Deformities of Lower Limbs

Deformity is an alternation in shape of limbs.
Causes of deformity can be broadly grouped as:

a) Congenital deformities

b) Acquired deformities
Congenital deformities:

The exact cause is still not established. There are several factors causing these deformities such as genetic factors operating on the developing fetus during intra uterine development. Teratogenous influence of drugs and chemicals can also cause congenital deformities.
Congenital deformities of upper limbs:

a) Shoulder – Sprengel’s shoulder.

b) Elbow – congenital superior radio ulnar synostesis.

c) Wrist – Madelung’s deformity.

d) Hand – syndactylism, poly dactylism
Congenital deformities of lower limbs:

a) Congenital talipus equino varus (club foot)

b) Congenital dislocation of hip

c) Congenital genu recurvatum, genu varus (bow knees)

d) Congenital pseudoarthrosis of tibia (bow legs)
Acquired deformities:

The most common causes of acquired deformities are;

a) Trauma

b) Infection

c) Degeneration

d) Tumor

e) Metabolic disorder
Trauma:

Injuries to bones, nerves, vascular and soft tissues cause deformities such as malunited fractures, claw hand, burns contractures etc.
Infections:

Infections of bone and joints are one of the most common causes of deformities. Tuberculosis and septic infections cause the largest number of deformities. Infected non-union of long bones is indeed a big challenge.
Degeneration:

Degeneration of the joints plays a major role in deformities and most commonly occurs in the knee joints. (Osteoarthritis)
Metabolic and other systemic disorders:

Metabolic and hormonal disorders may cause skeletal deformities. For example:- rickets, vitamin D deficiency, hyper parathyroidism, senile osteoporosis and Paget’s disease.
Management:
Conservative Methods :

Conservative methods must always be tried first. These include methods such as-

Physiotherapy: Passive stretching corrects many deformities of mild degree.
Splints and casts: this is the commonest method used to correct deformities in children.
Traction: may be used for deformities caused by muscle spasm.
Manipulation of joints under anesthesia can be done to release adhesions.

Surgical methods:

When conservative methods fall and deformity causes disability, surgical methods are used. Surgical procedures include-

Soft tissue procedures
Bony procedures

Soft tissue procedures:

These are always tried first to correct deformities.

Postero medial soft tissue release in club foot.
Tendoachilles lengthening and posterior capsulotomy in equinous foot.

Bony procedures:

In severe deformities bony procedures are done along with soft tissue surgeries.

Osteotomy is done to correct deformity of bones.
Arthrodesis is done to correct deformity of joints.

Let us now take a close look at one pioneering technique – limb deformity and limb length discrepancy correction by the Ilizarov technique. The advantages of this method are that the patient remains on weight bearing throughout treatment and can move the joints in the vicinity of the apparatus.

In associated infections or with osteoporotic bone no other method can be used and the Ilizarov method is the only treatment of choice.

Professor Garvill Abhramovich Ilizarov invented and developed this extremely versatile circular ring fixator in the remote Russian city of Kurgan in Western Siberia in the early 50s. For 15 years he worked in obscurity in a tiny two storey modern hospital treating patients with his revolutionary but unrecognized technique. In 1965, The Ministry of Health from Moscow observed Dr Iliazarov’s work on the circular fixator as they were applied to patients in various clinical situations in orthopaedics and also duly recognized his immense contribution. From 1965 to 1983 more than 25,000 patients were treated at the established All Pan Union Ilizarov Scientific Center for Restorative Orthopaedics and Traumatology in Kurgan, Siberia, U.S.S.R.

From 1984, surgeons from various parts of then world have trained in the Ilizarov Technique and popularized the concepts of Prof. G.A. Iliazarov throughout the world. Apollo Hospitals Chennai was the pioneer in India for this technique.
Ilizarov ring fixing method:

This consists of 3 phases.
Operative phase:

“K” wires are passed through bones proximal and distal to the deformity. These ‘K’ wires are fixed to the Ilizarov rings by wire fixation bolts – one ring proximally and one ring to the deformity. Both the rings are connected by hinges and threaded rods.
Distraction phase:

Distraction for correction of deformity is usually started on the 10th day and continues at the rate of about 3 mm daily till the deformity is corrected. Duration of correction depends on the amount of deformity to be corrected and limb length discrepancy. Once the deformity is fully corrected, the apparatus is locked.
Consolidation phase:

This phase extends from the locking phase to the completion of solid bone formation. It takes about 2-3 months. Once the bone is solid, the Ilizarov ring fixations are removed. The patient is mobilized initially for partial weight bearing and later to full weight bearing with support.

Article written by :

Dr. R. Gopalakrishnan

Chief Orthopedic Surgeon

Apollo Hospitals, Chennai.

Procedure Details

A stapedectomy is a surgical procedure of the middle ear performed to improve hearing.

If the stapes footplate is fixed in position, rather than being normally mobile, then a conductive hearing loss results. There are two major causes of stapes fixation. The first is a disease process of abnormal mineralization of the temporal bone called otosclerosis. The second is a congenitalmalformation of the stapes.

In both of these situations, it is possible to improve hearing by removing the stapes bone and replacing it with a micro prosthesis – a stapedectomy, or creating a small hole in the fixed stapes footplace and inserting a tiny, piston-like prosthesis – a stapedotomy. The results of this surgery are generally most reliable in patients whose stapes has lost mobility because of otosclerosis. Nine out of ten patients who undergo the procedure will come out with significantly improved hearing while less than 1% will experience worsened hearing ability or deafness. Successful surgery usually provides an increase in hearing ability of about 20 dB. That is as much difference as having your hands over both ears, or not. However, most of the published results of success fall within the speech frequency of 500 Hz, 1000 Hz and 2000 Hz; poorer results are typically obtained in the high frequencies, but these are normally less hampered by otosclerosis in the first place.

Article by

KIMS Kerala

Speech & Language Therapy is treatment of problems in communication. Therapy is given for problems like child not speaking at an early age, repeating certain word, not speaking clearly, and not speaking certain letters, voice disorders and problem in communication after an accident and so on.
MICROCARE provides one stop solution to all speech problems. Our lab with state of art equipment and a professional team of Speech pathologist, Audiologist, Voice Therapist and headed by Specialist ENT Microsurgeon Dr. Sriprakash Vinnakota MS ENT will look after your communicating difficulties. MICROCARE provides rehabilitation for the following speech problems.

Delayed Speech & Language
Misarticulation
Stammering
Aphasia
Cleft Palate
Mental Retardation
Cerebral palsy
Hearing loss
Voice Disorders

Individual speech, language, and literacy therapy sessions are scheduled for patients of all ages.

