The lining of the womb or uterus is called endometrium. Endometriosis is an estrogen hormone-dependent condition that is characterized by the presence of ectopic endometrial tissue in places within the body but outside of the uterus. The disease state and symptoms can be modified by pregnancy, breast feeding and menopause.

The pathogenesis of endometriosis remains an enigma in gynaecology and a topic of heated debate. There are 2 distinct entities:

Endometriosis (external – outside of the uterus)
Adenomyosis (in the muscle of the uterus).

Diagnosis:

A good clinical history and a thorough clinical examination help point in the direction of the correct diagnosis. To confirm the diagnosis, a woman will be advised to undergo a pelvic ultrasound assessment and laparoscopy (keyhole camera procedure) which is considered the “gold standard” tool. Other sophisticated tests such as MRI, intravenous urography (IVU), barium enema (X-ray procedure) may be required in some women with severe disease.

Treatments:
Endometriosis can be managed either with the help of drugs or with surgery. The drugs used for the management are geared towards reducing the impact of the oestrogen hormone.

Unfortunately, one cannot completely cure endometriosis or eradicate the disease by surgery or medications.
Following surgery for mild, moderate or severe disease, the chances of recurrence may be as high as 50% in 2 – 3 years. Also, symptoms of pain may recur once the medications are stopped.

Drugs:
Painkillers
Combined oral contraceptive pill (COCP)
Progesterone only pill
Gonadotropin releasing hormone agonist (GnRHa e.g. Zoladex, Prostap, Luprolide acetate etc)
Mirena IUS (Progesterone loaded IUCD)

Initial management of pain symptoms is generally with painkillers or analgesics. If a woman is not desirous of fertility and pain is her main symptom, the use of the combined oral contraceptive pill continuously for 3 – 6 months followed by short breaks of 7 days could help relieve the symptoms.
In women that are overweight or obese, those that have a family history of blood clots, or those that smoke and those with an altered liver function, the use of oestrogen containing pills is contraindicated. In such cases, one may use the progesterone only pill continuously for 3 – 6 months.

GnRH analogues are injections that will be given to cases with moderate to severe endometriosis. These injections are given either or a monthly or 3 monthly basis. The GnRH analogues temporarily switch off the ovaries thereby reducing the impact of oestrogen on the endometriotic deposits and causing a regression in their size and improvement in the pain symptoms. Women may need to use a small dose of hormone replacement therapy (HRT) during the GnRH analogue treatment to combat symptoms of low oestrogen such as hot flushes, night sweats, mood swings and irritability.
The Mirena IUS is a progesterone (levo-norgestrel) loaded intra-uterine device that has been found to have a beneficial impact on symptoms of pain.
Unfortunately, none of the above will allow a woman to conceive or fall pregnant during treatment.
Article by
Fortis Hospitals

Chronic pelvic pain is defined as pain the abdomen / pelvis below the level of the belly button (umbilicus) that has been present for 6 months or more.

It may or may not be associated with menses or periods. It is not a disease but a symptom that can be caused several different conditions.

Diagnosis:

Detailed history
Clinical examination
Blood tests
Urine test
Pelvic Ultrasound
Laparoscopy (key hole camera procedure through the belly button)
Others: CT scan, MRI scan.

Medical Managements:

Pain killer tablets (Paracetamol, Ibuprofen, etc)
Hormonal manipulation (Endometriosis / fibroids)
Surgical treatment of endometriosis / fibroids / adhesions or scarring
Relaxation techniques / hypnosis
Psychosocial support and counselling (Individual therapy / group therapy / patient support groups)

Article by
Fortis Hospitals

Pelvic inflammatory disease (PID) is a disease of the upper genital tract seen in women between 15 – 45 years of age and involves uterus (womb), fallopian tubes, ovaries and other areas within the pelvis. The infection affects the surface lining in all the above organs leading to damage with short and long term health implications.
The true prevalence of PID is unclear but it is known that nearly 1:50 women will see their GP with some symptoms due to the disease process. The common organisms associated with PID are Chlamydia trachomatis and Neisseria gonorrhoea. The other organisms that cause pelvic infection include Anaerobes, Mycoplasma genitalium, genital Tuberculosis etc.
Screening programes have revealed that asymptomatic Chlamydial infection can be picked up in as many as 6% women seeking contraception advice and up to 5% women undergoing cervical smear test (PAP smear). Overall screening programmes have shown a pick up rate of between 1-17% in asymptomatic women.

