Surgical site infection following spine surgery

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:38-44 | Dr. Kshitij Chaudhary, Dr. Gautam Zaveri

Author: Kshitij Chaudhary [1], Gautam Zaveri [1]

[1] Sir HN Reliance Foundation Hospital and Research Center, Mumbai
[2] Department of Spine Surgery, Jaslok Hospital & Research Centre.

Address of Correspondence
Dr. Kshitij Chaudhary
Sir HN Reliance Foundation Hospital and Research Center, Mumbai


Surgical site infection in spine surgery is a devastating complication not only from a medical perspective but also from an economic standpoint. Early detection and debridement are necessary, especially if one has to retain the instrumentation. In late infection, if the fusion is confirmed, implant exit can be performed to better treat the infection. The current review focuses on the decision making in Surgical site infections in Spine Surgery
Keywords: Surgical site infection, Spine Surgery, implant


1. Fang C, Wong T-M, To KK, Wong SS, Lau T-W, Leung F. Infection after fracture osteosynthesis – Part II. J Orthop Surg. 2017;25(1):230949901769271.
2. Falagas ME, Karageorgopoulos DE. Pandrug Resistance (PDR), Extensive Drug Resistance (XDR), and Multidrug Resistance (MDR) among Gram‐Negative Bacilli: Need for International Harmonization in Terminology. Clin Infect Dis. 2008;46(7):1121-1122.
3. Willenegger H, Roth B. [Treatment tactics and late results in early infection following osteosynthesis]. Unfallchirurgie 1986;12:241–246.
4. Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated with
fracture-fixation devices. Injury 2006;37:S59–S66.
5. W.J. Metsemakers et al. Infection after Fracture Fixation: Current surgical and microbiological concepts. Injury, Int. J. Care Injured 49 (2018) 511–522
6. Steinmetz et al. Infection after Fracture Fixation. EFORT Open Rev 2019; 4: 468-475.

How to Cite this article: Chaudhary K, Zaveri G. Surgical site infection following spine surgery. Journal of Clinical Orthopaedics July-Dec 2019;4(2):38-44.

(Abstract    Full Text HTML)   (Download PDF)






Fracture Related Surgical Site Infections

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:33-37 | Dr. Aditya Menon, Vikas Agashe, Dr. Camilla Rodrigues, Dr. Anjali Shetty, Dr. Rajeev Soman, Dr. Bimal Mody, Dr. Ayesha Sunavala

Author: Aditya Menon [1], Vikas Agashe [1], Camilla Rodrigues [1],  Anjali Shetty [1], Rajeev Soman [1], Bimal Mody [1], Ayesha Sunavala [1]

[1] PD Hinduja National Hospital, Mahim

Address of Correspondence
Dr. Aaditya Menon,
PD Hinduja National Hospital, Mahim


Surgical site infections following operative treatment of fractures are challenging because of the presence of implants and the problem of fracture healing. The senior author (VA) recommends a 6 legged table concept for good outcomes when dealing with surgical site infections in orthopaedics. This includes early detection of infection, radical debridement, local measures to control wound infection, early soft tissue cover, provision of adequate stability and targeted antibiotics for adequate duration.
Keywords: Surgical site infection, fractures, implant.


1. Fang C, Wong T-M, To KK, Wong SS, Lau T-W, Leung F. Infection after fracture osteosynthesis – Part II. J Orthop Surg. 2017;25(1):230949901769271.
2. Falagas ME, Karageorgopoulos DE. Pandrug Resistance (PDR), Extensive Drug Resistance (XDR), and Multidrug Resistance (MDR) among Gram‐Negative Bacilli: Need for International Harmonization in Terminology. Clin Infect Dis. 2008;46(7):1121-1122.
3. Willenegger H, Roth B. [Treatment tactics and late results in early infection following osteosynthesis]. Unfallchirurgie 1986;12:241–246.
4. Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated with
fracture-fixation devices. Injury 2006;37:S59–S66.
5. W.J. Metsemakers et al. Infection after Fracture Fixation: Current surgical and microbiological concepts. Injury, Int. J. Care Injured 49 (2018) 511–522
6. Steinmetz et al. Infection after Fracture Fixation. EFORT Open Rev 2019; 4: 468-475.

How to Cite this article: Menon A, Agashe V, Rodrigues C, Shetty A, Soman R, Mody B, Sunavala A. Fracture Related Surgical Site Infections. Journal of Clinical Orthopaedics July-Dec 2019;4(2):33-37.

(Abstract    Full Text HTML)   (Download PDF)



Surgical Site Infections in Orthopaedics: The Role of Antibiotics

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:26-32 | Dr. Mala V. Kaneria, Dr. Gautam Zaveri

Author: Dr. Mala V. Kaneria [1,2,3], Dr. Gautam Zaveri [4,5,6]

[1] Department of Medicine, T.N.Medical College and B.Y.L.Nair Ch. Hospital
[2] Kasturba Hospital for Infectious Diseases
[3] Consultant in Infectious Diseases and Tropical Medicine, Jaslok Hospital and Research Centre
[4] Department of Orthopaedics, Rajawadi Municipal Hospital, Mumbai
[5] Department of Spine Surgery, Jaslok Hospital & Research Centre
[6] Consultant Spine Surgeon,Reliance HN, Fortis, Zen Hospital, Mumbai

Address of Correspondence
Dr. Gautam Zaveri
Jaslok Hospital & Research Centre, Mumbai


Inspite of advancements of surgical techniques and operating room technologies, surgical site infections still remain a major problem. Bacteria have also evolved specially in nosocomial settings and both prophylactic and therapeutic use of antibiotics has to be rationally decided based on individual cases.
Keywords: Surgical site infections, orthopaedics, antibiotics, prophylaxis.