Different Types of Rehabilitation Methods:
Neurological Rehabilitation: Stroke,Head Injury,Spinal Cord Injury,Guillain Barre Syndrome,Myelopathy,Myopathies,Parkinson’s Disease,Motor Neuron Disease,Movement Disorders,Balance & Coordination Disorders,Cognitive Disorders,etc.
Musculoskeletal Rehabilitation: Neck & Back pain spondylosis,disc prolapse,etc.Frozen Shoulder ,knee pain Osteoarthritis,Bursitis,ligament injuries.Sports injuries like AnkleSprain,Rotator cuff tears,Impingement syndrome,Rehabilitation following AGL repair,hip/knee replacement, Osteoporosis,Deconditioning due to chronic Illness,Rheumatological disorders,Mobilization following surgery,fractures,polytrauma.
Pediatric Rehabilitation: This inter-disciplinary programme is for infants and childern.Services are provided in the treatment of physical disabilities,developmental delay,congenital deformities,n euro-sensory impairments,orthopedic injuries and communication disorders.Our pediatric therapists have special training in the areas of development hand function,Neuro-Development Treatment (NDT),handwriting,proprioceptive neuromuscular facilitation,sensory integration .Services are available for conditions like:Cerebral Palsy,Development Disorders,Autism,pre-maturity,Attention Deficit Disorder, Brain Injury,Specific Learning Disorders,Visual Perceptual Difficulties,Down’s syndrome,Feeding Problems,Hearing Impairments,Speech Delay,Multiple Disabilities,etc.
Geriatic Rehabilitation: A Balance and coordination issues,Fall risk assessment,Fall Prevention Programme .This programme will help improve balance,endurance,muscle strength and coordination so that they can perform day-to-day tasks comfortably thereby improving quality of life.
Cardio Pulmonary Rehabilitation: This aims to prevent and minimize impairments secondary to cardiac or pulmonary illnesses and improve fitness & the quality of life of patient.Individualized rehab programme which cover exercise schedule,education and lifestyle modification are designed based on the needs and abilities of patients.Services are available for condition like:Post Myocardial infarction,Post CABG,Stable angina,Valvular heart diseases,At risk cardiac patients,Obstructive/restrictive airway disease,etc.
Chronic Pain Management: Our holistic rehab approach including counseling,interventional pain procedures and therapeutic modalities helps the patients to overcome chronic pain syndromes like Fibromyalgia,Myofascial pain syndrome,Repetitive strain injuries,Failed Back syndrome,plantar fasciitis,Tendo-Achillits,Retrocalcaneal bursitis(Heel pain),etc.
Cancer Rehabilitation: Lymphedema management,Endurance training,Pain management etc.
Women’s Health Issues: Ante natal and post natal exercise programmes,Pelvic Pain Management,Urinary Incontinence,Pre or Post natal Postural/Musculoskeletal pain.
Vestibular/Balance Disorders Evaluation and Treatment: Vestibular Rehabilitation serves patients with dizziness and other related balance problems.It consists of a comprehensive evaluation and a stage by stage progressive treatment plan to alleviate the symptoms,identity possible triggers and minimize recurrence.
Amptuee Rehabilitation: Pre amputation assessment and counselling,prescription and checkout of prosthesis and prosthesis related musculoskeletal problems.
Fitness Programme Prescription: For those planning to join Gym.
Ergonomics /Onsite Workstations Evaluations: Ergonomics Awareness and Training to prevent Repetitive Strain Injury(RSI) and other Work Related Musculoskeletal Disorders(WRMSDs).

Hand Microsurgery

Surgery of the hand is a new speciality in our country. For the first time in the private sector, The Apollo Hospitals Group has developed a 24 hour state-of-the-art facility for comprehensive care of hand injuries at The National Institute in Hand Surgery, Microsurgery and Plastic Surgery, established at the Apollo First Med Hospital in Chennai. Apollo Hospitals, is one of the very few dedicated centers for treating hand injuries in the country.

Micro surgery is a sub-speciality performed with the aid of a microscope on structures that are barely visible to the naked eye. This sub-speciality mainly deals with ‘Replantations’ (reattaching severed parts of the limb). The department consists of senior consultants who have trained and worked at leading medical institutions in India and abroad.

Notable features of this department include:

A dedicated operating theatre, exclusively for hand and general trauma.
Fully trained staff round the clock
Senior consultants available on call
Latest series of equipment
Continuity in management on individual basis

Apollo Hospitals offers surgical treatment for hand injuries and problems such as:
Congenital Abnormalities

The most common hand problems in infants are syndactyly (webbed fingers) and polydactyly (extra fingers). In all hand surgeries and especially pediatric hand surgeries at Apollo Hospitals, India atraumatic techniques (causing no tissue damage) are used.
Carpal Tunnel Syndrome

Carpal Tunnel Syndrome occurs most commonly due to the compression of the median nerve at the wrist where it passes through a narrow area called the carpal tunnel. The symptoms include numbness in the thumb, index, and middle fingers especially at night or upon waking up in the morning.

Carpal Tunnel Syndrome can be treated by releasing the constriction through endoscopic or minimal access surgery.
Arthritis

Reconstruction of painful arthritic deformities is performed routinely and includes tendon transfers, muscle release and joint displacement fusion.
Reconstructive Surgery (for tumors, nerve compression and arthritis)

Reconstructive hand surgery alleviates pain and helps correct deformities caused by tumors, nerve compression and arthritis. Many benign tumors of the hand and wrist don’t always cause pain and subside soon. However, when pain persists or limits necessary function, removal is recommended and is almost universally curative.
Microsurgery (for finger deformities)

Replantation of a single finger or multiple fingers can be done through microsurgery. Even if multiple finger amputation has been done, one or more fingers can be replanted in a position that will allow functioning of the hand. Replantation surgery will be followed by rehabilitative therapy for the hand.

Article By
Apollo Hospitals

Surgical Therapy

Several surgical options for repair of CSF leaks arising from the anterior skull base exist. There has been a paradigm shift over the last 30 years while choosing the best approach given the advancements made in endoscopic techniques.
Intracranial repair

Intracranial repair was frequently used (and is still used in select cases) for the routine repair of anterior cranial fossa CSF leaks. These leaks were typically approached via a frontal craniotomy. In rare situations, a middle fossa or posterior fossa craniotomy was required. Different repair techniques have been used, including the use of free or pedicled periosteal or dural flaps, muscle plugs, mobilized portions of the falx cerebri, fascia grafts, and flaps in conjunction with fibrin glue. Leaks arising from the sphenoid sinus are difficult to reach by means of an intracranial approach.

