Search

BACKGROUND: Infrapatellar branch of the saphenous nerve lies subcutaneously and supplies the anterolateral aspect of knee below the patella. It is extremely susceptible to iatrogenic injuries during the surgeries around the knee, mainly total knee replacements (TKRs). Post operatively the patients present with localised area of numbness and in some instances a traumatic eczematous reaction termed autonomous denervation dermatitis (ADD) is witnessed, leading to skin manifestations that range from a simple rash to extensive lesions. METHODOLOGY: A review of literature was conducted with search of relevant articles from Medline (PubMed), Embase, and Scopus which discussed eczematous skin lesions secondary to total knee replacements. Additionally, we noted studies which described these lesions in other surgeries around the knee like arthroscopies and fracture fixations. RESULTS: Eight studies including atleast one case after TKR were reviewed. There was only one cohort study while the remaining included case reports and small case series. There were 69 cases of ADD appearing after TKR. The appearance of the skin lesions was lateral to the incision in 30/34 operated knees and on both sides of the incision in four knees after TKRs. Bilateral lesions were seen in only six patients of TKRs. There was no functional limitation caused by these lesions and they resolved either spontaneously or after using topical steroids. CONCLUSION: ADD is a relatively uncommonly reported complication of TKRs, which can reduce patient satisfaction and increase surgeon apprehension. Although all cases of nerve damage do not manifest as cutaneous lesions, steps to minimise the damage to the nerve intra operatively should be taken. The diagnosis requires a high index of suspicion, and should not be dispelled as a simple allergic reaction without adequate investigations. Patients should be counselled to alleviate unnecessary fear and apprehensions.

Background The second wave of SARS-CoV-2 pandemic has posed new challenges in the management of Orthopedic trauma patients due to the overburdened healthcare facilities and we aim to present the differences in demographics between the first wave and the initial part of the second wave. Methodology This study was a retrospective cross-sectional study of our trauma registry from June 19, 2020 to October 13, 2020 (1st study period) and from April 1, 2021 to the first week of May 2021 (2nd study period). We looked into differences in the following three parameters: (1) infection rate among Orthopaedic patients in the first and second study period of SARS-CoV-2 pandemic, (2) infection rate among the Health Care Workers and (3) hospital-acquired SARS-CoV-2 infections in admitted Orthopaedic trauma patients. Results 35 out of 852 patients (4.1%) were positive for SARS-CoV-2 infection in 1st study period as compared to 48 out of 262 patients (18.3%) in the 2nd study period (p

Involvement of toe phalanges by giant cell tumor (GCT) is extremely rare; tumors in these locations tend to be aggressive. Whereas aggressive GCTs of the distal phalanx may be managed successfully by en-bloc resection without reconstruction or amputation, management of these lesions, when they involve the proximal phalanx, can be challenging. We present a Campannaci grade III GCT of the hallucal proximal phalanx in a 14-year old girl that had breached into the dorsal soft tissues and the metatarso-phalangeal joint. Wide local resection of the proximal phalanx along with reconstruction arthrodesis with an autologous, non-vascularized fibular strut graft was performed. There was no recurrence at 3 years of follow-up. The patient had an excellent functional outcome. To the best of our knowledge, this is the first case reporting the outcomes of fibular strut arthrodesis for salvage of GCT of the hallucal proximal phalanx.

CLS Spotorno is a time-tested femoral stem design with excellent early results; the present review was designed to assess the published evidence on CLS Spotorno stem in the literature to evaluate its long-term outcomes and compare it to two other popular stem designs the uncemented Corail™ and the cemented Exeter™ stems. Do CLS Spotorno stems provide adequate long-term rates of survival in terms of revisions and functional outcomes? Medline, EMBASE and SCOPUS databases were searched for relevant articles and a total number of 670 hits were obtained, out of which 14 relevant studies were included in this review. Pooled analysis of revisions rates, subsidence and Harris Hip scores (HHS) were done. All the 14 studies were retrospective in design but had sufficiently large follow-up periods (12.3–27 years, mean 17.1 years). Of the 2459 hips reviewed, the documented revision rate was only 6.2%, with aseptic loosening reported in 3.1% and subsidence > 2 mm in 2.6% cases. The overall survival was similar to reported smaller cohorts of Corail (95% at 12 years) and Exeter stems (100% at 17 years). Varus malposition was seen in 10.6% cases, but it did not show any influence on implant survival or revision rates. Distal pedestal formation was seen in 172 of 805 hips across seven studies, while distal cortical hypertrophy was seen in 70 cases out of 398 hips; these were not related with stem malposition. The overall functional outcome was good, with mean HHS of 88.65 (95% CI = 86.08–91.23, p

Background Regeneration potential of Hamstring tendons after harvest assumes significant clinical relevance as its use has become widespread today. Methods which best assess the regeneration, extent and type of regeneration, plus issues related to functional loss are important for the surgeon to know. This review looks at the literature to find answers to the above questions. Purpose To summarize the evidence in support of hamstring tendon regeneration, and the most appropriate modality for evaluation of regeneration. Additionally, to evaluate the regeneration in terms of complete or partial, extent and its impact on strength deficit and functional outcomes. Methods We did a systematic review of literature through specified search engines and identified 30 of 285 studies to be relevant (19 prospective and 11 retrospective). Results Evaluation of above data suggests tissue regeneration at harvest sites does occur (78.9% of semitendinosus and 42.7% of gracilis tendons), but this regeneration is variable. No established definition of regeneration exists; MRI is an adequate tool to identify regeneration, while biopsy is confirmative. USG is a cost-effective screening method and can document distal progress of regenerate. Semitendinosus and gracilis tendons regenerate at different rates and extents, and often fuse together, but there is no evidence to state that one regenerates better than the other. Proximal retraction of the muscle-tendon junction occurs, along with some atrophy, which affects function to a variable extent. Strength deficits may persist, but they may not convert to significant functional deficits. Conclusion There is variable hamstring regeneration after harvest, with poorly defined definition of “regeneration”. Some changes in the muscle itself, abnormal distal insertion and absence of regeneration in some are documented, along with strength deficits. Although overall functional deficits have been reported to be minimal, a definite change in the anatomy of the medial hamstrings is a factor to be kept in consideration. More information is needed about the long-term consequences.

