Correlation of tunnel widening and tunnel positioning with short-term functional outcomes in single-bundle anterior cruciate ligament reconstruction using patellar tendon versus hamstring graft: a prospective study.

OBJECTIVE: To study the correlation between tunnel widening and tunnel position with short-term functional outcomes post-ACL reconstruction with patellar tendon and hamstring autografts in young adults. MATERIALS AND METHODS: A total of 33 patients who underwent ACL reconstruction between October 2013 and February 2015 were included and followed up for 6 months. A standardized surgical technique was used for each graft type. Intra-op arthroscopy findings and drilled tunnel diameters were noted. They were followed up for 3 and 6 months. Radiological assessment was done at 3 and 6 months with clinical score assessment at 6 months. RESULTS: At 6 months, clinical scores were comparable in both groups. Tunnel widening in both femoral and tibial tunnel at 3 and 6 months were significantly higher in STG group (p values <0.05). The rate of widening was higher in 0-3 months and reduced in 3-6 months. There was statistically significant negative correlation between femoral tunnel widening by CT and IKDC score at 6 months (p value 0.049). We found a positive correlation between posterior positioning of femoral tunnel and Lysholm and IKDC scores. The correlation with Lysholm scores was statistically significant (p value 0.046). CONCLUSION: To conclude, tunnel widening is more with hamstrings graft. Femoral tunnel widening has significant negative correlation with that of IKDC scores at 6 months. Posterior femoral tunnel positioning and Lysholm scores at 6 months had significant correlation.

Is There a Scope for an Open Source Philosophy in Robotic Joint Replacement?: Why and How to Make Robotic Platforms Common and Universal for All Implants !

Background: Standardisation and open source technologies has transformed our world by levelling the field for innovation and improvisation. In the field of arthroplasty, we are seeing robotic technology make giant strides in terms of wide spread adoption across geographies. The benefits of consistency, reduced intra-surgeon and inter-surgeon variability as well as decreased dependence on complex instrumentation sets and large implant inventories, is a step in the right direction. However they suffer from a very significant drawback; today's robotic systems are essentially closed systems and do not offer cross platform and cross implant compatibility. Materials and Methods: This point of view dwells on why it is important that robotics become open source and how this can be achieved. A universal system of implant sizing and nomenclature is proposed. This may enable the use of Robotic platform across various commercially available implants seamlessly. Results: As of today, scientific literature and also the marketing literature provides no verifiable rationale for use of varied implant sizing terminology. The proposed universal implant sizing and nomenclature can be based on the Anteroposterior and mediolateral size data obtained from various anthropometric studies down across varied races. Conclusion: TBy building a consensus on the universal implant sizing nomenclature, the field of arthroplasty will achieve a major milestone. It will have benefits including easier documentation, storage and transmission of data. Most importantly, it will be the right step in direction of making the Robotic Technology - open source and thus making it available, accessible and affordable to all.

Definition and Evolution of the Term Osteoporosis.

Osteoporosis is a metabolic bone disease in which the loss of bone mineral density causes the bone to become weaker and more susceptible to fracture. In the vulnerable individual, osteoporosis develops as a result of a combination of hereditary and environmental risk factors. The definition of the term osteoporosis as a clinical syndrome has evolved with the improved understanding of the pathogenesis, diagnostic terminology and treatment directions both pharmacological and non-pharmacological, over the past few decades.

A Review of Various Clinical Practice Guidelines on Osteoporosis in the Last 5 Years.

