Comparison between effects of instrument-assisted soft tissue mobilization and manual myofascial release on pain, range of motion and function in myofascial pain syndrome of upper trapezius - A randomized controlled trial

Background

Myofascial pain syndrome (MPS) is a muscle pain disorder characterized by the presence of Myofascial Trigger Point (MTrP) within a taut band, local tenderness, referral of pain to a distant site, restricted range of motion, and autonomic phenomena. The upper trapezius is the muscle most often affected by MTrPs. Manual myofascial release (MFR) and Instrument-Assisted Soft Tissue Mobilization (IASTM) are techniques of soft tissue release that are used to resolve MPS. Fifty six percent of physiotherapists complain of pain in multiple areas due to the massage and manual therapy that they have to perform.

Objective

The objective of this study is to find whether IASTM is better than manual MFR in treating patients with MPS in upper trapezius.

Methods

This study was a single-blinded randomized controlled trial that included 31 participants, both males and females between the age groups of 18-50 years. Participants were randomly divided into two groups. Three sessions were given over a period of one week for both groups. Group A received IASTM along with conventional treatment and Group B received Manual MFR along with the conventional treatment. The outcome measures evaluated were pain, cervical range of motion, pain pressure threshold (PPT) of trigger points, and the neck disability index. Pre- and post-measurements were taken and the analysis was done.

Results

Both the treatment methods significantly reduced pain, improved PPT, range of motion, and function. The effects between the groups showed that IASTM was significantly better than manual MFR to reduce pain. The improvement in PPT, range of motion and function were equal in both the groups.

Conclusion

IASTM and manual MFR both are effective individually as treatment procedures for pain, PPT, range of motion, and function. Neither of the treatment options can be considered better that the other. The clinician can decide based on the availability of the instrument, training, patient's preference, and his/her comfort whether which of the two treatment methods should be used.

Minimally invasive treatment for idiopathic chondrolysis of the hip: analysis of forty-one cases

PURPOSE

Idiopathic chondrolysis of the hip is characterized by the loss of the articular cartilage of the hip joint with spectrum ranging from full recovery to fibrous ankylosis. Study assessed outcomes following intra-articular steroid injections, joint manipulation and traction immobilization.

METHODS

Retrospective (2012-2021) review of 41 cases treated for idiopathic chondrolysis of hip, assessed pre-operatively and post-operatively (minimum 2-year follow-up) using Children's Hospital Oakland Hip Evaluation Score (CHOHES), visual analogue scale (VAS) and range of motion measurements.

RESULTS

Twenty-five patients (62%) achieved painless mobility, 6 (14%) had hip stiffness without pain and 10 (24%) had painful and stiff hips at final follow-up. They had a mean age of 12.49 ± 2.4 years and a mean follow-up duration of 33.15 ± 13.1 months. Range of motion improved significantly (p < 0.05). VAS improved to 3.93 ± 1.3 from 7.8 ± 0.7. CHOHES improved from 29.12 ± 9.9 to 56.37 ± 17.6.

CONCLUSION

Intra-articular steroid injection, manipulation and traction immobilization may effectively treat idiopathic chondrolysis of the hip by enhancing patient function and reducing the need for further surgical intervention.

Partners in Precision: Cultivating Trust and Respect in the Surgeonanesthetist Dynamics

Since William Morton’s administration of the inaugural anesthetic in 1846, there has been a significant transformation in the field of surgical specialties. The surgical practice underwent rapid evolution with the integration of anesthesiologists as an essential component of the surgical team. The surgeon, who previously held sole command of the ship, has now been joined by a co-pilot to guide the patient through the surgical waters. The fruitful teamwork between the surgeons and anesthesiologists resulted in favorable patient outcomes. The surgeon plays a crucial role in the patient’s care throughout the entire process, starting from the first diagnosis, through the operation, and all the way to the post-operative recovery [1]. The anesthesiologist assumes the role of a perioperative physician, allowing the surgeon to concentrate solely on the surgical procedure. The strategy devised by anesthetists is intricately connected to the rigorous planning undertaken by surgeons. The cornerstone of a cohesive approach to delivering the best possible care to patients is rooted in the principles of shared accountability, mutual comprehension, and collaborative communication. The surgeons and anesthesiologists work in separate positions, divided by a surgical drape, yet collaborate closely as a cohesive “team.” Effective cooperation within the surgical theater is an indispensable requirement. Throughout the surgical operation, surgeons focus on the intricacies of their profession, while anesthetists diligently ensure the patient’s physiological stability. Given the nature of this collaboration, it is essential to maintain regular communication to foster an environment that enables the surgeon to focus on the procedure, while the anesthetist assumes responsibility for assuring the patient’s stability and monitoring their vital signs. The existing state of collaboration among team members is examined in several studies, and there is a lack of research on the impact of anesthesiologist-surgeon collaborations on patient outcomes. The surgical sphere has greatly increased over time, thanks to the safety provided by contemporary anesthesia. However, occasionally circumstances take an unfavorable turn. There is always a chance of complications occurring during any surgical procedure. Amidst the prevalence of medicolegal lawsuits, there exists a subtle distinction between negligence and an adverse incident. Within the high-pressure setting of the operating room, instantaneous judgments might have significant outcomes. The attribution of blame is a regrettable phenomenon that exists in the present day. Surgeons and anesthetists may have divergent viewpoints in situations of complications. Hence, although not all aspects are under the control of doctors, the responsibility and effort always lie with the team as a whole. Irita and Takahashi conducted a survey in Japanese hospitals and reported that while most surgeons were satisfied with their own pre-anesthetic evaluation, the anesthetist’s primary reason for at major operative risk for postponement was communicated only to 17% of the surgical departments [2]. Gawande et al. noted that 43% of adverse events were caused by a breakdown in communication within the team [3]. The figure may appear to be inflated, but it certainly warrants careful consideration. In their study, Lingard et al. examined errors occurring in the operating room and discovered that team cohesion was absent in 30% of these instances [4]. In another study, the authors concluded that interprofessional checklist briefings reduced the number of communication failures and promoted proactive and collaborative team communication [5]. Therefore, despite the existence of standardization and norms in surgery, effective communication among the team members is crucial for the well-being of the patient. It is exceedingly unprofessional for a surgeon to address the anesthesiologist for the 1st time at the moment of incision. Ideally, communication within the team should be proactive. While routine instances may not require extensive deliberation with the same group of individuals, complex cases necessitate a discussion to formulate a comprehensive surgical-anesthetic approach. The reaffirmation of this strategy is necessary in the operating room, encompassing specific aspects of the procedure such as monitoring needs, planned methodology, duration, blood loss, and potential problems. Finally, it is necessary for good communication to go beyond the boundaries of the operating room. What causes communication failures? Cooper et al. identified several factors that contributed to the lack of communication, including a natural hesitancy to interrupt, fear of embarrassment or punishment, worry about being misunderstood, and a lack of understanding about how to effectively express oneself. The challenge is in surmounting the resistance and navigating the obstacles that impede one from expressing oneself. Effective communication entails articulating concerns without getting defensive and exhibiting curiosity to comprehend the viewpoint of the other individual. The authors additionally document several negative opinions that anesthesiologists hold toward surgeons and vice versa [6]. The anesthetist’s perceptions encompass deficiencies in medical and anesthesia-related knowledge, neglecting to recognize substantial blood loss, omitting to inform patients about potentially arduous recoveries, and disregarding patient health conditions and preferences. Furthermore, anesthesiologists may perceive that surgeons frequently underestimate the duration of surgical procedures and discourage other team members from expressing safety concerns. Conversely, surgeons may perceive anesthesiologists as prioritizing speed over patient care, being excessively eager to cancel procedures, disregarding schedules, being unfocused during surgery, and being resistant to adjusting anesthesia methods to accommodate surgical needs. There are also negative opinions regarding factors such as long turnover times, insufficient communication about changes in vital signs or the need for vasopressor support, and a lack of comprehension of the surgeon–patient interaction. Surgeons and anesthesiologists may sometimes exchange information that is incorrect or deceptive [7]. Surgeons and anesthesiologists are no longer perceived as “brains vs. blood” or as “needles vs. knives” [1]. Both categories, consisting of coworkers who lead teams responsible for securely caring for patients, are equally represented. The effectiveness of the surgical “team” and the results for patients rely on mutual respect and cooperation, even when anesthesiologists and surgeons may possess divergent ideals. Professionals in the medical domain must engage in effective communication with both their colleagues and patients across many contexts. Given the crucial role of the anesthesiologist in surgical procedures, it is imperative that future research examines the influence of the interaction between the anesthesiologist and the surgeon on patient morbidity and death rates. The collaborative cooperation between anesthesiologists and surgeons relies on mutual respect and a thorough understanding of each other’s responsibilities. Over time, medical professionals develop familiarity with one other’s working methods and areas of expertise. The relationship between a surgeon and an anesthesiologist is unique even if their interactions are often brief. Most surgeons, especially those in big practices, consistently consult with the same anesthesiologist and the familiarity helps in trust [6]. Hence, it may be imperative to spend several years honing one’s skills in the same environment to successfully develop this connection. Surgeons and anesthetists should enhance their interaction beyond the confines of the operating theater to foster professional collaboration and personal well-being [8]. This can facilitate the development of mutual trust and comprehension. Participating in social activities or meetings arranged by the hospital or medical community provides an opportunity to engage in a more informal environment. Engaging in inter-departmental seminars and cooperating on research projects will augment one’s understanding of different disciplines and solidify professional relationships. Organizing informal gatherings, such as coffee or lunch meetings, outside of regular business hours, to commemorate professional accomplishments, birthdays, or other personal milestones, can foster deeper personal connections among colleagues. Finally, it is necessary to recognize and value the contributions of both individuals to patient care. Expressing appreciation with a straightforward thank-you message or gesture of gratitude can significantly contribute to establishing a strong and positive relationship. Demonstrate mutual respect for one another’s work-life balance and foster an environment that promotes support, reduces burnout, and allows both individuals to prioritize their well-being beyond work.

