Recent advances in Joint Replacement include improvisations in pre-op optimisation, prehabilitation, precision surgical techniques, cutting-edge least-constraint to fully constrained implants, instrumentation and meticulous post operative care. Owing to the above, Joint Replacement is now one of the most successful surgery of the musculoskeletal system. On-time diagnosis, proper treatment planning, state-of-the-art operation theatre and a skilled surgeon with multidiscipilinary team are fundamental to this most rewarding surgery. Joint Replacement can improve the quality of life dramatically. Its not the length of life that matters, but the quality with which each day is lived. Pain-free mobility is a promise and not just a possibility with joint replacement surgery.

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The primary indication for Knee Arthroplasty is significant and disabling pain due to severe OA.
Depending on the location and severity of OA within the knee joint, several options may be
considered, including Total (TKA) or Partial Knee Arthroplasty (PKA).

While the conventional approach to total knee replacement uses implants to reconstruct all the
compartments of the knee, a total knee replacement may not be necessary for all patients. In knees
that are otherwise healthy with involvement of single compartment, a partial knee replacement can
preserve the healthy bone, cartilage and ligaments. Partial knee replacement may be either involve
Patello-Femoral Joint Arthroplasty or Unicompartmental Arthroplasty.

Unicompartmental, or unicondylar, knee arthroplasty (UKA)

Unicompartmental, or unicondylar, knee arthroplasty (UKA) is the preferred procedure when the
aim is to preserve the intrinsic joint stabilising structures, as well as healthy joint compartments.
Here, the partial knee implant is designed to repair only the damaged portion of the knee joint, i.e.,
either the medial or lateral condyle. Thus, it makes the implant much smaller than a conventional
total knee implant.

Evolution of UKA

UKA was introduced in 1970s with the promise of minimal bone loss and the potential ease of
future revision to a TKA if required. However, an inadequate understanding of appropriate
indications and surgical techniques, combined with suboptimal early prosthetic designs resulted in
an unacceptably high rate of failure early on and made the surgery quite unpopular at the time. But
advancements in UKA implant designs and improved surgical techniques in recent years have lead
to renewed interest in UKA . The resurgence of this less invasive knee arthroplasty is also
secondary to reports of excellent survivorship rivalling TKA in appropriately selected patients.
conventional total knee implant.

Indications for UKA

Careful selection of patients is the key to a successful UKA. Current indications for UKA
implantation are: isolated unicondylar osteoarthritis (OA) or osteonecrosis (identified radiologically
as bone-on-bone arthritis); frontal deformity < 15°; flexion contracture < 15°; functional integrity of
the anterior cruciate ligament (ACL) and peripheral ligaments of the knee, as well as the absence of
any inflammatory arthropathy. Indians are potential candidates for UKA because of our genetic
predisposition for tibia vara and antero-medial OA.

Advantages

UKA with microplasty instrumentation is definitely the ‘game changer’ in Knee Arthroplasty. This
less invasive surgery involves a smaller incision, removes less tissue, and preserves upto 80% of the
normal bone. Blood transfusions are generally not needed and this surgery is least associated with
intra-operative complications, infections, venous thromboembolism, cardiovascular events, etc.
Patients experience less pain and recover faster and the hospital stay is shorter compared to TKA.
Patients can walk on their surgical leg on the same day as the surgery. Since the knee ligaments are
preserved, near-normal kinematics is restored and patient gets the feeling of a ‘natural’ joint. Return
to low-to-intermediate sports within 3-6 months of the surgery is also possible without any
problems.

Disadvantages

Unicondylar knee replacement surgery can be extremely successful but most surgeons agree that it
is a more technically demanding procedure relative to TKA. Studies involving various National
Registries show a 3-times higher failure/revision rate for UKA compared to TKA making even
competent surgeons hesitate. 90% complications are due to the tibial side failure (overload). Tibial
strain increases by 60% following UKA causing antero-medial tibial pain following surgery. But it
has been found that the increased strain occurs with surgical errors like deep vertical cut, medial
vertical cut and deep tibial resection.

There are virtually no contraindications for UKA, but it must be avoided in patients with
inflammatory arthritis and morbid obesity.