1. Cooper RA. Surgical site infections: epidemiology and microbiological aspects in trauma and orthopaedic surgery. Int Wound J 2013; 10 (suppl. 1):3–8
2. Onyekwelu I, Yakkanti R, Protzer L, et al. Surgical Wound Classification and Surgical Site Infections in the Orthopaedic Patient.J of AAOS Glob Res Rev. 2017 Jun; 1(3): e022
3. Anderson DJ and Sexton DJ. Antimicrobial prophylaxis for prevention of surgical site infection in adults. Up To Date (2015): 1-31
4. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006; 43:322
5. Tonya C, Rodvold KA, and. Solomkin JS. Vancomycin for Surgical Prophylaxis? Clinical Infectious Diseases 2012 May 15; 54 (10): 1474- 1479
6. Al Buhairan B, Hind D, Hutchinson A. Antibiotic prophylaxis for wound infections in total joint arthroplasty: A systematic review. JBJS Br. 2008; 90:915–9
7. Wenzel RP. Minimizing surgical-site infections. NEJM 2010 Jan 7; 362 (1):75- 77
8. Ierano C,Nankervis MJ, James R, et al. Surgical antimicrobial prophylaxis.AustPrescr 2017 Dec;40 (6):225–229
9. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2012; 10:73
10. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg 2005 July; 190 (1):9-15
11. Goldmann DA, Hopkins CC, Karchmer AW, et al. Cephalothin prophylaxis in cardiac valve surgery. A prospective, double-blind comparison of two-day and six-day regimens. J Thorac Cardiovasc Surg 1977; 73:470
12. McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review. Aust N Z J Surg 1998; 68:388
13. Conte JE Jr, Cohen SN, Roe BB, Elashoff RM. Antibiotic prophylaxis and cardiac surgery. A prospective double-blind comparison of single-dose versus multiple-dose regimens. Ann Intern Med 1972; 76:943
14. Da Costa A, Kirkorian G, Cucherat M, et al. Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis. Circulation 1998; 97:1796
15. Martinez-Pastor JC, Vilchez F, Pitart C, Sierra JM, Soriano A. Antibiotic-resistance in orthopaedic surgery: acute knee prosthetic joint infections due to extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. Eur J Microbiol Clin Dis 2010; 29:1039–41
16. Finkelstein R, Rabino G, Mashiah T, et al. Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections. J Thoracic Cardiovasc Surg 2002; 123:326
17. Bull AL, Worth LJ, Richards MJ. Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections: report from Australian Surveillance Data (VICNISS). Ann Surg 2012; 256:1089
18. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. CORR 1989;243:36-40
19. Templeman DC, Gulli B, Tsukayama DT, Gustilo RB.Update on the management of open fractures of the tibial shaft. CORR 1998;350:18-25
20. Patzakis MJ, Wilkins J,Moore TM. Considerations in reducing the infection rate in open tibial fractures.CORR 1983; 178: 36- 41
21. PatzakisMJ, Wilkins J,Moore TM. Use of antibiotics in open tibial fractures. CORR 1983;178:31-35
22. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am. 1976; 58:453–8
23. Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics. 1987; 10:1781–8
24. Zalavras CG, Marcus RE, Levin LS, Patzakis MJ. Management of open fractures and subsequent complications. J Bone Joint Surg Am. 2007; 89:884–95
25. Cross WW III, Swintowski MF. Treatment principles in the management of open fractures. Ind J of Orthop 2008 Oct- Dec: 42(4): 377-386
26. Messsner J, Papakostidis C, Giannoudis PV, Kanakaris NK. Surg Infect 2017; Nov/Dec
27. Trebse R, Pisot V, Trampuz A. Treatment of infected retained implants. JBJS Br 2005; 87:249–56
28. Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA 1998; 279:1537–41.
29. Diagnosis and Management of Prosthetic Joint Infection • CID 2013:56(1):e1-25
30. Leone S, Borre S, Monforte A, et al. Consensus document on controversial issues in the diagnosis and treatment of prosthetic joint infections. Int J Infect Dis 2010; 14(suppl 4): S67–77
31. Byren I, Bejon P, Atkins BL, et al. One hundred and twelve infected arthroplasties treated with ‘DAIR’ (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother 2009; 63:1264–71.

How to Cite this article: Kaneria M V, Zaveri G. Surgical Site Infections in Orthopaedics: The Role of Antibiotics. Journal of Clinical Orthopaedics July-Dec 2019;4(2):26-32.

(Abstract    Full Text HTML)   (Download PDF)





Surgical Site Infections in Orthopaedics: An Introduction

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:5-6 |  Dr. Gautam Zaveri

Author: Dr. Gautam Zaveri [1]

[1] Department of Spine Surgery, Jaslok Hospital & Research Centre

Address of Correspondence
Dr. Gautam Zaveri,
Department of Spine Surgery, Jaslok Hospital & Research Centre