The Future of Spine Surgery: Navigating the Technological Revolution

In the realm of medicine, few fields have witnessed as rapid and profound a transformation as spine surgery. Over the last 5 years, technological advancements have not just trickled but surged, heralding a new era that promises to redefine surgical practices in the coming decade. Let’s explore the multifaceted impact of these changes, celebrating their potential while also contemplating the broader implications for healthcare. At the heart of this revolution, it is a commitment to enhancing patient safety and improving surgical outcomes. The latest innovations aim to make spine surgery safer and the techniques more reproducible. From robotics to augmented reality, from advanced imaging techniques to minimally invasive procedures, technology is setting new benchmarks in precision and efficiency. The spine surgeon community watches these developments with a mixture of excitement and anticipation, eager to embrace the possibilities that lie ahead. However, as we stand on the cusp of this new frontier, it is imperative that we consider the broader implications of these technological advances. One of the most pressing concerns is the impact on healthcare costs. As technology raises the bar for what is considered standard care, there is a risk that the overall cost of healthcare could escalate, making advanced treatments less accessible to a broader segment of the population. This raises ethical questions about equity and access, challenging us to find a balance between innovation and inclusivity. Moreover, the rapid pace of technological advancement could potentially shift the baseline for what is deemed minimally acceptable in terms of safety standards. As we push the boundaries of what is possible, we must ensure that the pursuit of excellence does not inadvertently compromise patient safety by making the exceptional the expected norm. Another critical consideration is the impact on the surgical community itself, particularly the training and development of younger surgeons. As they become increasingly reliant on technology, there is a risk that fundamental surgical skills could be overshadowed by technological proficiency. This dependency could create a chasm between those who have access to cutting-edge tools and those who do not, further exacerbating disparities within the medical community. As we navigate this technological revolution, each responsible spine surgeon must reflect on these issues. The integration of technology into spine surgery is not just a matter of embracing new tools but also understanding their implications for the practice, the health-care system, and society at large. It is about striking a balance between leveraging technology to push the boundaries of what is possible and ensuring that these advances benefit all patients, regardless of their socioeconomic status. To conclude, it is fair to say that the technological revolution in spine surgery is a double-edged sword. While it offers unprecedented opportunities to improve patient outcomes and redefine surgical practices, it also poses significant challenges that require careful consideration. As we move forward, it is crucial that we approach these developments with a sense of responsibility and a commitment to ethical principles. Love it or hate it, technology in spine surgery is here to stay, and it is up to us to ensure that its legacy is one of progress, equity, and compassion. Dr. Abhay Nene Spine Surgeon We Are Spine

Enhancing Orthopedic Rehabilitation: The Emergence and Impact of Virtual Reality Technology

Virtual Reality (VR) is progressively transforming the landscape of orthopedic rehabilitation. Initially conceptualized for entertainment, VR now plays a pivotal role in the medical field, particularly in orthopedics. Traditional rehabilitation methods in orthopedics often encounter limitations in patient engagement and the personalization of therapy. VR counters these limitations by offering immersive environments that can be specifically tailored to meet individual rehabilitation needs. The ascent of this technology from a groundbreaking concept to a practical therapeutic tool represents a notable advancement in rehabilitation techniques. The capability of VR to simulate real-life scenarios significantly enhances its applicability and efficacy in orthopedic care. This adaptability allows for a more engaged and personalized treatment experience for patients, marking a departure from traditional, more generic therapy methods. However, incorporating VR into orthopedic rehabilitation is accompanied by certain challenges. These include the high costs associated with the technology, potential technological barriers, and issues related to accessibility. These factors can hinder the widespread adoption of VR in clinical settings. Despite these challenges, the integration of VR into orthopedic rehabilitation practices signals a shift toward more innovative and effective patient care. This technology not only promises to heighten patient involvement but also steers therapy toward a more individualized approach. By addressing the issues of patient engagement and customization in therapy, VR stands out as a compelling solution in the realm of orthopedic rehabilitation. Its potential to reshape patient experiences and outcomes in orthopedic recovery is substantial, indicating promising prospects for its role in the medical field [1, 2].

Revolutionizing Orthopedic Surgery: The Integration of Holographic Technology

Orthopedic surgery, traditionally reliant on 2D imaging tools such as X-rays and magnetic resonance imagings (MRIs), is undergoing a revolutionary change with the introduction of holographic technology. Initially, a concept from science fiction used in entertainment and data representation, holography now offers groundbreaking applications in medicine, especially in orthopedics. Conceived by Dennis Gabor in 1948, holographic imaging has evolved significantly, providing real-time, three-dimensional visualizations of human anatomy, thereby aiding surgeons in complex procedures [1]. This technology enhances surgical precision through high-resolution, interactive representations of patient-specific anatomical structures, leading to more accurate planning and less invasive surgeries, crucial for better patient outcomes [2, 3]. This integration signifies a paradigm shift in surgical practices, equipping surgeons to visualize bones, joints, and tissues in unprecedented detail and immersion, similar to moving from radiographs to 3D computed tomography (CT) scans but with the added benefits of interactivity and real-time manipulation. However, challenges exist, including the cost of technology, the learning curve for professionals, extensive training requirements, and maintaining patient safety and medical standards in stringent regulatory environments [4]. This editorial provides an overview of the transformative potential of holographic technology in orthopedic surgery, discussing its historical evolution, current applications, challenges, and prospects, emphasizing the need for cautious optimism and sustainable integration to enhance patient care and surgical outcomes.

