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The Royal College of Surgeons (RCS) published the Good Surgical Practice guidelines in 2008 and subsequently revised them in 2014. Essentially, they outline the basic standards that need to be met by all surgical operation notes. The objective of the present study was to retrospectively audit the orthopaedic operation notes from a tertiary care hospital in Mumbai (between October 2020 to March 2021) against the recommended RCS Good Surgical Practice guidelines published in 2014.In the present study a total of 153 orthopaedic operation notes of 200 patients were audited by a single reviewer. During the period between October 2020 and March 2021, the data collection took place. All notes were typed on the standard operative proforma available on the hospital patient management software (SAP).Overall, the mandated fields in the EMR had excellent documentation. Documentation was excellent for the date and time of surgery, name of the surgeon, the procedure performed (100%), operative diagnosis (99.35%), an extra procedure performed (100%), and details of antibiotic prophylaxis (99.35); Inadequate for details of incision (94.77%), details of operative findings (92.16%), details of prosthesis (97.37%), DVT prophylaxis (96.08%) and detailed post-operative instructions (93.46%) and poor for tourniquet time (41.83%;), estimated blood loss (59.48%), closure details (16.99%), documentation of complications or lack of (51.63%) and setting of surgery elective or emergency (0%).Compliance for completion and documentation of operative procedures was high in some areas; improvement is needed in documenting tourniquet time, prosthesis and incision details, and the location of operative diagnosis and postoperative instructions. With wider adoption of electronic medical record systems, there is a scope of improving documentation by mandating certain fields.

AIM: The aim of this study is to assess the feasibility of the DACB in a clinical setting and compare the efficacy of postoperative pain relief after TKR in the patients administered DACB versus USG guided ACB. Also to see efficacy and safety of USACB in patients operated with medial parapatellar and subvastus approach. MATERIAL AND METHODS: 250 consecutive patients operated with TKR between Jan 2019 to March 2022 were included. Group A included patients operated with medial parapatellar approach and received USACB, Group B included patients operated with medial parapatellar approach and received DACB while Group C included patients operated with subvastus approach and received USACB. VAS scores between three groups were compared at 12 and 24 h. All three groups of patients were otherwise treated identically in the hospital. RESULTS: The mean age and BMI was not statistically significant between the three groups. The mean VAS pain score at rest at 12 h was 3.06 ± 1.49 (Group A) vs 1.58 ± 1.19 (Group B) [p

Robot-assisted arthroplasty is likely to grow exponentially in the years to come. While most surgeons recognize their superiority in refining alignment and improving component positioning accuracy, the universal adaptability of robots remains slow due to certain technological and behavioural gaps. Endoprosthesis robots currently suffer from increased reaction time, lack of natural adaptation to the surgeon's abilities, and unavailability and inapplicability in different surgical contexts. As humans and machines have to move forward into the next phase of their relationship, robots enabled with artificial intelligence (AI) may become more advanced and an alternative to overcome existing challenges like cost, training, and improve performance based on feedback provided by surgeons. Augmented intelligence is perhaps a more apt word than artificial, as it reflects more human-machine fusion and several areas are already proactively adopting the terminology. Arthroplasty robots can benefit from AI by using computer vision models, applying sensors, and integrating feedback and loop execution. All of this would help achieve a technical superiority to the surgeon alone. This brief perspective on how humans and machines are likely to benefit from the integration of AI outlines the technical side of this enablement.

