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.

Current Evidence and Expert Opinion on Thromboprophylaxis After Total Knee and Hip Replacement.

An effective anticoagulant provides a balance between the risk for venous thromboembolism (VTE) and bleeding and is crucial in achieving optimal clinical outcomes in patients undergoing total hip replacement (THR) and total knee replacement (TKR) surgeries. We performed a review of the literature on thromboprophylaxis for patients undergoing total hip or knee replacement. This review article summarizes current guidelines and evidence for anticoagulation along with the expert opinion about pharmacological VTE prophylaxis, particularly non-Vitamin K antagonist oral anticoagulants (NOACs), for patients after total hip or knee replacement. Aspirin for VTE prophylaxis after TKR/THR has been controversial and most of the evidence is reported from observational research. Although the guidelines do not recommend any specific thromboprophylaxis agent, available evidence suggests that NOACs are as effective as low molecular weight heparins (LMWHs) in preventing VTE. Oral administration and the lack of dose monitoring make NOACs easy to use in outpatient settings in cases with challenging treatment compliances. They can be used for two weeks after TKR and five weeks after THR - six weeks after TKR and THR to cover the at-risk period for VTE post-discharge. Owing to the lack of evidence for a head-to-head comparison of NOACs, an anticoagulant with better efficacy and safety may be suggested in special patient populations (elderly, obese patients, or those with renal dysfunction). The expert opinion on pharmacological VTE prophylaxis provided in this article could address some gaps in the management of anticoagulation in patients with total hip or knee replacement.

Expert Consensus on Best Practices for Optimal Wound Closure in Total Knee Arthroplasty: A STRIDE Initiative for Orthopedic Surgeons of India.

Background: Wound closure in joint replacement surgeries is crucial for postoperative rehabilitation. Despite substantial advances in total knee arthroplasty (TKA), no guidelines/recommendation or consensus practice statement available internationally or nationally around the optimal method of wound closure. The study aimed to develop evidence-based consensus on current practices, and proposed adoption of advanced wound closure initiatives. Methods: From Nov 2020 to Jan 2021, a group of 12 leading orthopedic surgeons from India met virtually under the Success in Total joint replacement through Recommendation In wounD closure (STRIDE) initiative. Expert committee used Delphi method to evaluate definitional statements that were identified through a comprehensive review of the published literature. Over three rounds of iterative voting, revision, and exclusion, the expert panel provided recommendations based on their clinical expertise and scientific evidence. Statements that reached ≥ 80% agreement was considered as "consensus". A survey poll was conducted following each round to add or suggest changes to the statements. Results: General recommendations include marking the arthrotomy before incision, placing the knee in flexion (less than 90°) for re-approximation during arthrotomy closure. The barbed suture can be a good alternative to traditional sutures for providing water-tight capsule closure and topical skin adhesives (TSAs) to staples for minimizing hospital visits and improving patient satisfaction. Conclusion: This consensus provides interim guidance and practical references to orthopedic surgeons of India enabling easy access to evidence-based healthcare solutions for TKA wound closure. These recommendations need to be periodically reviewed in light of emerging evidence.

Dimensional accuracy and details of the panoramic cross-sectional tomographic images: an in vitro study.

INTRODUCTION: Transversal slicing system (TSS) of Planmeca PM 2002 CC is a tomographic technique which enables us to take cross-sectional views of jaws. Tomographic imaging modalities are commonly applied to acquire cross-sectional images of the jaws for preimplant assessment of bone. Among the available tomographic imaging modalities, panoramic radiography is the most accessible imaging system. MATERIALS AND METHODS: Study was conducted using 25 mandibles, out of these five were used for linear dimensional accuracy measurement and the rest 20 were utilized to study the details within the mandible. Study was aimed to evaluate dimensional stability in the images using different parameters, such as determination of direction of slice, determination of horizontal and vertical magnification, angular distortion, three dimensional distortion and determination of details. RESULTS: For the direction of slice and for determination of horizontal and vertical magnification change in + 5º to - 5º was in acceptable limit. In determination of details, it was found that there was great discrepancy in readings given by nonradiologist which offset the mean value which was attributed to lack of training for interpretation of the observers. CONCLUSION: 99% of the readings were in the clinically acceptable limits. CLINICAL SIGNIFICANCE: The easy availability, use of routine equipment, the low cost, low radiation dose for cross-sectional radiography make the TSS most preferred modality.