Diagnosis:
The doctor will obtain a history and perform a clinical examination during which culture swabs will be taken from cervix (neck of the womb) and vagina to confirm the type of infective organism. This will be followed by blood tests, pelvic ultrasound scan and sometimes laparoscopy (camera procedure through the belly button). Genital Tuberculosis of the uterus can be confirmed following laboratory analysis of the endometrium (biopsy of the lining of the womb). Currently there is no single test that will accurately diagnose the presence of PID.

Medical Management:

Prevention – Safe sex education in schools and colleges, changing or modifying behaviour, programmes for screening of infection in the population
Oral drugs – prompt treatment for the infected individual with appropriate drugs for a prescribed time period
Contact tracing of sexual partners and treatment
Hospitalization, Intravenous drug therapy and surgery (laparoscopic / open) for severe cases and especially those that develop abscesses in the tubes and ovaries and also that fail to respond to standard oral drug therapy
In the future vaccination for prevention

Article by

Fortis Hospitals

The ankle-brachial index test is a quick, noninvasive way to check your risk of peripheral artery disease (PAD). Peripheral artery disease is a condition in which the arteries in your legs or arms are narrowed or blocked. People with peripheral artery disease are at a high risk of heart attack, stroke, poor circulation and leg pain.

The ankle-brachial index test compares your blood pressure measured at your ankle with your blood pressure measured at your arm. A low ankle-brachial index number can indicate narrowing or blockage of the arteries in your legs, leading to circulatory problems, heart disease or stroke. The ankle-brachial index test is sometimes recommended as part of a series of three tests, including the carotid ultrasound and abdominal ultrasound, to check for blocked or narrowed arteries.

The ankle-brachial index test is done to check for peripheral artery disease (PAD), a condition in which the arteries in your legs or arms are narrowed.

Ask your doctor if you should have this test if you are age 50 or older and have any of these risk factors for PAD:

Being a current or former smoker
Diabetes
Overweight (a body mass index of 25 or greater)
High blood pressure
High cholesterol

If you’ve already been diagnosed with PAD, your doctor may recommend having an ankle-brachial index test to see if your treatment is working or if your condition has worsened. If you have symptoms of PAD, your doctor may suggest you have an exercise ankle-brachial index test to determine if your symptoms are due to PAD or other conditions, such as spinal stenosis. In an exercise ankle-brachial index test, you walk on a treadmill for a short time before your ankle-brachial index is measured.
When the ankle-brachial index test is complete, your doctor calculates your ankle-brachial index by dividing the higher of the two blood pressure measurements at the arteries near your ankle by the higher of the two blood pressure measurements at your arms. Based on the number your doctor calculates, your ankle-brachial index may show you have:

No blockage (1.0 to 1.4). An ankle-brachial index number in this range suggests that you probably don’t have peripheral artery disease. But if you have certain risk factors, such as diabetes, smoking or a family history of PAD, tell your doctor so that he or she can continue to monitor your risk.
Borderline (0.9 to 0.99). If your ankle-brachial index number is less than 1.0, you may have some narrowing of the arteries in your leg. People with an ankle-brachial index of 0.9 or lower may have the beginnings of PAD. Your doctor may then monitor your condition more closely.
Mild blockage (0.8 to 0.89). An ankle-brachial index in this range shows you’re in the early stages of PAD. Your doctor may suggest medications or lifestyle changes to treat your condition.
Moderate blockage (0.5 to 0.79). An ankle-brachial index number in this range shows that you have more significant blockage of your ankle and leg arteries. You may have noticed some pain in your legs or buttocks when you exercise.
Severe blockage (less than 0.5). If your ankle-brachial index number is in this range, your leg arteries are significantly blocked and you may have pain in your legs even while resting. An ankle-brachial index of less than 0.4 suggests severe PAD.
Rigid arteries (more than 1.4). If your ankle-brachial index number is higher than 1.4, this may mean that your arteries are rigid and don’t compress when the blood pressure cuff is inflated. You may need an ultrasound test to check for peripheral artery disease instead of an ankle-brachial index test, or a toe-brachial index test, in which the blood pressures in your arm and big toe are compared.

