Correspondence
Dr. Vikas M. Agashe
Dr Agashe’s Maternity & surgical Nursing Home,
Vrindavan, Off L.B.Shastri Marg, Kurla, Mumbai 400070

1. Multi-drug resistant tuberculous spondylitis: A review of the literature  [1]

Reviewed articles on MDR- TB spondylitis till December 2015
 Osteoarticular TB represents 1- 2% and TB spondylitis 0.5- 1% of all TB cases
 Diagnosis of MDR- TB spondylitis is often delayed from 6 months to 2 years
 Culture and susceptibility testing are the gold standard for diagnosis
 Gene Xpert MTB/RIF is a faster test, with high sensitivity and specificity and has a lower limit of detection of 130 CFU/ml of bacilli compared to culture, which requires 10,000 CFU/ml
 Empirical therapy if necessary, should be based on drug exposure history, contact history, epidemiology and local drug resistance data, if available
 Minimum duration of therapy should be 18- 24 months
 Indications for surgery- neurologic deterioration, significant kyphosis, spinal instability, severe pain, and failure of medical management
 Review of an Indian study from Mumbai [2] showed that 87 (78.3%) cases of multi drug resistance (resistance to both isoniazid and rifampicin) and 3 (2.7%) cases of XDR-TB spine. They recommended routine biopsy, culture and drug sensitivity testing in all patients of tuberculosis spine [2]

2. Diagnosis and Treatment of Extrapulmonary Tuberculosis [3]

Biopsy material (preferably granulation tissue) for mycobacterial culture should be submitted fresh or in a small amount of sterile saline

3. Drug resistance patterns in 111 cases of drug-resistant tuberculosis spine [4]

78.3% were MDR and 2.7% were XDR- TB spine
39.6% patients had taken ATT in the past for some form of TB
Recommend routine biopsy, culture and sensitivity in all patients of TB spine for appropriate second line therapy when required highest resistance to isoniazid and rifampicin amongst the 1st line drugs; ethionamide and ofloxacin amongst the 2nd line drugs

4.Tuberculosis spine: Therapeutically refractory disease [5]

India ranks 2nd among the high burden MDR- TB countries
Study included 15 cases of TB spine not responding to 1st line drugs for minimum 5 months
Only 3 cases demonstrated a positive culture; 2 of these had MDR- TB
All were histopathologically positive
Healing was achieved in 13 cases with 2nd line ATT, in spite of low culture yield.
Clinical suspicion is important to detect MDR- TB
Empirical 2nd line ATT can achieve good results in such cases with negative cultures

5. Drug-resistant tuberculosis in Mumbai, India: An agenda for operations research [6]

Mumbai is the ideal environment conducive to the spread of TB, failure of treatment and emergence of resistance on account of 12.5 million people being squeezed into 437km2
▪ Mumbai houses 12% of the population of Maharashtra state, but accounts for 22% of notified cases of TB and — significant in terms of potential drug resistance — 50% of people undergoing retreatment after relapse
▪ The emergence of drug-resistant TB in Mumbai is a prospect so alarming that the paucity of available evidence may be a case of ‘out of sight, out of mind’.
Available reports have consistently shown higher levels of MDR-TB than in other parts of India, at 24%–30% of new cases
The problem of dropping out of a treatment programme and increasing the risk of development of MDR-TB is the result of an interplay of client and provider factors

6. RNTCP – Government TB Treatment Education & Care NSP
The RNTCP in India [7]
The Joint TB Monitoring Mission (JMM)

Problems highlighted by the JMM report
▪The RNTCP was criticized for its continued use of a thrice weekly intermittent regimen and initiation of treatment without knowing the resistance profile of the patients, which contributes to the amplification of resistance.
▪Daily anti-tuberculosis treatment and initiation of Isoniazid Preventative Therapy for PLHIV has not started yet. GeneXpert is still not being used as the initial diagnostic tool for PLHIVs.

Drug resistant TB in India – Transmission, diagnosis, treatment
In general the regimen should comprise 6 drugs:
1. Pyrazinamide,
2. Ethambutol,
3. A later generation Fluoroquinolone (such as high dose Levofloxacin)
4. A parenteral agent (such as Kanamycin or Amikacin)
5. Ethionamide (or Prothionamide),
6. And either Cycloserine or PAS (P-aminosalicyclic acid), if Cycloserine cannot be used.
This regimen should be used during six to nine months of the intensive phase. Four drugs usually Levoflaxacin, Ethionamide, Ethambutol and Cycloserine, should be used during the 18 months of the continuation phase.

7. Nontuberculous mycobacterial infection of the musculoskeletal system in immunocompetent hosts [8]

Clinically and on histopathology, musculoskeletal infections caused by NTM resemble those caused by Mycobacterium tuberculosis but are mostly resistant to routine antituberculosis medicines. There has been an increasing incidence in recent years of infections in immunocompetent hosts. NTM infections in immunocompetent individuals are secondary to direct inoculation either contamination from surgical procedures (arthroscopy, local injections for dye based imaging) penetrating injuries rather than hematogenous dissemination.
-This series had 6 cases, 2 following open injuries, 2 following intra articular injections for imaging, 1 after arthroscopy and 1 after hydrocortisone injection in calcaneum. Agents which can be used for treating NTM infections are macrolides (clarithromycin, azithromycin); rifampin or rifabutin; ethambutol; doxycycline; quinolones (ciprofloxacin, moxifloxacin, and gatifloxacin); sulfonamides; amikacin; streptomycin; isoniazid; ethionamide; cefmetazole; and imipenem. Ideally 3 drugs have to be given for a period of 6 to 12 months based on clinical and radiological improvement. Whenever a case of chronic granulomatous infection is encountered, that does not respond to standard anti-tuberculous treatment, with a history of open trauma, and surgical intervention or injection, there should be clinical suspicion of a possible NTM infection. It is important to have a good communication between clinicians and microbiologists so as to optimize culture conditions.


1. Kizilbash QF, Seaworth BJ. Multi-drug resistant tuberculous spondylitis: A review of the literature. Ann Thorac Med. 2016;11(4):233-236.
2. Mohan K, Rawall S, Pawar UM, Sadani M, Nagad P, Nene A, Nene A. Drug resistance patterns in 111 cases of drug-resistant tuberculosis spine. Eur Spine J. 2013 Jun;22 Suppl 4:647-52.
3. Lee JY. Diagnosis and treatment of extrapulmonary tuberculosis. Tuberc Respir Dis (Seoul). 2015;78(2):47-55. doi:10.4046/trd.2015.78.2.47.
4. Mohan K, Rawall S, Pawar UM, et al. Drug resistance patterns in 111 cases of drug-resistant tuberculosis spine. Eur Spine J. 2013;22(SUPPL.4):8-10.
5. Jain A, Modi P, Sreenivasan R, Dhammi I, Kumar J, Saini N. Tuberculosis spine: Therapeutically refractory disease. Indian J Orthop. 2012;46(2):171.
6. Mistry N, Tolani M, Osrin D. Drug-resistant tuberculosis in Mumbai, India: An agenda for operations research. Oper Res Heal Care. 2012;1(2-3):45-53.
7. RNTCP | Government TB Treatment Education & Care NSP 2012 – 2017. Accessed October 31, 2017.
8. Gundavda M, Patil H, Agashe VM et al. Nontuberculous mycobacterial infection of the musculoskeletal system in immunocompetent hosts. Indian J Orthop. 2017 Mar-Apr; 51(2): 205–212.

How to Cite this article:  Agashe V. Multi-drug resistant tuberculous spondylitis: A review of the literature. Journal of Clinical Orthopaedics July – Dec 2017; 2(2):32-33.

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2017 Sarcoma Year Review

Vol 2 | Issue 2 |  Juiy – Dec 2017 | Page 57-58 | Prakash Nayak, Ashish Gulia, Nehal Khanna, Jyoti Bajpai, Ajay Puri

Authors: Prakash Nayak [1], Ashish Gulia [1], Nehal Khanna [2], Jyoti Bajpai [3], Ajay Puri [1]

[1]Department of Surgical Oncology, Tata Memorial Hospital, Mumbai
[2]Department of Radiation Oncology, Tata Memorial Hospital, Mumbai
[3]Department of Medical Oncology, Tata Memorial Hospital, Mumbai

Address of Correspondence
Dr. Prakash Nayak
Orthopaedic Oncologist, Assistant Professor,
Dept. of Surgical Oncology, Tata Memorial Hospital, Mumbai

Are outcomes of osteosarcoma in Indian patients any different?

Most large series of osteosarcoma include Caucasian patients. This large retrospective study of 853 osteosarcoma patients from Tata Memorial Centre, Mumbai [1] analyzed their data to ask, if our patients do any differently than the rest of the world. The major difference is the lack of use of high dose methotrexate in this subset because of logistical constraints. Instead most patients received 2 cycles each of cisplatin/doxorubicin, ifosfamide/doxorubicin in the neoadjuvant setting, followed by 4 cycles of cisplatin/ifosfamide in the adjuvant setting. The 5 year overall survival for the entire cohort was 49 % and event free survival was 42%, while the non-metastatic ones had an OS of 53% and EFS of 47 % at 5 years. Eighteen (9%) patients developed local recurrence, 311 developed metastasis while, 47 developed both. Site of tumor, type of surgery and chemotherapy induced necrosis were significant even on multivariate analysis. Interestingly 70 % patients in this series were male, likely revealing a referral bias favoring the male in the subcontinent. The 11 % rate of metastasis is also a selection bias as only patients treated with a curative intent were analyzed n the study. One fourth patients underwent an amputation suggesting delayed referral to specialist sarcoma centers and / or inadvertent prior intervention. Ninety percent of tumors were over 8 cm. The overall survival has been lower than a lot of other Caucasian reports. Although the best results from the non HDMTX based chemotherapy report survival of up to 79% in a limited cohort of 72 patients, the change and intensification of therapy at TMC, Mumbai in 2012 does not seem to have significantly improved survival outcomes. The large tumor sizes may have a larger negative influence.