Introduction: Patients who receive orthopedic implants have been shown to develop sensitivity to its components and there are concerns that this sensitivity might lead to contact dermatitis or implant-related problems like loosening and/or failure. The objective of the study was to determine the sensitizing potential of orthopedic implants. Methods: Fifty-four patients undergoing knee, hip, or shoulder replacement surgeries between July 2014 and July 2015 were recruited. Patch tests were performed before the implant surgery with 10 allergens likely to be implicated in metal hypersensitivity. Postimplant patch test was performed 6 months after surgery. A majority of the patch tests were applied on the arms. Results: Four positive reactions were recorded in the preimplant patch tests – three positive reactions to nickel and one to chromium. Thirty patients made themselves available for the follow-up patch test. The incidence of new contact sensitivity to components of implants was 13.8% (4/29) at 6 months. One patient who had undergone knee replacement developed eczematous lesions around the knee joint after surgery. This patient tested negative to patch test at both the times. Limitations: Short follow-up duration and performing patch tests on the arms, a site known to elicit less positive patch test response compared to the back in sensitized individuals, are limitations of the study. Conclusion: There is an increase in the sensitivity to implanted components after 6 months of joint replacement surgery. The incidence of new sensitivity to a component of the implant was 13.8% (4/29). In this context, nickel is a good sensitizer and could sensitize 50% of patients who received a nickel-containing implant.

Background Primary amputation below the level of the knee joint is the most frequently performed amputation following trauma; however, data about incidence, patient profiling, and causative factors are seldom available in India. Objective To evaluate the profile and incidence of trauma-related amputations below the level of the knee joint at a level 1 trauma center. Methods An observational study over six months was conducted at a level 1 trauma center of north India. Epidemiological data such as age, sex, occupation, socioeconomic status, mechanism of injury, time of surgery, single or staged procedure, and complications were recorded from the admission files. Observations 125/3047 (4.1%) trauma patients underwent amputation, of which 32.8% (41 of 125) had amputation below the level of the knee joint. Unilateral transtibial amputation was the most common (85.3%) involving 40/41 males with a mean age of 37.2 years of low socioeconomic status. Road traffic accidents were the most common cause (85.36% of cases). 39 of 41 cases presented within 24 h of injury and underwent surgery within 24 h of presentation. Secondary surgery was needed in 24.4% of the patients and revision amputation was done in only 2.4% (n = 1/41). No patient developed medical complications, and the average hospital stay was 8.7 days with a range from 2 to 14 days. Conclusion We have documented a significant amputation rate in trauma cases (4.1%) reflecting on the seriousness of patients seen at our center. Most patients are young males at the peak of their productive lives, and from low socioeconomic status. Road Safety is essential, and specialized services for the amputees may be the need of the hour.

Purpose The on-going COVID-19 pandemic has curtailed the established practice norms of many ailments including clubfoot. We conducted a survey to study the changes in the clubfoot treatment practices, Achilles tenotomy methods, and the role along with the possible impact of teleconsultation during this pandemic. Methods A web-based survey was conducted using a questionnaire prepared on Google forms. The link for this questionnaire was sent to Indian Orthopaedic specialists with a special interest in clubfoot management via a social messaging platform. Results 127 eligible responses were analysed. Of them, 67% respondents were in practice for more than 10 years. During the study period, 30.7% of doctors did not perform any casting; 66.9% performed casting in 1–5 cases per week and only 2.4% performed casting in more than five cases per week. A statistically significant difference was noted in the number of doctors who performed casting in less than five cases per week and the doctors who performed casting in more than five cases per week, before and during the COVID-19 pandemic. 30.7% of doctors deferred doing Achilles tenotomy during the study period, and among those who performed one, a significant number of them avoided tenotomy under general anaesthesia. Conclusion The COVID-19 pandemic has significantly impacted clubfoot treatment practices during the lockdown period in India. Significant reductions in the number of cases, and a reduction with changes in Achilles tenotomy practices were noted too. However, whether this had any adverse influence on the eventual outcome in these feet is yet to be determined. Electronic supplementary material The online version of this article (10.1007/s43465-020-00277-2) contains supplementary material, which is available to authorized users.

BACKGROUND: Orthopaedic residency training is a 3-year period of preparation that converts a raw medical student into a proficient orthopaedic surgeon. Due to wide variations at different centers in India, the program in a tertiary hospital is presented, in an attempt to improve the overall levels of training. MATERIALS AND METHODS: PGIMER has produced many good surgeons who are well settled across the country and the world. A survey of the postgraduates of the last 30 years was done to highlight the perceptions about the program. An overview of the program was also added to the narrative to highlight the positive aspects of the training. RESULTS: 132 Orthopaedic passed-out residents from PGIMER could be contacted. 97% of them rated their residency experience as excellent or good, and stated that they would recommend this program to new residents. Key points highlighted by them were the readiness of trainees for any surgical contingency after graduation, continuation of the mindset for research, and their prompt acceptability into their subsequent places of work due to their place of graduation. DISCUSSION: Converting an orthopaedic resident into a competent surgeon involves knowledge upgrades and impartation of skills; these are not limited to the theory of orthopaedics, but involve the thought processes and the planning as a surgeon, the attitude towards patient management, and a continuously inquisitive scientific mind. The shortcomings and strengths of the residency program in PGIMER are discussed; international standard methodology limited to this institute like formal log books, mentorship program, hands-on skill development through courses, etc. is something that is recommended to be mandatory in all residency programs. CONCLUSION: The PGIMER Orthopaedic residency program could act as a basic model for other Indian medical schools, with any appropriate modifications. Standardization of Orthopaedic residency programs could allow upgrading to International levels.

Historically, arthroscopy originated from the concept of cystoscopy, and was limited to use in the large joints, principally the knee. It is only the past 50 years that has led to the techniques being applied to the small joints of the foot and ankle, and the success has mirrored the development of better lens systems and smaller instruments. Although Watanabe pioneered arthroscopy as a whole, and initiated foot-and-ankle arthroscopy, it was the fine tuning of techniques for the ankle and subtalar joints by pioneers such as Van Dijk in Europe and Ferkel in USA, who combined their innovative techniques along with extensive teaching worldwide that lead to its acceptance in the current form. Although limited in scale, arthroscopy of the foot and ankle is currently practiced in many centers in India, with trained surgeons applying latest techniques at a few centers. The current status of arthroscopy is that it has allowed minimally invasive surgery in smaller and smaller joints, with a huge potential for expansion in the future.