The above numbers are based on guidelines Mayo Clinic uses. The guidelines suggested by the American Heart Association and the American College of Cardiology differ slightly. They suggest a normal ankle-brachial index ranges from 1.0 to 1.4, a borderline index ranges from 0.91 to 0.99, and an abnormal index is 0.9 or lower. If you have an exercise ankle-brachial index test, the ranges for results differ. Talk to your doctor about what your results mean.

Depending on the severity of your blockage, your doctor may recommend lifestyle changes, medications or surgery to treat PAD. Talk to your doctor about your options. You may also need additional imaging tests to see what treatment is best for you.

The test may not adequately measure the ankle-brachial index if you have severe diabetes or calcified arteries with significant blockage. Instead, your doctor may need to read your blood pressure at your big toe (toe-brachial index) to get an accurate test result if you have either of these conditions.

Article by;
Fortis Hospitals

Results:

Medical Therapy:

The medical management of penile trauma is limited and usually depends on surgical optimization of the patient in preparation for the operating room. Penile trauma is often accompanied by other associated injuries, some of which may be life-threatening. Fluid resuscitation and stabilization of the patient should be the focus. Administration of preoperative antibiotics should be considered in patients with open wounds.

If penile reconstruction must be delayed in the setting of a urethral injury, suprapubic urinary diversion may be performed. If surgical therapy must be delayed, initial medical therapy consists of cold compresses, pressure dressings, and anti-inflammatory medications, followed by definitive surgical therapy.
Penile amputation

Pretreatment of the patient with an amputated penis has unique requirements. In the face of an acute psychotic episode, psychological stabilization is required, often with the aid of a psychiatrist. Management of the amputated penile remnant is imperative to a successful reimplantation. The severed penis should be cleaned of debris and wrapped in sterile, saline-soaked gauze. The wrapped penis should be placed into a sealed bag and placed inside a second container filled with an ice-slush mix. This helps to reduce the ischemic injury to the severed penis. Reimplantation should be performed as quickly as possible.
Penile soft tissue loss

Bite injuries to the penis require extra care, as they have the potential for infection with unique organisms. Dog bites, the most common animal bite, consist of multiple pathogens such as Staphylococcus and Streptococcus species, Escherichia coli, and Pasteurella multocida. Antibiotic treatment should generally include oral dicloxacillin or cephalexin. Patients with possible Pasteurella resistance can be treated with penicillin V. Chloramphenicol has also been shown to have good efficacy.

Human bites are considered infected by definition and should not be closed. They can be treated with antibiotics similar to those used in animal bites despite the fact that bacterial cultures may differ.

Surgical Therapy

No matter the form of penile trauma, the goals of surgery for the traumatized penis are universal: restore the penis to its preinjury state, prevent erectile dysfunction, maintain penile length, and allow normal voiding.[9, 10, 11]
Penile fracture

In the reported literature, surgical therapy has consistently resulted in fewer complications. Muentener et al reported good outcomes in 92% of patients treated surgically versus only 59% in those treated conservatively. In addition, surgery provides good outcomes after varying timing of presentation after injury. A study by El-Assmy et al found no substantial difference in recovery based on early or delayed presentation of penile fracture with subsequent surgery. Patients were divided into group I early presentation (1-24 hours after injury) and group II delayed presentation (30 hours to 7 days after injury). Mean follow-up was 105 months for group I and 113 months for group II.[12]

Principles of surgical therapy are as follows:

Optimize the surgical exposure.
Evacuate the hematoma.
Identify the site of injury.
Correct the defect in the tunica albuginea.
Repair the urethral injury.

Three types of incisions are generally used to repair penile fracture: incision directly over the defect, circumscribing-degloving incision, and inguinal-scrotal incision.