Introduction: Traumatic groin pain (GP) is frequently the result of acute trauma, often an indirect muscle injury. The most affected muscles in traumatic GP are the rectus abdominis, adductors, and iliopsoas. The obturator internus bursitis as a cause of GP is very rare. Case Presentation:The present case describes a rare indirect injury of obturator internus bursitis in a 22-year-old male football player who reported GP that used to worsen with sprinting and change in directions. The pain was relieved with rest and sprinting at 80% capacity. The patient had been diagnosed clinically and on magnetic resonance imaging (MRI) as a case of obturator internus insertional tendinopathy with bursitis. His symptoms resolved after ultrasound-guided injection in the inflamed tendon sheath at its insertion point. After 2 years, the patient was followed up with a triumphant return to professional football with no recurrence and a good prognosis in a relatively short recovery time. Conclusion: Clinical diagnosis of obturator injuries is often tricky. GP not responding to conservative management presents a unique challenge to the physician and the rehabilitation team. MRI must follow the radiological investigations and ultrasound if the reports were inconclusive of the diagnosis. In the present case study, the usual causes of such pain (osteitis pubis, and adductor muscle strains/tendinosis) were ruled out, and a specific unique condition was diagnosed with the help of the MRI. Keywords: Bursitis, groin pain, magnetic resonance imaging, obturator internus.

Introduction: Knee joint is not an uncommon site for penetrating injuries and a spacious articulation to accommodate foreign body. Extensive literature is available on removal of loose bodies and metallic foreign bodies from the knee joint with sparse documentation of unusual intruders. Case Presentation: We report an atypical case of neglected glass fragment retrieved from the knee joint of 26-year-old male by arthroscopy, who presented to us 14 months after the index injury, in view of sudden onset excruciating pain following bike ride. Conclusion: Arthroscopy is the preferred minimally invasive modality for removal of foreign bodies from the knee joint, particularly from deeper and remote areas of knee joint. Appropriate pre-operative radiological imaging aids in better understanding of the anatomical location, improves surgical orientation, and shortens the duration of surgery. A high degree of suspicion and a meticulous history taking is important to reach the appropriate diagnosis.

We tested the filtration efficiency of Stryker T5 surgical helmets with and without the addition of a filter medium. Two particle counters were used to count the particles of sizes .5 μm, 1 μm, and 5 μm, both inside and outside the Stryker T5 helmet, concurrently. The total inward leakage (TIL) for the helmet with and without the filter was zero for 5 μm particles at all time points. The TIL (3.4) for the .5 μm particles decreased significantly after application of the filter (1.7; P = .007). We recommend that an N95 should be used inside the helmet system.

1. Background The aim of this paper is to describe the process of designing and developing a mould for filter placement via 3D printing on top of the surgical helmet. This mould was designed to affix a filter material on top of the helmet system for use during the COVID - 19 pandemic. 2. Method The authors performed 3D scanning of the Stryker Surgical helmet (Stryker T5, REF 400–610, US patents 6,973,677:7,753,682) and created a negative template of the top of the helmet. A mould for filter placement was printed and fitted onto the top of the surgical helmet. This construct was tested to evaluate the surgeon’s comfort, aerosol filtration efficiency etc. 3. Result The helmet provided adequate comfort, showed no evidence of staining on spill test and the filter passed the industry filtration efficiency standards. 4. Conclusion The 3D printed mould is an inexpensive, efficient, and comfortable design to augment personal protection ability of the Stryker helmet system. This process can be extrapolated to 3D print templates for other surgical helmets.

Background In the fight against COVID 19, the government of India announced a 3 weeks lockdown of the entire country of 1.3 billion people on 24th March 2020. Methods One week after the lockdown was announced, we conducted an anonymous online survey of the orthopaedic surgeons in India through social media platforms to assess the impact of the lockdown during COVID 19. The survey had a total of 13 questions with (3–5) options and was designed with an aim to understand the perception and the state of mind of the Orthopaedic surgeons in the lockdown situation. Results The survey was completed by 611 orthopaedic surgeons from 140 cities in India. There were 22.5% orthopaedic surgeons who said that they were definitely stressed out, and 40.5% who said they were mildly stressed out. As the age decreased, the percentage of orthopaedic surgeons feeling “definitely stressed out” increased. Disruption of life-work balance and uncertainties regarding return to work were other strongly associated factors with the “definitely stressed out” group. Conclusion The psychological impact of the lockdown during COVID 19 on orthopaedic surgeons may become a potential concern that will require addressal through open discussion. Level of evidence diagnostic level 4.