Predictors of venous thromboembolism in patients with bone sarcoma

Venous thromboembolism is associated with both orthopedic surgery and cancer. The incidence is estimated to be 0.6 to 15 % with the use mechanical and or chemical prophylaxis. Prophylactic anticoagulation to decrease the morn=morbidity and mortality associated with VTE can itself lead to bleeding and wound complications especially in patients with perioperative radiation and large volume resections. Current recommendations are unclear about the choice or duration of the chemical prophylaxis. These recommendations are in patients undergoing knee or hip arthroplasty or hip fracture fixation. Kaiser et al in this study analyse the rate of VTE, the risk factors associated with VTE and discuss complications associated with prophylactic anticoagulation in patients with primary bone sarcoma. This retrospective study [2] in adult patients treated for sarcoma over 25 years were identified for radio-graphically confirmed VTE or pulmonary embolism occurring within 90 days of index surgery. Various patient characteristics, preoperative clinical variables and treatment variables were used for analysis. Bi-variate logistic regression was used to estimate a crude odds ratio, l significant and non collinear factors then underwent a backward elimination step-wise regression to calculate adjusted odds ratio. Out of 379 patients analyzed, 100 received no prophylaxis and 279 did. Two of those 100, while 19 of the 279 who received prophylaxis developed VTE (p= 0.012). Median time to event was 27 days. Initial bi-variate analysis showed pre=operative white blood cell count, preoperative hematocrit, estimated blood loss, post-operative wound infection, wound complications, additional surgery and multi-drug chemoprophylaxis. High pre-operative white blood cell count, post-operative wound complications were independent risk factors at final analysis. The risk of wound complications increased significantly in those who received chemical prophylaxis. Although retrospective nature of the data and that sub-clinical events of VTE were missed and prophylactic therapy was heterogeneous, the data resembles real life scenario and provides valuable data in bone sarcoma patients. It is important to note that wound complications often necessitates repeated surgery, bed rest or VAC therapy which worsen the risk of VTE. Since chemoprophylaxis worsens the risk of wound complications, we need to ask if we causing undue harm in a subset of patients. This is in the light of some studies that suggest that sites other than pelvis and hip may not have sufficient risk of VTE to warrant prophylaxis. To reduce the risk further, would mechanical devices with low risk aspirin suffice to optimally reduce VTE risk while also keeping risk of wound complications low? In conclusion prospective studies are needed to accurately stratify risk in this patient population for optimal and safe use of chemoprophylaxis. Aggressive prophylaxis may counter intuitively increase the risk of thromboembolic events. Individualized risk assessment for local recurrence and distant metastases for extremity soft tissue sarcoma Limb salvage surgery with radiation in adjuvant or neoadjuvant form is the standard of care for most patients with extremity soft tissue sarcoma (STS). Despite high rates of limb salvage, local recurrence and distant metastasis remain real concerns. Patient’s prognosis is determined by disease related variables which are fixed at diagnosis and treatment related factors which are modifiable. Surgical resection margins and use of radiation and chemotherapy are the only modifiable factors that can influence outcome. Small heterogeneous study populations are misleading to help predict outcomes in an individual patient. For instance would the predicted LR (local recurrence) and OS (overall survival) be the same in a 25 year old male with positive margin excision for myxo-fibrosarcoma vs a 65 year female with a large deep leiomyosarcoma? We know that LR risk is prohibitively high in the former, while metastatic risk is high in the latter. Willeumier et al (3) present a study where a multi-state model is used to predict LR and survival in a large population with high grade extremity STS. A multi-state model is a model for time to event data where all individuals start with one state (eg, surgery) and go on to develop one or more states of LR, metastasis or both of the above. The probability of getting an event are based on transition hazards as measured by a Cox model. These models can be used with 2 aims, one to gain biological insight into the disease process and the other to help predict outcomes from the training set which may impact treatment decisions. The results are provided in the form of stacked charts acting as a visual aid (shown below). The probabilities of having a recurrence or a metastasis change with time and with treatment evolution. Two interesting observations which need validation with prospective studies, are that neo adjuvant radiation is associated not only with decreased LR as compared to adjuvant radiation but also associated with better survival. The strengths of the study are the large cohort of high grade extremity STS and the use of multi-state model to assess probability of clinical future events. AJCC and other staging systems provide prognostic estimates for group of patients, this study introduces the possibility of allowing treatment to be tailored to individuals. The retrospective design, selection bias, multi-centre data are weaknesses. The authors mention that a web based application will further enable personalised care, however the model needs external validation from multiple centres.

Latest Guidelines and Reviews:
Few good reviews and guidelines were published this year. The National Comprehensive Cancer Network published their guidelines for Ewings sarcoma which provides a step wise evidence based algorithmic approach to Ewing sarcoma patients [4]. An excellent review on advancement in management of paediatric bone sarcoma was published by Grohar et al [5]. Details of most recent updates in literature are synthesized together with excellent commentary by authors. However probably one of the most important paper this year is published in Cancer Journal [5]. This paper by Reed et al [6] tries to establish a consensus statement for various pediatric bone sarcoma. A multidisciplinary approach involving the experienced orthopedists, radiotherapists, radiologists, pathologists, and oncologists was followed to develop a detailed management approach. The entire paper is put up in a question answer format which is includes clinically relevant question and proposed answers through consensus among all the disciplines including taking into account the current evidence. This seemed to a very interesting approach to answer locally relevant questions and also help prioritize research and resources in areas identified to be most promising. The article itself is a delight to read and similar consensus building exercises can be a part of orthopaedic oncology network in our country too.


1. Puri A, Byregowda S, Gulia A, Crasto S, Chinaswamy G. A study of 853 high grade osteosarcomas from a single institution—Are outcomes in indian patients different? Journal of Surgical Oncology. 2017;
2. Kaiser CL, Freehan MK, Driscoll DA, Schwab JH, Bernstein KDA, Lozano-Calderon SA. Predictors of venous thromboembolism in patients with primary sarcoma of bone. Surgical Oncology. 2017;26(4):506–10.
3. Willeumier JJ, Rueten-Budde AJ, Jeys LM, Laitinen M, Pollock R, Aston W, et al. Individualised risk assessment for local recurrence and distant metastases in a retrospective transatlantic cohort of 687 patients with high-grade soft tissue sarcomas of the extremities: A multistate model. BMJ open. 2017;7(2):e012930.
4. Biermann JS, Chow W, Reed DR, Lucas D, Adkins DR, Agulnik M, Benjamin RS, Brigman B, Budd GT, Curry WT, Didwania A, Fabbri N, Hornicek FJ, Kuechle JB, Lindskog D, Mayerson J, McGarry SV, Million L, Morris CD, Movva S, O’Donnell RJ, Randall RL, Rose P, Santana VM, Satcher RL, Schwartz H, Siegel HJ, Thornton K, Villalobos V, Bergman MA, Scavone JL. NCCN Guidelines Insights: Bone Cancer, Version 2.2017. J Natl Compr Canc Netw. 2017 Feb;15(2):155-167
5. Grohar PJ, Janeway KA, Mase LD, Schiffman JD. Advances in the Treatment of Pediatric Bone Sarcomas. Am Soc Clin Oncol Educ Book. 2017;37:725-735.
6. Reed DR, Hayashi M, Wagner L, Binitie O, Steppan DA, Brohl AS, Shinohara ET, Bridge JA, Loeb DM, Borinstein SC, Isakoff MS. Treatment pathway of bone sarcoma in children, adolescents, and young adults. Cancer. 2017 Jun 15;123(12):2206-2218.

How to Cite this article: Nayak P, Gulia A, Khanna N, Bajpai J, Puri A. 2017 Sarcoma Year Review Journal of Clinical Orthopaedics July-Dec 2017; 2(2): 57-58

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What’s new in Hand Surgery?

Vol 2 | Issue 2 |  Juiy – Dec 2017 | Page 55-56 | Pankaj Ahire

Authors: Pankaj Ahire [1]

[1]Godrej Memorial Hospital, Vikhroli East, Mumbai , India

Address of Correspondence
Dr. Pankaj Ahire
Godrej Memorial Hospital, Vikhroli East, Mumbai, India

Hand Surgery continues to be dominated by brilliance of individuals and prospective observational studies owing to paucity of randomized controlled trials. From the meta analyses of various published work we get a glimpse of what is in and what is out of Hand Surgery in the past decade.

Nerve Surgery

Distal nerve transfers have caused paradigm shift in the way surgeons across the globe treat Brachial Plexus [1,2] Injuries and peripheral nerve lesions. The popularity of transfer of Ulnar nerve to Musculocutaneous branch to Biceps (Oberlin) and Median nerve to Brachialis (MacKinnon), Triceps Branch to Axillary (Somsak), Spinal Accessory nerve to Suprascapular nerve(Alnot) – is due to a predictable and early recovery of targeted motors. The incidence of exploration and repair of Upper Trunk lesions has reduced in preference to these nerve transfers, though doing both gives superior results (Bertelli). For more distal lesions transfer of AIN branch to PQ to Motor branch of ulnar nerve in case of injury to ulnar nerve proximal to the elbow (Battiston), has shown promising results where once the recovery of intrinsic muscles of the hand was summarily ruled out. This will perhaps lead to nerve transfers replacing tendon transfers in the treatment of muscle dysfunction due to nerve paralysis, if referred in time. Management of global brachial plexus palsy no longer is seen as a losing battle with single, double and now triple functioning free muscle transfers (Doi, Tu) to restore elbow flexion, finger flexion and finger extension [3].

Tendon Surgery

Flexor tendon repair has moved from monofilament 2 strand modified Kessler’s core suture to a braided suture, 4 to 6 strand core suture with epitendinous repair [4]. From the days of Kleinertrubber band traction to early active & passive movements, the protocol of rehabilitation of flexor tendons has become more simplified and moving towards early active motion. With advent and popularity of WALANT (Wide Awake Local Anesthesia No Tourniquet)–(Donald Lalonde), the tendon repairs can undergo functional testing intra operative and any readjustments donot have to wait for a second surgery [5,6].