Advantages of the intracranial approach include the ability to inspect the adjacent cerebral cortex, directly visualize the dural defect and seal a leak in the presence of increased ICP with a larger graft. When preoperative localization attempts fail to reveal the site of a leak, intracranial approach with blind repair has been successful. In these situations, the cribriform and the sphenoid area, if necessary, are covered with the repair material.

Disadvantages of the intracranial approach include increased morbidity, increased risk of permanent anosmia, and trauma related to brain retraction, including hematoma, cognitive dysfunction, seizures, edema, and hemorrhage. In addition, the postoperative hospital stay is longer, adding to the overall cost of the procedure. Failure rates for this approach are 40% for the first attempt and 10% overall.
External approaches

Defects in the posterior table of the frontal sinus may be approached externally via a coronal incision and osteoplastic flap. The osteoplastic flap provides the surgeon with a view of the entire posterior table of the frontal sinus and is especially useful for defects more than 2 cm above the floor and lateral to the lamina papyracea. In select cases, these defects may also be approached with a simpler eyebrow incision and an extended trephination of the frontal sinus in combination with an extended endoscopic frontal sinusotomy. Care must be taken to avoid unnecessary trauma to the surrounding mucosa and the frontal recess entirely.

External approaches to the skull base can also be obtained through various incisions or through nasal approaches for access to the ethmoid sinuses and sphenoid sinus. These include external ethmoidectomy, transethmoidal sphenoidotomy, transseptal sphenoidotomy, and the transantral approach to the skull base. These procedures are infrequently chosen in current practice, given the high success rates and low morbidity associated with the endoscopic approach. However, they should be part of every skull base surgeon’s armamentarium.

External ethmoidectomy

An external ethmoidectomy begins with a tarsorrhaphy on the ipsilateral eye in order to prevent corneal injury. The incision is made halfway between the medial canthus and the midline of the nose down to bone. Lateral elevation of the periosteum exposes the anterior lacrimal ridge and the lacrimal fossa. The lacrimal sac is elevated and retracted out of the fossa.

As the periosteum is elevated posteriorly along the lamina papyracea, the anterior ethmoidal artery will be encountered 2-2.5 cm posterior to the lacrimal crest. This artery needs to be ligated to increase exposure. The frontoethmoid suture line marks the level of the fovea ethmoidalis, thus dissection should never be superior to this line. The posterior ethmoidal artery is found approximately 1.2 cm posterior to the anterior ethmoidal artery in the frontoethmoid suture line. The optic nerve lies 5 mm posterior to the posterior ethmoidal artery.

The ethmoidal cells are then entered in the area of the lacrimal fossa, and the anterior two thirds of the lamina are removed. A complete dissection of the ethmoid labyrinth is performed. The skull base is then identified in the posterior ethmoids, and the anterior wall of the sphenoid is exposed.

Transethmoidal sphenoidotomy

To perform a transethmoidal sphenoidotomy, an external ethmoidectomy is carried out first as described above. The sphenoid sinus ostium is identified and opened first with a small curette or a beaded probe. A Kerrison punch can then be used to enlarge the opening. The anterior wall of the sphenoid is removed in a meticulous fashion to gain access to the sellar region.

Transseptal sphenoidotomy

The transseptal approach to the sphenoid can be carried out using a sublabial or transnasal incision. An external rhinoplasty incision is preferred by the authors.

The sublabial approach requires the use of a gingivobuccal sulcus incision to expose the pyriform aperture and free the nasal spine. The caudal septal cartilage is then identified, and a left (or right) septal mucoperichondrial flap is elevated. This mucoperichondrial flap is elevated laterally and inferiorly along the nasal floor in the subperiosteal plane. The cartilaginous septum is dislocated from the maxillary crest, and the contralateral nasal floor mucoperiosteal flap is elevated. The contralateral nasal septum is, therefore, not elevated off the cartilage. Once the bony-cartilaginous junction is reached, it is disarticulated and the contralateral posterior flap is elevated. The bony septum is removed to expose the sphenoid rostrum, which is widely removed via osteotomies or a drill to expose the entire sphenoid sinus.

Transantral approach

A transantral approach to the skull base offers wider access to the anterior sphenoid, ethmoids, pterygopalatine fossa, and maxilla. An open anterior maxillary sinus antrostomy is known as the Caldwell-Luc procedure. A gingivobuccal sulcus incision is made, and the anterior wall of the maxilla is exposed. The periosteum is elevated superiorly as far as the infraorbital nerve, exercising extreme care to avoid injuring the nerve as it exits via the infraorbital foramen. A canine fossa osteotomy is performed to enter the maxillary sinus. Kerrison rongeurs are then used to extend the opening into the maxillary sinus. The ethmoidal bone can then be approached medially and superiorly through the maxilloethmoidal angle. A more posterior route is taken to expose the sphenoid sinus. When needed, exposure of the pterygopalatine fossa is achieved by creating an opening into the posterior wall of the maxillary sinus.

Endoscopic approaches;

Compared with external techniques, endoscopic techniques have several advantages, including better field visualization with enhanced illumination and magnified as well as angled visualization. Another advantage is the ability to more accurately position the underlay or overlay grafts. Multiple studies demonstrate a 90-95% success rate with closure of skull base defects using the endoscopic approach.

General endoscopic concepts

As previously mentioned, the role of antibiotic prophylaxis has not been studied in a controlled fashion for iatrogenic and spontaneous CSF rhinorrhea. However, the authors believe that given the previously published rates of ascending meningitis in untreated CSF leaks, the administration of perioperative intravenous antibiotics is warranted.

Decongestion of the nasal cavity with topical 1:1000 epinephrine or 4% cocaine solution is recommended in order to maximize endoscopic visualization. Injection of 1% lidocaine with 1:100,000 epinephrine at the axilla of the middle turbinate and region of the sphenopalatine artery via a transoral or transnasal route causes vasoconstriction of the blood vessels and helps to minimize bleeding. The use of intravenous anesthesia with propofol and remifentanil has also been demonstrated to reduce intraoperative blood loss when compared with inhalational anesthesia. This is related to a decreased heart rate, which translates into decreased cardiac output, thus reducing the amount of peripheral circulatory volume.

Placement of a lumbar drain has not been demonstrated to decrease recurrence rates of CSF rhinorrhea after endoscopic repair. In theory, lumbar drain placement decreases the pressure exerted by the CSF at the site of the repair, thus allowing the tissues to heal. However, this theory has not been validated. In fact, a recent study found no difference in leak recurrence when patients who had a lumbar drain were compared to those who did not. This finding remained true when the patients were subdivided according to the etiology of the leak.

In general, lumbar drain placement remains institution and surgeon dependant. One must take into account that a lumbar drain can lead to headaches related to overzealous CSF drainage and limits patient mobility postoperatively. One of the benefits of lumbar drain placement is the ability to administer fluorescein to guide in the localization of the leak.