Surgeon Burnout-Time to Heal the Healers

Burnout could be understood by the Old Testament, in which Moses father-in-law rebukes, You will only wear yourselves out. The work is too heavy for you; you cannot handle it alone (Exodus 18:1718). Burnout syndrome was first introduced by Freudenberger in 1974 [1]. It is now a global concern, though it is very much under-reported and discussed in our country. Shanafelt et al. reported it in about 40% of physicians and a slightly higher rate of 53% among surgeons, by comparison [2]. On top of this ladder, orthopedic surgeons are just behind trauma surgeons in ranking [3]. Occupational burnout syndrome is a feeling of emotional exhaustion, depersonalization, and low sense of personal accomplishment secondary to chronic occupational stress [4]. In the high-stakes world of surgery, the demanding nature of the profession can take a toll on surgeons mental and physical well-being and disturb their healthy work–life balance. The etiology is multifactorial, including personal, working environment, and career ambitions, and surgeons often have a combination of these [5]. Long working hours, intense pressure during surgeries, and the emotional burden of dealing with life-and-death situations can lead to chronic stress [6]. Hierarchy in the workplace, over-demanding aggressive patients, and increasing medicolegal implications are additions to surgeon burnout. Due to the incorporation of new techniques and equipment, surgeons are compelled to be lifelong learners for their scientific and technical excellence in their practice. On top of these, the inclusion of administrative tasks takes away their time from patient care and contributes to stress. Limited emotional support, both within the workplace and personally, also contributes to feelings of isolation and burnout. All of these negatively impact personal well-being and threaten surgeons longevity and the safety of patients to whom they provide care. Therefore, burnout affects the well-being of surgeons and can have severe implications for the quality of patient care. Fatigued surgeons may experience reduced job performance and develop an emotional milieu that contributes to medical errors [7]. On the personal front, they suffer from poor physical quality of life, psychosomatic issues, stress, depression, insomnia, fatigue, relationship issues, substance abuse, and suicide. Recently, Jennings et al. reported that burnout-induced suicides are highest among orthopedic surgeons [8]. Therefore, recognizing burnout among surgeons is crucial for medical professionals well-being and the quality of patient care. Several tools have been devised to measure burnout, which include the Maslach Burnout Inventory, the Copenhagen Burnout Inventory, and the Mayo Clinic Physician Well-being Tool [2, 9, 10]. Addressing burnout needs social and institutional-level support. A few strategies are improving the workplace environment, promoting teamwork, and reducing the administrative workload. Darrell Cambell even suggested modifying the surgical curriculum to the extent of providing proper mentorship right from the trainees time [11]. He said, “In the classic training program, we have taught how to perform surgery but not how to live as a surgeon. Organizations can conduct regular surveys for feedback and support, flexible working hours when required, and medicolegal support in adverse outcomes or major complication cases. Regular and timely physical and mental health checkups and training programs focused on resilience, stress management, and coping strategies can enhance surgeons ability to navigate challenging situations [12]. At an individual level, one needs to chalk out a work–life balance. As rightly said, “If your compassion does not include yourself, it is incomplete. One needs to introspect, recognize one’s own limits, and not set unrealistic goals. We need to understand that burnout is a Choice that we make, and once we understand and deal with the choices that lead to burnout, we would understand that the choices are completely avoidable. Although our organizations and society would have us continuously work to our maximum capacity (as per their standards), we should define these work parameters for ourselves. Personal acceptance of burnout and insights into reasons for burnout with measures that will reduce these reasons are the main measures for dealing with burnout for professional reasons. In addition, inculcating some self-care practices such as exercise, yoga, meditation, sports, and music. would help too. Vacation and vocation should be an integral part of busy surgeons lives. Finally, one should be bold enough to communicate and seek help when required because burnout is real and not a sign of personal failure. We should all strive to be resilient health-care providers in a conducive professional environment.

Functional Outcome of Mechanical Alignment in Total Knee Arthroplasty Surgery: A Short-Term Cohort Study at an Indian Tertiary Care Hospital

Background

In severe arthritis cases, goal of total knee arthroplasty (TKA) management is to attain pain-free joint and restore the overall limb alignment. There are limited short-term studies published from Indian hospitals that investigated the importance of neutral mechanical component alignment in TKA patients.

Methods

Retrospective and prospective study was conducted at the Department of orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune from June 2020 to September 2022. Enrolled patients were assessed preoperatively and postoperatively using clinical examination, radiological assessment and functional outcomes through the Oxford knee score, Knee society score and VAS score.

Results

204 patients enrolled, and 267 knees were evaluated for the study. Osteoarthritis was the commonest diagnosis (254 knees, 95.13%). Pre-operatively, 92.13% knees were varus, 4.87% valgus and 3% neutral while post-operatively, 51.69% were varus, 16.1% were valgus, and 32.32% were with neutral axis. Majority of patients with a pre-operative neutral axis converted to varus axis (62.5%), while most valgus axis cases preoperatively converted to a neutral axis (53.84%). For pre-operative varus subgroup, the majority patients with < 10° pre-operative axis converted to neutral (41.28%). Majority patients with 10°-20° pre-operative axis remained varus (60.53%) and with > 20° pre-operative axis remained varus (78.26%). Functional outcome parameters were significantly improved at follow-up (P < 0.05).

Conclusion

Short-term postoperative functional scores were significantly improved in postoperative cases, with the postoperative alignment of 0° ± 3° relative to the mechanical axis was achieved. Thus, postoperative neutral mechanical alignment of 0° ± 3° can be the standard of care for patients undergoing TKA.

Graphical abstract

The Era of Digital Orthopedics: A Bone or Bane?

Orthopedics, the medical specialty dedicated to diagnosing, treating, and preventing disorders of the musculoskeletal system, has long been a cornerstone of healthcare. With an aging population and an increasing emphasis on maintaining an active lifestyle, the demand for orthopedic care is on the rise. However, the field of orthopedics is rapidly evolving, and one of the most significant developments in recent years is the emergence of digital orthopedics [1, 2]. This transformation is reshaping the way orthopedic care is delivered, from diagnosis and treatment to patient outcomes and beyond. In this editorial, we explore the concept of digital orthopedics, its implications, and the potential benefits it offers to both patients and health-care professionals.

ORTHO AI : World's First ARTIFICIAL INTELLIGENCE IN ORTHOPAEDICS

The landscape of AI (Artificial Intelligence) and specifically AI in healthcare is growing rapidly. Although most of these are focussed on complex issues of imaging and planning, we came up with the idea of impacting the very foundation of Clinical Decision Making by using the AI Technology. OrthoAI is a product of this thought process and was launched on 11th Dec 2023 at the hands of Dr Raghunath Mashelkar eminent scientist from India. It was an amazing event structured around the World’s First AI Focussed on Orthopaedics. OrthoAI, or OrthoGPT, is designed to transform clinical decision-making with its sophisticated database and advanced AI capabilities. OrthoAI: A Generative AI Revolution in Orthopaedics We believe OrthoAI is the foundation of the AI Revolution in Orthopaedics, and we would like to share some more insights about it. OrthoAI primarily is a Generative AI like chat GPT. You can even call it OrthoGPT (Ortho Generative Pre-trained Transformer), a type of artificial intelligence model designed for understanding and generating human-like text. OrthoAI, akin to a specialized version of Chat GPT, or ‘OrthoGPT’, stands on three foundational pillars: 1. The OrthoAI Database: The essence of OrthoAI lies in its meticulously curated vector database, developed over nine months by a team of expert orthopaedic surgeons. This database is the cornerstone of OrthoAI’s reliability and validation. 2. PubMed Access: OrthoAI’s integration with PubMed enriches its evidence base, ensuring that its responses are grounded in the latest orthopaedic literature. 3. OrthoTV Access: With over eleven thousand orthopaedic videos, OrthoTV provides a wealth of expert knowledge and experiences. OrthoAI’s access to this repository allows it to offer comprehensive answers, supplemented with relevant article links and video content At its core, AI involves creating computer systems that mimic human intelligence, enabling them to perform tasks that usually require human intellect. OrthoAI is equipped with following AI Core functions • Machine Learning (ML) is a subset of AI that allows computers to learn and improve from experience without being explicitly programmed • Deep Learning (DL) is a more complex subset of ML that mimics the neural networks of our brain. DL involves feeding a computer system a vast amount of data, which it uses to make decisions. This ability to process and analyse a significant amount of data makes DL particularly valuable for OrthoAI. • Natural Language Processing (NLP) can read and understand human language, enabling it to extract essential information from clinical notes or respond to patient queries in real-time. OrthoAI has NLP built in and will continue to learn from all its interactions. We believe the most important area of impact of OrthoAI will be Clinical Decision Making. OrthoAI as discussed above is built on a validated database, along with PubMed and OrthoTV access. This makes the answers most relevant and trustworthy. With a synthesised answer from all sources, it will be source of having a huge thinking knowledge bank at your fingertips. It will act as CO-PILOT or as EBM Assistant to Orthopaedic Surgeons, helping them in tricky situations. The queries can vary from clinical, academic, case based, surgical steps, drug interactions, rehabilitation, complications, and surgical planning too. This is the version 1, and more things would be added in coming versions. We will urge all readers to visit OrthoAI on www.orthoai.in webportal or scan the code to access the portal. Conclusion: OrthoAI is launched at the threshold of a new era in orthopaedics, bringing significant improvements in diagnosis, treatment planning, surgical execution, prosthetics, rehabilitation, and predictive analytics. As we start to incorporate AI more comprehensively into our practice, we need to conscientiously navigate the ethical and legal challenges it presents. Our enthusiasm as technologically inclined orthopaedic surgeons drives us to harness OrthoAI’s full potential, ushering in an era of precision, efficiency, and patient-centric care in orthopaedics.