IP joint arthrodesis

IP joint injuries are on the rise with more people taking hobby sports as a way of physical fitness. Hemi Hamate replacement (Hastings) has made it possible to restore significantly damaged P2 bases thereby offering hopefully long lasting PIP joint with little deformities. While the need to restore injured PIP joints to a painless mobile unit continues the need to arthrodese non reconstructible joints also arises specially in the DIP joints. The use of mobile phones necessitates that we fuse the IP joint of the thumb in more flexion than was recommended earlier, to enable the tip of the thumb to precisely touch the small buttons of QWERTY key board on a small screen [7].

Wrist Surgery

The debate about fixation of distal radius fractures seems to be reaching no end. Corrective osteotomies of distal radius with volar locking plates without the use of bonegrafts may be considered as a significant change from the trapezoidal grafts used earlier with cumbersome fixations. The DRUJ has gained its due significance in the world dominated by DER & Scaphoids. DRUJ hemireplacement and Total replacement have arrived and will continue to pose serious challenge to the readiness with which we knocked off the distal end of the ulna only to shift the focus of pain from DRUJ to an inch proximal [8]. Wrist arthroscopy is now allowing us to identify treatable pathologies specially on the ulnar side of the wrist. It is now considered as a standard diagnostic procedure in the work up of ulnar sided wrist pain [9]. While we are doing more operative procedures on the carpus than ever before, the role of conservative management of carpal instabilities by modulating the Supinators and Pronators of the distal carpal row, is being recognized [10]. The understanding of anti supination helical ligaments and anti pronation helical ligaments is the new baby in understanding of carpal kinematics. (Marc Garcia Elias)

Hand Transplant

After Hand and Face were classified as VCAs (Vascularized Composite Allotransplants) and were given the status of an organ in the Transplant Law, the enthusiasm about their transplants was palpable. There have been successful bilateral hand transplants already in India (Amrita Institute Kochi). The debate however continues about use of high end prosthesis with no effect on life expectancy versus cadaveric Hand Transplants with a certain effect on life expectancy [11,12].

Microvascular Surgery

Better understanding of angiosomes and vascular anatomy has permitted us to choose newer and better flaps with minimal donor site morbidity. The advent of supermicrosurgery has taken reconstructive surgery to the next level. Complex reconstructions are now possible using perforators alone as donor and recipient vessels, sparing the main vascular axis. Supermicrosurgery has enabled us to perform lympho-venous anastomosis, as well as free lymph node transfers. The complex problem of lymphoedema now has a reliable surgical treatment option, significantly improving the quality of life of these patients [13].


Dr Mukund Thatte for reviewing the draft
Dr Nilesh Satbhai for contribution about Microvascular Surgery


1. Panagopoulos GN, Megaloikonomos PD, Mavrogenis AF. The Present and Future for Peripheral Nerve Regeneration. Orthopedics. 2017 Jan 1;40(1):e141-e156.
2. Forli A, Bouyer M, Aribert M, Curvale C, Delord M, Corcella D, Moutet F. Upper limb nerve transfers: A review. Hand Surg Rehabil. 2017 Jun;36(3):151-172.
3. El-Sayed AAF. Evidence of the Effectiveness of Primary Brachial Plexus Surgery in Infants With Obstetric Brachial Plexus Palsy-Revisited. Child Neurol Open. 2017 May 25;4:2329048X17709395
4. Gibson PD, Sobol GL, Ahmed IH. Zone II Flexor Tendon Repairs in the United States: Trends in Current Management. J Hand Surg Am. 2017 Feb;42(2):e99-e108
5. Steiner MM, Calandruccio JH. Use of Wide-awake Local Anesthesia No Tourniquet in Hand and Wrist Surgery. Orthop Clin North Am. 2018 Jan;49(1):63-68.
6. Lied L, Borchgrevink GE, Finsen V. Wide Awake Hand Surgery. J Hand Surg Asian Pac Vol. 2017 Sep;22(3):292-296.
7. McGowan S, Deisher M, Matullo KS. Functional Fusion Angle for Thumb Interphalangeal Joint Arthrodesis. Hand (N Y). 2016 Mar;11(1):59-64.
8. Moulton LS, Giddins GEB. Distal radio-ulnar implant arthroplasty: a systematic review. J Hand Surg Eur Vol. 2017 Oct;42(8):827-838
9. Michelotti BF, Chung KC. Diagnostic Wrist Arthroscopy. Hand Clin. 2017 Nov;33(4):571-583.
10. Harwood C, Turner L. Conservative management of midcarpal instability. J Hand Surg Eur Vol. 2016 Jan;41(1):102-9.
11. Nayak BB, Mohanty N, Patnaik AP, Bal PK. Considerations for double-hand replantation in a resource-constrained healthcare facility. Indian J Plast Surg. 2016 Jan-Apr;49(1):81-5.
12. Salminger S, Roche AD, Sturma A, Mayer JA, Aszmann OC. Hand Transplantation Versus Hand Prosthetics: Pros and Cons. Curr Surg Rep. 2016;4:8.
13. Scaglioni MF, Fontein DBY, Arvanitakis M, Giovanoli P. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery. 2017 Nov;37(8):947-953.

How to Cite this article: Ahire P. What’s new in Hand Surgery? Journal of Clinical Orthopaedics July-Dec 2017; 2(2): 55-56

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An update on Pediatric Orthopaedics: 2017

Vol 2 | Issue 2 |  Juiy – Dec 2017 | Page 48-50 | Chasanal Rathod

Authors: Chasanal Rathod [1]

[1]Consultant Pediatric Orthopaedic Surgeon, SRCC Childrens Hospital, Cloud Nine Hospital. Mumbai.

Address of Correspondence
Dr. Chasanal Rathod,
Consultant Pediatric Orthopaedic Surgeon,
SRCC Childrens Hospital, Cloud Nine Hospital. Mumbai

The year 2017 has come up with various studies in Pediatric Orthopaedics. Over the years, there have been established guidelines and protocols to treat the younger population for various disorders; however researchers, surgeons continue to correlate these guidelines in their set-up/population and report various results and findings, which can be helpful in treating the orthopaedic problems in children. Here is a quick update on some of the articles from various journals focusing on pediatric orthopaedics.

Pediatric Hip

Developmental Dysplasia of Hip
Screening for Developmental dysplasia of Hip(DDH) during the neonatal period and infancy has always been emphasized and has been a part of various nations in their health reforms. The debate of selective vs universal screening and its efficacy still continues, So is a “clicking hip” always a DDH? Paton et al [1] screened 362 hips over two decades and 97% of this clicky hips required no treatment and these are a normal variant and do not pose as a risk factor for DDH, However those with positive findings do need further investigations and treatment. The treatment of neonatal and infant DDH with pavlik harness is widely accepted treatment of choice with a success rate as high as 96.8% [2]. In spite of early screening and detection and treatment, cases with residual acetabular dysplasia (RAD) remain as one of the most common cause of secondary osteoarthritis of hip, a decision making algorithm for the management of RAD is established from the senior authors’ personal experience and the data collected from the literature [3].

Pediatric Hip: Perthes’ disease

A long term retrospective study by Shohat et al studied 24 hips of Perthes’ disease for effect of distal trochanteric transfer(DTT) following Varus derotational osteotomy ( VDRO). Ten hips with Articular trochanteric distance > 5mm underwent DTT. These patients were subsequently compared with 14 hips who did not undergo DTT. The radiographic results in the long-term follow-up of patients with GTO following VDRO were significantly better, there was no clinical benefit seen or incidence of osteoarthritis compared with patients who had not undergone DTT. Song et al[5] have wonderfully described an alternative minimal invasive technique of proximal femur osteotomy for the Perthes’ disease which helps attain precise correction for varus /valgus derotation osteotomy with stable fixation. The review for Perthes would not be complete without discussing the outcome of combined pelvic osteotomies and Femoral osteotomies and Rupprecht et al [6] have published their results of 52 children treated over a period of 10 years. The hips were analysed at skeletal maturity for Stulberg classification and sphericity deviation score. These findings were compared with the literature and did not show any significant change in the clinical and radiographic outcome and hence it is not recommended that combined osteotomies be performed.

Pediatric Trauma

One of the most common fracture seen in day to day practice is a supracondylar fracture of humerus. The treatment protocol is largely based on the fracture and displacement. The AAOS has published the Appropriate Use Criteria( AUC) for the management of these fractures based on recommendations from an expert panel. Study by Cemal et al[7] is a retrospective analysis of 991 patient records was reviewed for appropriateness of AUC and these criteria are useful for orthopedic surgeons to be used in clinical practice. However a comparison of the daytime and after after-hours surgical treatment of Gartland type 3, supracondylar humeral fractures in children shows a higher poor fixation rate in after-hours treatment as compared in daytime procedures. Although the other factors like operative time, quality of reduction, rate of open reduction, extent of poor functional outcome were not affected. Ideally this surgery can be performed during the daytime[8]. Persiani et al[9] in their study of management of cubitus varus with a lateral wedge osteotomy: K-wires or Locking angular plates recommend the use of the plate as it can rigidly stabilize the osteotomy . Often the forearm fractures in children are treated non-operatively. Paediatric forearm fractures, in particular, have seen an increased rate of surgical treatment despite the lack of comparative studies showing a clear benefit over non-operative treatment. Cruz et al[10] have reviewed the HCUP-KID database of 30,936 forearm fractures to evaluate the rate of surgical treatment over time. They concluded that increase in surgical rates were associated with older age, males and treatment at a Children’s hospital and having a non- Medicaid insurance status. Nandra et al[11]performed a retrospective analysis of 61 children with open tibia fractures. Various treatment modalities were opted, casting, elastic nailing, K wiring, intramedullary nailing, external fixator application and open reduction and plate fixation. All fractures united irrespective of the grade of compound injury and fixation. Aggressive initial wound management and early definitive treatment is recommended. Deformity correction and Growth modulation has been extremely effective in treating angular deformities in children without causing any permanent growth arrest. A retrospective multicentric study including 126 patients has studied correction outcomes and adverse events of Eight plate for lower limb deformity. The adverse events were noted in 18% patients were mainly screw related and hence a close monitoring is recommended[12]. Corradin et al[13] studied 7 cases of Renal osteodystrophy (ROD) for efficacy of temporary epiphysiodesis to correct angular deformities of lower limbs. They conclude that its safe and effective in cases with ROD, important is to have regular follow up as the deformities tend to progress or relapse around skeletal maturity Ceroni et al[14] puts forward a hypothesis that hemiepiphysiodesis at femoral or tibial is likely to cause modification of Tibial tuberosity( TT) – Trochlear groove (TG) distance by applying a trigonometric formula therefore predict that for every degree of angular correction during femoral distal hemiepiphysiodesis, there is a 1-mm simultaneous lateral or medial transfer of the TT. We also predict that, during proximal tibial hemiepiphysiodesis, 8° of angular correction will roughly translate the TT by 1 mm. However, these findings are based on retrospective MRI scans and the establishment of a relationship between femoral or tibial hemiepiphysiodesis and the modification of the TT–TG distance requires a prospective study.