Conflict between TKA and UKA

The dilemma faced by Orthopaedic surgeons across the world is whether to do a TKA or UKA for
isolated unicondylar osteoarthritis. The fear of early revision seems to have reduced the prospects of
UKA but what surgeons need to identify is that higher revision rates are mostly because of
subjective surgeon reasons; it is therefore more important to master the technique rather than to
repudiate the procedure altogether. Further, even TKAs fails. Though, the incidence of failure after
knee replacement is low, it has been reported that more than 22,000 knee replacements are revised
yearly for aseptic loosening, instability, infection, etc.

In decisions about which procedure to offer, the seemingly higher revision/re-operation rate of UKA
than of TKA should be balanced against a lower occurrence of complications, readmission, and
mortality, together with known benefits for UKA in terms of postoperative function. Conventional
UKA can be an economically attractive alternative in patients sixty-five years of age or older, and
modest improvements in implant survivorship could make it a cost-effective alternative in younger
patients.

Recent Advances

The difficulty with UKAs historically are the problems and failures from inaccurate placement.

Computer Navigation (CN), Robotic-Arm assisted (RA) UKAs are recent advances introduced to
increase accuracy and consistency of component placement. Pre-op CT based 3D anatomic
placement- 3D reconstruction of patients knee and patient specific anatomic planning assists
surgeons with optimal implant position and alignment. Robotic system allows to define alignment/
extension gaps/kinematics, consistent tracking and congruency through Range Of Motion, thereby
avoiding over/under correction. Robotic-assisted UKAs have demonstrated satisfactory clinical
outcomes, fewer revision and excellent survivorship on long term follow-up. However, as of now,
RA UKAs are associated with a longer operating time and increased cost to the patients. This
scenario may be improved by training new surgeons and by increasing the number of partial knee
surgeries at the given institution.

Summary

Partial knee replacement has many advantage over TKA. Understanding the indication is the key to
success of this minimal invasive surgery. Main indication is Antero-Medial Osteo Arthritis (boneon-bone OA) with intact ACL. However, broad indications have not been found to compromise
results. Improvements in implant design and surgical techniques of unicondylar knee arthroplasty
like Computer Navigation, and Robotics have led to reduced revision rates, but patient selection is
the most crucial factor for success of such arthroplasties.

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Data on injuries

But amidst all the adulation, fans forget that cricket is a physicallydemanding and stressful sport that exposes its players to variousmusculoskeletal injuries. In this direction, it is imperative to applaud acommendable effort by Rahul Dravid-led National Cricket Academy (NCA)in creating an ‘Injury Surveillance Report’ that identifies the list of mostcommon injuries among Indian cricketers. A first in its field, this 48-pagereport states that 262 cricketers (218 men and 44 women) attended arehabilitation programme at NCA between April 2019 to March 2020. Thisstatistic itself speaks volumes to the extent of injuries sustained bycricketers.

As with any other sport, cricket too is burdened by certain injuries typical tothe game. Since cricket involves variant postures for different players(batsmen, bowlers, wicket keepers, fielders etc), the injury can occuranywhere from head to toe. The insult may be acute or sudden-onset, mostoften due to traumatic injury, or chronic/long-standing issues occurringmainly due to overuse of the body.

Shoulder dislocation

The most common injury among cricketers is that of the shoulder joint andbowlers are susceptible to this type of injury. A vast majority of them arevery tall, in the range of 6-feet plus, and hence they have a long lever armmaking them more prone to rotator cuff tears, SLAP (superior labral tearfrom anterior to posterior) lesions etc.

Among acute injuries of the shoulder, traumatic dislocation is the mostcommon. It is said that Kapil Dev bowled more than 1 lakh balls infirst-class matches alone! One can only imagine the extent of damage thatthis legendary player’s shoulder joint might have sustained.

Hurting the knee & foot

The second most common joint to be damaged is the knee joint. Traumaticinjuries of the ACL(Anterior Cruciate Ligament), PCL (Posterior CruciateLigament) and multi-ligament injuries are common acute conditions. Amajority of career-threatening ACL injuries have been found to occur in thefirst two years of “return to sport”. Chronic overuse results in adegenerative meniscal tear that presents with excruciating knee painaccompanied by mechanical symptoms (painful clicking, popping, locking,catching, and giving way) but with no known traumatic event.