Objectives To Evaluate the results and the protocols of our Institution for 18 Emergency and Urgent Non Covid Surgeries during the Covid 19 Pandemic Methods 18 patients underwent Emergency and Urgent Orthopaedic Surgeries at institution. The Protocol was Screening, Segregation, Selection, Isolation, theatre modification, and Online Follow. Results Two adverse events including, one death and one intensive care admission due to underlying morbidity were recorded. Average Hospital stay was 2.5 days with no patients becoming covid positive at follow up. Conclusion Strict Surgical protocols need to be followed for surgery during the Covid19 pandemic.

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.

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.

BACKGROUND: A tissue bank is an establishment that aids in retrieval, processing, storage, and distribution of human tissue for transplantation. For many years, such banks have been dispensing tissue to orthopaedic surgeons, performing reconstructive surgeries. METHODOLOGY: The retrieval, preparation, and delivery of musculoskeletal tissue used for transplantation is an intricate process involving varying practices among different musculoskeletal tissue banks. RESULTS: Musculoskeletal allografts are used in various orthopaedic surgeries ranging from primary bone defects, trauma, and carcinoma to congenital disabilities. Every decade brings in paradigm shifts and new hope for treating challenging cases with the aid of newer devices and materials. CONCLUSION: This review article outlines various technical, regulatory and quality enhancement steps involved in tissue banking. Also, it discusses the road ahead and the research avenues for developing novel allograft products with the synergy of tissue banks and clinicians. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-022-00661-0.

BACKGROUND Medial coronal plane malalignment, also known as varus alignment, is commonly reported in osteoarthritic knees. Although the degree of deformity provides some insight regarding the severity of the disease, it does not always reflect the potential complexity of the surgical treatment. METHODS This prospective observational study was conducted by analyzing the radiographs of 100 consecutive knees in patients undergoing total knee arthroplasty. For each knee, coronal alignment, expressed as the hip-knee-ankle angle, was measured on a full-leg standing radiograph and classified in 3 stages. The primary location of the varus deformity was identified as intra-articular and/or extra-articular. Additionally, knees were evaluated to assess for 10 radiographic features of varus deformity and then classified in 3 grades of osteoarthritis severity. RESULTS The mean (and standard deviation) preoperative varus deformity was 11° ± 6° of varus (hip-knee-ankle, 169°), as measured on standardized full-leg radiographs. Extra-articular varus deformity was observed in 14% of patients. A higher number of radiographic features of varus severity corresponded with higher degrees of deformity. Varus grade correlated strongly with stage of varus deformity. Twenty-three (100%) of 23 stage-III deformities had grade-C features; however, 13 (48%) of 27 stage-I patients also had grade-C disease. CONCLUSIONS One of every 7 osteoarthritis patients with varus deformity had an extra-articular deformity, and 1 of 2 of these patients had severe intra-articular disease (grade C) despite limited coronal deformity (stage I). These findings reconfirm the need for individual deformity analysis that accounts for the degree, location, and severity of the varus deformity. This insight may help to formulate an algorithmic treatment approach specific to the epiphyseal knee anatomy of the patient and according to the surgical preferences of the surgeon. CLINICAL RELEVANCE Knee surgeons tend to consider knees with higher degrees of coronal deformity as more technically difficult, but the present study shows that knees with less deformity can still present with severe grades of osteoarthritis inside the knee, leading to more challenging joint reconstruction.