Background: Osteoporosis, also called the silent disease, affects the elderly with a significant contribution to their morbidity and mortality through fragility fractures. Most nations have developed their own guidelines on managing this condition. Clinical Practice Guidelines (CPGs) are the highest quality evidence documents on a particular topic prepared by expert panels. CPGs offer standardised recommendations on a particular topic. Methods: We looked at the CPGs of nations in the last five years and present the results of this review here. This review is divided into Risk assessment, prevention, diagnosis, Non pharmacological and pharmacological management with information from major CPGs only. Results: Most CPGs agree on the broad principles of assessment , core risk factors, prevention and management with some finer differences in subtle aspects of assessment and management. There are differences in the use of screening tools based on the population numbers and affordability between nations. FRAX has been advocated for the screening with or without DEXA. Most CPGs use DEXA for confirmation of diagnosis. Intervention is based on FRAX scoring. Intervention thresholds vary. We discuss non-pharmacological management included diet and nutrition, calcium and Vitamin D, Exercise and physiotherapy, lifestyle changes and falls prevention. Pharmacological management included aspects of using different medications and their indications. The key agents recommended include Bisphosphonates, Teriparatide, Denosumab, SERMs, Hormone Replacement Therapy, and other agents including any drug holidays and duration of therapy. Conclusions: This review identified some key recommendations from CPGs from multiple nations in each of the above given aspects of osteoporosis.

Evaluation of artificial intelligence models for osteoarthritis of the knee using deep learning algorithms for orthopedic radiographs.

BACKGROUND: Deep learning, a form of artificial intelligence, has shown promising results for interpreting radiographs. In order to develop this niche machine learning (ML) program of interpreting orthopedic radiographs with accuracy, a project named deep learning algorithm for orthopedic radiographs was conceived. In the first phase, the diagnosis of knee osteoarthritis (KOA) as per the standard Kellgren-Lawrence (KL) scale in medical images was conducted using the deep learning algorithm for orthopedic radiographs. AIM: To compare efficacy and accuracy of eight different transfer learning deep learning models for detecting the grade of KOA from a radiograph and identify the most appropriate ML-based model for the detecting grade of KOA. METHODS: The study was performed on 2068 radiograph exams conducted at the Department of Orthopedic Surgery, Sir HN Reliance Hospital and Research Centre (Mumbai, India) during 2019-2021. Three orthopedic surgeons reviewed these independently, graded them for the severity of KOA as per the KL scale and settled disagreement through a consensus session. Eight models, namely ResNet50, VGG-16, InceptionV3, MobilnetV2, EfficientnetB7, DenseNet201, Xception and NasNetMobile, were used to evaluate the efficacy of ML in accurately classifying radiographs for KOA as per the KL scale. Out of the 2068 images, 70% were used initially to train the model, 10% were used subsequently to test the model, and 20% were used finally to determine the accuracy of and validate each model. The idea behind transfer learning for KOA grade image classification is that if the existing models are already trained on a large and general dataset, these models will effectively serve as generic models to fulfill the study's objectives. Finally, in order to benchmark the efficacy, the results of the models were also compared to a first-year orthopedic trainee who independently classified these models according to the KL scale. RESULTS: Our network yielded an overall high accuracy for detecting KOA, ranging from 54% to 93%. The most successful of these was the DenseNet model, with accuracy up to 93%; interestingly, it even outperformed the human first-year trainee who had an accuracy of 74%. CONCLUSION: The study paves the way for extrapolating the learning using ML to develop an automated KOA classification tool and enable healthcare professionals with better decision-making.

Walking Pole Gait to Reduce Joint Loading post Total Knee Athroplasty: Musculoskeletal modeling Approach.

Excessive knee contact loading is precursor to osteoarthritis and related knee ailment leading to knee athroplasty. Reducing contact loading through gait modifications using assisted pole walking offers noninvasive process of medial load offloading at knee joint. In this paper, we evaluate the efficacy of different configuration of pole walking for reducing contact force at the knee joint through musculoskeletal (MSK) modeling. We have developed a musculoskeletal model for a subject with knee athroplasty utilizing in-vivo implant data and computed tibio-femoral contact force for different pole walking conditions to evaluate the best possible configuration for guiding rehabilitation, correlated with different gait phases. Effect of gait speed variation on knee contact force, hip joint dynamics and muscle forces are simulated using the developed MSK model. Results indicate some interesting trend of load reduction, dependent on loading phases pertaining to different pole configuration. Insights gained from the simulation can aid in designing personalized rehabilitation therapy for subjects suffering from Osteoarthritis.