Bone and Joint infection

Schmale et al[15] have retrospectively studied 16 patients with bone and joint syndrome and compared the frequency of severe systemic effects and Toxic shock syndrome(TSS) in Staphylococcal aureus with Group A β-haemolytic Streptococcus pyogenes (GABS) bone and joint infections. They concluded that GABS septic arthritis and/or osteomyelitis increase the likelihood of TSS when compared with bone and joint infections with SA. Also the GBS and Methicillin resistant Staphylococcus aureus (MRSA) they had an additional need of surgeries and hospital stay as compared to Methicillin sensitive Staphylococcus aureus (MSSA). Patients with rapidly positive blood cultures, particularly those with gram-positive cocci in chains, and a presenting CRP > 15 mg/dL are at an increased risk of developing septic shock and should be carefully monitored.
Dehority et al[16] recommend MRI at presentation so as to identify the suppurative complications of Acute hematogenous osteomyelitis and also any delay at presentation was associated with abscess formation. Should the subperiosteal abscess always be drained? Or can they be treated with just antibiotics alone? Montgomery et al [17] postulated a hypothesis that a corticotomy or intramedullary drainage(ID) reduces the rate of reoperation by clearing the infection. This hypothesis was statistically significant and hence a small drilling in the cortical bone /corticotomy is recommended.


Ponseti method, is internationally recognized as the gold standard of treatment for management of Clubfoot18]. How early should the intervention begin? Lebel et al have treated neonates in the NICU at 27 weeks to term and they conclude that clubfoot treatment is feasible and effective in the first week of life and efforts should be made to initiate the treatment with minimal delay, however clubfoot cannot be considered as a priority over life threatening medical problems. In cases of relapsed clubfoot[19], Gary et al[20] have emphasized the importance of recasting or repeating the modified Ponseti treatment to correct or improve the passive ankle dorsiflexion. The complex idiopathic clubfoot have been studied by Hosam et al[21] and they concluded that complex variety requires more casts than usual i.e average 7 ( range 5-10 ) and also a higher rate of tendoachillis tenotomy and a higher risk of relapse is expected. Maranho et al have reported repair of Achilles tendon after the TA tenotomy, ultrasonographic findings revealed mild thickening in 80% and thinning was noted on 15% although there was no effect on its function.


1. K. Nie, S. Rymaruk, R. W. Paton. Clicky Hip alone is not a true risk factor for developmental dysplasia of the hip . Bone Joint J 2017; 99-B: 1533-6.
2. Choudry, Qaisar; Paton, Robin W.Pavlik harness treatment for pathological developmental dysplasia of the hip: meeting the standard?Journal of Pediatric Orthopaedics B. 26(4):293-297, July 2017.
3. Mansour, Elie; Eid, Roy; Romanos, Elie; Ghanem, Ismat. The management of residual acetabular dysplasia: updates and controversies.Journal of Pediatric Orthopaedics B: 26(4): 344-49, July 2017.
4. N. Shohat, R. Gilat, R. Shitrit, Y. Smorgick, Y. Beer, G. Agar. A long-term follow-up study of the clinical and radiographic outcome of distal trochanteric transfer in Legg-Calvé-Perthes’ disease following varus derotational osteotomy.Bone Joint J 2017;99-B:987–92.
5. Park, Kwang-Won; Shah, Ishani P.; Ramanathan, Ashok K.; Lee, Tae-Jin; Song, Hae-Ryong Proximal femoral osteotomy in Legg-Calvé-Perthes disease using a monolateral external fixator: surgical technique, outcome, and complications. Journal of Pediatric Orthopaedics B: July 2017 26;(4):329–335.
6. Mosow N, Vettorazzi E, Breyer S, Ridderbusch K, Stücker R, Rupprecht M. Outcome After Combined Pelvic and Femoral Osteotomies in Patients with Legg-Calvé-Perthes Disease. J Bone Joint Surg Am. 2017 Feb 1;99(3):207-213
7. Kazimoglu C, Turgut A, Reisoglu A, Kalenderer Ö, Önvural B, Agus H. Are the Appropriate Use Criteria for the management of pediatric supracondylar humerus fractures useful in clinical practice? J Pediatr Orthop B. 2017 Sep;26(5):395-399..
8. Aydoğmuş S, Duymuş TM, Keçeci T, Adiyeke L, Kafadar AB.Comparison of daytime and after-hours surgical treatment of supracondylar humeral fractures in children.J PediatrOrthop B. 2017 Sep;26(5):400-404.
9. Persiani P, Noia G, de Cristo C, Graci J, Gurzì MD, Villani C. Lateral wedge osteotomy for pediatric post-traumatic cubitus varus: Kirschner-wires or locking angular plate? J Pediatr Orthop B. 2017 Sep;26(5):405-411..
10. Cruz AI, Kleiner JE, DeFroda SF, Gil JA, Daniels AH, Eberson CP. Increasing rates of surgical treatment for paediatric diaphyseal forearm fractures: a National Database Study from 2000 to 2012. Journal of Children’s Orthopaedics. 2017;11(3):201-209.
11. R. S. Nandra, F. Wu, A. Gaffey, C. E. Bache. The management of open tibial fractures in children. Bone Joint J 2017;99-B:544–53.
12. Joeris, Alexander; Ramseier, Leonhard Langendörfer, Micha von Knobloch, Michael Patwardhan, Sandeep; Dwyer, Jonathan, Slongo, Theddy. Paediatric lower limb deformity correction with the Eight Plate: adverse events and correction outcomes of 126 patients from an international multicentre study. Journal of Pediatric Orthopaedics B: September 2017 -26;(5):441–448
13. Gigante C, Borgo A, Corradin M. Correction of lower limb deformities in children with renal osteodystrophy by guided growth technique. J Child Orthop 2017;11:79-84.
14. Ceroni, Dimitri; Dhouib, Amira; Merlini, Laura; Kampouroglou, Georgios. Modification of the alignment between the tibial tubercle and the trochlear groove induced by temporary hemiepiphysiodesis for lower extremity angular deformities: a trigonometric analysisJournal of Pediatric Orthopaedics B 2017, 26:204–210
15. Kerr DL, Loraas EK, Links AC, Brogan TV,Schmale GA. Toxic shock in children with bone and joint infections. J Child Orthop 2017;11:387-392.
16. Johnston, Jennifer J.; Murray-Krezan, Cristina; Dehority, Walter. Suppurative complications of acute hematogenous osteomyelitis in children. Journal of Pediatric Orthopaedics B. 26(6):491-496, November 2017.
17. Montgomery CO, Porter A 3rd, Sachleben B, Suva LJ, Rabenhorst B.Treatment of subperiosteal abscesses in children: is drainage of the intramedullary canal required? J Pediatr Orthop B. 2017 Nov;26(6):497-500
18. Sanzarello I, Nanni M, Faldini C. The clubfoot over the centuries. J Pediat Orthop B. 2017 Mar;26(2):143-151.
19. Lebel, Ehud; Weinberg, Eliraz; Berenstein-Weyel, Tamar M.; Bromiker, Ruben.Early application of the Ponseti casting technique for clubfoot correction in sick infants at the neonatal intensive care unit.Journal of Pediatric Orthopaedics B: March 2017 – 26 ( 2): 108–111
20. Marquez, Erika; Pacey, Verity; Chivers, Alison; Gibbons, Paul; Gray, Kelly.ThePonseti technique and improved ankle dorsiflexion in children with relapsed clubfoot: a retrospective data analysis.Journal of Pediatric Orthopaedics B. 2017;26(2):116-121.
21. Matar, Hosam E.; Beirne, Peter; Bruce, Colin E.; Garg, Neeraj K.Treatment of complex idiopathic clubfoot using the modified Ponseti method: up to 11 years follow-up. Journal of Pediatric Orthopaedics B: March 2017 26;(2):137–142
22. D. A. Maranho, F. H. L. Leonardo, C. F. Herrero, E. E. Engel, J. B. Volpon, M. H. Nogueira-Barbosa. The quality of Achilles tendon repair five to eight years after percutaneous tenotomy in the treatment of clubfoot Bone Joint J Jan 2017, 99-B (1) 139-144.

How to Cite this article: Rathod C. An update on Pediatric Orthopaedics: 2017. Journal of Clinical Orthopaedics July-Dec 2017; 2(2):48-50

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New Frontiers in Spine Surgery

Vol 2 | Issue 2 |  Juiy – Dec 2017 | Page 44-47 | Akshay Gadia, Kunal Shah, Abhay Nene

Authors: Akshay Gadia [1], Kunal Shah [1], Abhay Nene [1]

[1] Wockhardt hospital, Anand rao nair marg, Mumbai central
[2] “We are spine” centre, Aarav polyclinic, Ghatkopar, Mumbai

Address of Correspondence
Dr. Kunal Shah,
Consultant spine surgeon, “We are spine” centre
Aarav polyclinic, LBS Road,ghatkopar west, Mumbai-400086

With the ongoing advancement in the field of spinal imaging, surgical techniques and postoperative care of patient it has become convenient for spine physicians to provide optimal treatment with short surgical time and decreased hospital stay. The aim of this article is to highlight the developments in the modern era of spine surgery while providing an insight into the exiting future trends in patient’s care. Advances in the management of spinal degenerative disorders, primary and metastatic spinal tumors, spinal trauma, pediatric and adult deformity, infections, use of osteobiologics, biomaterials, computer assisted navigation and robotics are described with the reference to the published papers.