Background A mysterious cluster outbreak of pneumonia in Wuhan, China in December 2019 was traced to Severe Acute Respiratory Syndrome Coronavirus 2 and declared a Pandemic by WHO on 11th March 2020. The pandemic has spread rapidly causing widespread devastation globally. Purpose This review provides a brief understanding of pathophysiology, clinical features, diagnosis and management of COVID-19 and highlights the current knowledge as well as best practices for orthopaedic surgeons. These are likely to change as knowledge and evidence is gained. Results Orthopaedic surgeons, like other front-line workers, carry the risk of getting infected during their practice, which as such is already substantially affected. Implementation of infection prevention and control as well as other safety measures for health care workers assumes great importance. All patients/visitors and staff visiting the hospital should be screened. Conservative treatment should be the first line of treatment except for those requiring urgent/emergent care. During lockdown all elective surgeries are to be withheld. All attempts should be made to reduce hospital visits and telemedicine is to be encouraged. Inpatient management of COVID-19 patients requires approval from concerned authorities. All patients being admitted to the hospital in and around containment zones should be tested for COVID-19. There are special considerations for anaesthesia with preference for regional anaesthesia. A separate Operation room with specific workflow should be dedicated for COVID-19 positive cases. Conclusions Despite the magnitude of challenge, the pandemic offers significant lessons for the orthopaedic surgeon who should seek the opportunity within the adversity and use this time wisely to achieve his/her Ikigai. Electronic supplementary material The online version of this article (10.1007/s43465-020-00135-1) contains supplementary material, which is available to authorized users.

The management of Osteoporotic ankle fractures is still considered to be a challenge by many surgeons. One of the issues seems to be a lack of data focused on this special subgroup, with very little evidence of good quality. We did a narrative review of the literature in an attempt to identify the magnitude of the problem and to evaluate the evidence in support of management options. The current review of the literature has brought to light some interesting facts. Despite limited data there seems to be an in increase in the incidence of these fractures. Although we could not demonstrate any clear distinction between geriatric and osteoporotic ankle fractures from the available literature; it is clear that all geriatric fractures are not necessarily osteoporotic and neither is the reverse true. The evidence to associate osteoporotic ankle fractures with poor outcomes is weak, and factors other than osteoporosis may have a stronger influence. From this analysis, we could not establish a higher incidence of implant failure for this specific fracture group, although many modifications in technique have been proposed due to the fear of fixation failure. Hook plating and Tibia-pro fibula fixation have weak evidence in support, but posterior fibular plating is preferred due to soft tissue protection. There is weak evidence in support of Locking plates for these fractures, as publications focused on this are limited; nevertheless some advantages have been documented. Augmentation by calcium based bone graft substitutes has been reported to improve pull out strengths of screws, but again the evidence of its role in Osteoportic fractures is limited. Fibular nailing has been proposed with specific advantages in osteoporotic fibular fractures, but the concept is new and it is indicated only in a select a subgroup of cases. Some evidence exists for the use of trans-articular nails in geriatric subgroups with limited pre-injury mobility, but the technique has to be used with caution to prevent other complications. Inference More data needs to be accumulated before clear guidelines for management of osteoporotic ankle factures are defined; however the current literature supports the need for modifications in standard ankle facture fixation methods to improve outcomes.

Lisfranc injuries may occur in the form of fracture-dislocations or pure ligamentous dislocations or subluxations. These innocuous appearing injuries have the potential for significant morbidity and long-term sequelae resulting in permanent deformities. Ligamentous subluxations account for 20% of these injuries and cases with partial incongruity are amenable to percutaneous fixation. In this article, we present step-by-step percutaneous fixation of these injuries as well as the post-operative management.

Calcaneus malunion is a common sequela to calcaneal fractures and is a cause of pain and discomfort. Multiple approaches have been described to address the subtalar joint and the lateral wall. Type 2 malunion is the most commonly encountered problem, and is usually addressed by the sinus tarsi approach. This has some limitations, as exposure for lateral wall excision beneath the peroneal tendons maybe a problem. We have slightly modified the sinus tarsi approach by a more horizontal skin incision, which may even be extended proximally by 1–2 cm; this allows access to the lateral wall on either side of the peroneal tendons. The approach is described in detail.

Background There are few studies in the literature that correlates the level of IL-6 with fat embolism syndrome (FES). But there is no conclusive correlative evidence of its specific relation to the establishment of FES. Also it is a proven fact that polytrauma due to its associated multiple long bone fracture and/or associated shock can predispose an individual to FES. By hypothesizing that polytrauma induces Fat Embolism in the animal; it was considered worthwhile to study the association of IL-6 in polytrauma induced Fat Embolism (FE) and to compare it with induced FE by injecting fatty acids in rabbits. Materials and methods An animal study was conducted in 32 New Zealand white rabbits. The animals were divided into 3 groups: control, fat embolism and polytrauma group. We injected 6 ml of normal saline and 0.2 ml of linoleic acid in the control and fat embolism group respectively. In the polytauma group we created bilateral femur and tibial shaft factures which were stabilized with intramedullary K- wires. Blood was taken before and at 6, 12 and 24 h after the procedure to measure plasma IL-6 levels. The rabbits were euthanized at 24 h and lungs were removed and stained for fat globules. Results All rabbits in the fat embolism group and around 72.22% rabbits in polytrauma group had fat embolism. The IL-6 levels were raised in all the groups reaching a peak at 6 h after procedure with a decline in the values at 12 h for polytrauma and fat embolism group. IL-6 in the control group was stationary after an initial raise at 6 h. There was no statistically significant difference seen among the groups (p value > 0.05) at 6 h. Conclusion IL-6 is not a specific marker to fat embolism per se or polytrauma who later develop complications like FES. Even though the recent literature says that IL-6 is an early marker of fat embolism, still the diagnosis of fat embolism syndrome is clinical only and can be supplemented by laboratory markers. None of the laboratory markers individually is good enough to predict the development of FES in an individual.