Anatomical Landmark Detection using Deep Appearance-Context Network.

Accurate identification of anatomical landmarks is a crucial step in medical image analysis. While deep neural networks have shown impressive performance on computer vision tasks, they rely on a large amount of data, which is often not available. In this work, we propose an attention-driven end-to-end deep learning architecture, which learns the local appearance and global context separately that helps in stable training under limited data. The experiments conducted demonstrate the effectiveness of the proposed approach with impressive results in localizing landmarks when evaluated on cephalometric and spine X-ray image data. The predicted landmarks are further utilized in biomedical applications to demonstrate the impact.

Artificial Intelligence and Machine Learning: A New Disruptive Force in Orthopaedics.

Orthopaedics as a surgical discipline requires a combination of good clinical acumen, good surgical skill, a reasonable physical strength and most of all, good understanding of technology. The last few decades have seen rapid adoption of new technologies into orthopaedic practice, power tools, new implants, CAD-CAM design, 3-D printing, additive manufacturing just to name a few. The new disruption in orthopaedics in the current time and era is undoubtedly the advent of artificial intelligence and robotics. As these technologies take root and innovative applications continue to be incorporated into the main-stream orthopedics, as we know it today, it is imperative to look at and understand the basics of artificial intelligence and what work is being done in the field today. This article takes the form of a loosely structured narrative review and will introduce the reader to key concepts in the field of artificial intelligence as well as some of the directions in application of the same in orthopaedics. Some of the recent work has been summarised and we present our viewpoint at the conclusion as to why we must consider artificial intelligence as a disrupting positive influence on orthopaedic surgery.

Robotic-Assisted Knee Arthroplasty (RAKA): The Technique, the Technology and the Transition.

BACKGROUND: There has been an exponential increase in knee arthroplasty over the past 20 years. This has led to a quest for improvement in outcomes and patient satisfaction. While the last decade of last century proved to be the decade for Computer-Assisted Surgery (CAS) or Computer Navigation wherein the technology demonstrated a clear benefit in terms of improving mechanical axis alignment and component positioning, this decade is likely to belong to Robotics. Robotics adds an independent dimension to the benefits that CAS offers. The article deals with the generation of robots, technical steps in robotics, advantages and downsides of robotics and way forward in the field of knee arthroplasty. MATERIALS AND METHODS: The review article was designed and edited by six different authors reviewing 32 relevant pubmed-based articles related to robotics in arthroplasty and orthopaedics. The concept, design and the definition of the intellectual content were based on the internationally published literature and insightful articles. The review is also based on the clinical experimental studies published in the literature. DISCUSSION: The robotic arm is actively involved with surgeon to achieve the precision and outcomes that the surgeon aims for. With the concept of haptic boundaries and augmented reality being incorporated in most systems, Robotic Assisted Arthroplasty (RAA) is likely to offer several advantages. The potential advantages of these systems may include accuracy in gap balancing, component positioning, minimal bone resection, reduced soft tissue handling and trauma, patient anatomy specific resection, and real time feedback. They, however, come with their own downsides in terms of capital cost, learning curve, time consumption and unclear advantages in term of long-term clinical outcomes. CONCLUSION: To conclude, this review article offers a balanced view on how the technology is impacting current arthroplasty practice and what can be expected in coming years. The commitment of almost all major implant manufacturers in investing in robotics likely means that the evolution of Robotic technology and this decade will be exciting with rapid strides revealing paradigm shift and evolution of technology with significant reductions of cost enabling it to be available universally. For technology to populate in operating room, I think it will be result of exposure of young surgeons to these computers and robotics, as they grow in with confidence with technology from residency days to offer better precision in future.

Musculoskeletal modeling to predict and reduce Antetrior Cruciate Ligament injury during single leg drop jump activity: Synergistic muscle co-activation approach.