Degenerative disorders of spine

Cervical Spondylotic Myelopathy (CSM):
The term CSM includes degenerative pathologies (e.g: cervical spondylosis, degenerative disc disease, ossification of posterior longitudinal ligament) resulting in compression of spinal cord and a cluster of clinical features characterized by imbalance, decreased fine motor function of hands with or without sphincter dysfunction. Due to variability in the etiology and natural history of CSM the controversies in the management are related to timing of surgery as well as surgical approach. In a prospective international, multicenter study (n=479), authors found surgical decompression was effective in moderate and severe CSM. In another prospective international observational multicenter study (n=264) authors found no difference in outcomes of anterior versus posterior surgery. However there is still no consensus in the literature with respect to efficacy of MIS versus open cervical decompression, laminectomy versus laminoplasty and the role of adjuvant pharmacological treatment in CSM[1]. In another level 2 mataanalysis of ACDF performed on outpatient basis (n=2448), 63.8% patients undergoing one level surgery while almost all rest of the patients undergoing 2 level surgery were included in the analysis. 2% patients required readmission. Author’s thus concluded that outpatient ACDF is becoming increasingly useful and safe in an adequate setup. However the optimal patient selection for this modality of treatment it is still a matter of debate [2]. Segmental cervical kyphosis has been considered to be one of the important predictors of outcome following cervical decompression in patients with CSM. In the retrospective analysis of 68 patients, Jain et al compared the functional outcome in patients with overall lordotic alignment with those having segmental kyphosis. At the mean follow up period of 5 years, authors found no difference in functional outcome between the two groups thus establishing the notion that segmental alignment of cervical spine does not affect the long term outcome following laminectomy [3].

Disc replacement

In a level 1 study, 99 patients were randomly divided into 2 groups; one group receiving Mobi-C (Zimmer Biomet) TDA implant and other group undergoing ACDF. These patients were followed for 5 years. The prevalence of further surgery differed significantly between the 2 groups (p = 0.049); 7 patients who underwent ACDF required further surgery compared to only 1 patient requiring reoperation in the Mobi-C group. There were significant differences (p < 0.001) between the 2 groups in the imaging-defined range of motion of the treated segment. However, treatment with use of the Mobi-C implant and ACDF both were effective in improving patients’ clinical symptoms [4]. In another level-1 prospective randomized control trial, Sasso et al. examined the 7-year and 10-year outcome of cervical arthroplasty and anterior cervical discectomy and fusion (ACDF). As a part of FDA IDE trial, 47 patients were randomized in a 1:1 ratio to ACDF or cervical arthroplasty (BRYAN, Medtronic) group. 22 patients received arthroplasty while 25 received an ACDF. Outcomes were assessed by Neck disability index (NDI) and Visual analogue scales (VAS) for neck and arm pain. Success of both surgical interventions remained high at the 10-year interval. Both arthrodesis and arthroplasty demonstrated statistically significant improvement in neck disability index, visual analog scale neck and arm pain scores at all intervals including 7- and 10-year periods. Cervical arthroplasty demonstrated an advantage in comparison to arthrodesis as measured by final 10-year NDI score (8 vs. 16, P=0.0485). At 10-year follow-up the reoperation rate in the arthroplasty cohort of this investigation is lower but not statistically different (9%) than that observed in the arthrodesis cohort (32%) (P=0.05551). 3 patients (13.63 %) crossed over to arthrodesis group from arthroplasty group due to technical difficulty in implanting arthroplasty device. Authors concluded that at 7 years and 10 years, cervical arthroplasty had favorable outcome in comparison to ACDF in highly selected population with radiculopathy[5].

Lumbar canal Stenosis

In a level 2, case matched observational study from Norwegian registry for spine surgery; authors evaluated the effectiveness of decompression alone compared with additional fusion for lumbar spinal stenosis with degenerative spondylolisthesis. 260 patients from each group were studied for functional outcome. Primary outcome were measured for leg pain and back pain by NRS (numeric rating scale) and ODI score at 12 months. Though the authors were not able to conclude the superiority of decompression alone over decompression with additional fusion, they however highlighted the fact that considerable number of patients can be treated with decompression alone owing to small difference in group’s effect sizes in the mentioned study[6].

Spinal Deformity

Early onset scoliosis (EOS)
Decreased amount of lengthening over a period of time is one of the known problems that haunt the management of early onset scoliosis with traditional growth rods (TGR). The ‘law of diminishing returns’ defines the amount of lengthening that a TGR can undergo before stiffness across the construct prevents further increases in overall length. In a retrospective analysis of consecutive series of 54 patients of Magnetic expansion control growth rods (MCGR), Gardner et al stated that ‘The law of diminishing returns’ does not affect the serial lengthening of MCGR. They also proposed that it is growth velocity rather than the total number of lengthening episode independent of age of child is a better measure of the success of system that maintain the spine growth[7]. In another retrospective review of prospectively collected clinical and radiographic data of 30 patients with minimum 2 year follow up, Kwan et al studied the unplanned reoperations and other complications associated with MCGR surgery for EOS. Mean age of implantation of MCGR was 7.2 years with mean follow up of 37 months. 14 (46.7%) patients underwent reoperation with in the follow up period. The mean time for reoperation was 23 months (5-48 months) after initial surgery. They found that patients undergoing frequent distractions (1 week – 2 months) hade higher rate of reoperations compared to patients undergoing distraction at the longer interval (3-6 months). They found jamming of rod, failure of proximal construct, rod breakage and infections as a cause for reoperation[8].

Adolescent idiopathic scoliosis

In a level 3, retrospective cohort study of 149 patients of adolescent idiopathic scoliosis; Ohrt-Nissen et al. compared the radiographic outcome and health related quality of life in patients treated with hook/hybrid (H/H) or all-pedicle screw (PS) instrumentation. SRS-22 score was used to measure functional outcome. All patients were followed for minimum of 2 years of postoperatively. H/H and PS group had 85 and 64 patients respectively. Mean curve correction at final follow up was 31% ± 13% versus 49% ± 12% in the H/H and PS group, respectively (p < .001), and mean loss of correction was 7° versus 4° (p < .001). The Cincinnati correction index was significantly higher in the PS group at final follow-up (p < .001). SRS-22 scores did not differ between the two groups (p > .090), and the reoperation rate at final follow-up was 9% in the H/H group and 6% in the PS group (p = .556). The authors found that PS instrumentation compared to H/H instrumentation had significantly better curve correction and less loss of correction. However, there was no significant difference between SRS-22 scores at final follow up[9]. Postoperative loss of correction has been reported with the use of modern segmental instrumentation. In a level 4 retrospective analyses of 42 patients of Lenke 1 AIS, Le Navéaux evaluated the 3D changes in spine and rod in 2 years after AIS instrumentation with different rod materials. This was a unique study as it tried to establish the relation between postoperative loss of correction with the different rod materials. Rods made up of titanium, stainless steel and cobalt chrome were studied. The main thoracic (MT) curve (61±9°) was corrected on average by 75% (15±6°, p<0.01) with no change at 2-year follow up (2YFU) (17±7°, p=0.14). The apical vertebral rotation (23±7°) was corrected by 44% (13±9°, p<0.01) with no change at 2YFU (14±9°, p=0.64). The thoracic kyphosis (24±12°) remained unchanged (p=0.78). Rod curvature and deflection also remained unchanged (all p>0.05). 3D curve correction was maintained in the 2YFU for all rod materials subgroups (all p>0.05). Authors concluded that there was no significant change in the 3D shape change of instrumented thoracic spine or of the rods for any of the cases irrespective of rod material used[10].

Adult degenerative Scoliosis

In an ambispective study of 125 elderly patients (> 65 years) undergoing elective spine surgery for correction of adult degenerative scoliois, Adogwa et al. studied the effects of early mobilization on patient outcomes, complications and 30 day readmission rates. Patients in the top and bottom quartiles were dichotomized into “early ambulators” and “late ambulators”, respectively. Early ambulators were ambulatory within 24 hours of surgery, whereas late ambulators were ambulatory at a minimum of 48 hours after surgery. The prevalence of at least one perioperative complication was significantly lower in the early ambulators cohort (30% vs. 54%, P = 0.06) compared to late ambulators. The length of inhospital stay was 34% shorter in the early ambulators cohort (5.33 days vs. 8.11 days, P = 0.01). Functional independence was superior in the early ambulators cohort, with the majority of patients discharged directly home after surgery compared with late ambulators (71.2% vs. 22.0%, P = 0.01). Authors suggested that even the delay of 24 hours in ambulation was associated with higher complications rate and inferior functional outcome[11]. In a level 1 meta-analysis, Lee et al., reviewed the literature for identifying advantages and disadvantages of long versus short fusion for patients with spinal stenosis with balanced de novo degenerative lumbar scoliosis without substantial sagittal imbalance. Data from 6 studies involving 362 patients was analyzed (short fusion in 202 and long fusion in 160 patients). The long fusion group showed a substantial decrease in Cobb angle (WMD, 8.94; 95% CI, 2.55–15.33) and in C7 plumb (WMD, 5.90; 95% CI, 0.39–12.18), compared to the short fusion group. At final follow-up, ODI had decreased similarly in both groups (WMD, 1.70; 95% CI, 13.04–9.65). The short fusion group showed advantages including decreased blood loss (mean difference, 739.9mL) and shorter operative time (mean difference, 68.0 minutes) compared to the long fusion group. Based on these results, authors suggested that short fusion might be reasonable option for patients with sagittaly balanced degenerative scoliosis[12].