Insights from Robotic Total Knee Replacement (TKR) Can Add Enhancements in Conventional TKR Procedures

Despite the technological advancements in robotic total knee replacement (TKR) surgeries, the majority of TKR procedures worldwide remain conventional. Our practice maintains a balance between robotic and conventional TKRs, offering a distinctive viewpoint and gaining certain insights over a period of time. While we typically apply our knowledge from conventional TKR to robotic procedures, we have identified specific insights from robotic TKR that can be retrofitted to enhance conventional TKRs. In this article, we share these insights and practical recommendations. Basic Concepts In conventional TKR, surgeons conceptualize a three-dimensional model of the patient’s deformed leg by physical examination and X-ray analysis. Based on this, they determine the desired post-operative alignment and balancing, subsequently devising a surgical plan. In contrast, navigated TKR employs intraoperative registration of specific points to generate the three-dimensional model. However, inaccuracies in registration can lead to an erroneous model. Computed tomography (CT)-based robotic TKR, on the other hand, utilizes a pre-operative CT scan to create the three-dimensional model. The robot is informed of the soft-tissue laxity/tightness status by stressing the ligaments in flexion and extension, providing a precise representation of the deformed leg. This precision allows for minimal bone removal and limited soft-tissue release. These tactics of minimal bone resection and limited soft-tissue release can be applied to conventional TKRs too by following certain principles as mentioned below. Applying Insights from Robotic TKR to Conventional Procedures Positioning the femoral implant at 3–5° of flexion aligns with the patient’s distal femur shape, accurately replicating the posterior condylar offset. This positioning also ensures a seamless transition between the femoral implant and anterior femur, mitigating anterior notching or patellofemoral joint overstuffing. The posterior condylar axis and transepicondylar axis are unrelated. Therefore, when aligning the sizing jig on the femur, it should correspond with the transepicondylar axis, not the posterior condylar axis. This alignment, combined with the prior point, facilitates optimal patellar tracking. A standard distal femoral resection of 8 mm is unnecessary unless the patient exhibits a non-correctable fixed flexion deformity under anesthesia. Typically, a 6-mm distal femoral resection suffices. A significant number of Indian patients presents with an exaggerated posterior tibial slope. Consequently, planning a 9-mm resection from the posterolateral point on the tibia often results in excessive anterior tibial bone removal. This increases the extension gap – further reducing the need for standard 8-mm resection of distal femur. Medial tibial reduction osteotomy significantly corrects varus knee deformities. Undertaking this step before any release is crucial for most varus knees. Occasionally, it is even required before excising femoral posteromedial osteophytes, which become more accessible post-osteotomy. This step along with putting tibia in 2–3° of varus reduces the need for medial soft-tissue release. If the knee exhibits limited flexion under anesthesia, anteriorizing or downsizing the femur to excise more bone from the posterior condyle proves beneficial. Some patients display physiological femoral valgus and tibial varus. Replicating this configuration widens the medial flexion gap, especially beneficial in a CR knee. These insights are gained over a period of decades of using robots and have been utilized in our conventional TKR surgeries for years now. Although we have not conducted a formal research project to study the outcome difference by applying these changes to conventional TKR, we believe that these steps surely enhance conventional surgical principles. In conclusion, the technological innovations in robotic TKR and the shape-matching concept have ushered in a transformative phase in TKR surgery. These advancements might influence conventional TKR procedures, potentially achieving consistent alignment and balancing. The long-term implications of these changes on prosthesis longevity and patient satisfaction remain to be seen.

A Case of Symmetrical Bilateral Bifocal Femur Fracture with Bilateral Patella Fracture - A Case Report!

Introduction

Bilateral bifocal femur fractures occur as a result of high-velocity trauma mainly road traffic accidents with dashboard injuries or fall from height. These fractures can result in high morbidity or mortality as they are usually presented with hypovolemic shock or fatal fat embolism syndrome.

Case Report

We present a 47-year-old male with a history of fall from 35 feet. He sustained a symmetrical intertrochanteric femur fracture with a diaphyseal femur fracture with a bilateral patella fracture. There was no evidence of any head injury or spinal fracture. The patient reached the emergency room in hypotension and was maintaining saturation on room air. The patient was admitted to the intensive care unit; hypotension was corrected overnight and was operated on after 24 h with bilateral intramedullary long proximal femoral nail and tension band wiring for the bilateral patella fractures. At 1-year follow-up, he was able to do his daily activities with minimal limitation.

Conclusion

Bilateral bifocal femur fractures result from a high-velocity trauma. In such injuries, careful evaluation of all the systems should be performed to find out concomitant injuries. Single-staged surgical intervention decreases the morbidities of the subsequent surgeries, helps in a rehabilitation hospital stay as well as financially suitable for the patient.

Labral Support Shelf Acetabuloplasty for Late Presenting Perthes Disease: Outcomes in Indian Patients

Introduction

The treatment of late-presenting Perthes disease with extrusion is controversial and debatable. One of the options available is the labral shelf acetabuloplasty (LSA).

Aim

The aim of the study was to evaluate the results of LSA in late-presenting Perthes disease in terms of clinic-radiological outcome measures.

Materials and Methods

A retrospective analysis of prospectively collected data of patients with late presenting Perthes disease (Elizabethtown stage 2B onwards) treated by LSA by 2 experienced paediatric orthopaedic surgeons was performed. Data was collected of clinical parameters such as hip range of motion(ROM) and Harris Hip score and radiological parameters such as acetabular height, width and volume, shelf width, Centre Edge angle(CEA) and the lateral extrusion.

Results

Thirty-five patients (28 males and 7 females) treated between 2012 to 2019 were analyzed. Majority were in Elizabethtown stage 3A (23) followed by 2B and 3B (12 each). At a mean follow up of 36 months, the hip ROM and the Harris Hip Score (from 65 ± 3.5 to 81.33 ± 7.12) improved significantly and there was a statistically significant improvement in terms of all radiological parameters. Majority of the hips were in Stulberg grade 3 (20) followed by grade 1 and 2 (7 each) and Stulberg 4 (1). There were no major complications in any of the patients of the series.

Conclusion

Labral support shelf acetabuloplasty is a valuable surgery for late presenting Perthes disease and helps in maintenance of good coverage and allows restoration of range of motion over time.

Case Reports and their impact on Journal Metrics, Researcher's Indices, and other sundry issues

Case reports (CR) are essential for documentation, particularly for managing rare diseases, presenting a new/emerging disease, reporting adverse reactions to a medication, or sometimes sharing novelty among medical professionals [1]. However, they are a matter of impugn between the journal editors on one side and the researcher and the clinician on the other. The advent of impact factor (IF) as a tool to determine the academic status of journals and the evolution of the evidence-based pyramid has pushed many journals into the muddy rat race of claiming supremacy over other journals. CR is less cited and, therefore, reduces the total IF of the journal [2]. Additionally, the perception that CR and case series form the lowest rung of the evidence pyramid has progressively led to most journals shying away from CR. The result is the burgeoning numbers of armchair researchers replacing hard-worked original clinical and basic science studies with meta-analysis and systematic reviews, often concluding in ambiguous statements like “more studies are required to…”. Some journals have an ornamental CR section allowing 1-2 CRs, while many have already done away with this section. Some even have mentioned in the author’s guidelines that CR is no longer accepted in their journal. This might appear paradoxical in an era where most journals are published online, often solely so, and the number of submissions is (at least theoretically) unlimited. But do CRs negatively influence the IF of a journal? Interestingly, Erivan et al. did a bibliometric study of the effect of the CR on the IF of journals. The authors found that mean IF would have improved from 2.013 to 2.072 (p-value- 0.00001 and therefore statistically significant) without CR. Academicians have long debated “questionable editorial policies that affect the IF of journals,” like manipulating the denominator, coercive citations, etc. The real question is – Are the journals truly meant to compete for IF in the name of publishing high-quality original research only? Clearly, the core purpose of disseminating scientific/medical knowledge amongst peers may be lost in this battle, and the journals would be restricted to a handful of select contributors and readers (the elite club). A researcher has to be perceived as an ever-evolving entity. In their formative years, most clinical students start reading CR as they search for similar cases for diagnosis, investigations, and management, all of which are given in precise detail. CR is also an initial article for many of them as they enter the publishing world. Unfortunately, several academic institutions and organizations have shunned CR for one reason or another. CR is typically not even counted as a publication for authors. Therefore, many authors move away from CR while only a few hold on to the old passion and keep publishing CR, often at considerable financial expense. Can a CR contribute to a researcher or author? The h-index and I-10 index are the recent critical parameters for measuring the research abilities of authors and journals. Here is an example of the author’s (MJ) Google profile (Fig. 1). The figure clearly illustrates that CRs are high in citation and have contributed substantially to the author’s higher indices. One can argue that CR, having higher citations, was published long ago. The journey of every researcher progresses from CR to the original articles and studies higher up in the evidence pyramid. The IF considers two or five years into the calculation, but CRs are also frequently cited in the long run and are beneficial for journals. A clinician, meanwhile, is a mute spectator in this ongoing transformation. The publishing world conundrum is snatching away his opportunity for scientific knowledge in the form of CR. CR is a valuable learning resource to enhance his clinical knowledge and analytical skills that ultimately affect patient care [3]. A medical undergraduate or post-graduate student who is a new entrant to the “world of research” would first dive into the CR section as they are most easily relatable to their daily life. Even there is a paradigm shift in medical education from traditional teaching to case-based and problem-solving scenarios. CR is a complete package to give intricate details to any situation. For example, if a CR discusses the differential diagnosis of a disease. It will include the commoner to the rarest possibility. Originally meant to disseminate knowledge among medical professionals, journals have de facto become a staggeringly profitable business model rivalling the film and music industries. This trend, in turn, unfortunately, reflects the global career imperatives to publish or perish. The need for objective criteria to monitor the quality of such outputs is, therefore, increasingly necessary to stratify the players in the market. But in the bargain, are they losing the wide readership once enjoyed to select “intellectuals”? Many journals have issued a death sentence to CR, but few journals (JOCR is one of them) have given a fresh lease of life by exclusively publishing CRs. JOCR articles are archived in PubMed, and being an open access journal, they give easy opportunity for reading and citations.