Purpose Roof arc angle (RAA) is determined by measuring angle between a vertical line drawn from center of the acetabulum towards the acetabular dome and a second line drawn from center of acetabulum to the fracture through the acetabulum. Joel and Matta demonstrated that when roof arc angle was less than 45° on Pelvic AP and Judet's views, the fracture line is considered to be passing through the weight-bearing dome and require surgical fixation. The main purpose of the study is to calculate patient-specific angle and width for the better evaluation and management of acetabular fractures. Methods Radiographs of normal hips were retrieved from electronic data and parameters were calculated. Two observers calculated the parameters at two different intervals. Pearson correlation formula was used to find a correlation between groups. Results Fifty radiographs of 28 patients were reviewed. The mean age of patients was 75.58 years ±13.28. The radius of the acetabulum, the radiographic measurement of sector width for 45° angulation at the roof, and the mathematical calculation for roof arc for 45° angle had significant positive correlation for both observers at two different occasions. Conclusions The measured roof arc width ranges from a minimum of 16.20 mm–31.50 mm and the calculated arc width for a 45-degree angle varies from a minimum of 15 mm–25.56 mm. These values are higher than the described values of 10 mm equals to 45 degrees. Hence, the values measured in this study should be considered for decision making in the management of acetabular fractures.

As COVID 19 continues to over burden the healthcare system globally, the scientists are relentlessly pursuing research and publishing copious data on relevant managements strategies for the infection. This short communication has attempted to simplify the available information on the subject in a manner that is easy to understand and implement in clinical setting. COVID 19 is not a single disease but a spectrum and should be classified based on clinical, radiological and laboratory parameters. A simple yet powerful way is to classify COVID 19 as COVIN - COVID Infection but no disease; COVIRI - COVID infection with predominant respiratory symptoms; COVIDI - COVID infection leading to an abnormal immune response and COVID S- referring to the sequalae of an acute COVID Infection. A clinical subtype specific approach may result in easier communication between healthcare providers which in turn may improve patient outcomes by providing targeted therapy.

Today the orthopedic world with respect to COVID remains focused on resumption of elective surgery and impact of the pandemic on scientific activities. However, it is equally important that we keep our eyes on the phenomenon that is quietly unraveling in front of the eyes. The phenomenon of post-COVID musculoskeletal sequelae may become a major orthopedic public health problem in coming months and needs to be investigated in depth. The usual post-COVID symptoms include arthralgia and myalgia that are common in many viral diseases. It is the unusual symptoms like occurrence of primary septic joint infection and elevated rates of post-operative infections that warrant attention and further investigation. Could this be attributed to immune consumption leading to a phase of temporary immunosuppression is a matter of speculation and hypothesizing. A short communication here reveals a glimpse of musculoskeletal sequalae that COVID may bring in coming months. These could be usual arthralgia or myalgia which are self-limiting but could also be more sinister like spontaneous osteonecrosis and primary joint infections.

Background Adductor canal block (ACB) is one of the preferred methods of analgesia in total knee arthroplasty (TKA). However, conventionally its use is time-consuming, requires ultrasound guidance, a trained anaesthesia team and adherence to strict asepsis by members of the allied teams. This study was done to assess the feasibility and safety of direct adductor canal block (DACB) as a part of surgeon-administered periarticular infiltration. Materials and methods Thirty computed tomography (CT) angiography films of the patients were retrospectively reviewed. The trajectory of the needle placement for a DACB in relation to the target region of the adductor block was determined. Fourteen knees in seven cadavers, were dissected through a medial parapatellar approach to perform TKA. After administering the DACB using the technique based on CT data, dissection was carried out to ascertain the correct placement of the dye by visualising the stained areas. Results The angle of approach in the coronal plane from the entry point to the medial high point and to the adductor hiatus was 10.2° (8−14°) and 6° (3.8−11°), respectively. The angle of approach in the sagittal plane from the entry point to the medial high point and to the adductor hiatus was 7° (5−10.5°) and 29° (19−43°), respectively. In all the 14 cadaveric knees, we confirmed the correct placement of the methylene blue dye as demonstrated by the staining of the adductor canal. Conclusion The study demonstrates the feasibility of the DACB. This surgeon-driven technique is likely to reduce the cost of the procedure, reduce operating room time and also eliminate the risks of surgical-site contamination.