Spinal Trauma and spinal cord injury

In a prospective multicenter study to find out burden of spine fractures in India, Aleem et al. analyzed 192 patients over a period of 8 weeks across 14 hospitals in India. The aims of this study were to determine the characteristics of patients sustaining spinal trauma in India and to explore the association between patient or injury characteristics and outcomes after spinal trauma. This srudy was in affiliation with ongoing INternational ORthopedic MUlticenter Study (INORMUS). Mean age was 51.0 years, 72 % patients were injured from falls. Thirty-day mortality and complication rates were 2.6% and 10.0%, respectively. Care in the public hospital system (odds ratio [OR] = 6.7, 95% CI = 1.1-41.6), chest injury (OR =11.1, 95% CI = 1.8-66.9), and surgical intervention (OR = 4.8, 95% CI = 1.2-19.6) were independent predictors of major complications. The presence of chest injury and surgical intervention following spinal trauma were predictive of adverse outcomes in 30 days. The limitation of this study was that the follow-up period was only 30 days. Hence, complications arising after 30 days were not analyzed[13].

Spinal tumors

In a retrospective analysis, Patil et al studied 5 patients for early results of total en-bloc spondylectomy for solitary metastatic lesion. Average duration of follow-up was 18 months (range 16-20 months). The average preoperative visual analog scale score of 9.4 (range 9-10) improved to 2 (range 1-4) at last followup. Average blood loss was 1440 mL (range1000-2000 mL). Average duration of surgery was 198 min (range180-240 min). Significant pain relief was noticed in each patient in the immediate postoperative period and during followups. Authors suggested that en bloc spondylectomy has good short-term results for solitary, metastatic, high-grade vertebral body tumors[14].

Spinal Infections

In a level 3 retrospective study of, 84 patients were analyzed to determine the role of fixation in deep spinal infections. Patients were divided in 3 groups; those treated with antibiotics alone, those treated with antibiotics and debridement and those treated with antibiotic, debridement and instrumentation. Patients were compared for mortality, reoperation and reinfection rates. Patients were analyzed using multivariate logistic regression model. The most common form of infection was osteomyelitis and spondylodiscitis (69.4%). Staphylococcus aureus was the most common causative organism (61.2%). There was no difference in terms of reoperation or relapse for patients treated with antibiotics alone, antibiotics with debridement, or antibiotics with debridement and instrumentation. However, compared with antibiotics alone, the crude in-hospital mortality was lower for patients treated with instrumentation (odds ratio, OR, 0.82; P = 0.01), and antibiotics with debridement (OR 0.80; P = 0.02). Authors suggested that spinal instrumentation in infected spine is safe and not associated with higher reoperation and relapse rates. Mortality is lower for patients treated with spinal instrumentation[15].

Navigation and robotics in Spine surgery

Molliqaj et al. analyzed 169 patients, with the aim to compare the accuracy of robot guided and conventional free hand-fluoroscopy guided pedicle screw placement in thoracolumbar surgery. Pathological entities included degenerative disorders, tumors, and traumatic cases. In the robot-assisted cohort (98 patients, 439 screws), pedicle screws were inserted with robotic assistance. In the freehand fluoroscopy-guided cohort (71 patients, 441 screws), screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. The accuracy of screw placement was assessed based on the Gertzbein-Robbins scale by a neuro-radiologist blinded to treatment group. The radiological slice with the largest visible deviation from the pedicle was chosen for grading. A pedicle breach of 2 mm or less was deemed acceptable (Grades A and B) while deviations greater than 2 mm (Grades C, D, and E) were classified as misplacements. In the robot-assisted cohort, a perfect trajectory (Grade A) was observed for 366 screws (83.4%). The remaining screws were Grades B (n = 44 [10%]), C (n = 15 [3.4%]), D (n = 8 [1.8%]), and E (n = 6 [1.4%]). In the fluoroscopy-guided group, a completely intrapedicular course graded as A was found in 76% (n = 335). The remaining screws were Grades B (n = 57 [12.9%]), C (n = 29 [6.6%]), D (n = 12 [2.7%]), and E (n = 8 [1.8%]). The proportion of non- misplaced screws (corresponding to Gertzbein-Robbins Grades A and B) was higher in the robot-assisted group (93.4%) than the freehand fluoroscopy group (88.9%) (p = 0.005). In this retrospective review, authors found that robot-guided pedicle screw placement is a safe, useful, and potentially more accurate alternative to the conventional freehand technique for the placement of thoracolumbar spinal instrumentation[16].

Biomaterials and tissue biologics

A level 1 study compared the use of osteogenic protein-1 (OP-1, also known as bone morphogenetic protein [BMP]-7) combined with local autograft in comparison with iliac crest autograft combined with local autograft in posterolateral lumbar fusion. This randomized prospective study was performed at 4 centers in Europe and included 119 patients. Fusion was documented on computed tomography (CT) scans. The authors found a 54% fusion rate in the OP-1 group and a 74% fusion rate in the iliac crest group. The authors concluded that OP-1 was not as effective as autologous iliac crest bone for achieving posterolateral lumbar fusion. The fallacy of this study was being a randomized control trial there was no standard uniform technique that was used for preparation of graft bed, which is equally important for fusion[17]. In a case series study, 10 patients undergoing anterior cervical corpectomy and fusion (ACCF) with use of trabecular titanium metal interbody implants had frequent radiographic subsidence, but radiographic fusion and an improved functional outcome at 2 years of follow-up[18].

3D printing in spine surgery

In a systemic review, Wilcox et al., searched 6 electronic database with the aim to summarize literature on use of 3D printing technologies for planning or production of patient-specific implants for spinal surgery. These searches returned a combined 2,411 articles, of which 453 duplicates were removed, before the remaining 1,958 articles were screened by title and abstract for relevancy, leaving 75 articles for full text review. Of these, 54 were included in this review. Authors concluded that 3D printing technology is being used profoundly for surgical planning, intra operative surgical guides and customized prostheses as well as “Off-the-shelf” implants. The technology allows manufacturing implants with enhanced properties as well as decreasing the surgical time and improved patient outcome. Though the technology looks promising, larger scale studies and longer-term follow-ups will enhance the knowledge of 3D printing and its impact on spine surgery[19].


1. Fehlings MG, Ibrahim A, Tetreault L, et al. A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy: results from the prospective multicenter AOSpine international study on 479 patients. Spine (Phila Pa 1976). 2015;40(17):1322-1328.
2. McClelland S 3rd, Oren JH, Protopsaltis TS, Passias PG. Outpatient anterior cervical discectomy and fusion: a meta-analysis. J Clin Neurosci. 2016 Dec;34:166- 8. Epub 2016 Jul 27.
3. Jain A, Rustagi T, Prasad G, Deore T, Bhojraj SY. Does Segmental Kyphosis Affect Surgical Outcome after a Posterior Decompressive Laminectomy in Multisegmental Cervical Spondylotic Myelopathy? Asian Spine Journal. 2017;11(1):24-30.
4. Hou Y, Nie L, Pan X, Si M, Han Y, Li J, Zhang H. Effectiveness and safety of Mobi-C for treatment of single-level cervical disc spondylosis: a randomised control trial with a minimum of five years of follow-up. Bone Joint J. 2016 Jun;98-B (6):829-33.
5. Sasso WR1, Smucker JD, Sasso MP, Sasso RC. Long-term Clinical Outcomes of Cervical Disc Arthroplasty: A Prospective, Randomized, Controlled Trial. Spine (Phila Pa 1976). 2017 Feb 15;42(4):209-216.
6. Austevoll, I.M., Gjestad, R., Brox, J.I. et al. The effectiveness of decompression alone compared
with additional fusion for lumbar spinal stenosis with degenerative spondylolisthesis: a pragmatic comparative non-inferiority observational study from the Norwegian Registry for Spine Surgery. Eur Spine J (2017) 26: 404.
7. Gardner, A., Beaven, A., Marks, D., Spilsbury, J., Mehta, J., & Ede, M. (2017). Does the law of diminishing returns apply to the lengthening of the MCGR rod in early onset scoliosis with reference to growth velocity?. Journal Of Spine Surgery, 0. Retrieved from
8. Kwan, Kenny Yat Hong, et al. “Unplanned Reoperations in Magnetically Controlled Growing Rod Surgery for Early Onset Scoliosis with a Minimum of Two-Year Follow-Up.” Spine, 2017, p. 1.
9. Ohrt-Nissen, Søren, et al. “Radiographic and Functional Outcome in Adolescent Idiopathic Scoliosis Operated With Hook/Hybrid Versus All-Pedicle Screw Instrumentation—A Retrospective Study in 149 Patients.” Spine Deformity. 2017. vol. 5, no. 6, 2017, pp. 401–408.
10. Navéaux, Franck Le, et al. “Are There 3D Changes in Spine and Rod Shape in the 2 Years After Adolescent Idiopathic Scoliosis Instrumentation?” Spine, 2017. vol. 42, no. 15, pp. 1158–1164.
11. Adogwa, Owoicho, et al. “Early Ambulation Decreases Length of Hospital Stay, Perioperative Complications, and Improves Functional Outcomes in Elderly Patients Undergoing Surgery for Correction of Adult Degenerative Scoliosis.” The Spine Journal, 2017. vol. 17, no. 10, pp. 1420–1425.
12. Lee, C., Chung, C. K., Sohn, M. J., & Kim, C. H. (2017). Short Limited Fusion Versus Long Fusion With Deformity Correction for Spinal Stenosis With Balanced De Novo Degenerative Lumbar Scoliosis. Spine, 42(19).
13. Aleem, I. S., Demarco, D., Drew, B., Sancheti, P., Shetty, V., Dhillon, M., Bhandari, M. The Burden of Spine Fractures in India. Global Spine Journal,2017, 7(4), 325-333.
14. Patil SS, Nene AM. Total enbloc spondylectomy for metastatic high grade spinal tumors: Early results. Indian Journal of Orthopaedics. 2016;50(4):352-358..
15. Hey, H. W., Ng, L. W., Tan, C. S., Fisher, D., Vasudevan, A., Liu, K. G., Tambyah, P. A. Spinal Implants Can Be Inserted in Patients With Deep Spine Infection. Spine 2017, 42(8).
16. Molliqaj, G., Schatlo, B., Alaid, A., Solomiichuk, V., Rohde, V., Schaller, K., & Tessitore, E. Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery. Neurosurgical Focus, 2017, 42(5).
17. Delawi D, Jacobs W, van Susante JL, Rillardon L, Prestamburgo D, Specchia N, Gay E, Verschoor N, Garcia-Fernandez C, Guerado E, Quarles van Ufford H, Kruyt MC, Dhert WJ, Oner FC. OP-1 compared with iliac crest autograft in instrumented posterolateral fusion: a randomized, multicenter non-inferiority trial. J Bone Joint Surg Am. 2016 Mar 16;98(6):441-8.
18. King V, Swart A, Winder MJ. Tantalum trabecular metal implants in anterior cervical corpectomy and fusion: 2-year prospective analysis. J Clin Neurosci. 2016 Oct;32:91-4. Epub 2016 Aug 8.
19. Wilcox, B., Mobbs, R. J., Wu, A., & Phan, K. Systematic review of 3D printing in spinal surgery: the current state of play. Journal of Spine Surgery, 2017, 3(3), 433-443.