The Witness to an Informed Consent for Surgery/Invasive Procedure: The Ethical and Legal Aspects

Informed consent is an exercise to protect the right of the patient to make an informed decision regarding his/her willingness to undergo a procedure. The doctor needs to explain all aspects of the procedure to the patient beforehand, including the nature of the procedure, its purpose, alternatives, and possible complications. The patient’s signature is required on a written informed consent to document their willingness for the procedure. It is required by law that such an informed consent be obtained from every patient undergoing any invasive procedure. However, the role of a witness for the informed consent is ambiguous. This brings up certain important questions regarding the witness for an informed consent – is it necessary? And if so, who should be a witness? These questions have been largely been unexplored and unanswered. There is scarce literature regarding the requirement and role of a witness for an informed consent before an invasive procedure/surgery. The supreme court of India, even in its landmark judgment on the requirements of informed consent, did not address the role of a witness for the consent. While it laid down the guidelines for a valid informed consent and explained the contents to be present in an informed consent, it made no mention of requiring a witness to be present at the time of obtaining such consent [1].

"Critical pedicle wall" breaches analysis in complex spinal deformity using O-arm navigation

Background

Free-hand and fluoroscopic-guided pedicle screw placement has been associated with higher rates of pedicle breaches (frequency range 15-40% especially in deformed pedicles). Neurological complications are more "critical" (i.e., frequent and significant) with medial and inferior pedicle-wall breaches due to the proximity of the neural elements. Here, we analyzed the effectiveness of O-arm navigation in minimizing "critical" pedicle wall breaches and their complications in 21 complex spinal deformity cases.

Methods

Twenty-one complex spinal deformity cases were prospectively managed with O-arm-navigated posterior-instrumented fusions. Preoperative assessment included; evaluation of the type of scoliosis, the magnitude of the deformity, and the anatomy of the pedicles - (i.e., classified using Watanabe et al.). The O-arm was used to confirm and grade both the intraoperative and postoperative location of screws. Other variables analyzed included; duration of surgery, estimated blood loss, complications, and radiation exposure.

Results

In 21 patients, 259 (63.45%) of 384 pedicles were instrumented; we observed 22 of 259 pedicle screw breaches. Significant (>2 mm) breaches were observed in two medial and one inferior wall cases that required revision; the overall biomechanically significant screw breach rate was (3/259) 1.2% with an accuracy rate of 98.8%. Pedicle screw placement resulted in another 14 nonsignificant (<2 mm) breaches; ten were medial and four involved the inferior wall. As anterior, lateral, and "in-out-in" trajectory pedicle screws beaches were nonsignificant, they were not included in our analysis.

Conclusion

O-arm navigation decreased the incidence of medial and inferior (i.e., >2 mm "critical") pedicle screw breaches applied in 21 patients with deformed pedicles due to scoliosis. Further, the O-arm minimized the operating time, decreased the estimated blood loss, and reduced the incidence of complications.

Osteoporosis - An Imminent Ethical and Legal Debacle?

Osteoporosis is a condition characterized by a decrease in bone density. Its prevalence is on the rise and is only going to continue to rise further. Fragility fractures such as neck of femur fracture fractures and intertrochanteric fractures are among the most common fractures encountered by orthopedic surgeons today. Yet, the management of these fragility fractures has unfortunately fallen short of addressing the etiology behind the fracture. Orthopedic surgeons routinely perform arthroplasty or osteosynthesis for stabilization of these fractures, but rarely do they address the coexisting osteoporosis. We explore the factors, leading to this scenario, the practical hurdles faced, the ethical and legal considerations on the matter, and the road ahead. We believe that this is a topic which should be discussed further among orthopedic surgeons to arrive at practical solutions and change in perspectives. The aim of this article was to encourage a debate on the matter, increase awareness about the current situation, and help change the trend in the management of osteoporosis in developing countries like India.

Rhino-orbito-cerebral mucormycosis: patient characteristics in pre-COVID-19 and COVID-19 period

Background: Rhino-orbito-cerebral-mucormycosis (ROCM), a rare and potentially fatal disease was seen in increasing numbers during the COVID-19 pandemic. This study describes and compares the patient characteristics and outcomes in COVID-19 associated mucormycosis (CAM) and non-COVID-19 mucormycosis (non-CAM). Methodology: CAM patients (24 cases) were recruited from the COVID-19 period and non-CAM (24 controls) from the pre-COVID-19 period. Clinical data of the CAM group was collected retrospectively with 3 month outcomes prospectively. The non-CAM group data was collected retrospectively. Patient characteristics were compared and risk factors for mortality in ROCM were assessed. Results: Orbital symptoms [altered vision, restricted eye movements, ptosis] and intracranial involvement were higher in CAM patients on presentation. Similarly, the radiological involvement of orbit (orbital apex, superior orbital fissure) and intracranial cavity (intracranial thrombosis, cavernous sinus) was also higher in CAM patients. Newly detected diabetes was found only in CAM patients (29.2%). Although univariate analysis suggested an increased mortality risk in ROCM patients with orbital involvement, the multivariate analysis showed no increased risk with any of the parameters assessed, including COVID-19 positivity. Conclusions: Compared to the non-CAM, the disease presentation was severe in CAM with higher frequency of orbital and intracranial involvement. However, with early detection and treatment, the short term survival was comparable in both groups.

A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients

Aim and objective

To study the radiological and functional outcomes as well as complications in the management of fractures involving both columns of the acetabulum using a single surgical approach.

Design

Type IV, prospective clinical study.

Setting

Level I trauma centre.

Materials and methods

Inclusion criteria were as follows: (a) patients over 20 year of age and (b) patients suffering from acetabular fractures involving both columns as per Letournel and Judet classification, namely transverse, transverse + posterior wall, T type, anterior column posterior hemi-transverse (ACPHT) and associated both columns. Exclusion criteria were as follows: (a) patient suffering from isolated anterior column, posterior column, anterior wall, posterior wall and posterior wall + column fractures; (b) patient who have undergone surgical procedures of the hip prior to trauma; and (c) compound acetabular fractures. A total of 23 patients having both column acetabulum fractures were included prospectively from June 2016 to December 2018 and followed up till 1 year postoperatively. Open reduction and internal fixation were performed through one of three described approaches, i.e., iliofemoral, Kocher-Langenbeck, and anterior intrapelvic or ilioinguinal.

Results

Our study population consisted of 30.4% transverse, 39.1% associated both columns, 21.7% T type and 8.7% anterior column + posterior hemi-transverse. Of these, 65.2% were operated using the Kocher-Langenbeck approach, while 30.4% of patients required the anterior intrapelvic approach. The remaining 4.3% of patients were operated by the iliofemoral approach. Anatomic reduction was achieved in 100% of our study population with remaining displacement less than or equal to 1°mm. At 1-year follow-up, all fractures showed a satisfactory union with an excellent Matta index in 100% study subjects. Complications at 1 year included one case of foot drop, which was present preoperatively but failed to improve and one case of post-traumatic arthritis. Average Harris Hip score (HHS) and mean Merle D'Aubigne (MDA) scores suggested good clinical outcomes in the study population.