INTRODUCTION: 3D printing has widespread applications in orthopaedics including creating biomodels, patient-specific instruments, implants, and developing bioprints. 3DGraphy or printing 3D models enable the surgeon to understand, plan, and simulate different procedures on it. Despite widespread applications in non-healthcare specialties, it has failed to gain traction in healthcare settings. This is perhaps due to perceived capital expenditure cost and the lack of knowledge and skill required to execute the process. PURPOSE: This article is written with an aim to provide step-by-step instructions for setting up a cost-efficient 3D printing laboratory in an institution or standalone radiology centre. The article with the help of video modules will explain the key process of segmentation, especially the technique of edge detection and thresholding which are the heart of 3D printing. CONCLUSION: This is likely to enable the practising orthopaedician and radiologist to set up a 3D printing unit in their departments or even standalone radiology centres at minimal startup costs. This will enable maximal utilisation of this technology that is likely to bring about a paradigm shift in planning, simulation, and execution of complex surgeries. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s43465-020-00254-9) contains supplementary material, which is available to authorized users.

Returning to Arthroplasty amidst the COVID-19 pandemic requires a well aligned and a balanced approach. Following a set protocol and staged measures are the need of the hour. This article details the specifics for resumption of arthroplasty in the era of COVID19. While formulating the policy for resumption, it is necessary that we consider the following factors: patient's general health status, follow strict guidelines issued by the government, alter and enhance our operating room discipline and last but not the least, leverage technology for optimal patient care and enhanced outcome.

Background This study was done to study the anthropometry of nonarthritic Asian knees; to determine the differences in morphology between knees of different ethnicities and to compare the knee anthropometry values with sizes of available knee implants. Methods Magnetic resonance imaging scans of 100 nonarthritic Indian knees were analyzed. Anteroposterior (AP) length, mediolateral (ML) length, and aspect ratio of the distal femur and proximal tibia, patellar length, and patellar tendon length were measured. These values were compared with values of other ethnicities from literature. The values were also compared with sizes of available knee implants and evaluated for mismatch. Results All the parameters of female knees were significantly smaller than those of male knees (p < 0.05). The distal femur of Indian knees resembled that of Chinese knees with similar AP and ML lengths and aspect ratio. The distal femur of Indian knees had a significantly smaller AP, ML, and aspect ratio than those of Hispanic knees did. In comparison to Caucasian distal femur, Indian knees had smaller AP and ML lengths and larger aspect ratio. In terms of the proximal tibia, the Indian knees were smaller than Chinese (only ML), Caucasian (AP and ML) and Hispanic (AP and ML) knees. On comparison with implant sizes, there was a mismatch between the distal femur morphology and the dimensions of all implants. For a given AP length, the ML dimensions of all implants were smaller than the measured ML length of the knee. However, the tibial components of all the studied implants correlated well with the tibial morphology. Conclusions Distinct anthropometric differences exist between knees of different ethnicities. The knees of females were smaller than the knees of males. In Indian knees, the ML-AP aspect ratio of the distal femur was higher than that of the currently available femoral components. These results suggest the need for race-specific knee implants.