Background Owing to the coronavirus disease 2019 (COVID-19) pandemic, a nationwide lockdown was imposed in India, with strict confinement measures imposed on the elderly. Because mobility and regular physical activity are considered to be the key determinants of musculoskeletal health, this study aimed to investigate the effect of lockdown and confinement measures on the musculoskeletal health and activities of daily living of the urban geriatric population. Methodology A cross-sectional survey was conducted among the elderly aged ≥60 years. The survey instrument consisted of a questionnaire, a modified Nordic Musculoskeletal Questionnaire (mNMQ), and the Barthel activities of daily living (ADL) index. The net mNMQ score and Barthel ADL index were compared before and during the lockdown. Univariate and multivariate analyses were performed to determine which factors could result in the worsening of the net mNMQ score. In addition, floor and ceiling effects of the net mNMQ score were determined. Results In this study, a total of 105 out of 150 eligible participants were enrolled. A significant decline in physical activity status was noted during the lockdown. Overall, 54.3% of the respondents reported that their medical services were impacted during the lockdown. The net mNMQ score showed a significant worsening during the lockdown (P < 0.0001). A statistically significant increase in the modified NMQ score was noted for the lower limb (P < 0.0001) and spine (P = 0.002), but not for the upper limb (P = 0.052). Elderly whose medical services were impacted during lockdown had significantly worse net mNMQ scores than those whose services were not impacted (odds ratio = 6.16; 95% confidence interval = 2.51-15.08; P = 0.0001). Age, gender, ambulatory status, increase in body weight, and indulgence in exercise before and during lockdown had no effect on the change in the net mNMQ score. A significant ceiling effect was noted in the mNMQ score; however, no floor effect was noted. Conclusions Lockdown and confinement measures resulted in a significant decline in physical activity as well as the overall musculoskeletal health of the urban geriatric population in the present study. Hence, policymakers should ensure uninterrupted medical care to the elderly during extended periods of confinement and develop optimal home-based physical activity programs to counter the problems associated with sedentarism.

Introduction: Arthroscopic anterior cruciate ligament reconstruction (ACLR) is associated with moderate-to-severe postoperative pain which may delay hospital discharge as well as physiotherapy resulting in poor outcome. The aim of our study was to compare the effect of clonidine or fentanyl as adjuvant to bupivacaine in femoro-sciatic nerve block (FSNB) on the duration of pain-free period and requirement of rescue analgesic postoperatively. Materials and Methods: Sixty adult patients undergoing ACLR of the knee joint received subarachnoid block as anesthesia for surgery and FSNB for postoperative analgesia. Patients in Group C (control group) received 40 ml of 0.25% isobaric bupivacaine (20 ml in femoral and sciatic block each), whereas Group F (fentanyl group) received fentanyl (1 μg/kg) and Group CL (clonidine group) received clonidine (1 μg/kg) with 40 ml of 0.25% isobaric bupivacaine. The duration of pain-free period, rescue analgesic consumption, postoperative pain score, sedation levels and adverse effects were monitored along with hemodynamic parameters for 24 h postoperatively. Results: The patients in the clonidine group had longer pain-free period (10.06 ± 3.62 h) as compared to the fentanyl group (7.94 ± 3.62 h) and control group (4.59 ± 1.20 h) (P < 0.001). Postoperative pain scores were higher in the control group at the 4th, 8th, and 12th h and comparable between the fentanyl and clonidine groups. The total amount of rescue analgesic requirement was less in the clonidine group (71.25 ± 16.77 mg) than the fentanyl group (86.25 ± 36.71 mg) and control group (161.20 ± 50.34 mg) (P < 0.001). No clinically significant adverse effects were observed in any group. Conclusion: Clonidine as an adjuvant to bupivacaine in FSNB provides better postoperative analgesia compared to fentanyl by significantly prolonging the pain-free period and decreasing rescue analgesic requirement in postoperative period without any untoward side effect.

Calcaneus fractures are a complex injury. Since the calcaneus plays a key role in weight-bearing and gait cycle, rehabilitation after injury needs to be individualized, and a structured program needs to be implemented. The rehabilitation protocol also varies depending on the type of injury, the associated injuries, and the management of the injury itself, be it surgical or conservative. It is important to understand that mobilization starts much earlier than weight-bearing. The nonweight-bearing time period also differs from patient to patient as that too depends on the type of approach that has been taken to manage the injury. That being said, weight-bearing is very important to minimize reflex sympathetic dystrophy syndrome and osteopenia, so the patients should be encouraged to start weight-bearing as soon as possible. Protocols will differ between patients having bilateral and unilateral calcaneal fractures. The structuring of the rehabilitation program according to the patients’ needs is what is essential to ensure good outcomes and will determine the return to activity and work. Stress fractures are a unique problem, and periodization of rehabilitation is the key. How to cite this article: Adhya B, Dhillon H, Dhillon S, et al . Rehabilitation Protocols for Calcaneus Fractures. J Foot Ankle Surg (Asia Pacific) 2020;7(2):77–82.

Background Intramedullary nailing is the treatment of choice for shaft of femur fractures in adults. Antegrade nails involve entry through either piriformis fossa (PE) or greater trochanteric (GT) tip. The superiority of one entry point over the other is a matter of debate, and the present review was done to determine the same. Research question Is GT entry for antegrade femur nailing superior to the PE for shaft femur fractures in adults? Objective The present systematic review was conducted to determine the superiority of one entry point over the other by comparing the outcome parameters like operative time, exposure to fluoroscopy, mal-unions, non unions, abductor weakness, varus malalignment and Harris Hip scores (HHS). Methodology Three databases of PubMed, EMBASE and SCOPUS were searched for relevant articles that directly compared GT with PF for nailing in shaft femur fractures in adults. Results We analysed a total of 9 studies published between the years 2011 to 2017. There were 5 retrospective and 4 prospective studies out of which 3 were randomised. The total number of patients was 256 in GT group and 460 in PE group. Outcomes There was significant superiority of GT entry over PE on meta analysis; lesser operation time: standard mean difference (SMD): -21.01; lesser exposure to fluoroscopy : SMD: 36.36; lesser incidence of abductor weakness: Odd’s ratio (OR): 14.35; better functional outcome(HHS): SMD -2.48. Conclusion GT entry nails are superior to PE nails for treating shaft of femur fractures in adults. They have a shorter learning curve and better functional outcomes, however the rates of union are comparable in both.