When a lumbar drain is used, fluorescein mixed with autologous CSF is injected slowly over several minutes. As previously discussed, fluorescein is not approved by the FDA for the diagnosis and treatment of CSF leaks. Precisely 0.1 mL of 10% fluorescein is mixed with 10 mL of CSF or bacteriostatic saline. The authors have found that injecting this mixture over 10 minutes has resulted in significantly fewer adverse events such as seizures when compared with early reports in the literature.

A study by Elmorsy and Khafagy of 31 patients with spontaneous CSF rhinorrhea indicated that skull base defects can be successfully closed endoscopically using a septal graft and a middle turbinate rotational flap. In a retrospective chart review, the investigators found that defect closure was obtained in 27 patients after one surgery, with closure achieved in two more after a second surgery, giving the procedure an overall success rate of 93.5%. Closure was unsuccessful in two of the 31 patients even after a third surgery, leading to referral for a shunt procedure.[14]

A study by Lemonnier et al indicated that endoscopic endonasal eustachian tube closure is an effective management technique for refractory CSF rhinorrhea occurring after lateral skull base surgery. The surgery was successful in seven out of nine patients in the study, although one of the seven patients required a revision procedure.[15]

Specific endoscopic approaches

Several different endoscopic approaches have been developed. Each is designed to gain access to the area of interest in the most efficient fashion. The transfrontal, transcribriform, transplanum, transsellar, transclival, and transpterygoid have all been well described.

Transfrontal approach

The transfrontal approach allows access to the floor and posterior wall of the frontal sinus. Leaks originating from this area can be successfully repaired using this approach in the majority of the cases. The frontal sinus outflow tract must be carefully preserved in order to prevent mucocele formation in the long term. The main advantage of the transfrontal approach is that it avoids obliteration of the frontal sinus with an osteoplastic flap. This approach, however, may not effectively manage defects originating in the most lateral or superior aspects of the frontal sinus, since these regions may exceed the limitations of current instrumentation when the technique is performed endoscopically.

The approach begins by performing a complete ethmoidectomy. This is followed identification and dissection of the frontal recess. This area is then widened via a modified endoscopic Lothrop or Draf III procedure, which provides a panoramic exposure of the posterior table of the frontal sinus.

Transcribriform approach

The transcribriform approach exposes the medial anterior cranial fossa from the medial aspect of the middle turbinate to the olfactory groove. Posteriorly, it extends to the anterior aspect of the planum sphenoidale. Removing the perpendicular plate of the ethmoid allows access to the crista galli. Extreme care must be used when dissecting near the area of the olfactory groove as damage to the olfactory fibers will cause anosmia.

Transfovea approach

Access to the lateral aspect of the anterior cranial fossa can be achieved by using the transfovea approach. The dissection extends from the middle turbinate laterally to the lamina papyracea. The frontal sinus marks the anterior limit, and the anterior wall of the sphenoid sinus defines the posterior limit. In some cases, the middle turbinate is removed and the transfovea and transcribriform approaches are combined.

Transplanum approach

The transplanum approach allows exposure of skull base defects along the planum sphenoidale and those with significant involvement of the suprasellar region. An anterior ethmoidectomy is performed first. This is followed by a posterior ethmoidectomy, which provides access to the most anterior aspect of the planum. The anterior wall of the sella is taken down to provide posterior exposure.

Transsellar approach[16]

The transsellar approach is the route of choice for defects on the sella turcica with minimal suprasellar extension. It begins with a complete ethmoidectomy followed by identification and opening of the sphenoid ostia. The opening is then generously enlarged to provide wide exposure to the sella. If bilateral access is needed, the posterior bony septum and the intersinus septum can be removed.

Transclival approach[17]

The first steps to perform a transclival approach include a bilateral complete ethmoidectomy and a wide sphenoidotomy. The intersinus septum and rostrum are taken down. The dissection extends from carotid to carotid bilaterally and exposes the floor of the sella, the optic canals, and the upper clivus. Drilling the posterior wall of the sphenoid sinus permits exposure of the upper one third of the clivus. The abducens nerves define the lateral limit of the dissection. If access to the lower two thirds of the clivus is required, the nasopharynx is exposed via a transnasal route. The basopharyngeal fascia and prevertebral muscles are incised. The clivus is drilled down until the dura is exposed. The eustachian tubes mark the vertical segments of the carotid arteries and define the lateral extension of the dissection.

Transpterygoid approach

The transpterygoid approach begins by performing an endoscopic modified medial maxillectomy. This permits a wide view of the lateral extent of the maxilla and the posterior wall of the maxillary sinus. The infraorbital nerve is then identified and its trajectory followed. A complete sphenoethmoidectomy is then performed. The crista ethmoidalis is isolated, and the main branch of the sphenopalatine artery is identified.

At this point, the surgeon should decide whether a vascularized nasal-septal flap is going to be used to close the defect. If so, every effort to preserve the sphenopalatine artery and its more proximal supply is made. If free mucosal grafts are going to be used, the artery may be cauterized. In either situation, the bone of the posterior wall of the maxillary sinus is removed so the sphenopalatine artery can be dissected proximally to identify the (internal) maxillary artery and its ascending and descending branches. The sphenopalatine artery is also an important landmark since the pterygopalatine ganglion is situated directly posterior to the artery. Care must be taken to preserve the ganglion and its parasympathetic fibers, which contribute to lacrimation.

After the infraorbital nerve, maxillary artery and parasympathetic fibers are identified, the fat within the pterygopalatine fossa may be dissected or cauterized with bipolar cautery until the anterior wall of the lateral recess of the sphenoid sinus is identified. This bone is removed with a drill, thus exposing the contents of the lateral recess of the sphenoid sinus. Typically, any defect in the middle fossa floor occurs in this vicinity, lateral to the Sternberg canal and the foramen rotundum.

IPF:

Idiopathic pulmonary fibrosis (IPF), the prototype of interstitial lung diseases, has the worst prognosis and is the only interstitial lung disease for which approved pharmacological treatments are available. Despite being considered a rare disease, IPF patients pose major challenges to both physicians and healthcare systems. It is estimated that a large number of IPF patients reside in BRIC countries (Brazil, Russia, India, and China) given their overall total population of approximately 3 billion inhabitants. Nevertheless, the limited availability of chest imaging in BRIC countries is considered a chief obstacle to diagnosis, since high-resolution computed tomography of the chest is the key diagnostic test for IPF. Further, obtaining reliable lung function tests and providing treatment access is difficult in the more rural areas of these countries. However, IPF might represent an opportunity for BRIC countries: the exponentially increasing demand for the enrollment of IPF patients in clinical trials of new drugs is predicted to face a shortage of patients – BRIC countries may thus play a crucial role in advancing towards a cure for IPF.