This paper presents a `drop jump' modeling to study the effect of synergistic muscle activation on controlling Anterior Cruciate Ligament (ACL) injury. ACL injuries are mostly caused during high impact loading. A full body musculoskeletal model with knee ligaments have been developed in `OpenSim platform' to simulate ACL injury during drop jump activity. The model is used to quantify the effect of change in muscle activation on different kinetic and kinematic parameters, which are associated with ACL injury. A neuromusculoskeletal controller have been designed which selects optimal muscle activation of Quadriceps, Hamstrings, Gastrocnemius and Tibilias anterior muscle group so as to reduce the chance of ACL injury and ankle inversion risk while jumping from elevated platforms. The OpenSim model along with the neuro-muscular controller forms an injury `predict-adapt' system, which can be useful in designing specific training sessions for athletics or for planning personalized rehabilitation therapy.

Radiologic assessment of femoral and tibial tunnel placement based on anatomic landmarks in arthroscopic single bundle anterior cruciate ligament reconstruction.

BACKGROUND: Accurate tibial and femoral tunnel placement has a significant effect on outcomes after anterior cruciate ligament reconstruction (ACLR). Postoperative radiographs provide a reliable and valid way for the assessment of anatomical tunnel placement after ACLR. The aim of this study was to examine the radiographic location of tibial and femoral tunnels in patients who underwent arthroscopic ACLR using anatomic landmarks. Patients who underwent arthroscopic ACLR from January 2014 to March 2016 were included in this retrospective cohort study. MATERIALS AND METHODS: 45 patients who underwent arthroscopic ACLR, postoperative radiographs were studied. Femoral and tibial tunnel positions on sagittal and coronal radiographic views, graft impingement, and femoral roof angle were measured. Radiological parameters were summarized as mean ± standard deviation and proportions as applicable. Interobserver agreement was measured using intraclass correlation coefficient. RESULTS: The position of the tibial tunnel was found to be at an average of 35.1% ± 7.4% posterior from the anterior edge of the tibia. The femoral tunnel was found at an average of 30% ± 1% anterior to the posterior femoral cortex along the Blumensaat's line. Radiographic impingement was found in 34% of the patients. The roof angle averaged 34.3° ± 4.3°. The position of the tibial tunnel was found at an average of 44.16% ± 3.98% from the medial edge of the tibial plateau. The coronal tibial tunnel angle averaged 67.5° ± 8.9°. The coronal angle of the femoral tunnel averaged 41.9° ± 8.5°. CONCLUSIONS: The femoral and tibial tunnel placements correlated well with anatomic landmarks except for radiographic impingement which was present in 34% of the patients.

Unusual presentation of a radial neck fracture in a child.

Fracture of the radial neck are uncommon injuries. In children, they may present as radial neck fractures, a components of forearm fracture dislocations, or as isolated fracture dislocations. Here, we present an unusual and previously undescribed variant of radial neck fracture with dislocation of the radial head to the medial side and ulnar nerve injury. The fracture dislocation was openly reduced and fixed with a small fragment plate. The fracture healed with some loss of rotational movements. At short followup of 6 months patient had useful elbow function but ulnar nerve did not recover.

Asymmetrical Fracture Dislocation of Shoulder - A Case Report and Review of Literature.

INTRODUCTION: A bilateral shoulder dislocation is an extremely rare injury with only a few reported cases in English literature, and most of these cases have occurred following a seizure episode or an electric shock. We present the first ever reported case of simultaneous bilateral anterior and posterior fracture dislocation of shoulders and its unique mechanism of injury in a 48 year old diabetic male. CASE REPORT: A 48 year old male presented to our emergency department with pain and restriction of movements involving both shoulders following a fall. The patient was standing by the side of a two wheeler when he had a sudden syncopal attack and toppled on the other side of the vehicle. On examination there was flattening of deltoid contour with a positive Dugas test in both sides. Humeral head was palpable posteriorly on the right side and anteriorly on the left side. Plain radiograph anteroposterior view of both shoulders showed posterior dislocation of right shoulder with a fracture of greater tuberosity and anterior dislocation of left shoulder with a greater tuberosity fracture. Closed reduction was achieved for both shoulders under general anaesthesia. After a couple of weeks, complete range of motion exercises was started. X-ray of bilateral shoulders, at 3 months, showed complete union of the fracture. CONCLUSION: Bilateral shoulder dislocation is suspected only following a violent mechanism of injury, however, we would like to point out, giving an example of our case that this injury may also occur after a trivial fall. And if associated with a fracture sometimes, the characteristic attitude of the limb may not be seen leading to a missed diagnosis. However a thorough clinical examination and the knowledge that such injuries may occur after a simple fall will help prevent missing these injuries.