An incision directly over the identified defect in the corpus cavernosum allows minimal dissection of neurovascular bundles but does not afford complete evaluation of both the corpora cavernosa and the corpus spongiosum. The authors do not advocate this type of entry. A circumferential-degloving incision begins 1 cm proximal to the coronal sulcus and affords excellent exposure. However, decreased penile sensation has been reported with this type of incision. The inguinal-scrotal incision provides excellent exposure of the base, root, and dorsal surfaces of the penis. If necessary, the entire penis may be averted inside out to maximize surgical exposure.

At the authors’ institution, a circumferential-degloving incision is routinely used with excellent results. On occasion, the authors have also used an inguinal-scrotal incision for more complex injuries located near the base of penis.
Penile amputation

An amputated penis should be immediately and expeditiously repaired to prevent further ischemic injury to the penile remnant. This should be undertaken at a center of excellence, and the patient should be stabilized and transferred if a reconstructive urologist or plastic surgeon is not available at the presenting institution.

Principles of surgical therapy are as follows:

Optimize the surgical exposure.
Judiciously debride necrotic tissue.
Anastomose the severed urethra over a Foley catheter to provide stabilization.
Repair the tunica albuginea.
Use microsurgery to repair the dorsal nerves, arteries, and veins of the penis.

Penetrating injury

Expeditious surgical repair of the penis should be undertaken as soon as possible.

Principles of surgical therapy are as follows:

Optimize the surgical exposure.
Judiciously debride necrotic tissue.
Repair injured urethra.
Repair tunica albuginea injuries.

Penile soft tissue injury

Surgical repair should be initiated as soon as possible in soft tissue injuries. This prevents colonization of the wound. The only exception is that of the human bite because of the high risk of polymicrobial infection.

Principles of surgical therapy are as follows:

Debridement of necrotic tissue
Copious irrigation of wound with povidone iodine and antibiotic solution
Closure of injury with exception of human bites
Skin grafting and harvest to cover large defects

Article by
Apollo Hospitals

Single Port Endoscopic technique of Carpal Tunnel Release (ECTR)

Carpal Tunnel Syndrome is a medical condition where in people suffer from numbness, pain and discomfort in the hand accompanied by tingling, burning, numbness, weakness of hand grip or simply pain. It is caused by the gradual strangulation of the Median nerve by the surrounding structures coursing within the carpal tunnel of the wrist, leading to nerve entrapment symptoms. These are usually felt over the thumb, index and middle finger, though the pain may extend up to the shoulders.

One in every five people suffering from such symptoms can be expected to have CTS following a thorough clinical examination, imaging and electrophysiologic (Nerve Conduction) studies. If untreated, it may result in permanent nerve damage causing constant numbness, wasting of the muscles of the hand involved in thumb movements.

This condition may affect both hands, though symptoms may predominate on one side. In early stages, the symptoms are intermittent in nature and usually occur at night times, the possible explanation being the flexed position of the wrist joint during sleep. However, the numbness can be intense enough to wake one from sleep.

Non surgical treatment includes the use of night splints, steroid injection, oral anti-inflammatory and analgesic drugs. However, for acute cases, surgery is the only option. Done under local anesthesia, the procedure itself doesn’t last more than half an hour, though an added mild sedation of the patient does help in making it quicker.

With the aid of an optically linked video monitor and Smart Release device in this single port endoscopic technique of carpal tunnel release, the surgeon precisely cuts the transverse carpal ligament from underneath using a retractable blade, without cutting open the entire palmar skin. Once done the blade retracts and the endoscopic instrument is withdrawn. The less than 1 cm skin incision is closed with absorbable sutures.

The resultant cosmetically acceptable scar is small and concealed within the wrist skin crease. Patients have the advantage of returning to work after surgery within eight days or earlier.

Article by.

Apollo Speciality Hospitals, Teynampet, Chennai. Dr (Major) GB Rajan, Consultant Plastic Surgeon, Apollo Speciality Hospitals, Teynampet, Chennai.

Procedure Details

An automated implantable cardioverter-defibrillator (AICD) is a tiny electronic device implanted in the chest to prevent sudden death from cardiac arrest caused due to fast heart rhythms (tachycardias).