Keywords: BRIC countries; High-resolution computed tomography; Idiopathic pulmonary fibrosis; Nintedanib; Pirfenidone

COPD:

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality across the globe. According to World Health Organization estimates, 65 million people have moderate to severe COPD. More than 3 million people died of COPD in 2005 corresponding to 5% of all deaths globally and it is estimated to be the third leading cause of death by 2030.[1] Most of the information available on COPD prevalence, morbidity and mortality comes from high-income countries. Even in those countries, accurate epidemiologic data on COPD are difficult and expensive to collect. However, it is known that low- and middle-income countries already shoulder much of the burden of COPD with almost 90% of COPD deaths taking place in these countries.[2,3] In this issue of Lung India, the joint ICS/NCCP (I) consensus guidelines for the diagnosis and management of COPD have been published[4] to facilitate the Indian practitioner in burden reduction, diagnosis and management of COPD.
Idiopathic pulmonary fibrosis (IPF) is a disease of unknown aetiology associated with progressive parenchymal fibrosis 1. Patients with IPF face substantial morbidity and mortality, and report substantially impaired quality of life 2. Lung transplant (LT) represents the lone intervention that potentially improves survival in IPF 3.

Pulmonary hypertension (PH) is evolving as an important factor that can adversely affect outcomes in chronic lung disease. In advanced chronic obstructive pulmonary disease (COPD), therapy directed at controlling the pulmonary artery pressure has been recommended 4. In fibrotic lung diseases more akin to IPF, such as sarcoidosis, secondary PH is common and is a marker for early death 5, 6.

Less is known about PH in IPF. Epidemiologically, several retrospective analyses indicate that PH in IPF may be frequent 7–9. Illustrating the emerging interest in PH and IPF, Ghofrani et al. 10 examined the impact of sildenafil on pulmonary haemodynamics in lung fibrosis and concluded that it caused pulmonary vasodilation and improved gas exchange. Others have also explored inhaled agents in IPF related to PH 11.

With the advent of newer options for treating PH, coupled with the lack of effective therapies for IPF, targeting PH appears attractive. However, before studying interventions it is important to define the prevalence and extent of this process. With improved information regarding the prevalence of and clinical factors associated with PH in IPF, clinicians can better determine whom to evaluate for PH, and researchers can design more appropriate clinical trials. Thus, to explore the frequency of PH in IPF, the present authors retrospectively analysed the United States LT registry. The specific objectives were to describe the prevalence of PH in IPF, to assess the severity of PH in this population and to identify clinical variables that correlated with PH

Panchakarma:

Panchakarma is the five-fold purification therapy, which is a special form of treatment in Ayurveda consisting of vamanam, virechanam, nasyam, sneha vasti and kashaya vasti. This Detox procedure is indicated for the healthy as well as for the diseased for eliminating toxins from the body. The speciality of Nagarjuna Ayurvedic Centre is that it does Panchakarma in its own classical way. It is acknowledged as an excellent method to maintain health and to slow down premature aging.

1 – Poorvakarma (Preparation of the body for Panchakarma) Abhyangam (Massage), Elakizhi (Herbal leaves bolus massage), Podikizhi (Herbal powder bolus massage), Steam bath are the procedures done to prepare body. .

2 – Pradhanakarma (Purification Procedure ) Vamana (Therapeutic emesis) Virechana (Purgation ) Nasyam (Nasal Treatment) Kashaya Vasthy (Enema prepared with herbal decoctions ) and Sneha Vasthy (Oil enema)
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3 – Paschath Karma (Rejuvenation Therapy) Njavara Kizhi(Rice bolus Massage) Pizhichil (Oil bath) etc. are the procedures usually done.
Abhyanga:

The term “Abhyanga” means oil massage. Here in Nagarjuna we do “Abhyanga” as a pre-process of Panchakarma. Two expert therapists perform the “Abhyanga” in a synchronised and systematic way. Massage improves metabolism which leads to better tissue respiration, increases circulation, causing the body to flush out its waste products more efficiently. “Abhyanga” improves concentration, intelligence, confidence, and youthfulness. It helps in alleviating Vata troubles. It provides comfort to the eyes, sound sleep, tones up the body, Improves flexibility, softness and firmness of the skin and provides long life. It is the most ancient method used to remove muscular fatigue and pain. The massage is done in a special wooden table called “Dhroni”. The wooden “Dhroni” are made from trees like Neem or Nuxvomica or trees which has similar medicinal properties.

Pizhichil:

Pizhichil is a unique treatment emerged in Kerala, which was developed from ancient classical treatment called “Kayadhara”. In Pizhichil lukewarm medicated herbal oil is poured all over the body. Trained therapists do it in a special rhythmic way continuously for about 45-60 minutes every day.It should be done as a course of 7 days minimum. This treatment is very effective in Rheumatic diseases like arthritis, paralysis, hemiplegia, nervous weakness and nervous disorders.

Njavara Kizhi:

It is the most rejuvenating treatment in which the whole body massage is given with bolus of Njavara. Njavara is special variety of rice. It is cooked in medicinal decoction with milk in to a pudding which is made to boluses tied up in muslin bag. This procedure is done by trained therapists for about 45 to 60 minutes. Njavara Kizhi works on deep tissues and improves neurological and joint functions. Njavara Theppu – Application of the same as a paste all over the body is a variation of this treatment and has cosmetic effect on the skin to improve the lustre and complex.

Siro Dhara:

In this process, herbal oils, medicated milk, medicated butter milk etc., are poured on the forehead in a particular method using a special pot for about 45 minutes a day. This treatment is effective for diseases of the head and neck, insomnia, impaired memory, spondylitis, paraplegia, fatigue and lack of vitality. This treatment also stimulates nerves, reduces stiffness and is proven to be effective for rheumatoid arthritis and other auto immune diseases.

Siro Vasthi

Medicated lukewarm herbal oil is poured into a cap fitted on the head and kept for 15 to 60 minutes per day according to the patient’s conditions. This treatment is highly effective for facial paralysis, Migraine, dryness of nostrils, mouth and throat, severe headaches and other Vata- related diseases. Also effective for the loss of tactile sense, facial paralysis, speech difficulties, insomnia and nervous disorders. Also prescribed for other diseases of the head, eyes, ears and nose.

Kati Vasthi :

In this process specially prepared warm medicated oil is kept over the lower back with a tank prepared with herbal powder paste. This treatment lasts for 30-45 minutes. Specifically for low back pain, lumbago and degenerative vertebral diseases, disc prolapse Etc.