Surgical Site Infections in Orthopaedics: An Introduction

Surgical site infections (SSIs) are defined as infections of tissues, organs or spaces exposed by surgeons during the performance of an invasive procedure, that occur within 30 days of surgery or within 1 year of surgery involving implants[1]. In the USA, SSIs are ranked third amongst all reported cases of inpatient nosocomial infections [2,3]. Approximately, 5,00,000 SSIs are reported in the USA every year (2.8 per 100 operations) [4], accounting for 16% of nosocomial infections in all hospitalized patients [5]. Between 30,000- 35,000 SSIs are reported annually in the USA following the performance of an orthopaedic invasive procedure[6]. In a developing nation such as India where surgeries are performed in operating theatres with varying standards and practice of asepsis, the incidence of SSIs is estimated to be many folds higher. As our horizons continue to expand, and we are called upon to perform more complex procedures on patients who are elderly, immuno-compromised and with multiple medical comorbidities, the incidence of SSIs is likely to rise further.
Orthopaedic surgeons have always dreaded SSIs. They compromise the outcome of an otherwise successful surgery resulting in increased suffering, disability, morbidity and mortality and may often compromise the eventual outcome. Besides SSIs result in more extended hospitalization, increased direct and indirect costs, loss of work hours and even job loss. Whitehouse et al. performed a case-controlled study to look at the outcomes following SSIs in orthopaedics [7]. They reported an increase in hospital stay by a median of 2 weeks per patient, approximately double rehospitalization rates and increased healthcare costs by more than 300%. They also found patients with SSIs to have substantially higher physical limitations and significant reductions in health-related quality of life.
Early detection of wound infection requires careful vigilance by the operating team. Pain that is out of proportion to the nature of surgery, fever and difficulty in moving the limb are early signs of infection that may appear even before the surgical site shows signs of infection such as local warmth, tenderness, redness, shininess, oedema, induration and discharge. Laboratory tests and x-rays are of limited use in diagnosing an early infection. In the immediate postoperative setting, an MRI scan is also of limited use because soft tissue hyperintensities and fluid collections are typically seen within the wound at this time. Obtaining a tissue sample to isolate an organism is vital in planning the subsequent treatment.
SSIs in orthopaedics is especially challenging because of the large muscle bulk, the problem of persistence of infection within the bone and the formation of biofilms on dead bone and implants. The treatment of an established SSI entails source control, coupled with targeted anti-biotics. Source control involves drainage of purulent material, physical debride-ment of dead and infected tissue including bone, and copious irrigation of the wound. Implants can be retained, removed or replaced based on the progress of bone healing, the formation of biofilms and the fixation of the implant within the bone. A variety of techniques can be used to obtain local control of infection including antibiotic-loaded cement beads, biocomposites like Stimulan coupled with antibiotics or application of silver nitrate solution. In severe infections, especially in the presence of implants, primary wound closure is avoided and negative pressure wound therapy is used to obtain a reduction in local infection, to promote granulation and healing of the wound. Occasionally, especially for extremity wounds, a flap may be required to cover exposed implant/ bone/ joints/ tendons / nerves. Antibiotics must be targeted to the organism isolated and administered for prolonged periods (8 to 12 weeks or even longer). Rifamycins are active against biofilms of staphylococci and fluoroquinolones against those of gram-negative bacilli.
The endpoint of stopping antibiotics and declaring complete eradication of infection has not yet been clearly outlined in the literature. No single investigation or clinical sign in isolation can help determine the healing of the infection. Clinical improvement wound healing, reduction in CRP, ESR and Total WBC count, MRI evidence of reduction in soft tissue hyperintensities, fluid collection and bone marrow oedema, fatty conversion of bone marrow with fusion, and a negative bone scan are some of the features of a healed infection.
In spite of considerable improvements in the operating room environment, surgical techniques and aseptic practices, SSIs continue to constitute a significant challenge for the medical team and healthcare institutions. A multipronged approach involving surveillance, antimicrobial prophylaxis, eradication of carrier status, infection control program-mes and education is vital to reduce the risk of SSI. The old adage, “An Ounce of Prevention is better than a Pound of Cure” is aptly suited to the problem of surgical site infections in orthopaedics.


1. Guideline for Prevention of Surgical Site Infection (2017). Centre for disease control and prevention. accessed 15th March 2019
2. Haley RW, Culver DH, White JW, et al. The nation-wide nosocomial infection rate: a new need for vital statistics. Am J Epidemiology 1985; 121: 159- 167 Epidemiol 1985;121:159-167.
3. Horan TC, Culver DH, Gaynes RP, et al. Nosocomial infections in surgical patients in the United States, January 1986–June 1992. Infect Control Hosp Epidemiology 1993; 14:73-80
4. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiology 1996; 17:552- 557 Epidemiol 1996;17:552-557
5. Lee J, Singletary R, Schmader K, et al: Surgical site infection in the elderly following orthopaedic surgery. Risk factors and outcomes. J Bone Joint Surg Am 2006; 88:1705-1712
6. Greene LR: Guide to the elimination of Orthopaedic surgery surgical site infections: An executive summary of the Association for Professionals in Infection Control and Epidemiology elimination guide. Am J Infect Control 2012; 40:384-386
7. Whitehouse JD, Friedman D, Kirkland KB, et al. The impact of surgical site infections following orthopaedic surgery at a community hospital and a university hospital: Adverse quality of life, excess length of stay and extra costs. Inf Control & Hosp Epidemiology 2002; 23: 183- 189.

How to Cite this article: Zaveri G. Surgical Site Infections in Orthopaedics: An Introduction. Journal of Clinical Orthopaedics July-Dec 2019;4(2):5-6.

(Abstract    Full Text HTML)   (Download PDF)








Ethical marketing of Pharmaceutical products appliances by Medical practitioners

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:2-4 | Dr. Anukant Mittal

Author: Dr. Anukant Mittal [1]

[1] Head of dept of Psychiatry, Rajiv Gandhi Memorial hospital, Academic Dean of FIAMC Biomedical Ethics Centre Goregaon

Address of Correspondence
Dr. Anukant Mittal,
Head of dept of Psychiatry, Rajiv Gandhi Memorial hospital, Academic Dean of FIAMC Biomedical Ethics Centre Goregaon

Ethical marketing of Pharmaceutical products appliances by Medical practitioners

Doctors and the pharmaceutical industry have significant common interests. To start, both are concerned with encouraging the use of existing drugs effectively and responsibly in the treatment and care, monitoring of their use, and innovative research.
However, both have different emphases and are answerable to various stakeholders. Doctors are concerned primarily in patient care and scientific advance, while the industry is mainly interested in commercial outcomes. The primary stakeholder for the Doctors is in patient care – the patient, whereas the principal stakeholder in the industry is – the shareholder. In spite of these shared interests and benefits of cooperation, concerns of an ethical nature arise between both the medical profession and the community. There are three main concerns:
1.The possibility that associations between doctors and drug companies may serve commercial objectives of industry and personal interests of clinicians rather than legitimate care, educational or research goals compromising the primary ethical objectives of doctors to patients, undermining the necessary foundation of trust on which clinical relationships depend;
2. The risk that drug promotion will unjustifiably influence doctors’ decisions;
3. The danger that industry involvement in research will lead to distortions, now proven in many cases worldwide, in scientific evidence & independent assessment of data.
An “interest” is a commitment, goal or value that arises out of a particular social relationship or practice. The possibility that dealings with drug companies might lead “conflict of interest”, has been of concern, but identifying such conflicts is not easy.

Sources of concern
It is common for relationships to be associated with several interests. Interests of medical practitioners include both altruistic as well as personal:
· Patient welfare
· Community welfare
· Research grants
· Advancement of career by participation in research
· Hospitality & pecuniary interests (eg, consultancy fees, shareholdings, paid sessions)
When a doctor is engaged in a relationship with a pharmaceutical company, a duality of interests exists. It can’t be assumed that such a duality will constitute a “conflict” in each case; this depends on the particular circumstances. Dualities of interest are common; conflicts relatively rare. Further, whereas the distinction between the two is sometimes clear-cut, at other times, it may be subtle and depend on values of the community within which it occurs. Dualities of interest constitute “conflicts” only when they are associated with competing obligations that are likely to lead directly to a compromise of primary responsibilities. To establish whether a conflict of interest exists, it is necessary for the factual details to be declared and for the community to have the opportunity to scrutinise the issues publicly.