Ankle, thigh and lumbar spine are among the next most susceptible jointsto be injured among cricketers. During the delivery stride, the bowler’s foottouches the ground with a force of nearly 7-8 times the body weight.

Plantar fasciitis, Achilles tendinitis, retrocalcaneal bursitis, metatarsal andtoe fractures, stress fractures of the foot are some of the common injuriesafflicting the ankle joint.

Pulling the hamstring

Hamstring strain in the back of the thigh is a tear in the muscle that mostcricketers are prone to regardless of their position. It often occurs duringsudden, explosive movements, such as sprinting, lunging or jumping, andis very common, especially in batsmen and fielders.

Disc diseases, lumbar spondylosis and disc prolapse are some of the majorproblems of the spine and are most frequently seen in bowlers.

Overuse injuries

This is not to imply that other joints and muscles are spared. Tennis elbow,for example, is a common condition in both bowlers and batsmen, involvingpain on the lateral side of the elbow. In fact, Sachin Tendulkar himself hasbeen treated for this condition. In small joints like the wrist and fingers,ailments like small joint degeneration, overuse tendon injury are found –mostly in spinners due to inappropriate grip on the ball. Other injuriesinclude TFCC (Triangular Fibrocartilage Complex) injury and mallet finger.

Periostitis or runner’s disease is a chronic exertional compartmentsyndrome of the leg caused due to repetitive stress on the tibia, orshinbone. Amidst others, this disease underscores the need for the use ofproper footwear in cricket. It is estimated that Sachin ran a distanceexceeding 350 km in between wickets! Hence, there is little surprise thatcricket is associated with manifold stress and strain injuries of themusculoskeletal system.

How to prevent injuries

Sports injuries might beunavoidable under certaincircumstances but players needto remember that prevention isbetter than cure. Learning thecorrect technique for individualsports under a trained person,and adopting safety measurescan definitely go a long way in preventing sports injuries. Players should do warm-ups and general stretching exercises, along with stretching exercisesspecific to the game, before indulging in the sport.

Each sportsperson must know his or her own body limits and take care notto over exert themselves. After each game, a warm-down period is crucialand players should give importance to maintaining hydration as well asgood sleep. Adequate relaxation and unwinding oneself in between trainingsessions are equally vital.

Managing injuries

If injured, the player should avoidself-medication and self-treatment.Instead, he or she shouldimmediately seek the help of aqualified medical professional. Mostinjuries are amenable to treatment,and with competent management,normal anatomic and biologicfunctionality of the joint can beregained to the satisfaction of the player. These facts are relevant not justfor those in sports but for the common public too. One should never delaygetting help for any problem lest it turns from a minor discomfort to aleviathan one.

Now that the IPL has begun in the UAE, cricket is in the limelight onceagain. Let us take this moment to reflect that it is not only important to ‘playwell’ but also to ‘play right’ — play using the right technique, and if injured,get the right treatment at the right time, from the right expert.

Dr. Nijith O Govindan (BPT, MBBS, MS Orthopaedics)

Consultant Orthopaedic Surgeon
Lakshmi Group of Hospitals, Cochin, Kerala, India – 682 016
Phone: 9475601731

The post Common Cricket Injuries & How to Prevent Them appeared first on MIOC Ortho Clinic.

The incidence of sports-related injuries is stated to be as high as 11 per100 persons in the Olympic games. These injuries occur mostly in contactsports, which involve participants coming into bodily contact with oneanother. Football, hockey, martial arts etc. are examples. Not uncommonly,injuries may also be associated with non-contact sports. Amongst thevarious Olympic events, lower limb injuries alone constitute 20% of thecasualties, while head, neck and torso account for another 25%.Though not the most prevalent, shoulder joint injuries have often beenfound to cause debilitating infirmity for sportspersons.

Shoulder joint

The shoulder joint is the most mobile joint in the human body, yet it’sconsidered relatively unstable. It is a ball and socket type of joint whereinthe head of the humerus forms the ‘ball’ and the glenoid of the scapula, the‘socket’. There is a 4:1 ratio in surface area between the size of thehumeral head compared to the shallow glenoid fossa, and this sizedifference is responsible for the inherent instability of the joint. Its stability,therefore, is dependent on the soft tissues surrounding it as well as on therotator cuff.