Ela Kizhi

Small bags containing Herbal leaves are applied to the whole body in boluses heated with hot medicated oils for 45 minutes per day. This treatment is for Osteo arthritis, Rheumatoid arthritis, Spondylosis, sports injuries etc.

Nasyam:

Nasyam is the treatment of nasal application of herbal oil or juices. A purification method meant for eliminating vitiated doshas in the head and neck. Nasyam is also effective for paralytic and mental disorders.

Good offspring:

Today’s circumstances related to life style is of unhealthy food habits, use of hormones and steroids, adulteration of food stuffs, mindless use of chemical fertilizers and pesticides. The vital components for embryo formation, such as sperm and ovum are essentially cells. These cells, for the reasons mentioned above, are polluted, with the result that their effective way of functioning has been tampered with – leading to the probable birth of a progeny with weak genetics.

Clinically the three humours (Tridosha) and the seven elementary substances (Sapta dhatus) get tampered. If the offspring that is born has to be of a high standard, physically, mentally and intellectually, the source from it is born must be pure. In other words, Semen and Ovum must be without any blemish, the mind ought to be pure and the intellect must be endorsed with purpose and scientific logic.

It is in this context that the cleansing and purification process in Ayurveda achieves paramount importance. Cleansing regimen or therapy purifies every cell, source and m… more
Rejuvenation for healthy life
Emotional pressures & metabolic toxins

Many times the pressures of living situation force us to behave in a certain way to aggression and suppression of our emotional feelings. The body secretions become excess or inadequate, leading to abnormalities in the effective metabolism. Metabolism (ability to transform and convert ) is the process by which the food we eat is digested and converted to energy in cells through many stages. When metabolism is impaired, the food you eat doesn’t convert to the body element (Dathu) and become the final energy (Ojjas) in your cells. Then what does it become? It forms deficient cells and accumulates toxins in the cells that blocks the micro channels in your body. This affects the physiological functions and cause diseases.

The same problems occur due to improper food and life style. Food habits including contradictory elements taken at improper times and lack of physical exercise, all contribute to poor digestion leading to accumulation of toxins in our cells
Ayurvedic Approach to optimizing health

Ayurveda assigns prime importance to prevention rather than just curing diseases. Proper care of health through daily regimens (Dinacharya) and seasonal regimens (Ritucharya) has tremendous value in keeping your metabolic systems in best condition.

Ayurveda treats each individual as a special living being with whole of physical, mental, intellectual and spiritual qualities. Accordingly the diagnosis of diseases is also very specific. The solutions are person specific. Problems that have cumulated over years can be eliminated in a short time by few weeks of treatment. As a result of the care, your digestion and absorption, metabolism and circulation improves and the self-healing property of your body becomes optimal.

Act today wholesomely:

Rejuvenation program leads to correction of metabolic strength resulting in healthy mind, body, intellect and spirit. It helps you to evolve as a balanced mature individual. It is always advisable to undergo this care by both husband and wife together so that corrections could be attained simultaneously. The learning programs will help both to understand each other better. It helps to guide and support each other at all times.

Rasayana Chikitsa

The promotive treatment is to attain longevity and freedom from disorders by optimizing the strength of physique and sense organs. This treatment has tremendous scope in arresting the process of aging and building up immunity against diseases like Cancer and many other degenerate conditions. Rasayana Chikitsa known in the classics as ‘Vatatapikam’ and ‘Kutipravesika’ for complete rejuvenation is undertaken only after detailed discussion with the Physician.

Do’s and Dont’s
For providing better results from Ayurvedic Treatments, we strictly advise following regimen during treatment days

During therapy, indulging in activities requiring more than ordinary physical exertion is contra effective.
Smoking/Consumption of Alcohol or any Narcotic Drugs in rooms and any of the premises of the Nagarjuna Ayurvedic Centre is strictly prohibited.
Nagarjuna Ayurvedic Centre is strictly vegetarian. Meat, fish, eggs are not allowed. Eatables from outside are also not allowed
During your stay in our Nagarjuna Ayurvedic Centre, we provide medicated herbal drinking water only, as a part of detoxification treatment
No major treatments during menstruation days.

Article by
Nagarjuna Ayurvedic Centre: Kalady – 683 550, Kerala, India

NATUROPATHY:

Naturopathy is a natural ayurvedic healing technique using the healing powers of nature. The principle of Naturopathy is that the accumulation of toxins is the root cause of all diseases. Prevention and elimination of toxins is the route to health. Treatments are based on the 5 great elements of nature that have immense healing properties. There is no role of internal medications in the nature cure system.

The Five great elements of nature and the treatments based on them are:

Earth – Mud baths, Mud packs,
Water – Hydrotherapeutic methods in the form of Baths, Jets, Douches, Packs, Compresses, Immersions
Air – Breathing exercises, Outdoor walking, Open air baths
Fire – Sun baths, Thermoleum baths, Magnetised water, Colour charged oils / water
Ether – Fasting therapy

Other Naturopathic Therapies:

Yoga
Oriental healing techniques like Reflexology, Acupressure, Acupuncture and Auriculotherapy
Food and Nutrition
Magnetotherapy
Physiotherapy
Chromotherapy

This multi disciplinary approach uses the healing power of natural resources like foods, herbs, earth, water, air, sun and magnets to allow the body to heal itself. It helps in degenerative and chronic conditions like asthma and arthritis, gastro-intestinal problems and hypertension.
Dead Sea PackEARTH – MUD THERAPY

Of the five elements of nature, mud represents Earth and has tremendous impact on the maintenance of health and prevention of diseases. Minerals and trace elements present in the mud are known for its renowned effects and healing properties. Mud also has the remarkable property of holding moisture for a long time, which has a cooling effect on the part of the body applied.

Helps improve circulation and relax the muscles
Improves the digestive activity and sets right the metabolism
Local application helps relieve inflammations, swellings and reduces pain
Excellent in skin conditions without open lesions
Helps bring down blood pressure
Nourishes the skin
Conditions the hair
Specific kind of application relieves the stiffness of joints

MUD PACKS

Frequent application of mud helps in improving the complexion of the skin by getting rid of spots and patches, which appear in various skin disorders. Mud baths are also generally recommended for all skin diseases, including psoriasis, leucoderma and urticaria and other allergic conditions of the skin.
BODY WRAPS

Using special Natural Muds high in natural minerals and salts the pack is applied on the entire body except the head.
Dead Sea Mud Body Wrap

The mud from the Dead Sea is highly saturated with natural salts and minerals like calcium chloride, iron and sulphates. These minerals are known for their renowned effects and healing properties.