Main areas are:
Drug promotion
Promotion and marketing (including advertising, gift-giving and support for medically-related activities such as travel to meetings), a considerable part of the activities of drug companies (consuming a quarter to a third of their entire budgets). It is estimated that, of this, a third is spent on advertising and a third on sales representatives, while the rest third is spent on physicians.

Doctors generally perceive the way they practise to be determined by knowledge and evidence, but they often fail to recognise and underestimate the subtle and pervasive effects of pharmaceutical promotion. Some practitioners rely on pharmaceutical company representatives for much of their drug prosthesis and appliance information. There is considerable evidence that advertising affects clinical decision-making behaviour, As it does in every as an aspect of day to day life. Contact with drug company representatives leads to prescribing of their drugs and products; physicians exposed to advertising are more likely to accept commercial rather than well established scientific views, and is associated with an inability of some physicians to identify wrong claims and a propensity to engage in non-rational prescribing behaviour.

Gift giving
Gift-giving is another widespread drug-promotion strategy. A study showed that, over a period of one year, psychiatry residents and interns attended up to 35 meetings and 70 drug lunches and received up to 75 promotional items gifts. Although physicians deny that gifts influence their behaviour, there is clear evidence to the contrary. Those who met with pharmaceutical representatives were more likely to ensure inclusion of the company’s products in their prescriptions; those who accepted money to speak at symposia were more likely to do so, and those who accepted money to perform research were also more likely to do so.

Support for travel
There is evidence that drug company support for travel expenses changes the prescribing behaviour of practitioners, it has been shown that a physician who accepts money to travel to a symposium is more likely to prescribe a company-sponsored drug and product after such sponsorship than before.

Meeting sponsorship and continuing medical education activities
Support for meetings is an important issue. There are clearly common interests between professional societies, which are usually responsible for organising conferences, and the pharmaceutical industry: one stands to gain funding for their meetings and other activities, while, for the other, opportunities are provided to showcase their wares. However, the impressions that people go away with may be significantly altered by the choices of speakers and topics at meetings, which may have important implications for pharmaceutical companies, Indeed, sponsorship of conferences has been shown to lead to bias in favour of the sponsoring companies’ drugs, with increases in prescriptions for sponsors’ drugs in the six months after an event. Similarly, pharmaceutical support for continuing medical education (CME) activities leads to increased prescribing of sponsoring companies’ products. This occurs even when the course content is controlled by the society or institution and the drugs are referred to by their generic names only.

Control of publication and research outcomes
The effect of drug company sponsorship on research and publications is a significant issue. Briefly, there are many ways in which research findings can be directed towards producing the desired result, ranging from careful design of a trial and selection of drug doses to selective reporting of results or actual suppression of unfavorable outcomes, those with unfavorable results are never sent for publications. The prominence of a publication can be enhanced by paying authors to participate or publishing non-peer-reviewed material as a supplement in a respected journal.

Guidelines for action ( the new MCI code)
Professional bodies have considered these issues and other organisations, which have from time to time developed guidelines and codes of conduct for their members. Although opinions differ, no professional bodies or institutions have proposed a ban on interactions between doctors and the pharmaceutical industry. Indeed, it is accepted that such a policy would not serve the interests of any party. The most preferred approach is to develop a relationship that allows transparency and is based on clear, but non-coercive guidelines.
The MCI is a qausi-judicial body and its code, though not law, is ethically binding on all practitioners of modern medicine in India. The Medical Council of India (MCI) in an amendment to its existing code of conduct, the Indian Medical Council (Professional conduct, etiquette and ethics) regulations2002, has proposed sweeping guidelines on the relationship between the pharmaceutical industry and the medical profession in India
Following the initial guidelines, the MCI has now gone a step further by announcing a list of punishments which are graded based on the financial quantum of the gift received. For example, those who have received more than Rs 1 lakh(Rs 100 000) will be deregistered for more than a year. The MCI claims that this is the first time in the world that quantum of punishment has been specified. The MCI amendments look at two broad areas.
First, they address the issue of gifting and sponsorship. In the current Indian scenario, with the increasing activism of the pharmaceutical industry, attempts at wooing physicians have been taking unique forms. Frequent foreign trips to exotic locations allegedly to attend conferences is well known. Holiday junkets for family, sponsorship of personal celebrations including birthday parties have also appeared on the scene. Things have reached a point where medical practitioners can perhaps no longer envisage continuing medical education (CME) without pharmaceutical presence. The new MCI code now specifically prohibits practitioners from accepting gifts, travel facilities, hospitality and monetary grants from the healthcare industry either in their name or in the names of their family members. It also bars doctors and their family members from accepting rail or air travel facilities, cruise tickets, hospitality and paid vacations from the industry.
The guidelines are much more specific on these issues than on many others because they actually do not leave room for any biased interpretation of what is often termed ‘reasonable hospitality’. For example, the guidelines explicitly state that: ‘A medical practitioner shall not accept individually any hospitality like hotel accommodation for self and family members under any pretext.’ Doctors, in general, are opposed to incentives but are also convinced that accepting gifts would not influence their professional behaviour. This is perhaps one of the reasons that there has not been much-organized action by the profession to root out the practice of receiving gifts.
Most doctors claim that incentives never obscure their own judgement about drugs and brands, but that other colleagues have ‘given in’ to the pressure of incentives. Drug company-sponsored CME preferentially highlighted the sponsor’s drug compared with other CME programmes. Attending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsor’s medication. Attending presentations given by pharmaceutical representative speakers was also associated with non-rational prescribing.
Pharmaceutical companies stated that funding medical conferences had become less cost-effective; they claim that doctors as a group had begun to pressurize pharma-ceutical companies into financing their associations’ programmes and boycott drug companies that did not do so
The other area addressed by this amendment is industry-sponsored research which has acquired tremendous importance in view of the explosion of the clinical trial industry in India. It recommends that researchers ensure that the particular research proposal has due permission from the competent, concerned authorities including clearance of national, state or institutional ethics committees. It also recommends that the researcher ensure that the source and amount of funding is publicly disclosed at the beginning of the project and that proper care and facilities are provided to human volunteers if they are necessary for the research. Finally, the guidelines state that while accepting such an assignment a medical practitioner shall have the freedom to publish the results of the research, even if negative, in the greater interest of society by inserting such a clause in the document for the assignment.