Periprosthetic femoral fracture after a well-fixed revision total knee arthroplasty treated with in situ effective lengthening of prosthesis.

The increasing number of total knee arthroplasties implies a greater likelihood of periprosthetic fractures and need for successful treatment options. We report a case where in situ effective lengthening of the stem of a well-fixed indwelling prosthesis by a custom-made intramedullary nail with taper-lock coupling provided a successful alternative to the established internal fixation techniques involving prosthesis exchange. We believe that effective lengthening of indwelling prosthesis by a custom-made intramedullary nail is an effective option for treating periprosthetic femoral fractures in selected cases, where an attempt of removing well-fixed implant would result in unacceptable bone loss at the joint level.

Thromboprophylaxis with dabigatran after total hip arthroplasty in Indian patients: A subanalysis of a double-blind, double-dummy, randomized RE-NOVATE II study.

OBJECTIVE: In the Re-NOVATE II study, oral dabigatran provided thromboprophylaxis after total hip arthroplasty and improved compliance postdischarge in a global population. This article aims to identify trends (if any) in the Indian population. METHODS: In this prospective, double-blind, double-dummy study, patients scheduled for primary, unilateral, elective total hip arthroplasty were randomized to 220 mg oral dabigatran once daily, starting with a 110 mg half-dose, 1-4 hours after surgery, or subcutaneous enoxaparin 40 mg once daily, starting the evening before surgery. Each group received a placebo of the other study drug. The primary efficacy outcome was the composite of total venous thromboembolism (VTE) and all-cause mortality. Secondary outcome measures were composite of major VTE and VTE-related mortality during the treatment period. The major safety outcome was incidence of bleeding events. RESULTS: Of the 179 Indian patients randomized, 91 received oral dabigatran and 88 received subcutaneous enoxaparin for 28-35 days. Total VTE and all-cause mortality occurred in 18.7% of patients in the dabigatran group and 13.7% in the enoxaparin group [odds ratio = 1.4 (95% confidence interval 0.6, 3.5)]. Major VTE and VTE-related mortality was numerically lower in the dabigatran group (7.9%) compared with the enoxaparin group (9.9%). Safety outcomes were comparable between both groups. CONCLUSION: Dabigatran is an effective oral alternative to enoxaparin for thromboprophylaxis as demonstrated by the RE-NOVATE II study global results. Data analyzed in Indian patients indicate comparable effects of dabigatran etexilate for major efficacy and safety outcomes.

Adenomatoid Odontogenic Tumor (AOT) Arising from a Dentigerous Cyst: Literature Review and Report of a Case.

Adenomatoid odontogenic tumor (AOT) is an uncommon benign tumor of odontogenic origin composed of odontogenic epithelium in a variety of histopathological patterns. These lesions are usually solid but are occasionally cystic. AOT has been reported to occur in association with odontogenic cysts. Very few cases have been described that arise in association with a dentigerous cyst. A systematic search of the English-language medical literature in PubMed and Medline search (keywords adenomatoid odontogenic tumor, dentigerous cyst) data bases revealed only ten such cases. The present case is very unique, exceptional and first of this kind that occurred in the posterior mandible associated with an impacted lower first premolar in a 19-year old female patient. The intraosseous follicular AOT, as this case reported here, frequently resemble dentigerous cysts. There is an uncertainty whether the lining of an associated cyst represents a true dentigerous cyst, cystic change within an AOT or may represent a distinct entity. We believe that this case represents an odontogenic cyst with neoplastic change. Hence, in such cases, the final diagnosis should be made on the basis of histological examination of extensive tissue sampling of entire excised tissue specimen. Further studies to determine whether the AOT derived from an odontogenic cyst could represent a distinct variant are to be done.

Bony fusion of the maxilla and mandible as a sequelae of noma: A rare case report.