How to Cite this article: Gadia A, Shah K, Nene A. New Frontiers in Spine Surgery. Journal of Clinical Orthopaedics July-Dec 2017; 2(2):44-47

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Recent Trends in Arthroplasty

Vol 2 | Issue 2 |  Juiy – Dec 2017 | Page 40-43 | Shrinand V Vaidya, Jitesh Manghwani

Authors: Shrinand V Vaidya [1,2], Jitesh Manghwani [2]

[1]Consultant Joint Replacement Surgeon, Hip & Knee Arthritis Clinic Global,Breach Candy,Hinduja Healthcare,Jupiter Hospitals.
[2]Professor Of Orthopaedic Surgery-King Edward VII Memorial Hospital, #608, Dept Of Orthopaedic Surgery, Multistoreyed Building, Parel, Mumbai, India 400012.

Address of Correspondence
Dept Of Orthopaedic Surgery,
Multistoreyed Building, Parel, Mumbai, India 400012.

I. Out patient total joint arthroplasty

1. It is advised bilateral THA should be in high volume centers in young and healthy patients [1].
2. The OARA score for primary TJA has more precise predictive ability than the ASA-PS and CCI scores for the same or next day discharge. However it should have a robust patient education program to establish appropriate expectations for early discharge [2].
3. With appropriately selected patients, outpatient THA is not at a greater risk of 30 days adverse events or readmission than those that were performed as inpatient procedures [3].
4. With optimized discharge protocols, shorter stays decrease costs associated with TKA. This helps in diverting the limited healthcare resources towards the patients who are more likely to leave in 1 day [4].

Editorial Comment:Day care surgery is definitely a solution to save resources & effectively lessen the burden on any healthcare model. However it has some definite pre-requisites which should be taken care of:
a) “on call” availability of good physician -24X7-taking care of communication and complications if any, to prevent readmissions.
b) Trained staff to help patients with effective pain management and blood loss monitoring, immediately after the operation.
c) Trained nursing staff-Nurse anaesthetist/Nurse Physician level in the US (Level Of B.Sc nursing in, India)continuously at home.
However trying to save money shouldn’t be at the cost of mortality/ morbidity of the patient.

II. Infection
1. It is time to develop new formulations for diagnosis and treatment of PJI. Also we need to know the implications of the same in future with current rise in PJI [5]. This is a very important and landmark editorial, by Javad Parvizi.
2. Irrigation and Debridement with exchange of Poly Liner, was successful in the majority of patients falling in a specific criteria. However it is recommended that PJI patients with MRSA or Psuedomonas Aeruginosa should not undergo Irrigation and Debridement and be treated with 2-stage revision [6].
3. The results of this have shown a 4-fold decrease in acute PJI with the use of silver-impregnated occlusive dressings supporting its use [7].
4. Vancomycin if used prophylactically, should be titrated as per weight. Under-dosage without realizing the excessive weight of the patient has been a proven cause of PJI [8].

Editorial Comment:PJI is at resurgence owing to the tremendous increase in the volume of the Total Joint Surgeries, worldwide in the last decade, with suboptimal environment. There is very important and landmark editorial, by Javad Parvizi.
Other factors ,are modalities of early detection with the discovery of tests like Alpha-defensin (Zimmer) or esterase test, or specific threshold of Polymorphonuclear counts , to aid the early diagnoses of the infection.
Caution should be taken while dealing with high virulence organisms like MRSA, pseudomonas. Over enthusiastic loading with antibiotics in these infections without implant removal should have a calculated risk benefit ratio.
Causes of infection may be multi factorial. Drugs like Vancomycin should be used with weight calibration and caution should not substitute for poor universal precautions. However with editors experience, as a part of Consensus Committee, held at Philadelphia, 2013, it is worthwhile to read complete document- 1.

III.Health policies and Economics
1. In the year prior to TKA, over half of the non-inpatient costs associated with knee OA are trials of conservative management. Of which around 30% of this is due to HA injections alone. If only interventions recommended by the Clinical Practice Guidelines are utilized then the costs associated with knee OA could be decreased by 45% [9].
2. Nerve injury, dislocation, and leg length discrepancy (–from max. to min.-) are the most common reason for malpractice after primary THA. Patient education regarding the details of the risks and limitations of the surgery should be a mandatory protocol [10].
3. The use of a joint hospital-physician committee is a potential strategy for achieving lower average purchase prices for prosthetic implants. Policies to increase hospital-physician collaboration may lead to lower average purchase prices in this market [11].

Editorial Comment: Extreme conservatism to delay knee replacement, is a costly affair, may be as much as or more than the implant of the knee replacement. Editors feel, that there is no point in waiting in cases of established tri compartmental arthritis beyond 2 months with chondro protective or cartilage protective agents (including intra articular lubricants).  As opposed to what we feel leading causes of law suits after THR, remain foot drop,(Not LLD !) dislocation, limb length discrepancy-in that order. While the first two are technique dependent, third is dependent on pre operative and post operative counseling. We feel that lengthening upto 5 mm is physiological and within 3 to 6 months patients can hardly perceive it-interim time may be best managed with compensatory footware. However one must not forget the additional benefits of slightly tight hip replacement which adds to the stablility at the same time. Article by Derek Hass et al has a lot of importance especially in the view of NPPA’s capping policy in our country, which has been recently implemented for the Total Knee Implants. We strongly believe that although the margins of commonly used designs of TKR implants are too high and needed to be corrected for the mass usage, the point to be kept in mind is the amount of resources spent on a elite new technology-almost four times expensive, across companies. It may include cost of development, trials, approvals etc. We believe that the latest design, which are recently launched, should be allowed to be sold at premium cost for a duration of 3-5 years after the launch, respecting the innovation, after which capping may be applied (View purely personal).

IV. Robotic surgery
1. Robotic-assisted UKA was found to have high survivorship and satisfaction rate at short-term follow-up. Long term follow up studies are required [12].
2. Computer-assisted navigation TKA may restore biomechanics during walking that are closer to normal than conventional TKA. However apart from walking, other biomechanics are almost the same between conventional and computer assisted navigation [13].
3. The article shows no difference no difference in 2-year outcome scores in TKAs implanted using the KA versus an MA technique. The theoretical advantages of improved pain and function that form the basis of the design rationale of KA were not observed in this study. However long term results are yet to be evaluated [14].

Editorial Comment: Robotics and navigation definitely are the new dimension in Arthroplasty. The short term results have been promising with greater satisfaction and restoration of the biomechanics. We should analyze the technology with its outcome vis-à-vis cost of the set up. MAKO (Stryker) with Robotic Hand, for UKR, has shown very promising initial results. However very stiff cost, has kept this, out of bounds, from average Hip and Knee Surgeons.

V. Miscellaneous
1. With this study it is the call of the hour to revise the indications of unicompartmental knee arthroplasty. The results in patients who were contraindicated to UKA as per the current norms have been good or even better than the ones without contraindications [15].
2. The use of minimally invasive mobile bearing UKA is advised in patients who require higher degrees of flexion as a part of their lifestyle. However, they also showed relatively high rates of bearing dislocation and aseptic loosening [16].

Editorial Comment: The resurgence of UKR is owing to better instrumentation and precision in component position which can be checked intra operatively, both manually and with advanced robotics (Mako)
Undoubtedly Oxford knee leads the rest as “spoon jig” has made the sizing and orientation of femoral component highly precise. Adding double pegs, on the femoral component has enhanced the stability. Oxford group-Dodd et al, together with Keith Berend , and Adolf Lombardi ,from Ohio ,have fine-tuned the art of mobile partial knees to a fair level of perfection. The reports of studies by Thomas Hamilton [15] et al and Won Sik Choy [16] et al should definitely encourage “Non-believers” to believe in Unicompartmental or partial knee replacement.
3. Both physical as well as psychological factors contribute to dissatisfaction. Identification of these factors may help in planning focused interventions to address dissatisfaction [17].
4. Depression and patella maltracking may be associated with lack of “Forgotten Knee” acquisition after TKA, while postoperative increase in flexion may have a positive impact [18].

Editorial Comment: Starting with Robert Bourne, from Canada, there are series of papers that started appearing in the literature, which talk about “Dissatisfaction”, amongst the cohorts, which are otherwise doing well as per KSS scores. KSS and WOMAC scores are not the determinants of patient satisfaction as they are narrowly put up. Further stratification of patient activities like playing with grand children, indulging in sports activities have put under the microscope the issues of satisfaction. We strongly believe that an exhaustive process of pre operative counseling followed by true limits of artificial knee irrespective of surgeon and implant must be discussed.
5. The study concludes that reaching a high degree of flexion did not influence surface damage or 3D deviation of the polyethylene inserts [19].

Editorial Comment: Although the article is supportive of no damage occurring to polyethylene inserts during high flexion activities, it doesn’t clarify, whether the knee was being loaded or unloaded. We feel that this article , stand alone, should be dealt with caution and rather follow the traditional path of restricting knee flexion to not more than 130 degrees and avoiding loaded flexion.
6. No significant differences are found between the PFC Sigma and Attune knees in KSS or satisfaction. However, the Attune group had a lesser incidence of AKP and crepitation [20].
7. The paper concludes that early failure at tibial base plate is owing to use of HVC cement rather than any problems with the implant [21].