‘Rotator cuff’ is the common term for a group of four muscles and theirtendons surrounding the shoulder joint. These include Supraspinatus,Infraspinatus, Teres minor and Subscapularis.

Acute or chronic injuries

Injuries around the shoulder may be acute (of sudden onset) or chronic(due to continuous overuse). Acute shoulder joint injuries include acutestrain/sprain, acute dislocation, rotator cuff tears, SLAP (superior labral tearfrom anterior to posterior), and fractures of the humerus, scapula, clavicle.Chronic injuries include rotator cuff tendinopathy, degenerative rotator cuffinjury, long biceps tendinopathy and recurrent shoulder dislocation.

Shoulder dislocation

Dislocation may be classified as forward (anterior) or backward (posterior)shoulder dislocation. Bankart and Hill-Sachs lesions are specific injuries tothe glenoid labrum and humeral head respectively found in association witha forward dislocation. Backward dislocation of the humeral head iscomparatively rare and is often missed in diagnosis.

Rotator cuff tear

The rotator cuff plays a major role in shouldermobility, especially in flexion-extension andinternal external rotation movements. Any of thefour muscles may be damaged resulting insevere impairment of shoulder range of motion;however, it is the supraspinatus and the subscapularis that are commonlyinjured.

Tears may be partial or complete. Complete tears of the rotator cuff areclassified as C1 (small complete tear, pinhole-sized), C2 (tear less than 2cm of only one tendon, no retraction), C3 (large complete tear of an entiretendon, retraction of 3-4 cm) and C4 (massive tear involving two or moretendons of the rotator cuff).

Rotator cuff tears occur as a result of chronic overuse in sports involvingoverhead movements of the shoulder such as in swimming, golf, basketballetc. and due to trauma in contact sports such as football, hockey etc.

SLAP lesion

The glenoid cavity is a shallow depression in the scapula on which thehumerus articulates to form the shoulder joint. The glenoid labrum is afibrocartilaginous rim attached around the margin of the glenoid that helpsto deepen the cavity. SLAP (superior labral tear from anterior to posterior)is a form of tear of the glenoid labrum caused by repetitive overheadthrowing and lifting, or catching heavy objects above the shoulder height.Common sports associated with the injury include swimming, bowling,javelin etc.

Shoulder fracture

Fractures of the clavicle, humerus, scapula and glenoid are commonaround the shoulder. These usually occur due to trauma in contact sportslike football, wrestling, hockey etc. They may also be associated with sportssuch as biking, skateboarding etc. where there is a chance of heavy falling.Clavicle or collarbone fracture is comparatively rare and forms only 3% ofthe fractures around the shoulder.

Management of shoulder injuries

As with any other injury, management guidelinesfollowing a shoulder injury also consist of:

1. A clinical examination
2. Investigation and imaging
3. Treatment

A proper clinical examination by a trained physician/surgeon forms the cruxfor accurate diagnosis of the injury. Specific blood tests may be donebased on the underlying condition. However, a complete blood profile isoften required if surgery is to be performed.

Imaging investigations include plain X ray, CT scan and/or MRI of theshoulder joint, especially if rotator cuff or soft tissue injury is suspected.The treatment challenge in a sports injury is the need to revert back tonormal or near-normal at the earliest, in order to allow the players topractice and perform. The treatment options in a shoulder joint injury maybe non-operative or operative. There are definite evidence-basedguidelines available today to identify which shoulder injury needs operativemanagement versus non-operative management.

In acute cases, non-operative management includes Rest, Ice,Compression, and Elevation (RICE) followed by medication (pain-relief andanti-inflammatory) and physiotherapy (electrotherapy, exercise therapy).Operative management consists of either open surgery orarthroscopic/keyhole surgery. Open surgery is rarely performed now andhas certain strict indications as in shoulder dislocation, fractures etc. For allother conditions, an arthroscopy may be performed.

Arthroscopy or keyhole surgery

Arthroscopic surgery is of gaining importance in the world of sports and is acommon procedure for most shoulder injuries. The word arthroscopy isderived from the Greek terms ‘arthro’ (relating to joints) and ‘scopy’(meaning ‘looking into’).