It cleanses, exfoliates, draws out toxins, hydrates and improves the flow of nutrients to the skin surface

Moor Mud Body Wrap

This mud is from the boggy lake and marshland in Austria, which is home to a rich inheritance of plants and herbs, some of which are unique It contains about 300 medicinal herbs, lipids, enzymes, essential oils, minerals and vitamins.

Good for acne, eczema, psoriasis and other skin disorders
A natural anti-inflammatory
Good for rheumatism and arthritic conditions
Helps break down cellulite by stimulating the circulation and lymphatic system

Great Salt Lake Mud Body Wrap

The whole body is covered with this mud which is composed of pure natural clay and a trace elements and minerals blend product from the Great Salt Lake.

Restores and revitalizes the skin for a healthy appearance
Excellent for psoriasis, eczema, acne and other skin irritants

Hungarian Wellness Mud Body Wrap

Improves the skin cells metabolism and gently soothes irritation
Provides firmness and strength and deeply penetrates the tissues to help clear stored toxins

Hydro TherapyWATER – HYDROTHERAPY

This uses the therapeutic properties of water. This medium was made use in therapeutics hundreds of years ago. Water has great healing properties and exhibits different properties at different temperatures. The temperature of the water for any treatment depends on the effect desired. Kellogg is considered to be the Father of Hydrotherapy.

Water is used internally and externally in all its forms- steam, liquid or ice, to cleanse and restore health. It is used in the form of Baths, Jets/Douches, Packs, Compresses and Immersions to name a few.

Drinking a specific amount of water also has therapeutic effects:

Helps maintain hydration of the body
Helps in proper secretion of body fluids and maintenance of Ph.
Aids digestion and prevents constipation
Improves skin condition and nourishes it
Maintains the flexibility of joints
Helps in detoxification

HYDRO WASHES

This helps cleanse and detoxify even the internal cavities of the face.
HYDRO BATHS

Arm and Foot Bath

Relieves localized pain and inflammations
Relieves congestive headaches
Relieves the spasms of the bronchioles and facilitates easy breathing as in asthma and bronchitis
Excellent for relieving the numbness and tingling in the extremities as in diabetes mellitus

Hip Bath

Stimulates the circulation towards the pelvic and digestive organs relieves constipation, flatulence and indigestion
Helps set right the menstrual disorders like dysmenorrhoea, menorrhagia, leucorrhoea
Helps strengthen the hips and lumbar sacral spine and the coccyx and relieves pain if any
Beneficial in relieving haemorrhoids

Spinal Bath / Anti-Stress Bath

Stimulates the spinal nerves
Relaxes the paraspinal muscles
Helps maintain the blood pressure
Helps in regulating the moods like anxiety or depression
Relaxes irritable nerves

Steam Bath

Exposing the entire body with the exception of the head to a superheated atmosphere helps in many ways. Steam inhalation helps decongest the respiratory tract

Medicated ayurvedic or herbal steam helps rejuvenate the body
Helps open up the skin pores
Helps remove the toxins of the skin through sweating
Helps the skin maintain its natural moisture and softness

WET PACKS

This treatment allows an in-depth detoxification of the areas which are swollen, blocked or sensitive and helps to restore the vitality of the skin and the body. There are several packs like abdomen, knee, trunk, shoulder, ankle and neck packs.

Relieves inflammation and swellings
Improves circulation
Relieves the stiffness and spasms of muscles and joints

HYDRO JETS / DOUCHES

These spa treatments help refresh, stimulate and boost vitality of the body. They improve the peripheral blood circulation and stimulate the nervous system.
COMPRESSES

This is the application of water in the form of a pack wrung out in water of different temperatures.

Helps in detoxification of areas which are swollen, blocked or sensitive
Excellent for tight sore muscles, edema, cellulite
Stimulates the blood and lymph stream
Gives soothing, refreshing, calming and decongesting qualities

IMMERSIONS

It is one of the hydrotherapeutic techniques where the body locally or wholly is immersed in water of different temperatures.

Helps improve the circulation to the part immersed and also the peripheral circulation
Helps relieve edema
Useful in treating skin disorders
Helps to relieve congestion of the reflex regions thereby relieving symptoms of asthma, migraine, insomnia, etc

COLONIC HYDROTHERAPY / IRRIGATION

The colon is the seat of all toxins in the body. This detoxifying treatment involves a soothing gentle flow of filtered, temperature-controlled water throughout the colon to flush out logged waste and toxins.

Helps bring about efficient elimination of waste products
Helps restore tissue and organ function
Rebalances body chemistry

REFLEXOLOGY

An Oriental healing technique used to relax the nerves and release the trapped energy. There are energy zones that run throughout the body and reflex areas in the feet that correspond to all the major organs, glands and parts of the body. Based on the principle that reflex points in the feet and palms correlate to individual organs and parts of the body, manipulations on these reflexes help stimulate the organs. It helps those suffering from insomnia, menstrual problems and pains.Reflexology

Reduces stress and induces deep relaxation
Improves circulation
Cleanses the body of toxins and impurities
Brings the whole system into balance
Vitalises energy
A preventive healthcare by enhancing the immune system
Helps encourage healing in combination with specific treatments

ACUPRESSURE

This natural Oriental healing technique uses applied pressure to specific points on the body to relax trapped nerves and release blockages. It is used both as a preventive and curative therapy. It helps alleviate pain, fatigue and addresses musculoskeletal problems.

Induces relaxation and restores balance
Stimulates the circulatory and lymphatic system
The therapeutic touch stimulates certain chemicals in the brain that boost the immune system, lifts depression and relieves stress

AcupunctureACUPUNCTURE

Chinese Acupuncture works by using fine needles painlessly applied to specific points around the body to stimulate channels of energy flow allowing the body to balance itself. It helps in migraines, pains, sciatica and allergies like asthma and sinusitis.

Effective in alleviating pain particularly in painful recurring diseases
Relaxation of muscle spasm so that the toxicity held in the muscle and internal organs and glands is released
Promotes healing and rebalancing of the subtle bodies and physical body

AURICULOTHERAPY
All the internal organs of the body and the most vital functions like heart rate, blood pressure, etc and also thirst, hunger, etc are represented in each ear. By pricking needles in these regions we are aiming at stimulating and normalizing the functions of these organs.

There are also points which help get rid of addictions, increase or decrease appetite, raise or lower blood pressure, heart rate and pulse rate.
NutritionNUTRITION & DIETETICS

Using food as medicine, an individually devised, wholesome and natural diet is aimed at balancing nutritional deficiencies, combating allergies, digestive disorders and building resistance to disease. Medical nutrition therapy and specific diet strategies are advised for chronic conditions, illnesses, or injuries.