Potential Conflicts of Interest
The arrangements between physicians and pharmaceutical companies should be open and transparent. Conflicts ought to be clarified and clearly declared in the relevant context – to the patients, research parti-cipants, hospital committees. Whether they constitute conflicts should not be left to the individuals concerned to decide, but to a process of informed public debate within the setting in which the conflict arises. Where conflicts appear likely, special procedures should be devised to avoid unacceptable outcomes.

Drug promotion, including acceptance of gifts and travel support
Ideally, drug promotion should be restricted to the dissemination of well-founded data about specific products. Various levels of advice have been advanced to medical practitioners about accepting gifts. from blanket rejection to a gradient of moral acceptability based on cost, to the principles that gifts should not be excessive and should not influence decision-making, to the test of whether the recipient would be willing to have the arrangements publicly known.
The safe way for practitioners to adopt is that they should go to the rejection of gifts. Support for travel to meetings (including conferences organised by professional societies and CME courses) should be restricted to those making formal contri-butions, like speakers and faculty.

Sponsorship of meetings
Full disclosure of commercial sponsorship of meetings should be made. Sponsorship should always be provided through independently organised scientific committees; speakers should indicate dualities of interest at the time of pre-sentation; and sources of commercial funding should not influence scientific, educational decisions. There needs to be lesser expectation of entertainment, grand dinners, receptions and free food in association with conferences and symposia.

In cases where research projects are being funded by the pharmaceutical industry, the overriding principle is that of bias in research and publication. This is an issue of major public importance that needs to be actively addressed by the medical profession in consultation with consumer organisations, government and the pharmaceutical industry.

Medical practitioners and the pharma-ceutical industry serve interests that sometimes overlap and sometimes conflict.
· There is strong evidence that associations between industry and doctors influence the behaviour of the doctor in relation to both clinical decision making and the conduct of research. In view of this risk of compromising relationships with patients and the integrity of the research process, doctors must exercise care in their dealings with industry.
· The basic principles underlying the conduct of doctors with respect to pharmaceutical companies should be open and transparent.
· Clear guidelines should be developed to deal with specific issues such as travel subsidies, receipt of gifts, sponsorship of conferences and continuing education activities, and dualities of interest arising in clinical and research settings. There should be penalties laid down for transgressions.
In the end, the clinician should exercise his fundamental ethical values in all such interactions.
The current pattern of relationships between doctors and the pharmaceutical industry is the outcome of a long-established culture in which gratuities, gifts and the like are both expected and provided. As a result, the change will require a substantial shift in attitudes and values and thus is likely to be slow. Research into the expectations of stakeholders and the impact of the various practices discussed may contribute fruitfully to community debate.
In reviewing a number of the issues concerning the relationships between medical practitioners and the pharmaceutical industry, we have tried to emphasise that benefits received from pharmaceutical companies must leave the independent judgement of physicians unimpaired and that arrangements between physicians and pharmaceutical companies ought to be open and transparent. The overriding principle should be a firm belief that the values of science and clinical medicine must prevail over commercial imperatives. If these simple guidelines are followed, we feel that much progress will be made towards alleviating the concerns of both the community and the medical profession.

How to Cite this article: Mittal A. Ethical marketing of Pharmaceutical products appliances by Medical practitioners. Journal of Clinical Orthopaedics July-Dec 2019;4(2):2-4.

(Abstract    Full Text HTML)   (Download PDF)



The Paramount Importance of Ethics in Clinical Practice

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:1 | Dr. Nicholas Antao, Dr. Ashok Shyam

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

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

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

The Paramount Importance of Ethics in Clinical Practice

The strongest endeavour that any human being going for itself is its own moral integrity and its own heart. Only Morality can give beauty & dignity to Life
-Albert Einstein

Ethics is derived from Greek word Ethos which means -the study of what is morally right and what is not. Oxford Dictionary defines it as “The science of morals, the department of study concerned with the principles and physics of human behaviour and conduct”. In a more practical sense by morals and ethics, it is meant the doctrine of a special kind of pleasure or displeasure which is felt by the human mind in contemplating certain courses of conduct, whereby they are felt to be right or wrong, and of a special desire to do the right things and avoid the wrong ones. We believe that it is an inbuilt and strong program which is evolved in human psyche over thousands of years of evolution and we agree with Einstein that it is what adds beauty and dignity to Life as a whole.
For ethical things that have a clear black and white definitions, there are laws of the land that uphold them. But for most day to day ethical issues, our own moral compass guides us. How does this impact clinical practice? This part has been specifically addressed in our guest editorial by Dr.Anukant Mittal. He has written about the MCI guidelines that apply to us as clinicians and also on moral issues. Dr KH Sancheti also in his walkathon, has spoken on how we should function keeping ethical things in mind for building our clinical practice.
We believe that at many places, we start to discount ethics early in career due to various social and financial reasons. We try to follow the current trends in ethics and since we see many following particular trends we believe it to the right one. This discounting of morals and ethics slowly becomes a habit and we start discounting them in other areas of life too and soon enough before we realise it becomes significant enough to affect our mental peace. At this stage, we take the defence of ignoring it and also rationalising it [by taking examples of peers and colleagues]. This vicious cycle once sets in; it is tough to break as it becomes completely invisible to us. Once in a while when certain things like violence against doctors happen or there is a talk on the degrading status of doctors in society, that we realise it. However, as a habit, we learn to ignore it and go with it for as long as possible. The journey of the medical profession that begins with very high ethical and moral standards in each of our minds thinks less and less of it as we grow in the profession.
We feel keeping a check on our ethical and moral on a regular basis in clinical practice would definitely help us in becoming better surgeons. It will not only help us in becoming more peaceful and hold our dignity but will also avoid incidences like patient violence.
We believe a more introspection is needed in this aspect from all of us.