Backgroud Optimal placement of the components and achieving a neutral mechanical axis are the main goals of total knee arthroplasty (TKA). Different computerised navigation systems are presently used for these purposes. This aim of this study was to compare the pinless navigation (PNA) TKA performed using iAssist with the conventional instrumented (CIN) TKA in terms of functional and radiological outcomes. Methods A total of 100 knees operated for TKA by a single surgeon were studied retrospectively for a period of 2 years. Weight-bearing postoperative radiographs of the knees along with scanograms of the lower limbs were used for measurements of component positioning, mechanical axis alignment, and number of outliers. Oxford knee scoring was used for functional analysis. Results No statistically significant difference was seen in the mean mechanical axis alignment (hip-knee-ankle angle), coronal alignment (α and β angles) and sagittal alignment (γ and δ angles) of the femoral and tibial components between the two groups. Though the percentage of outliers for mechanical axis alignment was lower in the PNA-TKA group than in the CIN-TKA group, the difference was not statistically significant (p = 0.73). The number of outliers for the femoral and tibial component positioning in coronal and sagittal planes was not statistically significantly different between the two groups. No statistically significant difference (p = 0.68) was noted between the two groups with respect to the Oxford Knee Score. The mean surgical time was greater in the PNA-TKA group by 11 minutes, which was statistically significantly longer (p = 0.018). Complications were seen in 6.89% of the cases in the CIN-TKA group, while none in the PNA-TKA group. Conclusions The accurate mechanical axis alignment and component positioning can be achieved with the conventional instrumentation, so the use of PNA system, which adds to the surgical cost, is questionable. Also, equally good short-term functional outcome can be achieved with the conventional instrumentation. The surgeon must be accustomed with the instrumentation of the PNA system, or it adds to the surgical time.

Distal femur fractures are common but complex fractures and often are associated with complications. The cases of failure may be secondary to mechanical failure or biological failure. The current review offers overview of these complications and tips and tricks on how to manage these complications. Keywords: Distal Femur Fractures, Complications, Surgical management

The use of 3D printing in Orthopedics is set to transform the way surgeries are planned and executed. The development of X rays and later the CT scan and MRI enabled surgeons to understand the anatomy and condition better and helped plan surgeries on images obtained. 3DGraphy a term used for 3D printed orthopedic patient models and Jigs has gone a step further by providing surgeons with a physical copy of the patient's affected part that can not only be seen but also felt and moved around spatially. Similarly 3D printed Jigs are patient specific devices that are used to ensure optimal screw trajectory and implant placement with minimal exposure. While the use of 3D printed models and Jigs have now become routine, a similar revolution is happening in the field of designing and printing patient specific implants. Metal printing along with enhanced capability to print other biocompatible materials like PEEK and PLA is likely to improve the current implant manufacturing process. On the horizon is another interesting development related to this field – 3D Bio printing. Printing human tissues and organs is considered the final frontier and impressive strides have been made in printing bone graft substitutes and cartilage like material. This paper is an overview of all the current developments and the road ahead in this invigorating field.

Achilles tendon is the strongest and the thickest tendon of the human body. Due to its superficial location and stress, it has to face due to loading, the tendon is susceptible to injuries and ruptures. This is aggravated due to the precarious blood supply in the region and also age-related changes that occur in the tendon. Of the specific causes age-related and steroid induced tendinosis and sports injuries are the commonest mechanism of injury. Kite playing is a very common sport in the Indian subcontinent, which involves the use of a string (manja) often coated with powdered glass to fly the kite. Many grievous injuries are reported due to its use especially in two wheeler riders. However, to the best of our knowledge a kite thread injury causing Achilles tendon tear due to direct impact has so far not been reported. In this case series, we describe two cases that had such injury and a brief note on specifics of management of this case is described. How to cite this article Bagaria V, Nemade A, Joshi N. Achilles Tendon Rupture Secondary to Kite String (Manja) Injury: A Rare Etiology seen in Two Cases. J Foot Ankle Surg (Asia-Pacific) 2015;2(2):90-93.