Noma is a gangrenous disease of the orofacial region that leads to severe facial tissue destruction and is a significant cause of death among children. With the advent of modern antibiotics and improved nutrition, children with noma may survive into adulthood, but must face the challenge of undergoing repair of the sequelae of noma. This report describes a case of bony fusion of the maxilla and mandible in a 28-year-old female patient, which was a sequelae of a childhood case of noma.

A randomized placebo-controlled trial of the efficacy of denosumab in Indian postmenopausal women with osteoporosis.

INTRODUCTION: Osteoporosis is a serious condition affecting up to 50% of Indian postmenopausal women. Denosumab reduces bone resorption by targeting the receptor activator of nuclear factor-κB ligand. This study assessed the efficacy and safety of denosumab in Indian postmenopausal women with osteoporosis. MATERIALS AND METHODS: In this double-blind, multicenter, phase 3 study, 250 Indian postmenopausal women aged 55 to 75 years (T-score <-2.5 and >-4.0 at the lumbar spine or total hip; serum 25(OH) D levels ≥20 ng/mL) were randomized to receive one subcutaneous dose of denosumab 60 mg or placebo. All subjects received oral calcium ≥1000 mg and vitamin D3 ≥ 400 IU daily. The primary end point was mean percent change in bone mineral density (BMD) at the lumbar spine from baseline to Month 6. Secondary end points included mean percent change from baseline in BMD at total hip, femoral neck, and trochanter at Month 6 and median percent change from baseline in bone turnover markers at Months 1, 3, and 6. RESULTS: Total 225 subjects (denosumab = 111, placebo = 114) completed the six-month study. Baseline demographics were similar between groups. A 3.1% (95% confidence interval, 1.9%, 4.2%) increase favoring denosumab versus placebo was seen for the primary end point (P < 0.0001). Denosumab demonstrated a significant treatment benefit over placebo for the secondary end points. There were no fractures or withdrawals due to adverse events. CONCLUSIONS: Consistent with results from studies conducted in other parts of the world, denosumab was well tolerated and effective in increasing BMD and decreasing bone turnover markers over a six-month period in Indian postmenopausal women.

Arthroplasty in young adults: options, techniques, trends, and results.

Total knee arthroplasty (TKA) has been established as a very successful and commonly performed procedure for primary and secondary osteoarthritis, and also for inflammatory arthropathies of the knee in all age groups and both genders. It has predominantly been used as a procedure in the age group of patients 65 years and above. Consequently, the literature is replete with data relevant to various issues associated with TKA in the above 65 years age group population. Although there is reasonable clarity and consensus on the broad parameters of the use of TKA in the above 65 years age group (older), this cannot be said for the same issue as relevant to the below 65 years age group (young adults). Over the last 2 decades there has been an increasing tendency toward the use of TKA in young adults, with some countries reporting a 5-fold increase in the last 10 years [1]. The present article is designed to review the most recent literature specific to this subject and assess it vis-à-vis various issues as listed in the subsequent text, with the aim of highlighting evolving thoughts and trends, which could be useful for decision making by clinicians practicing in the community.

Range of movements of lower limb joints in cross-legged sitting posture.

Cross-legged sitting posture is integral to activities of daily living in Eastern and Asian cultures. This posture has not been studied or defined in any significant detail from an orthopedic view point. The movements of right lower limb joints were measured in cross-legged sitting posture in 44 volunteers from the Indian population with no prior history of problems related to the knee or hip joint. Flexion at the hip joint ranged from 82 degrees to 100 degrees , with a mean of 91 degrees . Abduction at the hip joint ranged from 19 degrees to 57 degrees , with a mean of 39 degrees . The external rotation ranged from 42 degrees to 58 degrees , with a mean of 49 degrees . Flexion at the knee ranged from 126 degrees to 142 degrees , with a mean of 135 degrees . Equinus at the ankle ranged from 17 degrees to 34 degrees , with a mean of 29 degrees . The resultant data would be useful in understanding kinematics of the knee and hip in the healthy and post-total joint arthroplasty population. The data could be used for design features of prosthetic joints, surgical technique, and rehabilitation protocols. Such data have not been available hitherto in any relevant published literature.