Conclusions

A single approach can be used to achieve good functional and radiological outcomes in carefully selected bicolumnar fractures of the acetabulum, with less approach-related morbidity.

Clinical significance

Traditionally, multiple approaches are used for acetabulum fractures involving both columns, but with proper patient selection, single approach can be used with good functional and surgical outcomes.

How to cite this article

Patil A, Attarde DS, Haphiz A, et al. A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients. Strategies Trauma Limb Reconstr 2021;16(3):152–160.

Validation of an on-screen application-based measurement of shoulder range of motion over telehealth medium

BACKGROUND

Shoulder range-of-motion (ROM) assessment is vital for the follow-up evaluation of operated patients and for the outcome-based research studies. The aim of this study was to investigate the accuracy and reliability of a remote on-screen application (app)-based method of shoulder ROM measurement through a telehealth medium.

MATERIALS AND METHODS

A consultant shoulder surgeon, a board-certified orthopedic resident, and a graduate medical doctor served as the examiners. The cohort consisted of 24 healthy volunteers and 16 symptomatic patients with expected shoulder ROM deficits. Shoulder ROM was first examined physically using a goniometer in the clinic and then over Zoom remote conferencing using the protractor extension app of the Chrome browser.

RESULTS

Instrument validity was examined by comparing the goniometer method with the protractor app-based method of the expert shoulder consultant using Bland-Altman analysis. It showed only minor mean differences between the healthy volunteers and the patients in elevation (2.0° and 5.0°, respectively), abduction (2.0° and 3.0°, respectively), external rotation with the elbow adducted (1.9° and 0.2°, respectively), external rotation with the elbow abducted at 90° (0.4° and 4°, respectively), and internal rotation with elbow abducted at 90° (2.3° and 1.2°, respectively), with limits of agreement that were below the well-established minimal clinically important difference values. The intraclass correlation coefficient (ICC) values varied between 0.83 and 0.96 for the volunteers and between 0.90 and 0.98 for the patients, indicating excellent correlation between the 2 methods. The interobserver reliability between 2 examiners for the protractor app-based method as evaluated by ICC scores was excellent; it ranged between 0.86 and 0.98 for the volunteers and between 0.88 and 0.99 for the patients. Comparison of the protractor app-based method with the gold-standard goniometer method for the resident and the graduate doctor showed excellent ICC values.

CONCLUSION

A protractor app-based method of measuring shoulder ROM over a telehealth medium is accurate and reliable compared with a clinical goniometer method. This validated method can be used during remote telehealth consultation with significant benefits of saving patients travel and time during the COVID-19 (coronavirus disease 2019) pandemic and even later.

Osteosclerotic Multiple Myeloma without POEMS Syndrome - A Rare Case Report

Introduction

Multiple myeloma is a plasma cell neoplasm that is commonly associated with lytic bone lesions; however, osteosclerotic multiple myeloma is a rare entity. Osteosclerotic multiple myeloma has been reported in association with POEMS syndrome.

Case Presentation

A 60-year-old female patient presented to us with low back pain for 2 months. The investigations revealed that the patient had multiple osteosclerotic lesions in the axial skeleton with a L4 ivory vertebra. The serum immunoelectrophoresis was negative. Positron emission tomography scan was done which showed multiple skeletal lesions in the right iliac bone, left femoral neck, thoracic vertebrae T1, T6, T12, and lumbar vertebra L4. Biopsy and immunohistochemistry of the lesion showed plasma cell proliferation; producing lambda light chains. However, there were no features of POEMS syndrome including polyneuropathy, organomegaly, endocrinopathy, and skin changes. The patient was started on chemoradiation and achieved clinical remission and was asymptomatic at 12 months follow-up.

Conclusion

Osteosclerotic myeloma without the features of POEMS syndrome is an extremely rare entity. This case reports documents a unique clinical scenario of osteosclerotic non-secretory light chain myeloma without POEMS syndrome.

Outcomes of operative management in the delayed presenting neck of femur fractures in children: A case series

Introduction: Fracture neck of femur in pediatric age group occurs due to high energy trauma and is an uncommon entity with high complication rate. No uniform guidelines are present to manage these fractures, especially in delayed presentation of fracture neck of femur as a smaller number of such cases were reported. Case Report: Eight children (nine hips), five boys and three girls of age <15 years, were operated on. The mean delay in surgery time was 8.6 days (range: 5–22 days). The mean union time was 13.44 weeks. The mean follow-up was 20.88 months (range: 12–36 months). All the cases were managed with closed or open reduction followed by internal fixation with or without hip spica application and resulted in satisfactory outcomes in most of the cases. Conclusion: Anatomical reduction (open or closed) and fixation reduce the risk of complications even in delayed presentation if the orthopedic surgeon is familiar with the management.

Case Reports: The Art of Writing, the Importance of Publishing it and Avoiding Facing Rejection

Journal of Orthopaedic Case Reports (JOCR) has a rich history of 12 years in publication and has proven to be a leading choice for publishing orthopedic case reports, being registered with major Indexing and Abstracting partners. I have been associated with the journal for more than 7 years as a regular reviewer of the case reports and have recently been handed the responsibility of serving as an Associate Editor of the journal. I would like to congratulate the entire Indian Orthopaedic Research Group for its success and for promoting orthopedic research in India for the past decade. With diversity in its Editorial Board section editors, this journal considers case reports of all orthopedic subspecialties with a relevant clinical message. Being easy to write and comparatively less time consuming, case reports are the stepping stone for any clinician’s research journey. The Numerous Types of Case Reports Can be Subdivided into the Following Categories [1, 2]

Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts

PURPOSE

There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic.

METHODS

The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus.

RESULTS

Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis.

CONCLUSION

It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

Tuberculosis of the Cuboid in a 16-Month-Old Child: A Case Report

CASE

A 16-month-old male child presented with swelling over the dorsolateral aspect of the right foot associated with limp and no other constitutional symptoms. Tenderness and swelling were noted over the dorsolateral aspect, and radiographs revealed an eccentric lytic expansile lesion in the right cuboid. Biopsy of the lesion revealed necrotizing granulomas, and molecular testing later documented tuberculosis. The child received antitubercular medications and was relieved of symptoms in 6 weeks. Complete healing was observed after 12 months.

CONCLUSION

In developing countries, a high index of suspicion helps in the early diagnosis and appropriate management of tubercular osteomyelitis in children.

Orthopaedic surgeons and covid- 19, the fear quotient "What are we really worried about?"

INTRODUCTION

The COVID-19 pandemic swiftly affected the world in a very short duration, and the orthopaedic surgery practice is no exception. Unprecedented lockdown was enforced in many countries including India as a first response to contain virus and its spread. That lead to a lot of confusion, fear, anxiety among general population as well as orthopaedic surgeons. We have studied the impact of this pandemic with fear as a denominator and how it affected the practice and health of orthopaedic surgeons.

METHODS

Cross-sectional web-based national survey distributed to orthopaedic surgeons by social media platform over period of one month from July 25, 2020 to August 25, 2020.

RESULTS

Among 1065 responders, 731 completed the survey. Among 1065 responders, 27.22% had orthopaedic practice experience ranging from 10 to 20 years while 21.48% had orthopaedic experience more than 20 years. Scientific literature as well as social media and news media contributed significantly to Covid-19 knowledge and fear. 98.88% were worried about contracting disease by themselves or by family members. 89.47% were worried due to financial loss due to pandemic. 37 (5.06%) surgeons had a FCV- 19 scale (Fear for Covid-19 scale) score more than 60 (8.2%) while 291 (39.8%) had 41-60 and score was <40 in 403 (55.12%) surgeons. According to survey vaccine availability and emergence of effective drug and treatment protocol will alleviate most of the concerns. 70.81% felt mildly depressed during pandemic times while 65.33% surgeons expressed interest in joining discussion groups and meetings encouraging positive thoughts.

CONCLUSION

Financial liabilities and well-being of self and family are important factors which induced fear of Covid-19 among orthopaedic surgeons. Positive discussions and timely information from credible sources regarding prevention, diagnosis and management and will reduce psychological burden due to Covid-19, also this will help to form policies for future pandemics.