The rising incidence of mangled extremity seen in modern trauma has lead to significant patient mortality. A lot of research is going on at microcellular level for a better understanding of tissue injury, repair and regeneration. PAX-7 is one such transcription factor, a marker of satellite stem cells in skeletal muscle. Though few studies have shown concrete evidence of increased expression of PAX-7 in the nearby injured zone in skeletal muscle post-injury, none has studied its expression in an event of mangled injury of limb in humans. We, hereby, attempted to identify whether PAX-7 expression of tissue near the zone of injury, after grievous trauma like mangled injury of extremities, actually increases, decreases or remains unaffected. A pilot study was conducted on 30 cases at a level 3 trauma centre; patients were segregated into two groups—group I with MESS score ≥ 7 and group II with score

Unstable intertrochanteric femoral fractures in the elderly require either fixation or joint sacrificing surgery; proximal femoral nail (PFN) and bipolar hemiarthroplasties (BPH) are the most common interventions. PFN is considered to be the ideal construct for these fractures; however, the usage of hemiarthroplasties to facilitate earlier mobilization has been on a rise. Currently there is no consensus on the superiority of one of these two techniques over the other and the present review was done to determine this. Is PFN a better alternative to BPH for unstable intertrochanteric femur fractures in the elderly? The present systematic review and meta-analysis was conducted to determine the superiority of PFN over BPH by comparing the primary outcomes like mortality, Harris Hip scores (HHS), complications, and re-operations. Additionally, secondary outcomes like blood loss, duration of surgery, and period of hospital stays were also compared. Three databases of PubMed, EMBASE, and SCOPUS were searched for relevant articles that directly compared PFN and BPH in unstable intertrochanteric femur fractures in the elderly. We analyzed a total of seven studies published between the years 2005 to 2017. There were four retrospective and three prospective randomized controlled studies. The number of patients in these studies ranged from 53 to 303. There was a significant difference in HHS between two groups with standard mean difference of − 0.51 (range − 0.67 to −0.36), favouring the PFN group. The rate of mortality was higher in the BPH group with odds ratio of 2.07 (range 1.40–3.08). Implant-related complications like fractures and subsidence were more in BPH group but this was not significant. Mean surgical time (standard mean difference 2.19) and blood loss (3.75) were significantly less in the PFN group. The duration of hospital stay was also found to be significantly less in the PFN group (2.66). Proximal femoral nails are superior to bipolar hemiarthroplasties for unstable intertrochanteric femoral fractures in the elderly. PFN imparts better functional outcomes and has lower rates of overall mortality. Additionally it is faster surgery, with lesser blood loss contributing to better results.

Introduction: Implant wear and loosening with eluding metal/polythene debris are commonly implicated in the occurrence of Baker’s cysts in post-operative total knee replacement (TKR) patients, who present with post-operative pain and swelling, mimicking deep venous thrombosis. However, we present two symptomatic cases presenting with ruptured Baker’s cysts post-TKRs, with no evidence of implant loosening or wear. Cases Report: The 1st patient was a 55-year-old male, who underwent TKR for Grade 4 bilateral knee osteoarthritis and presented with acute onset of pain and swelling over the left popliteal fossa, which progressed to involve the calf. Radiographs showed no sign of infection or loosening, and venous color Doppler and magnetic resonance imaging (MRI) showed a hy-poechoic collection in the intermuscular plane at the upper part of popliteal fossa. Histological examination of the aspirated fluid showed mixed features of cystic fluid and a resolving hematoma. There was complete resolution of the 4 months with rest and graduated physiotherapy. The 2nd patient was a 51-year-old female who developed the cystic swelling 2 years after the surgery, and the ultrasound showed hypoechoic echoes in a Baker’s cyst-like collection. Cytological findings were suggestive of hemorrhagic nature of the aspirate, without any evi-dence of polyethylene debris, and the cultures were sterile. She became asymptomatic over 4 weeks with conservative management; the swelling resolved after 3 months. Conclusion: Majority of the cases in literature show implant loosening as cause of popliteal cysts after TKRs, however present cases highlight alternative mechanisms, and there are good chances of self-resolution of cysts with conservative treatment in such cases. Keywords: Knee replacement, Baker’s cyst, deep vein thrombosis, ruptured popliteal cyst.

Three part and four-part fractures of the proximal humerus offer challenges in reduction and plate fixation, with considerable debate about use of Deltoid splitting (DS) and Delto-pectoral (DP) approaches, especially when they involving the greater tuberosity. We prospectively compared the results using DS approach and DP approach in these cases, with special focus on functional outcomes, complications, and ease of tuberosity reduction. 84 patients with three- and four-part proximal humerus fracture were alternately allocated the DP approach or DS approach for proximal humerus locking plate fixation. The outcome analysis was done by evaluating relative Constant score and ease of surgical reduction of greater tuberosity; radiological malunion was evaluated using Beredjiklian classification and complications were noted. At mean follow-up of 23 months (19–48 months), the mean ‘relative Constant score was 74.27 ± 8.19 in the DP group and 73.26 ± 8.02 in the DS group and the difference was statistically insignificant (p = 0.988). There was no significant difference with respect to shoulder ROM, abductor strength, radiological malunion or complications. However, the mean surgical time was significantly less (p value = 0.042) in DS group (65 ± 5 min) in comparison to DP group (92 ± 4.3 min); significantly less difficulties were documented by the surgeon in reducing the greater tuberosity in DS group(p value = 0.02). Although surgical time was reduced and greater tuberosity reduction was easier in DS group, the other outcomes were similar; either surgical approach can be used based, and can be based on the experience and comfort level of the surgeon.

Foot and ankle disorders and deformities are one of the common subsets of conditions encountered in the outpatient clinic. Understanding the basic anatomy is pivotal in diagnosing various conditions that arise in and around the foot and ankle. The tarsal kinematics are unique, and the clinician needs to be well-versed to understand normal and altered biomechanics resulting from various pathologies. As is rightly said, examination starts by observing the child walking into the clinic, and gait evaluation offers insights about the pathology and the compensations adapted. Head-to-toe examination is very important as the etiology may be distant, like a spinal dysraphism. Evaluation of each joint complex is important as every joint in the foot and ankle has a different action and function. A systematic approach to the foot and ankle as well as individual joints, such as the ankle joint, subtalar joint, midfoot, and forefoot, are important. The chapter discusses a systematic approach to narrow down possible presentations and pathologies around the foot and ankle.