Swedish MassageMASSOTHERAPY

There are different types of massages dependent on the materials and techniques used. To add to the experience we have soft soothing music and aromatic oils to stimulate the senses.

ENERGY BALANCE MASSAGE

This cream massage is soothing and is ideal for stress relief, relaxation and as a remedial treatment for physical and emotional problems.
SWEDISH MASSAGE

A therapeutic massage using a variety of manipulations helps eliminate toxic accumulation which causes stress, fatigue, muscular aches and pains.
THAI MASSAGE

This massage is based on the theory that the body is made up of 72,000 sen or energy lines. Many of these channels correspond to Chinese meridians while others correspond to the concepts of Nadis from the Ayurvedic medical science. The massage helps stretch and stimulate the body. The patterns of gentle rocking, stretching and rhythmic compressions opens up blockages on the energy lines.

Helps remove blockages and improve vitality
Opens the joints and balances all the major muscle groups in the body
Suitable for long term injuries
Builds a high level of fitness
Bring one into a deeply relaxed state
Helps one become more flexible

FOMENTATION MASSAGE

With the help of hot or cold packs the massage is done to stimulate or relax the body.
UNDERWATER MASSAGE

This massage under water helps balance the pressure within the body. It makes the body feel lighter as the body under water increases the buoyancy of the body.

Relieves joint stiffness
Relieves muscle spasms
Improves the circulation especially peripheral circulation
Activates the functions of the skin

DRY MASSAGE

This gentle massage without oil/cream helps stimulate the area.
AROMA OIL MASSAGE

A very relaxing and refreshing massage using the aromatic oils that have very specific properties and effects on the body.

Refreshing to the senses and mind
Highly relaxes and calms the mind
Sets right the metabolic disorders
Improves the skin condition and nourishes it

MAGNETO THERAPY
This is the treatment of diseases with the healing powers of magnets. Magnets are natural substances which exhibit different properties on different poles. The same properties of magnetism are exhibited in humans as well. It is this similarity which helps in therapeutic administration.

It is a totally non-invasive therapy where no medications or radiations are involved and no side effects are seen. Through the application of magnetic field on the body, it has proved beneficial in certain diseases, especially in rheumatic and muscular aches and pains, as it has the power of draining pains out of the body. It is contraindicated in case of those having pace makers, pregnancies or carcinomas.
ZERO BALANCING

It is the art and skill of balancing body energy with body structure through touch. This is a hands-on bodywork system designed to align energy of the body with the physical structure.
CRANIO SACRAL THERAPY
This subtle technique listens to the rhythm of the body particularly the spinal column which in turn helps release the natural flow of energy within the body. Latent injuries be they physical or emotional will help get healed.

Knee Replacement Implant Materials:

The replacement knee joint is comprised of a flat metal plate and stem implanted in your tibia, a polyethylene bearing surface and a contoured metal implant fit around the end of the femur. The use of components made from metals and polyethylene allow for optimum articulation (or joint mobility) between the joint surfaces with little wear. Because the knee implant has a flatter bearing, wear is less of a problem than in a hip implant which has a very deep bearing.

Materials which can be used in knee implants are:

Stainless Steel

Due to limited ability to withstand corrosion in the human body in the long term, stainless steel is not often used in knee replacement implants. It is more suited to being used as temporary implants such as fracture plates and screws.
Cobalt-chromium Alloys

Cobalt-chromium alloys are hard, tough, corrosion resistant, bio-compatible metals. Along with titanium, cobalt chrome is one of the most widely used metals in knee implants. There is no consensus as to which material is better and more suitable.

Although the percentage of patients having allergic reactions related to the use of cobalt-chromium alloys to is very low, one area of concern is the issue of tiny particles (metal ions) that may be released into the body as a result of joint movement. These particles can sometimes cause reactions in the human body, especially in case of those patients who have allergy to special metals like nickel.
Titanium and Titanium Alloys

Pure titanium is generally used in implants where high strength is not necessary. For example, pure titanium is sometimes used to create fiber metal, a layer of metal fibers bonded to the surface of an implant which allows bone to grow into the implant or allows cement to better bond to the implant for stronger fixation.

Titanium alloys are bio-compatible in nature. They commonly contain amounts of vanadium and aluminum in addition to titanium. The most used titanium alloy in knee implants is Ti6Al4V. Titanium and titanium alloys have great corrosion resistance, making them inert biomaterial (which means they will not change after being implanted in the body).

Titanium and its alloys have a lower density compared to other metals used in knee implants. Additionally, the elastic nature of titanium and titanium alloys is lower than that of the other metals used in knee implants. Because of this, the titanium implant acts more like the natural joint, and as a result, the risk of some complications like bone resorption and atrophy are reduced.

Uncemented implants

Knee implants may be “cemented” or “cementless” depending on the type of fixation used to hold the implant in place. The majority of knee replacements are generally cemented into place. There are also implants designed to attach directly to the bone without the use of cement.

These cementless designs rely on bone growth into the surface of the implant for fixation. Most implant surfaces are textured or coated so that the new bone actually grows into the surface of the implant.

For this, surface of the titanium is modified by coating the implant with hydroxyapatite, a bioactive surfacing agent that will ultimately bond as the bone grows into it.
Tantalum

Tantalum is a type of pure metal, which has excellent biological and physical properties, namely flexibility, corrosion resistant, and biocompatibility. Recently, a new porous substance has been made of tantalum named Trabecular Metal. It contains pores, the size of which makes this material very good for bone in-growth. In addition, Trabecular Metal has an elastic nature which aids bone remodeling.
Polyethylene

The tibial and patellar components in knee replacements are made of polyethylene. Though standard polyethylene surfaces traditionally suffered from wear in hip implants, wear is less of a problem in knee implants as the bearing surfaces are flatter and do not result in the same kind of wear. The use of Ultra Highly Cross Linked PolyEthylene (UHXLPE) or Ultra High Molecular Weight PolyEthylene (UHMWPE) reduces even the minimal wear enabling the knee implants to last for a much longer time.
Zirconium

Zirconium alloy and all plastic tibial component:

Zirconium alloy is used in a new ceramic knee implant. The zirconium alloy is combined with an all-plastic tibial component, replacing the metal tray and plastic insert used in other knee replacements. It is believed that this new knee could last for 20-25 years, substantially more than the 15-20 years that cobalt chromium alloy and polyethylene implants are effective. The new combination can be lubricated, which results in a smoother and easier articulation through plastic.

Another important characteristic of this material is that it is biocompatible, meaning that people who have nickel allergies and cannot have knee implants made of cobalt chromium alloy (because nickel is an ingredient of cobalt chromium alloy). Zirconium alloy implants eliminate the risk to nickel-allergic patients because this new material contains no nickel.