A Polyostotic Paget’s Disease Involving Lumbar Spine Presenting with Cauda Equina Syndrome: An Unusual Entity

Introduction:

Paget’s disease of bone (PDB) is a metabolic bone disease presenting as polyostotic or monostotic lesions of the spine. Although common in the Anglo-Saxon population, it is rare on the Indian subcontinent. Neurological complications though infrequent can be severe in pagetic spine.

Case Report:

We report a case of a polyostotic variant of PDB involving lumbar spine (L2 vertebrae), iliac bones, and femur presenting as chronic low back pain and neurological deficit, i.e., cauda equina syndrome. On initial workup, a diagnosis of PDB was made and given cauda equina compression with neurological deficit, posterior spinal decompression, and biopsy was performed. The histopathological evaluation confirmed the diagnosis and the patient was treated with bisphosphonates for 6 months, along with serial monitoring of alkaline phosphatase levels.

Conclusion:

Through this case report, we hope to emphasize that PDB should be considered as a possible cause of neurological symptoms at presentation, especially in elderly patients. Also furthermore, early surgical intervention followed by bisphosphonates therapy can lead to favorable outcomes in such patients.

Osteochondrosis of Primary Center of Patella: A Case Report

Introduction

Osteochondrosis of the primary ossification center of the patella (Kohler's Disease) is a rare and self-limiting condition of unknown etiology. Sometimes it may be found as normal variant.

Case Report

A 7-year-old boy presented with anterior right knee pain. On radiological examination, there was increased density, irregularity, and fragmentation of the patellar primary ossification center. Activity modification and exercise led to marked symptomatic improvement after 1 year.

Conclusion

It was concluded that the disease either physiological or pathological, diagnosis is usually difficult. However, the treatment is simple. There was improvement functionally as well as radiologically with activity modification.

Functional Outcome of Pipkin Type III Fracture Managed by Osteosynthesis through Trochanteric Flip Osteotomy in a Young Patient after 5 Years Follow-Up – A Case Report and Literature Review

Introduction:

Femoral head fractures are uncommon. A femoral head fracture associated with an ipsilateral neck of femur fracture is classified as a Pipkin’s Type III fracture and is exceedingly rare. It is a high-energy injury associated with an extremely poor prognosis. This has led some authors to advocate primary arthroplasty for these injuries. The aim of reporting this case is that in young patients even with severely displaced Pipkin’s Type III injuries, it is reasonable to opt for internal fixation of these fractures. It is possible to obtain good function for a significant amount of time as evidenced by the 5-year follow-up in this case.

Case Report:

A 25-year-old male presented 4 days after a motorbike accident. He was diagnosed as a femoral head fracture with neck fracture of the left side. This fracture is classified as type III Pipkin fracture or OTA type 31C.3. This case was managed with open reduction and internal fixation utilizing the trochanteric flip osteotomy and multiple screws. It is worth to report the first case of Pipkin type three fracture having satisfactory functional outcome after 5 years of follow-up.

Conclusion:

It is worth preserving the femoral head in young patients. Good pre-operative planning, meticulous reduction, tissue handling, and fixation could get satisfactory results. The outcome also depends on post-operative rehabilitation and compliance of patient.

Achondroplasia with seronegative spondyloarthropathy resulting in recurrent spinal stenosis : A case report

Background:

Achondroplasia is an autosomal dominant condition caused by the G380 mutation of the gene encoding fibroblast growth factor receptor 3 on chromosome 4P. The classical findings include rhizomelic extremities, short stature, and spinal stenosis involving the upper cervical and distal lumbar spine. Rarely, achondroplasia coexisting with seronegative spondyloarthropathy can result in recurrent canal stenosis. Here, we report a 36-year-old male with symptomatic recurrent L3-L4 spinal stenosis 9 years following an original L2-S1 lumbar decompression for stenosis.

Case Description:

A 36-year-old male with achondroplasia (height of 113 cm and weight 43 kg [BMI-33.7]) presented with low back and right lower extremity sciatica (ODI 39). He had achondroplasia with a short stature. Nine years ago, he had an L2-S1 laminectomy for decompression of stenosis. When the new MRI revealed recurrent severe L3-4 stenosis, he underwent a repeated L3-L4 decompression with fusion. One year later, the patient was neurologically intact with radiographic confirmation of adequate L3-L4 arthrodesis.

Conclusion:

A 36-year-old male with achondroplasia and a history 9 years ago of an L2-S1 laminectomy for stenosis, presented with symptoms and signs of recurrent L3-L4 stenosis that responded to repeated decompression and fusion.

Recurrent solitary bone plasmacytoma: A case report

BACKGROUND

Plasmacytoma is an hematological malignancy that originates in bone. It may involve a single skeletal location. Notably, these lesions can progress to involve multiple segments in 50% of cases, at which point they are classified as having multiple myeloma (MM).

CASE DESCRIPTION

One year ago, this patient had undergone a D6 laminectomy and biopsy for plasmacytoma. Now at age 73, she newly presented with the onset of a progressive paraparesis of 4 weeks' duration. On examination, she had 3/5 strength in both lower extremities accompanied by diffuse hyperreflexia, and bilateral Babinski signs. She underwent a D5-D7 decompression, D6 corpectomy with anterior mesh cage reconstruction, and a D3-D9 posterior fusion.

CONCLUSION

Patients originally treated for plasmacytoma present 50% of the time with the new onset of neurological symptoms and signs due to the subsequent evolution of MM. As these lesions may be refractory to radiation and/or chemotherapy, surgery is often warranted.

Anterior proximal humerus fracture dislocation with concomitant glenoid fracture: An operative challenge! A case report

Introduction

Combined proximal humerus fracture dislocation and glenoid fracture is a rare combination of injuries which presents technical operative challenges. There is little evidence to guide surgical management.

Case Report

We report a case of a proximal humerus fracture with anterior dislocation and glenoid fracture treated in the same sitting with open reduction and internal fixation with angular stability locking plate and cannulated screw. The surgical technique involved standard deltopectoral approach with coracoid osteotomy.

Conclusion

By addressing both fractures operatively at the same time, we reported a satisfactory clinical and functional outcome with bony union of the fracture sites without instability at end of 1 year. Coracoid osteotomy may open an alternative pathway to treat complex proximal humerus injuries with ipsilateral glenoid fracture.

Indian Paradigm of Orthopedic Care in Post-COVID-19 Era

COVID-19 pandemic caused by the newly emerged strain of coronavirus (SARS-CoV-2) has had phenomenally casted its impact on the health-care systems globally. The rampant spread of contagiosity has challenged the solidarity of the medical fraternity of the developed and developing world. The rising turmoil enforces to trudge with stoicism and expresses the need for planning because of subjugating the prevailing conditions with judicial channelization of available resources. In many developed and developing countries, the resources such as appropriate equipment as well as personnel have been extended to combat the pandemic substantially. At the same time, the populous country such as India has taken a stand to cancel electively planned orthopedic surgeries. However, under the issued guidelines of apex authorities, trauma and emergency services had have been in continuity with a reorganized manner. Hereby, we discuss the present shift in paradigm in the field of orthopedics with an interplay of regenerative orthopedics and telemedicine and its pivotal role against the odds of the COVID-19 pandemic. Besides, we see over the future perspectives and challenges in the purview of resorting to an effective clinical practice in orthopedics specialty. Albeit these guidelines expound strategies to manage trauma and orthopedic cases amidst pandemics but the subsequent post-COVID-19 phase warrants explicable vision and planning. Indeed, resuming elective orthopedics surgical intervention in post-phase of pandemic shall definitively be a task invoking fundamental planning, especially in a resource-limited background. With the rollout of vaccines in the country, the scenario is in favor of returning to normalcy with evaluation for COVID-19 being added to the list of routine medical and surgical screening profiles.

Triggering of Thumb by a Ganglion Cyst of the Flexor Tendon Sheath at A1 Pulley: A Case Report

Introduction:

Ganglions of the wrist and hand are commonly seen but the most common sites are in the dorsum of the wrist followed by the volar side in the distal forearm at the wrist crease. The Ganglion cysts arising from the flexor tendon sheath are rare and only a few are reported in the literature.

Case Report:

We report a rare case of a ganglion cyst of the flexor tendon sheath at A1 pulley of thumb in a 35-year-old male who came with the complaint of chronic triggering of the left thumb. The histopathological examination confirmed the ganglion which was removed from the A1 pulley area.

Conclusion:

A1 pulley ganglion causing trigger thumb is uncommon entity. Although, traditional treatment for this is conservative or aspiration. High recurrence is observed. When it comes to preservation of fine movements such as thumb, aggressive approach involving exploration and excision of cyst gives good functional outcome and reduces chance of recurrence.