Introduction: Orthopedic surgical procedures (OSPs) are known to generate bioaerosols, which could result in transmission of infectious diseases. Hence, this review was undertaken to analyse the available evidence on bioaerosols in OSPs, and their significance in COVID-19 transmission. Methods: A systematic review was conducted by searching the PubMed, EMBASE, Scopus, Cochrane Library, medRxiv, bioRxiv and Lancet preprint databases for studies on bioaerosols in OSPs. Random-effects metanalysis was conducted to determine pooled estimates of key bioaerosol characteristics. Risk of bias was assessed by the RoB-SPEO tool; overall strength of evidence was assessed by the GRADE approach. Results: 17 studies were included in the systematic review, and 6 in different sets of meta-analyses. The pooled estimate of particle density was 390.74 µg/m3, Total Particle Count, 6.08 × 106/m3, and Microbial Air Contamination, 8.08 CFU/m3. Small sized particles (

Introduction: The resident’s ridge is an arthroscopic landmark that is consistent with the anterior border of the anterior cruciate ligament (ACL) femoral attachment. The identification of the landmark allows for accurate graft placement. Case Report: We report a case of a 30-year athletic individual with an ACL-deficient knee, who had an abnormally large resident’s ridge, abutting the midsubstance of the torn ACL; the residual femoral attachment was behind the ridge. Resection and burring of this ridge were needed to expose the posterior aspect of the intercondylar notch; even after bone-patellar tendon-bone graft placement, some additional removal of bone had to be done to reduce graft impingement on this area in extension. Conclusion: Abnormal resident’s ridge may be misleading about the anatomy of the lateral femoral condyle area. Appropriate resection of abnormal bone is the key to the identification of femoral footprint and graft placement. We speculate that this bony projection may even have contributed to the ACL injury, and extra bone had to be removed to minimize subsequent impingement. Keywords: Anterior cruciate ligament reconstruction, resident’s ridge, knee arthroscopy, anterior cruciate ligament impingement, bone-patellar tendon-bone graft.

BACKGROUND: Hip arthroscopy is a minimally invasive technology for diagnostic and therapeutic interventions in various hip disorders. Over the past decade or so, the technology and understanding related to this surgery have improved by leaps and bounds; however, in India the overall pace has been limited. The present review highlights the status of hip arthroscopy in the Indian context. METHODOLOGY: A small survey with five questions related to practice of hip arthroscopy among Indian orthopaedic surgeons was conducted. Additionally a PubMed database search was conducted to recognise and assess studies pertaining to hip arthroscopy originating from India. RESULTS: Forty-two responses were received for the questionnaire, out of which 38 surgeons performed hip arthroscopy in their practice; the overall numbers were very low with only one respondent performing more than 50 surgeries in a year. For 84.2% of the respondents, the practice was limited to less than ten surgeries per year. 63.2% of the surgeons affirmed that there has been no change in their practice of hip arthroscopies over the past 5 years, signifying the slow growth and limited application of the technique. Only nine studies pertaining to the topic were available in the literature search, out of which five were case reports. The most common indication was removal of intraarticular foreign bodies, followed by joint debridement and lavage, synovial biopsies and femoroacetabular impingement (FAI). The outcomes in all the studies were satisfactory. CONCLUSION: Hip arthroscopy is in its nascent stages in India and much is still needed to be done for better implementation of the technique on a wider scale. Adequate training and continued medical education programme, with exposure to the experts in the field, will go a long way in better utilisation of the surgery in India.

Introduction COVID-19 has emerged as a medical threat to mankind, with a serious disruption of lifestyle in 2020. This has not only changed the way we live and work but has also changed the pattern of hospital admissions and medical care. To see if there was significant change in the pattern and management of trauma in our region, we evaluated data from our centre for the lockdown period and compared it with data from the previous year, and also with some available international data. Methods We collated data from our Tertiary care hospital for two periods, i.e. from 25th March 2020 to 3rd May 2020 signifying strict lockdown and then from 4th May to 31st May during which some conditional relaxations were given. This was compared to data from similar periods in 2019. We looked at patient demographics, fracture types, injury mechanisms, and even changes in treatment protocols. Results Significant reductions in caseloads were noted; open injuries were less, road accidents were infrequent, but cases due to falls, especially children and the elderly were still seen, although slightly reduced. The plan to minimize operative interventions could not be fully implemented due to complex nature of trauma seen by us. Only one case of bilateral amputation turned out to be positive, with no infectious consequences to the treating staff. Conclusions COVID-19 pandemic led to significant reductions in trauma caseload and change in injury patterns. Doctor responses and patient management needs significant alteration to prevent spread of disease.

Background: With increasing geriatric patient population worldwide, hip fracture exists as a major health-care issue with its high mortality, morbidity, and financial liability. Anesthetists play a very important role in the perioperative care of these patients. Methods: The present study was a prospective observational study and was registered prospectively in the clinical trials registry- India (CTRI) with registration number of CTRI/2018/03/012853. Duration of study was from August 2017 to November 2018. Results: A maximum of (n=43) patients had a mobility scale of 7 at 30 days. (n=46) had a mobility scale of 6 at 60 days. Bimodal peaks were seen at 90 days with (n=27) had a mobility scale of 4 and (n=28) had a mobility score of 6 at 90 days. The median mobility score was 7(7-9), 6(6-7), 4.5(4-6) at 30, 60 and 90 day postoperatively. Keywords: Outcome, Neck, Femur.

Background: Pressure ulcer (PU) is one of the common, neglected and avoidable complications among bedridden patients. Despite the potential to reduce PU incidence, the evidence on the effect of patient/caregiver education is low. This pragmatic randomized controlled trial (CTRI/2011/07/001862) compared the impact of two structured educational interventions to patients and caregivers on prevention of PU in immobile orthopaedic patients. Methodology: Ninety-two orthopedically immobile patients (Braden score ≤12 or stage I PU) and their caregivers were (block) randomized into two equal groups. One group was offered Prevention Package 1 (PP1), i.e., self-instruction manual (SIM), one to one training and counselling on PU care practices. The second group (PP2) was given SIM only. Patients were followed equally at the hospital and home after discharge. Intention to treat analysis was conducted. Results: The cumulative incidence of PU was 8.7% in PP1 and 21.7% in PP2 for the entire study period. PU incidence rate in PP1 and PP2 was 0.9 and 2.41 per 1000 person-days, respectively. Incidence rate ratio was 2.67 (95% CI: 0.89, 8.02, p-0.04). The Kaplan-Meier survival curves of PP1 and PP2 were statistically significantly different (p-0.043). PP1 also showed statistically significant improvement in knowledge on the prevention and management of PU compared to PP2 at post-intervention (p < 0.001). Conclusion: Individualized, structured education of patients and caregiver is effective in improving the knowledge and preventing the PU in immobile orthopaedic patients. A comprehensive approach involving hospital administrators, health care professionals, patients and caregivers may be further researched upon for a sustainable reduction in PU.