Introduction Preoperative planning is an important aspect of any orthopedic surgery. Traditionally, surgeons mentally rehearse the operation and anticipate problems based on data available from “radiography” like MRI and CT. 3D printed bio-models and tools, or “3Dgraphy” can simplify this mental exercise and provide a realistic and user-friendly portrayal of this radiographic data. Methods Five surgeons participated in this multicenter study. 3D printed biomodels were obtained for 50 surgical cases that included periarticular trauma (24), pelvic trauma (11), complex primary (7), and revision arthroplasty (8). CT scan data was used to generate computer models which were then 3D printed in real size. These models were used to understand pathoanatomy and conduct simulated surgery as a part of preoperative planning. The models were sterilized and were used for intraoperative referencing. Following each case, the operating surgeon was asked to fill out a structured questionnaire to report on the perceived benefits of these tools. Results All surgeons reported that the biomodels provided additional information to conventional imaging that enhanced their knowledge of the complex pathoanatomy. It was useful in preoperative planning, rehearsing the operation, surgical simulation, intraoperative referencing, surgical navigation, preoperative implant selection, and inventory management. This probably reduced surgical time and improved accuracy of the surgery. All surgeons reported that they would not only use it themselves but also recommend it to other surgeons. Conclusion 3Dgraphy was found to be a valuable tool in orthopedic surgeries that involve complex pathoanatomy like pelvic trauma, revision arthroplasty, and periarticular fracture. As the technology evolves and improves, they are likely to become a standard component of many orthopedic procedures.

Background: Coronal fractures of distal end femur, referred as Hoffa’s fracture are not uncommon, yet easily missed injuries lacking proper classification system and consensus for ideal treatment. While most trauma surgeons adopt different strategies based on the fracture configuration and their own experience, there are no set ways to classify these based on the most appropriate treatment strategy. Methods: Thirty cases of Hoffa fracture from tertiary care centres were studied for the fracture pattern, fragment size, comminution and possible variations to formulate a radiological classification and treatment guidelines. Additionally, a literature search was used to analyze 77 case studies based on Hoffa fracture to find out the common fracture patterns and treatment modalities adopted for varying fracture patterns in these studies. Six independent observers participated in testing the inter-observer reliability of the proposed classification. Results: A new proposed radiological classification for Hoffa fracture consists of four main types. Type 1 is with fracture fragment >2.5 cm, Type 2 with fragment Conclusion: The new suggested classification helps identify different types of Hoffa’s fracture. This is likely to help decide optimal surgical treatment depending on the nature of the injury. The classification system has high inter and intra-observer reliability that enables its universal applicability.

Planning is a key step in all surgeries. Well-planned cases have better outcomes than the unplanned ones. The conventional planning used to be done on radiographs and other imaging. Three-dimensional (3D) printing using additive manufacturing process has tak‐ en this a step further. The process involves converting the radiographic digital formats into machine-printable format. The three-dimensional model is typically made of a plas‐ tic material that allows surgical simulation. In complex arthroplasty, especially those such as revision scenarios or difficult primary cases such as dysplastic hips, protrusio, fused, or posttraumatic arthritic hips, these mod‐ els serve as an invaluable tool in planning the surgery. They help reduce inventory by fa‐ cilitating optimal implant and instrument ordering, and also serve as intraoperative referencing. By performing surgical simulations preoperatively, the surgeons can re‐ hearse their surgical steps and also decide upon the implant type and accurate implant placements.

The objective of this study was to fabricate a successful implant for temporomandibular joint (TMJ) disorder patients who could not be treated through conventional surgeries.A custom-made implant was fabricated using rapid prototyping (RP) for the TMJ surgery. The stability of the metallic implant was validated using a finite element analysis.The results of finite elements were stable and the design of the TMJ implant was suitable as per the patient's need. The customised implant was made using a fused deposition modelling method of RP and a vertical machining centre. The implant has provided normal jaw function for over 2 years since surgery.The approach utilised will be helpful in providing successful treatment to the deformed mandible and the mandible joints. This method allows to customise and to accurately fabricatie the implant. Advantages of this approach are that the physical model of the implant was tested for stability before the implantation, the surgeon can plan and rehearse the surgery in advance, it is a less invasive and less time-consuming surgical procedure.

Intravascular papillary endothelial hyperplasia is a rare benign vascular proliferative process as a result of papillary proliferation of the endothelial cells within the vascular lumen. We report two cases of intravascular papillary endothelial hyperplasia affecting the extremities. The characteristic sonological and MR imaging features are discussed, with updated review of literature. Imaging features are helpful in achieving a definitive diagnosis of the intravascular papillary endothelial hyperplasia.