An arthroscopy is not just a treatment procedure but can be diagnostic andcan supplant non-invasive imaging techniques. This minimally invasiveprocedure is performed using endoscopes which are inserted into theconcerned joint through one or two small incisions.

Compared to open surgery, arthroscopy has multiple advantages. Scopysurgeries are cosmetically better due to small incisions and are associatedwith lesser blood loss, faster recovery, faster healing and shorter hospitalstay. Arthroscopy may be performed as a day care surgery and involvesless use of pain medications. Infections and neuro-vascular injuries mayoccur later but the complication rates are lower compared to open surgery.

Dr. Nijith O Govindan (BPT, MBBS, MS Orthopaedics)

Consultant Orthopaedic Surgeon
Lakshmi Group of Hospitals, Cochin, Kerala, India – 682 016
Phone: 9475601731

The post Shoulder injuries in the world of sport appeared first on MIOC Ortho Clinic.

• Learn the correct technique to play the sport of your choice under atrained person. This can help minimise the risk of injury
• Do warm ups and general stretching exercises, plus stretchingexercises specific to your sport, before the game begins. Researchshows that a heated muscle is less likely to be strained and stretchingexercises help improve your flexibility. Start slowly and build up to amore brisk and energetic pace
• Wear the right protective gear and ensure it is in excellent conditionbefore every game. Ill-fitting helmets, gloves, shoes etc can lead toserious injuries, especially in contact sports like rugby, football etc
• Know your body limit and take care not to over-exert yourself. Pain inyour joints, for example, is a sign that you should cut back on youractivity. Avoid exercise when you are tired or in pain
• A cool down period is crucial after every game. The cool-downprocess allows your heart rate to return to its normal pace. It will alsolet your muscles recover steadily from physical activity
• Maintain good hydration to minimise cramps and ensure adequatesleep. Drinking sufficient water will help prevent dehydration,exhaustion, and heat stroke and keep fatigue and stress away
• Adequate relaxation and unwinding oneself between trainingsessions is also important

Post-injury care

Once injured, athletes should avoid self-medication and self-treatment andshould immediately seek the help of a qualified medical professional. Mostinjuries are amenable to treatment, and with competent management,normal anatomic and biologic functionality of the joint can be regained tothe satisfaction of the player.

Dr. Nijith O Govindan (BPT, MBBS, MS Orthopaedics)

Consultant Orthopaedic Surgeon
Lakshmi Group of Hospitals, Cochin, Kerala, India – 682 016
Phone: 9475601731

The post Preventing Sports Injuries appeared first on MIOC Ortho Clinic.

The word arthroscopy is derived from the Greek terms ‘arthro’ (relating to joints) and‘scopy’ (meaning ‘looking into’). It is a minimally invasive procedure performed usingendoscopes that are inserted into the concerned joint through one or two smallincisions. Surgeons view the joint area on a video monitor and determine the amount ortype of injury and then repair or correct the problem.

Arthroscopy can be performed on many parts of the body like the shoulder, wrist, elbow,hip, knee, ankle etc but it is most commonly performed on the shoulder (to treat rotatorcuff tears or shoulder impingement) and knee (ACL/PCL or ligament tears).An arthroscopy is not just a treatment procedure. It can be diagnostic and can supplantnon-invasive imaging techniques.

Faster, safer, less painful

Compared to open surgery, arthroscopic procedures have multiple advantages. Scopysurgeries are cosmetically better due to small incisions and are associated with lesserblood loss, faster recovery, faster healing and shorter hospital stay. Arthroscopy may beperformed as day care surgery so patients can return home on the same day itself andit typically involves less use of pain medications.

While infections and neuro-vascular injuries could occur later, the complication rates aremuch lower compared to open surgery.

To sum up, arthroscopy has many advantages over traditional surgical methods. These include:

• Smaller incisions
• Minimally invasive
• Lesser bleeding
• Faster recovery time
• Less post-surgery pain
• Fewer complications
• Fewer scars

Dr. Nijith O Govindan (BPT, MBBS, MS Orthopaedics)

Consultant Orthopaedic Surgeon
Lakshmi Group of Hospitals, Cochin, Kerala, India – 682 016
Phone: 9475601731

The post Arthroscopy – A Good Choice to Treat Sports Injuries appeared first on MIOC Ortho Clinic.