Dr Nicholas Antao
Dr Ashok Shyam.

How to Cite this article: Antao N, Shyam AK. The Paramount Importance Of Ethics in ClinicalPractice. Journal of Clinical Orthopaedics July -Dec 2019; 4(2):1.

(Abstract    Full Text HTML)   (Download PDF)





Surgical Management of Surgical Site Infections in Orthopaedics

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:17-25 | Dr. Sitaram Prasad, Dr. Gautam Zaveri

Author: Dr. Sitaram Prasad [1], Dr. Gautam Zaveri [2]

[1] Department of Plastic Surgery, Fortis & Zen Hospitals, Mumbai.
[2] Department of Spine Surgery, Jaslok, Fortis & Zen Hospitals, Mumbai.

Address of Correspondence
Dr. Gautam Zaveri
Department of Plastic Surgery, Fortis & Zen Hospitals, Mumbai


Surgical site infections are a source of great misery to both patients and surgeons. The management requires a multipronged approach specially in orthopaedics. The current chapter outlines the various methods of source control when dealing with musculoskeletal infections.
Keywords: Surgical site infections, orthopaedics, management


1. Manna B, Morrison CA. Wound debridement. [Updated 2019 Feb 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:
2. Meyers B. Wound Management: Principles and Practice. 2nd edition. Upper Saddle River, New Jersey: Pearson Prentice Hall; 2008
3. Owens B, White D, Wenke J. Comparison of irrigation solutions and devices in a contaminated musculoskeletal wound survival model. Journal of Bone and Joint Surgery. 2009;91(1):92-98.
4. Swezey L. 8 key steps to performing proper wound irrigation. Wound Source, 2014 Aug 29 at
5. Zimmerli W, Sendi P. Orthopedic biofilm infections. APIMS 2017 April; 125(4): 353-364
6. W.J. Metsemakers, Kuehl R, Moriarty TF, et al., Infection after fracture fixation: Current surgical and microbiological concepts, Injury (2016),
7. Doud Galli, S & Constantinides, M. Wound Closure Technique. Medscape. Updated April 2013
8. Myers, Betsy. (2008). Wound Management Principles and Practice. Pearson Prentice Hall. Upper Saddle River, New Jersey pg. 17-18
9. Swezey L. Types of wound closure. 2014 April.
10. Simman R. Wound closure and reconstructive ladder in plastic surgery. J Am Col Certif Wound Spec. 2009 Jan; 1(1): 6–11
11. Bistolfi A, Massazza G, Verne E, et al. Antibiotic loaded cement in orthopaedic surgery. A review. International Scholarly Research Network ISRN Orthopedics Volume 2011, Article ID 290851, 8 pages doi:10.5402/2011/290851
12. Gogia JS, Meehan JP, DiCesare PE. Local antibiotic therapy in osteomyelitis. Seminars in plastic Surgery 2009; 23(2): 100- 107
13. Putnis S, Khan WS, Wong J M-L. Negative pressure wound therapy. A review of its uses in Orthopaedic trauma. Open Orthop J. 2014 June; 8: 142–147
14. Jones SM, Banwell PE, Shakespeare PG. Advances in wound healing:topical negative pressure therapy. Postgraduate Medical Journal 2005;81:353-357.
15. Sarabahi S. Recent advances in Topical wound care. In J Plastic Surg. 2012 May- Aug;45(2): 379-387
16. Dhivya S, Padma VV, Santhini E. Wound dressings- a review. Biomedicine (Taipei). 2015 Dec: 5(4): 22.

How to Cite this article: Prasad S, Zaveri G. Surgical Management of Surgical Site Infections in Orthopaedics. Journal of Clinical Orthopaedics July-Dec 2019;4(2):17-25.

(Abstract    Full Text HTML)   (Download PDF)




Diagnosis of Surgical Site Infection

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:12-16 | Dr. Manish Kothari

Author: Dr. Manish Kothari [1]

[1] Consultant Spine Surgeon, Jaslok Hospital & Research Centre, Mumbai

Address of Correspondence
Dr. Manish Kothari
Jaslok Hospital & Research Centre, Mumbai


Diagnosis of Surgical site infection is one of the most important factors that determines the further management of SSI. The diagnosis is based on various factors including clinical, laboratory investigations, Radiology, Bacteriology and molecular modalities. The current review summarises the salient features in all modalities.
Keywords: Surgical Site infection, Diagnosis.