Editorial Comment: This expensive, rich inventory category of knee designs and state of art instrumentation provided, has been the target of some criticism for early debonding below tibial base plate. Together with Attune at least 6 more companies in market place have come out with this “Futuristic knees” with excellence in design, abundant sizes and unmatched inventory and superlative instruments.
This paper by Ranawat et al [20] is very encouraging. We strongly feel that this is more of technique related issue rather than that of the technology. Technique of cementing and not using High Viscosity Cement (HVC) are the factors, which can make significant difference, in the quality of under tibial plate cementing. Judeth et al, have shown problems in Vanguard knee tibial base plates, when implanted with HVC cement. Same, if implanted with Palacos cement with multiple drill holes establishing micro- macro lock should be per se immune to debonding. However, to have any more emphasis in this matter we will have to wait for another 2-3 years.
8. An all-polyethylene tibial component provides excellent results in the elderly population along with a significant cost savings. [22]

Editorial Comment: All poly is the Knee implant for all the ages, all surgical hands and all seasons . We shouldn’t change just for the sake of change as posterior stabilized all poly has seen unparalleled results since 3 decades. However it’s use should be restricted in cases with severe bone losses & deformities more than 15 degrees in the coronal plane, which may require constrained designs.
9. Results of patellofemoral arthroplasty in patients with minimal radiological change don’t have significant improvement in pain and function [23].

Editorial Comment: Only 10 percent of the knees are pain free. Careful patient selection is a must. One must rethink before proceeding with the same.
10. Social media being a powerful tool today, a research showed TKA posts focused more on rehabilitation and wound healing than THA patients. However THA patients shared more posts on ADLs [24].

Editorial Comment: This article innovatively used data from social media. The concern of patients clearly have been ADL, rehabilitation and wound healing.


1. Lazaros A. Poultsides , Georgios K. Triantafyllopoulos , Stavros G. Memtsoudis, Huong T. Do, Michael M. Alexiades, Thomas P. Sculco. Perioperative Morbidity of Same-Day and Staged Bilateral Total Hip Arthroplasty. The Journal of Arthroplasty. 2017; 32 :2974-2979.
2. R. Michael Meneghini , Mary Ziemba-Davis, Marshall K. Ishmael, Alexander L. Kuzma, Peter Caccavallo. Safe Selection of Outpatient Joint Arthroplasty Patients with Medical Risk Stratification: the “Outpatient Arthroplasty Risk Assessment Score”. The Journal of Arthroplasty. 2017; 32: 2325-2331.
3. Stephen J. Nelson, Matthew L. Webb, Adam M. Lukasiewicz, Arya G. Varthi, Andre M. Samuel, Jonathan N. Grauer. Is Outpatient Total Hip Arthroplasty Safe?. The Journal of Arthroplasty. 2017; 32:1439-1442.
4. Udai S. Sibia, Paul J. King, James H. MacDonald. Who Is Not a Candidate for a 1-Day Hospital-Based Total Knee Arthroplasty?. The Journal of Arthroplasty. 2017; 32:16-19
5. Javad Parvizi. Periprosthetic Joint Infection: The Current Hot Topic. The Journal of Arthroplasty. 2017; 32:2039.
6. Andres F. Duque, Zachary D. Post, Rex W. Lutz, Fabio R. Orozco, Sergio H. Pulido, Alvin C. Ong. Is There Still a Role for Irrigation and Debridement With Liner Exchange in Acute Periprosthetic Total Knee Infection?. The Journal of Arthroplasty. 2017; 32:1280-1284.
7. Matthew J. Grosso, Ari Berg, Samuel LaRussa, Taylor Murtaugh, David P. Trofa, Jeffrey A. Geller. Silver-Impregnated Occlusive Dressing Reduces Rates of Acute Periprosthetic Joint Infection After Total Joint Arthroplasty. The Journal of Arthroplasty. 2017; 32: 929-932.
8. M. Daniel Wongworawat. Editor’s Spotlight/Take 5: Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin. Clin Orthop Relat Res. 2017; 475:1762–1766 / DOI 10.1007/s11999-017-5354-1.
9. Nicholas A. Bedard, Spencer B. Dowdle, Christopher A. Anthony, David E. DeMik, Michael A. McHugh, Kevin J. Bozic, John J. Callaghan. The AAHKS Clinical Research Award: What Are the Costs of Knee Osteoarthritis in the Year Prior to Total Knee Arthroplasty? The Journal of Arthroplasty. 2017;32: S8-S10.
10. Diana C. Patterson, Ronald P. Grelsamer, Michael J. Bronson, Calin S. Moucha. Lawsuits After Primary and Revision Total Hip Arthroplasties: A Malpractice Claims Analysis. The Journal of Arthroplasty. 2017; 32 : 2958-2962.
11. Derek A. Haas, Kevin J. Bozic, Anthony M. DiGioia, Zirui Song, Robert S. Kaplan Drivers of the Variation in Prosthetic Implant Purchase Prices for Total Knee and Total Hip Arthroplasties. The Journal of Arthroplasty. 2017; 32: 347-350.
12. Andrew D. Pearle, Jelle P. van der, List Lily Lee, Thomas M. Coon, Todd A. Borus, Martin W. Roche. Survivorship and patient satisfaction of robotic-assisted medial unicompartmental knee arthroplasty at a minimum two-year follow-up. The knee. March 2017 Volume 24, Issue 2, Pages 419–428.
13. Jodie A. McClelland, Kate E. Webster, Alankar A. Ramteke, Julian A. Feller. Total knee arthroplasty with computer-assisted navigation more closely replicates normal knee biomechanics than conventional surgery. The knee. June 2017 Volume 24, Issue 3, Pages 651–656.
14. Simon W. Young, Matthew L. Walker, Ali Bayan, Toby Briant-Evans, Paul Pavlou, Bill Farrington. The Chitranjan S. Ranawat Award No Difference in 2-year Functional Outcomes Using Kinematic versus Mechanical Alignment in TKA: A Randomized Controlled Clinical Trial. Clin Orthop Relat Res. 2017; 475:9–20.
15. Thomas W. Hamilton, Hemant G. Pandit, Cathy Jenkins , Stephen J. Mellon, Christopher A.F. Dodd, David W. Murray. Evidence-Based Indications for Mobile-Bearing Unicompartmental Knee Arthroplasty in a Consecutive Cohort of Thousand Knees. The Journal of Arthroplasty. 2017; 32:1779-1785.
16. Won Sik Choy, Kwang Won Lee, Ha Yong Kim, Kap Jung Kim, Young Sub Chun, Dae Suk Yang. Mobile bearing medial unicompartmental knee arthroplasty in patients whose lifestyles involve high degrees of knee flexion: A 10–14 year follow-up study. The knee. August 2017 Volume 24, Issue 4, Pages 829–836.
17. Kunal Dhurve, Corey Scholes, Sherif El-Tawil, Aseem Shaikh, Lai Kah, Weng Kumbelin, Levin Brett Fritsch David Parker, Myles Coolican Multifactorial analysis of dissatisfaction after primary total knee replacement. The knee. August 2017 Volume 24, Issue 4, Pages 856–862.
18. Florent Eymard, Anais Charles-Nelson, Sandrine Katsahian, Xavier Chevalier, Michel Bercovy Predictive Factors of “Forgotten Knee” Acquisition After Total Knee Arthroplasty: Long-Term Follow-Up of a Large Prospective Cohort.The Journal of Arthroplasty. 2017; 32: 413-418.
19. Steven B. Daines, Chelsea N. Koch, Steven B. Haas, Geoffrey H. Westrich, Timothy M. Wright. Does Achieving High Flexion Increase Polyethylene Damage in Posterior-Stabilized Knees? A Retrieval Study. The Journal of Arthroplasty. 2017;32:274-279.
20. Chitranjan S. Ranawat, Peter B. White, Sarah West, Amar S. Ranawat. Clinical and Radiographic Results of Attune and PFC Sigma Knee Designs at 2-Year Follow-Up: A Prospective Matched-Pair Analysis The Journal of Arthroplasty. 2017;32:431-436.
21. Judith E. Kopinski, Ajay Aggarwal, Ryan M. Nunley, Robert L. Barrack, Denis Nam. Failure at the Tibial Cement Implant Interface With the Use of High-Viscosity Cement in Total Knee Arthroplasty The Journal of Arthroplasty. 2016; 31: 2579-2582.
22. Kenneth A. Gustke, Martin K. Gelbke. All-Polyethylene Tibial Component Use for Elderly, Low-Demand Total Knee Arthroplasty Patients. The Journal of Arthroplasty. 2017;32:2421-2426.
23. Casey M. deDeugd, Ayoosh Pareek, Aaron J. Krych, Nancy M. Cummings, Diane L. Dahm. Outcomes of Patellofemoral Arthroplasty Based on Radiographic Severity. The Journal of Arthroplasty. 2017; 32:1137-1142.
24. Prem N. Ramkumar, Sergio M. Navarro, Heather S. Haeberle, Morad Chughtai, Megan E. Flynn, Michael A. Mont Social Media and Total Joint Arthroplasty: An Analysis of Patient Utilization on Instagram. The Journal of Arthroplasty. 2017; 32 : 2694-2700.

How to Cite this article:  Vaidya SV, Manghwani J. Potpourri – Recent And Relevant Literature In Arthroplasty 2017. Journal of Clinical Orthopaedics July-Dec 2017; 2(2):40-43

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Potpourri – Recent and relevant literature in 2017

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

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

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

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

Hip Arthroscopy

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

Thromboprophylaxis in Arthroscopy

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

Inappropriate use of arthroscopic meniscal surgery in degenerative knee disease

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

Femoroacetabular impingement and arthroscopy

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

Rotator cuff tear

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

Special Articles

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


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

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

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

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


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.


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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.
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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!

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.

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.


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?

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.

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)


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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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