Results and complications of head-preserving techniques in chronic neglected shoulder dislocation: a systematic review

BACKGROUND

Humeral head-preserving procedures may be needed for chronic neglected shoulder dislocation because the presenting age of the patient is often reported to be less than 45 years. The aim of this systematic review was to evaluate the results of the various head-preserving procedures for chronic anterior dislocation (CAD) and chronic posterior dislocation (CPD). This review also aimed to evaluate the results of conservative neglect for CAD.

METHODS

PubMed, Embase, and Cochrane library databases were queried for studies that reported on results of head-preserving procedures for CAD or CPD and for studies that reported on the results of conservative neglect for CAD. Case reports, review articles, acute dislocations, and fracture-dislocations were excluded. The results of the different techniques were pooled for further evaluation.

RESULTS

Seventeen studies were selected for qualitative analysis. These were further subdivided into 9 studies for the CAD group and 11 studies for the CPD group. In the CAD intervention group, 53 shoulders in 7 studies were managed by 5 different head-preserving techniques. The choice of procedure to stabilize the shoulder after open reduction varied between coracoid transfer, capsulolabral repair, remplissage, and Putti-Platt procedure and acromiohumeral K-wire fixation. High resubluxation rates and early arthrosis were reported after open reduction techniques for CAD. In the CAD conservative group, 8 shoulders in 2 studies were managed by conservative methods. In the CPD group, the 2 most common techniques, McLaughlin or modified McLaughlin and bone grafting, were used to treat 74 shoulders in 7 studies and showed good functional outcomes.

CONCLUSION

The choice of open reduction and stabilization technique for CAD was highly variable between the different studies and led to a wide variation in the reported outcomes with a high number of complications such as resubluxation and early arthrosis. The conservative treatment of CAD led to poor functional results. The choice of treatment for CPD was mostly between 2 techniques-McLaughlin and modified McLaughlin reconstruction or the bone graft reconstruction-and they consistently led to good functional outcomes with less complications.

Actinomycotic Infection of Spine - A Rare Disease with Diagnostic Challenge, an Update on Spinal Infection

INTRODUCTION

We are reporting a rare case of lumbar spinal actinomycosis with superficial discharging sinuses in an elderly female.

CASE REPORT

A 56-year-old female came in outpatient with chief complaints of low back pain radiating to both buttocks, burning sensations to both lower limbs. Magnetic resonance imaging (MRI) re-vealed signal intensity changes suggestive of patchy marrow edema present over the L2 to S1 vertebra. Surgery was performed in the form of laminectomy and decompression by posterior approach and tissue was collected from right sacral ala. Contrast MRI showed patchy areas of marrow signal ab-normality L1, L2, L4, and L5 vertebra and adjoining end plates of L5, S1, and S2 segments. Ring en-hancing lesions at L2 and L3 levels. The patient underwent revision surgery. Histopathology revealed clumps of basophilic filamentous bacteria in a vaguely rosette-like configuration surrounded by acute inflammatory cells, characteristic of actinomycosis.

CONCLUSION

Actinomycotic infections of spine are a rare cause of spinal infections but should be kept in mind once the tubercular infection is ruled out. The definitive diagnosis of actinomycosis can be made by finding actinomycetes in the pus from affected tissue.

Comparison between neurodynamic therapy and foam rolling in cool-down sessions for delayed onset muscle soreness in healthy individuals

BACKGROUND

Delayed onset of muscle soreness (DOMS) is a common finding in trained and untrained individuals post high intensity exercises which can lead to injuries. Foam rolling (FR) and neurodynamic therapy (NDT) are types of active cool-down which provides effective for treatment of DOMS. But their role in reduction of intensity of the same in cool down is not established.

STUDY DESIGN

Crossover study.

METHODOLOGY

Total 60 healthy individuals participated in the study. Pre intervention readings were taken of strength and tightness by Range of motion. Subjects performed both the types of cool-down separated by 4 weeks interval with random allocation. Post intervention readings of hamstring and quadriceps tightness, grade of tenderness and stand to sit VAS score was taken post 24 h and 48 h and strength post 48 h.

RESULTS

Analysis was done for using repeated measures ANOVA and Friedman's test. The difference of values for Straight Leg Raise and Prone knee Flexion between NDT and FR post 24 h were statistically significant (p < 0.05) while that of NDT post 24 h being similar to FR post 48 h (p > 0.05). There was a significant difference between strength, tenderness and VAS in NDT and FR (p < 0.05). With the mean of post 24 h as well as post 48 h being less in the FR intervention.

CONCLUSION

Foam rolling is a better option than Neurodynamic therapy for reduction of intensity of DOMS.

Successful sterilization and immediate reimplantation of extruded femoral diaphyseal segment: A case report and review of literature

Extrusion of bone is a rare situation in open fractures due to high energy trauma. There are few studies, reporting successful reimplantation of the extruded bone segment using various sterilization and fixation protocols. However, there are no definitive treatment strategies for this challenging situation. We report a case of 30-year-old male patient with grade IIIB compound right distal femur fracture with an extruded long bone segment, who was treated with successful sterilization and immediate reimplantation of an extruded long diaphyseal segment of distal femur following extensive cleaning with sterile normal saline, removal of debris with scrubbing by sterile brush, soakage in the broad-spectrum antimicrobial solution for 30 min, sterilization by autoclaving at 121°C for 45 min, and reimplantation during stable internal fixation with lateral distal femur locking plate using Arbeitsgemeinschaft für Osteosynthesefragen techniques. At 3 months, iliac crest bone grafting, osteoperiosteal flaps, and augmented fixation with a medial locking plate were performed through a subvastus approach for a void in the medial supracondylar femur region. Intraoperatively, punctate bleeding was observed from the reimplanted fragment. Infection was ruled out with normal leukocyte count, C-reactive protein marker, no evidence of unhealthy granulation tissue, and a sterile culture report from the fracture site. The fracture healed in 12 months and the patient had good functional outcome with a lower extremity functional score of 80% and knee range of motion of 110° at short-term follow up of 2 years without any complication. Decision of reimplantation is individualized depending on the time of presentation, contamination, and comminution of extruded fragment with scarce literature on standard treatment strategies. In our case, early presentation, meticulous debridement, unique sterilization technique, immediate reimplantation, and augmented dual distal femur plating with bone grafting aided in achieving successful union with good functional outcome and knee range of motion, avoiding any complications.

Clinical and radiological factors associated with postoperative shoulder imbalance and correlation with patient-reported outcomes following scoliosis surgery

Background

Shoulder balance (SB) is an important cosmetic concern and is a determinant to assess outcomes following scoliosis surgery. Shoulder imbalance (SI) has been studied predominantly in idiopathic scoliosis with limited literature on other etiologies.

Purpose

To assess SB following scoliosis surgery and correlate SRS-30 self-image scores with radiological shoulder imbalance SI.

Methods

A retrospective analysis was performed for 43 patients undergoing scoliosis surgery with a minimum 2-year follow-up. Radiological SI was assessed by the coracoid height difference on whole spine standing radiographs at preoperative, 12-weeks postoperative and 2-year follow-up. The preoperative Cobb angle, postoperative Cobb angle and mean correction were recorded. The upper and lower end vertebrae (UEV/LEV), and instrumented vertebrae (UIV/LIV) were documented. The aetiology of scoliosis and functional outcomes based on the SRS-30 questionnaire were noted.

Results

There were 19 males and 24 females with a mean age of 14.5 ± 4.7 years. The 12-week postoperative radiographs showed SI in 15 patients and residual SI in 7 patients at 2-year follow-up. SI was seen in four congenital scoliosis with segmentation or mixed anomalies in the proximal thoracic spine. Two idiopathic scoliosis (Lenke type 1 and type 3) showed SI where the UIV was T3 and T2 respectively. The mean preoperative SRS-30 score for patients with SB (N = 9) was 2.5 ± 0.72 and for SI (N = 34) was 3 ± 0.42 without significant difference (p > 0.5). The final mean SRS-30 self-image score for patients with SB was 3.7 ± 0.54 and for patients with SI was 3.7 ± 0.53 without significant difference (p > 0.05).

Conclusion

Radiological SI assessed by coracoid height difference was not associated with a significant difference in SRS 30 scores preoperatively and at 2 year follow up. SI was seen with congenital scoliosis associated with segmentation and mixed anomalies of the proximal thoracic spine.