1. Harrop JS, Styliaras JC, Ooi JC, Radcliff KE, Vaccaro AR, Wu C. Contributing factors to surgical site infections. J Am Acad Ortho Surg. 2012; 20(2):94-101.
2. WHO document on Global Guidelines For the Prevention of Surgical Site Infection. WHO Guidelines Development Group; Geneva, Switzerland; 2016;58-177
3. Guideline for Prevention of Surgical Site Infection (2017). Centre for disease control and prevention. accessed 15th March 2019.
4. Simodynes, EE, Cochran, RM. Aeromonas hydrophila infection complicating an open tibial fracture. A case report. Clin OrthopRelat Res 1982; 171: 117–120
5. Levitsky KA, Hozack WJ, Balderston RA, et al. Evaluation of the painful prosthetic joint. Relative value of bone scan, sedimentation rate, and joint aspiration. J Arthroplasty. 1991;6:237–244.
6. Schinsky MF, Della Valle CJ, Sporer SM, et al. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90:1869–1875. doi: 10.2106/JBJS.G.01255.
7. Spangehl MJ, Masri BA, O’Connell JX, et al. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81:672–683.
8. Bilgen O, Atici T, Durak K, et al. C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty. J Int Med Res. 2001;29:7–12.
9. Park KK, Kim TK, Chang CB, et al. Normative temporal values of CRP and ESR in unilateral and staged bilateral TKA. Clin OrthopRelat Res. 2008;466:179–188. doi: 10.1007/s11999-007-0001-x. [PMC free article]
10. Forster IW, Crawford R. Sedimentation rate in infected and uninfected total hip arthroplasty. Clin OrthopRelat Res. 1982;168:48–52.
11. Lee Y, McKechnie T, Doumouras AG, Handler C, Eskicioglu C, Gmora S, Anvari M, Hong D. Diagnostic Value of C-Reactive Protein Levels in Postoperative Infectious Complications After Bariatric Surgery: a Systematic Review and Meta-Analysis. Obes Surg. 2019 Mar 21
12. Aljabi Y, Manca A, Ryan J, Elshawarby A. Value of procalcitonin as a marker of surgical site infection following spinal surgery. The Surgeon. 2019 Apr 1;17(2):97-101.
13. Cyteval, C, Hamm, V, Sarrabère, MP. Painful infection at the site of hip prosthesis: CT imaging. Radiology 2002; 224(2): 477–483
14. Kohan, AA, Rubbert, C, Vercher-Conejero, JL. The impact of orthopedic metal artifact reduction software on interreader variability when delineating areas of interest in the head and neck. PractRadiat Oncol 2015; 5(4): e309–e315.
15. Cyteval, C, Bourdon, A. Imaging orthopedic implant infections. Diagn Interv Imaging 2012; 93(6): 547–557
16. Plodkowski,A.J., Hayter,C.L., Miller,T.T., Nguyen,J.T., Potter,H.G. Lamellated hyperintense synovitis: potential MR imaging sign of an infected knee arthroplasty. 2013/1; 1: 256-260
17. Talbot BS, Weinberg EP. MR imaging with metal-suppression sequences for evaluation of total joint arthroplasty. Radiographics. 2015 Nov 20;36(1):209-25.
18. Glaudemans, AWJM, Signore, A. FDG-PET/CT in infections: the imaging method of choice? Eur J Nucl Med Mol Imaging 2010; 37(10): 1986–1991.
19. Basu, S, Kwee, TC, Saboury, B. FDG-PET for diagnosing infection in hip and knee prostheses: prospective study in 221 prostheses and subgroup comparison with combined (111)In-labeled leukocyte/(99)mTc-sulfur colloid bone marrow imaging in 88 prostheses. J Nucl Med 2014; 39(7): 609–615.
20. Schwotzer N, Wahl P, Fracheboud D, Gautier E, Chuard C. Optimal culture incubation time in orthopedic device-associated infections: a retrospective analysis of prolonged 14-day incubation. Journal of clinical microbiology. 2014 Jan 1;52(1):61-6.
21. Bémer, P.; Plouzeau, C.; Tande, D.; Léger, J.; Giraudeau, B.; Valentin, A.S.; Jolivet-Gougeon, A.; Vincent, P.; Corvec, S.; Gibaud, S.; et al. Evaluation of 16S rRNA gene PCR sensitivity and specificity for diagnosis of prosthetic joint infection: A prospective multicenter cross-sectional study. J. Clin. Microbiol. 2014, 52, 3583–3589.
22. Hartley, J.C.; Harris, K.A. Molecular techniques for diagnosing prosthetic joint infections. J. Antimicrob. Chemother. 2014, 69 (Suppl. 1), i21–i24.
23. Yano, M.H.; Klautau, G.B.; da Silva, C.B.; Nigro, S.; Avanzi, O.; Mercadante, M.T.; Salles, M.J.C. Improved diagnosis of infection associated with osteosynthesis by use of sonication of fracture fixation implants. J. Clin. Microbiol. 2014, 52, 4176–4182.
24. Yano, M.H.; Klautau, G.B.; da Silva, C.B.; Nigro, S.; Avanzi, O.; Mercadante, M.T.; Salles, M.J.C. Improved diagnosis of infection associated with osteosynthesis by use of sonication of fracture fixation implants. J. Clin. Microbiol. 2014, 52, 4176–4182.
25. Schinsky, M.F.; Della Valle, C.J.; Sporer, S.M.; Paprosky, W.G. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J. Bone Jt. Surg. Ser. A 2008, 90, 1869–1875.
26. Drago, L.; Signori, V.; De Vecchi, E.; Vassena, C.; Palazzi, E.; Cappelletti, L.; Romanò, D.; Romanò, C.L. Use of dithiothreitol to improve the diagnosis of prosthetic joint infections. J. Orthop. Res. 2013, 31, 1694–1699.
27. Al-Adsani A., Niazy M. N. ,Mohd M., Ewing’s sarcoma of the ilium mimicking sacroiliitis Rheumatology (1999) 38 (8): 792-793
28. Wang J, Wu X, Xi ZJ. Langerhans cell histiocytosis of bone in children: a clinicopathologic study of 108 cases. World J Pediatr. 2010 Aug;6(3):255-9.

How to Cite this article: Kothari M. Diagnosis of surgical site infection. Journal of Clinical Orthopaedics July-Dec 2019;4(2):12-16.

(Abstract    Full Text HTML)   (Download PDF)



Potpourri – Recent and relevant literature in 2019

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page:57-60 | Rajendraprasad R Butala, Shikhar D Singh, Sachin Y Kale, Prasad Chaudhari, Sanjay Dhar, Prakash Samant

Author: Rajendraprasad R Butala [1], Shikhar D Singh [1], Sachin Y Kale [1], Prasad Chaudhari [1], Sanjay Dhar [1] , Prakash Samant [1]

[1] Department of Orthopaedics, Dr. DY Patil Medical College, Navi Mumbai

Address of Correspondence

Address of Correspondence

[1] Department of Orthopaedics, Dr. DY Patil Medical College, Navi Mumbai

Address of Correspondence
Dr. Shikhar D Singh,
Department of Orthopaedics, Dr. DY Patil Medical College
Sector 7, Nerul, Navi Mumbai, Maharashtra 400706


Introduction: Anterior cervical discectomy and fusion (ACDF) is an effective treatment of intervertebral disc herniation. The zero-profile interbody fusion device, Zero-P was invented to reduce complications due to previously used anterior constructs. The present study investigates the outcome of surgical decompression and stabilization by anterior approach using Zero-P-Plate.
Methodology: We collected data of 22 patients of cervical disc prolapse with neurological deficits treated with ACDF using Zero-P implant. The patients were assessed pre-operatively and during follow up on outpatient basis at 2 weeks, 6 weeks, 12 weeks, 24 weeks and then on yearly basis for 2 years. The outcome was assessed based on Visual Analogue Scale (VAS) score, Nurick grading and Odom’s criteria and success of fusion.
Results: Radiculopathy was present in all patients pre-operatively. We observed that 77% of the patients had VAS score of 4 or higher pre-operatively, which reduced to 13% in the immediate post-operative period and 0% at the last follow up. Nurick grade 2 or higher was seen in 31% pre-operatively, a percentage which reduced to 0% in the post-operative period. Final clinical outcome using Odom’s criteria revealed excellent outcome in 87% of the patients and good outcome in 13%.
Conclusions: ACDF by Zero-P-Plate can be considered in treatment of patients with cervical disc prolapse with neurological deficit.
Keywords: Anterior cervical discectomy and fusion; Cervical disc disease; Intervertebral fusion device.