INTRODUCTION: Ideal surgical positioning and placement of implants during arthroplasty are crucial for long-term survival and optimal functional outcomes. Inadequate bone stock or defects, and anatomical variations can influence the outcomes. Three-dimensional printing (3DP) is an evolving technology that could provide patient-specific instrumentation and implants for arthroplasty, taking into account anatomical variations and defects. However, its application in this field is still not adequately studied and described. The present review was conceptualised to assess the practicality, the pros and cons and the current status of usage of 3DP in the field of hip and knee arthroplasties and joint reconstruction surgeries. METHODS: A PubMed database search was conducted and a total number of 135 hits were obtained, out of which only 30 articles were relevant. These 30 studies were assessed to obtain the qualitative evidence of the applicability and the current status of 3D printing in arthroplasty. RESULTS: Currently, 3DP is used for preoperative planning with 3D models, to assess bone defects and anatomy, to determine the appropriate cuts and to develop patient-specific instrumentation and implants (cages, liners, tibial base plates, femoral stem). Its models can be used for teaching and training young surgeons, as well as patient education regarding the surgical complexities. The outcomes of using customised instrumentations and implants have been promising and 3D printing can evolve into routine practice in the years to come. CONCLUSION: 3D printing in arthroplasty is an evolving field with promising results; however, current evidence is insufficient to determine significant advantages that can be termed cost effective and readily available.

BackgroundOrthopedic surgical procedures involve a number of aerosol generating procedures; these include electrocautery, power instruments for bone cutting, burring and drilling, and tools for wound lavage. This assumes a great significance in the context of the current COVD-19 pandemic, as there are chances of aerosol-borne disease transmission in orthopedic surgical procedures. Hence, this systematic review and meta-analysis will be undertaken to assimilate and analyse the available evidence on bioaerosols in orthopedic surgical procedures and their significance with respect to SARS-CoV-2 virus transmission.ObjectivesTo determine the characteristics (amount and/or density, size, infectivity, and spread etc.) of bioaerosols found in orthopaedic operating rooms (ORs) and to determine the characteristics of aerosols generated by different orthopaedic power tools and devices.MethodsA systematic review and meta-analysis will be conducted. The PRISMA guidelines will be strictly followed. The primary search will be conducted on the PubMed, EMBASE, Scopus, Cochrane Library, medRxiv, bioRxix and Lancet preprint databases, using a well-defined search strategy. Any original research study (including cohort, case-control, case series, cadaveric studies and studies, animal models, laboratory based experimental studies) looking at aerosol generation in orthopedic surgical procedures, or aerosol generation by orthopaedic power tools and devices will included. Outcome measures will include characteristics (amount and/or density, size, infectivity, and spread etc.) of bioaerosols found in orthopaedic operating rooms (ORs) and those generated by various orthopaedics power tools and devices. Metanalysis using the random-effects model will be conducted to determined pooled estimates of the outcome variables. Heterogeneity will be assessed by the I2 test. Risk of bias will be assessed by the Risk of Bias in Studies estimating Prevalence of Exposure to Occupational risk factors (RoB-SPEO) tool. The overall strength of evidence will be assessed by the GRADE approach.

Head preserving modalities in avascular necrosis (AVN) hip are variably effective in early stages, and further options that could prevent head distortion and osteoarthritis are needed. Core decompression (CD) is the most commonly used surgery in the early stages of osteonecrosis with variable rates of success. The present review aimed to determine the effectiveness of bone marrow aspirate concentrate (BMAC), platelet-rich plasma (PRP), bone morphogenetic proteins (BMP) or their combination with CD in early stages of AVN hip, prior to collapse of femoral head. Additionally, any newer unexplored modalities were also searched for and ascertained. PubMed and SCOPUS databases were searched for relevant articles in English language describing CD with aforementioned orthobiologics. We analysed a total of 20 studies published between 2011 and 2020. There were 6 retrospective and 14 prospective studies. PRP showed improved survival and functional outcomes; however, with only three studies, there is inconclusive evidence for its routine utilization. BMAC enhances the efficacy of CD which can further be increased by culture and expansion of cells or combining it with PRP to stimulate growth. In conclusion, CD with BMAC works more efficiently than CD alone prior to collapse of femoral head in AVN. However, PRP needs more evidence for extensive application. Addition of PRP to BMAC or culturing the latter could further enhance the potency of CD + BMAC combination. Very limited data is available for the efficacy of BMP-7 and the role of intraosseous bisphosphonates should be evaluated for a cheaper and potential alternative.

Objectives To identify epigenetic and transcriptional factors controlling osteoclastogenesis (OCG), that have been shown to play a role in the pathogenesis of skeletal diseases. Methods A systematic review was conducted in accordance with the PRISMA guidelines. The PubMed and EMBASE databases were searched up to 30th April 2020; references of included articles and pertinent review articles were also screened to identify eligible studies. Studies were included if they described epigenetic and/or transcriptional regulation of OCG in a specific skeletal disorder, and quantified alterations in OCG by any well-described experimental method. Risk of bias was assessed by a previously described modification of the CAMARADES tool. Results The combined searches yielded 2265 records. Out of these, 24 studies investigating 12 different skeletal disorders were included in the review. Osteoporosis, followed by osteopetrosis, was the most commonly evaluated disorder. A total of 22 different epigenetic and transcriptional regulators of OCG were identified; key epigenetic regulators included DNA methylation, histone methylation, histone acetylation, miRNAs and lncRNAs. In majority of the disorders, dysregulated OCG was noted to occur at the stage of formation of committed osteoclast from preosteoclast. Dysregulation the stage of formation of the preosteoclast from late monocyte was noted in rheumatoid arthritis and fracture, whereas dysregulation at stage of formation of late monocyte from early monocyte was noted in osteopetrosis and spondyloarthritis. Quality assessment revealed a high risk of bias in domains pertaining to randomization, allocation concealment, blinding of outcome assessors and determination of sample size. Conclusions A variety of epigenetic and transcriptional factors can result in dysregulated osteoclastogenesis in different skeletal disorders. Dysregulation can occur at any stage; however, the formation of committed osteoclasts from preosteoclasts is the most common target. Although the published literature on this subject seems promising, the overall strength of evidence is limited by the small number of studies evaluating individual skeletal disorders, and also by deficiencies in key aspects of study design.