Anthropometric variations in humans make it difficult to replace a temporomandibular joint (TMJ), successfully using a standard “one-size-fits-all” prosthesis. The case report presents a unique concept of total TMJ replacement with customized and modified TMJ prosthesis, which is cost-effective and provides the best fit for the patient. The process involved in designing and modifications over the existing prosthesis are also described. A 12-year- old female who presented for treatment of left unilateral TMJ ankylosis underwent the surgery for total TMJ replacement. A three-dimensional computed tomography (CT) scan suggested features of bony ankylosis of left TMJ. CT images were converted to a sterolithographic model using CAD software and a rapid prototyping machine. A process of rapid manufacturing was then used to manufacture the customized prosthesis. Postoperative recovery was uneventful, with an improvement in mouth opening of 3.5 cm and painless jaw movements. Three years postsurgery, the patient is pain-free, has a mouth opening of about 4.0 cm and enjoys a normal diet. The postoperative radiographs concur with the excellent clinical results. The use of CAD/CAM technique to design the custom-made prosthesis, using orthopaedically proven structural materials, significantly improves the predictability and success rates of TMJ replacement surgery.

There has been a gradual shift in the approach towards managing the occupational and physical health of patients in last few decades. While the earlier approach was standardized and involves using time tested solutions for all patients, the new era is moving towards customized medicine in which the focus is on an individual and how the solutions can be tailor made for his maximal benefit. Clinicians and therapists worldwide are looking for technological advancements that help them realize their goal to ensure optimal outcomes that are patient specific. 3D patient optimized rehabilitation tools also known as 3D PORT is based on additive manufacturing of customized devices using 3D printers. This review describes the basics of the use of technology and also on the future trends and possible clinical applications of the same.

Closed intramedullary nailing is a well-accepted method of treatment for femoral shaft fractures. The issue of the correct entry point for antegrade nailing remains a matter of controversy, and the literature is confusing. We reviewed the opinions of 100 orthopaedic surgeons by means of questionnaires. Only four surgeons were able to identify and label their respective entry points for femoral nailing correctly, possibly because of incorrect illustration in publications or errors in terminology. Although the piriformis fossa appears to be the ideal entry point, the importance of exact localisation in the sagittal plane, centered over the axis of medullary canal, cannot be overlooked.

We report here a case of posterior dislocation of hip with fracture of posterior lip of acetabulum, with retained fracture fragments after a successful closed reduction. The fractured fragments were removed by arthroscopy of the hip. The technique of hip arthroscopy used in removing the fragments is discussed.

Background: Optimal femoral component rotational alignment in total knee arthroplasty (TKA) is crucial to establish a balanced knee reconstruction. Unbalanced knees can lead to instability, patellofemoral problems, persistent pain, stiffness, and generally poorer outcomes including early failure. Intraoperative techniques to achieve this optimal femoral component rotation include the use of the transepicondylar axis (TEA), the posterior-condylar-cut-parallel-to-the-tibial-cut (PCCPTC) technique and the anteroposterior axis technique (Whiteside's line). The purpose of this study was to compare the PCCPTC technique to the TEA technique using computed tomography (CT) scans to assess femoral component rotational alignment. Materials and Methods: This study used postoperative CT scans to compare the degree of femoral component rotation obtained with the use of PCCPTC technique and the TEA. The femoral component rotation of 30 TKA was measured on postoperative CT scans the angle of deviation between the two lines radiographic trans-epicondylar axis (rTEA) and femoral prosthesis posterior condylar line (FPPCL) was determined. This angle represented the rotation of the femoral component relative to the true rTEA. Results: The degree of rotation measured 2.67 ± 1.11 degrees in the PCCPTC group and 5.60 ± 1.64 degrees in the TEA group. Conclusion: The use of the TEA technique for determining rotational alignment in TKR results in excessive external rotation of the femoral component compared to the PCCPTC technique.