Serum Procalcitonin is a sensitive and specific marker in the diagnosis of septic arthritis and acute osteomyelitis.

BACKGROUND: Early diagnosis of Acute Osteomyelitis (OM) and Septic Arthritis (SA) is of vital importance to avoid devastating complications. There is no single laboratory marker which is sensitive and specific in diagnosing these infections accurately. Total Count, ESR and CRP are not specific as they can also be elevated in non pyogenic causes of inflammation. Pus Culture and sensitivity is not a true gold standard due to its varied positivity rates (40 - 70%). Serum Procalcitonin (PCT), at 0.5 ng/ml is found to be an accurate marker for pyogenic infections. The objectives of this study were to show that PCT is an accurate marker in differentiating Acute Osteomyelitis and Septic Arthritis from viral and non infective inflammatory bone and joint conditions. METHODS: Patients of all age groups (n = 82) with suspected Acute Osteomyelitis and Septic Arthritis were prospectively included in this study. All patients were subjected to TC, CRP, PCT, IgM Dengue, IgM Chikungunya, pus and blood culture and sensitivity. At the end of the study, patients were classified into 3 groups: Group 1 = Confirmed Pyogenic (n = 27); Group 2 = Presumed Pyogenic (n = 21); Group 3 = Non - infective inflammatory (n = 34). RESULTS: Group 1 has higher mean PCT levels than Group 2 and 3 (p < 0.05). PCT, at 0.4 ng/ml, was 85.2% sensitive and 87.3% specific in diagnosing Septic Arthritis and Acute Osteomyelitis. In comparison, PCT at conventional cut - off of 0.5 ng/ml is 66.7% sensitive and 91% specific. CONCLUSION: Serum Procalcitonin, at a cut - off of 0.4 ng/ml, is a sensitive and specific marker in the diagnosis of Septic Arthritis and Acute Osteomyelitis.

Radiolunate coalition: a case report and literature review.

Radiolunate coalition is a very rare entity and was never reported before. we herein describe a case of congenital non-syndromic radiolunate coalition in a 30 year old male with a brief review of literature. we have also suggested a modification to Minaar's classification for carpal coalition.

Orthopaedic surgeons and the device industry: skeletons in the closet.

The relationship between orthopaedic surgeons and the device industry is one that is mutually beneficial and productive. However there are skeletons in the closet. The financial implications of this relationship have come under intense scrutiny. The sponsorships and the financial benefits of this symbiotic relationship have been found to cross the boundaries considered acceptable to ethical practice of the profession. In India, the ethical transgressions resulting from unhealthy associations between the orthopaedic surgeon and the industry have yet to be given due importance. Adequate rules and regulations are yet to be enforced and self-regulation is practically non-existent. It is essential to deal with the problem and potential implications that can arise from this kind of misconduct at the organisational level and enforce them for compliance.

Diplomate of the National Board: inefficient parallel education.

The National Board of Examinations conducts the Diplomate of the National Board in broad specialities as well as in core super specialities. The programme was meant to provide a common standard and a mechanism of evaluation the These programmes, as per the prospectus of the DNB course are meant to provide the basic level ofcompetence required for the postgraduate qualification in that subject. However, it has failed to meet these objectives. It is imperative to re-examine and revamp the system to improve its credibility and acceptability at both the national and international levels.