Background Surgical management of burst fractures is controversial, with many different operative options. From a posterior approach, decompression of the spinal cord can be performed through both indirect and direct methods, the former relying on ligamentotaxis. It is unclear whether indirect decompression with ligamentotaxis is as effective as direct decompression. Methods Prospective, randomized controlled data were retrospectively analyzed to include only burst fractures of the thoracolumbar junction. Patients were treated with either direct decompression, involving wide posterior decompression in addition to operative stabilization, or indirect decompression, where decompression was performed solely through ligamentotaxis. Patients were followed up at 6 months with clinical assessment and imaging. Additional clinical assessment was performed at 1 year. For all analyses, P Results The study included 46 patients, with 18 patients in the direct decompression subgroup and 28 patients in the indirect decompression subgroup. The average age of the full cohort was 35.1 ± 13.1 years (range, 16–60 years). Most patients had L1 fractures (21/46; 46%), with an AOSpine classification type A4 fracture morphology (17/46; 37%), and were American Spinal Injury Association grade B (18/46; 39%). Both treatments resulted in similar increases in canal diameter and decreases in dural sac compromise (P > 0.5) at 6-month follow-up. Both treatments resulted in similar grades of neurological improvement (P = 0.575) at 1 year. Conclusions There were no significant differences in clinical and imaging outcomes when comparing direct decompression with ligamentotaxis. Ligamentotaxis alone may be effective in carefully selected cases.

Background As more evidence comes to light that hamstring harvesting may not be as benign a procedure as previously thought, considerable interest is being generated towards corelating the knee flexural strength deficits with the degree of tendon regeneration. The current study aimed to corelate knee flexion strength deficits with ultrasonographically quantified degree of hamstring regeneration after tendon harvest. Study design 31 patients of ACL reconstruction with hamstring grafts were divided into 2 groups (6 months and 1-year post op) according to time of follow up. Ultrasonography of both the knees to assess Semitendinosus tendon dimensions was done. Regeneration was classified as non-significant, mild (Zone 1, till 4 cm above the lateral joint line), moderate (Zone 2 ,at the level of the lateral joint line) and significant (Zone 3, 1.5 cm below the lateral joint line) as the regenerate happens from proximal to distal. Regenerate dimensions were compared with US measurements from the opposite knee. Bilateral isokinetic strength tests of the knees were done to evaluate flexion strength, and strength deficits were compared with degree of tendon regeneration. Results 14 (45%) of cases had no regeneration at both time periods. 7 patients (41%) in the 6-month post-op group showed some form of regeneration, and 10 patients (71%) in the 1-year post-op group showed regeneration. 29/31 patients had some flexion strength deficit. Strength deficit correlated with the level and degree of tendon regeneration, with non-significant regeneration cases showing higher strength deficit (mean - 28.51%), and cases with significant regeneration showing least amount of strength deficit (mean - 3.66%). Conclusion Flexion strength deficits after hamstring harvest are significant and corelate with degree of tendon regeneration, which improves over time. US is adequate to quantify degree of tendon regeneration, which in turn can help prognosticate return of flexion strength.

An editorial is presented on Olympics in the time of a Coronavirus Pandemic Topics discussed include International contributors have added to the knowledge pool which maybe relevant to Orthopods and other medical practitioners;and understand the genetic make-up of the athlete, and this can be used in a good sense to train some athletes with specific genes into specific sports

Background: Osteogenesis imperfecta (OI) is a genetic connective tissue disorder characterized by skeletal deformity and increased risk of fracture. Independent mobility is of concern for OI patients as it is associated with the quality of life. The present study investigates the variation of kinetic and kinematic gait parameters of type IV OI subjects and compares them with age-matched healthy subjects. Materials and Methods: Gait analysis is performed on five type IV OI patients and six age-matched normal subjects. Spatiotemporal, kinematic, and kinetic data are obtained using Helen Hayes marker placement protocol. Results: The results indicate an imprecise double-humped profile for vertical ground reaction force (GRF) with reduced ankle push off power and walking speed for OI subjects. Moreover, a comparison of vertical GRFs in OI subjects with that of healthy subjects suggests lower values for the former. The results encourage and motivate for further investigation with a bigger set of subjects. Conclusion: This information may be useful in developing a better understanding of pathological gait in type IV OI subjects, which ultimately helps the design of subject-specific implants, surgical preplanning, and rehabilitation.

Introduction Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment. Material and methods Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes. Results Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor. Conclusion "Fix and Flap" in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

Modern competitive sport has evolved so much that athletes would go to great extremes to develop themselves into champions; medicine has also evolved to the point that many genetic elements have been identified to be associated with specific athletic traits, and genetic alterations are also possible. The current review examines the published literature and looks at three important factors: genetic polymorphism influencing sporting ability, gene doping and genetic tendency to injury. The ACTN3 gene has an influence on type II muscle fibres, with the R allele being advantageous to power sports like sprinting and the XX genotype being associated with lower muscle strength and sprinting ability. The ACE gene polymorphisms are associated with cardio-respiratory efficiency and could influence endurance athletes. Many other genes are being looked at, with specific focus on those that are potentially related to enhancement of athletic ability. Recognition of these specific gene polymorphisms brings into play the concept of genetic engineering in athletes, which constitutes gene doping and is outlawed. This has the potential to develop into the next big threat in elite sports; gene doping could have dangerous and even fatal outcomes, as the knowledge of gene therapy is still in its infancy. Genetic predisposition to injury is also being identified; recent publications have increased the awareness of gene polymorphisms predisposing to injuries of ligaments and tendons due to influence on collagen structure and extracellular matrix. Ongoing work is looking at identifying the same genes from different races and different sexes to see if there are quantitative racial or sexual differences. All of the above have led to serious ethical concerns; in the twenty-first century some sports associations and some countries are looking at genetic testing for their players. Unfortunately, the science is still developing, and the experience of its application is limited worldwide. Nevertheless, this field has caught the imagination of both the public and the sportsperson, and hence the concerned doctors should be aware of the potential problems and current issues involved in understanding genetic traits and polymorphisms, genetic testing and genetic engineering.