1. Smith GW, Robinson RA. The Treatment of Certain Cervical-Spine Disorders by Anterior Removal of the Intervertebral Disc and Interbody Fusion. The Journal of Bone & Joint Surgery. 1958;40-A(3):607–24.
2. Kaiser MG, Haid Jr RW, Subach BR, Barnes B, Rodts Jr GE. Anterior cervical plating enhances arthrodesis after discectomy and fusion with cortical allograft. Neurosurgery. 2002 Feb 1;50(2):229-38.
3. Nurick S. The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain. 1972 Jan 1;95(1):101-8.
4. Odom GL, Finney W, Woodhall B : Cervical disk lesions. J Am Med As-soc 166 : 23-28, 1958
5. Scholz M, Schnake KJ, Pingel A, Hoffmann R, Kandziora F: A new zero-pro le implant for stand-alone anterior cervical interbody fusion. Clin Orthop Relat Res 469:666–673, 2011
6. Njoku I, Alimi M, Leng LZ, Shin BJ, James AR, Bhangoo S, Tsiouris AJ, Härtl R. Anterior cervical discectomy and fusion with a zero-profile integrated plate and spacer device: a clinical and radiological study. Journal of Neurosurgery: Spine. 2014 Oct 1;21(4):529-37.
7. Alimi M, Njoku I, Hofstetter CP, Tsiouris AJ, Kesavabhotla K, Boockvar J, Navarro-Ramirez R, Härtl R. Anterior cervical discectomy and fusion (ACDF): comparison between zero profile implants and anterior cervical plate and spacer. Cureus. 2016 Apr;8(4).
8. Duan Y, Yang Y, Wang Y, Liu H, Hong Y, Gong Q, Song Y. Comparison of anterior cervical discectomy and fusion with the zero-profile device versus plate and cage in treating cervical degenerative disc disease: a meta- analysis. J Clin Neurosci. 2016;33:11–18.
9. Lee MJ, Bazaz R, Furey CG, Yoo J. Influence of anterior cervical plate design on Dysphagia: a 2-year prospective longitudinal follow-up study. J Spinal Disord Tech. 2005;18(5):406–9.

How to Cite this article: Deogaonkar K, Menon A, Zaveri G. Surgical Site Infections in Orthopaedics: Epidemiology & Microbiology. Journal of Clinical Orthopaedics July-Dec 2019;4(2):7-11.

(Abstract    Full Text HTML)   (Download PDF)









Idiopathic Tumour Calcinosis in Foot

Journal of Clinical Orthopaedics | Vol 4 | Issue 2 |  July-Dec 2019 | page: 61-63 | Tarun Verma, Abhishek Mishra, Gaurang Agarwal, Lalit Maini.

Author: Tarun Verma [1], Abhishek Mishra [2], Gaurang Agarwal [2], Lalit Maini [2].

[1] Department of Orthopaedics, Medical College, Baroda and Sir Sayajirao General Hospital Baroda, Gujarat
[2] Department of Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi.

Address of Correspondence
Dr. Tarun Verma,
Permanent address: C-40, Omkar society, Maneja, Vadodara, Gujarat- 390013


Idiopathic tumoral calcinosis (TC) is a rare disorder characterized by the development of calcified masses within the periarticular soft tissues of large joints like hip, elbow, shoulder, and rarely foot. A variety of conditions causing heterotopic calcifications can mimic this disorder like chronic renal failure, hyperparathyroidism, vitamin D intoxication, milk alkali syndrome, scleroderma etc. Due to similar plain radiograph picture, it can also be confused with synovial chondromatosis. Biochemical, radiological investigations and biopsy are essential to establish the diagnosis. This article describes a case of idiopathic tumour calcinosis around 5th metatarso-phalangeal joint in a 20 years old female. It’s radiographic and MRI features, types and management options are discussed subsequently.
Keywords: Tumour calcinosis; heterotopic calcification; Normophosphatemic; synovial chondromatosis; white paste.


1. Tezelmann S, Siperstein A E, Duh QY, Clark O H (1993) Tumoral calcinosis: controversies in the etiology and alternatives in the treatment. Arch Surg 128: 737–45.
2. Chaabane S, Chelli-bouaziz M, Jelassi H, Mrad K, Smida M, Ladeb M F (2008) Idiopathic tumoral calcinosis, Acta Orthop Belg 74:837–45.
3. Martinez S (2002) Tumoral calcinosis: 12 years later. Semin Musculoskelet Radiol 6:331-39.
4. Rambani R, Dhillon MS, Aggarwal R (2003) Tumoral calcinosis with unusual presentation. A case report. Acta Orthop Belg 69:368–72.
5. Leung Y.Y., Lai R (2011) Tumoral calcinosis: a case report, J. Orthop. Surg. (Hong Kong) 19: 108–12.
6. Henry GI, Teven CM (2012) CASE REPORT idiopathic tumoral calcinosis of the nontraumatic thumb. Eplasty 12:e29.
7. Harkness JW, Peters HJ (1967) Tumoral Calcinosis — Report of Six Cases. J. Bone Joint Surg 49:721-731.
8. Mohamed S, Jong-Hun J, Weon-Yoo K (2007) Tumoral calcinosis of the foot with unusual presentation in an 11-year-old boy: A case report and review of literature. J Postgrad Med 53:247-9.

How to Cite this article: Verma T, Mishra A, Agarwal G, Maini L. Idiopathic Tumour Calcinosis in Foot. Journal of Clinical Orthopaedics July-Dec 2019;4(2):61-63.

(Abstract    Full Text HTML)   (Download PDF)