The AICD is capable of monitoring the heart rhythm to identify abnormal heart rhythms and determines the appropriate therapy to return your heartbeat to a normal heart rhythm.

The patient is admitted for 1 to 2 days for the AICD implantation. The implant procedure usually lasts about one hour and is performed in the Invasive Cardiac Laboratory. As it is very important to keep the area of insertion sterile to prevent infection, sterile drapes will be used to cover the patient from neck to feet. A small plastic cannula will be inserted in one of the veins on the hand to facilitate injection of medication. Just before implantation, the patient will be given an injection of an antibiotic to prevent wound infections. He/she will also receive medication through the intravenous cannula. After injection of a numbing medication, a small incision (cut) is made in the upper left chest (if you are right-handed) and a small pocket is created under the skin to accommodate the pulse generator. The lead is then inserted through a vein in the upper chest and is positioned under X-ray guidance until its tip lies snugly within the heart. The other end of the lead is then connected to the pulse generator. Your doctor may have to test the AICD by inducing an abnormal heart rhythm in the laboratory and observing if the AICD functions as expected. The patient will be put to sleep with medication before the test. The incision wound is then stitched up, cleaned and a waterproof dressing applied to the wound.

Most patients can be discharged one to two days after the implantation.

Article By

Manipal Hospitals

What is Shoulder Fracture Reduction?

The term reduction indicates restoration of a fracture or dislocation of the bone back to its normal anatomic location.

Who is a candidate for Shoulder Fracture Reduction & Fixation?

Following patients are usually candidates for shoulder fracture reduction surgery:
Patients with comminuted fractures.
Proximal humeral dislocated fractures.
Fractures with displacement.
Glenoid (shoulder socket) involvement.

How is the procedure performed?

During open reduction and internal fixation, under the effect of anesthesia, the broken bones are put back into their normal anatomical position. Fixation is done internally using pins, screws, or bands. The incisions are then closed with stitches and sterile dressing is placed.
Closed reduction procedure placing fragments of bone back into their normal anatomic position and then external fixation with sling is used to keep them in place which is removed later on.

How long does the hospital stay last?

Most of the patients need to stay in hospital for about 2 to 3 days depending on surgeon’s discretion.

What would be done for pain relief?

Pain medications are administered per the patient requirements. Oral pain medications are continued in the recovery period as long as the patient continues to need them.

What should be expected in the postoperative period/rehab?

Pain management is designed per the patient’s requirement.
Necessary precautions and medications would need to be taken.
Immobilization of arm would be done with sling.
Wound care and bandaging would be advised.
Bathing advice would be given by the surgical team.
Balanced diet with iron supplements to promote healing would be advised.
Intake of plenty of fluids to maintain hydration.
Physical therapy is very crucial for successful recovery of the patient. Under the guidance of physical therapist, the patient is instructed exercise to help with strengthening and mobility. Also exercise helps reduce swelling and stiffness of the joint.

What are the advantages of procedure?

Fracture reduction results in placing bones back to their normal anatomical position which is very important in order for the joint to function properly without pain.

What is the outcome of Shoulder Fracture Reduction & Fixation?

With advancement of surgical techniques, appropriate treatment that is rendered yields excellent results for most of the patients.

Why NOSH for Shoulder Fracture Reduction?

NOSH is a doctor owned hospital and consequently attracts the top talent available in the country. NOSH has the best Orthopedic doctors and surgeons for Shoulder Fracture Reduction in India. Equipped with the state-of the-art infrastructure and latest high-end technology, NOSH is the best Orthopedics hospital for Shoulder Fracture Reduction in Delhi, India.

Total Shoulder Replacement :
If the shoulder joint is worn leading on to severe pain, an artificial joint can be implanted and this is called Total shoulder replacement. A satisfying function and good pain relief can be achieved after performing total shoulder replacement. If no complications occur, more than 95% of the time a shoulder replacement can last for more than 10-15 years.

The procedure is done for those suffering from advanced arthritis of the shoulder joint. Total shoulder replacements are also performed for fractures of the upper end of arm bone. In fractures, usually it is such a situation that the fixation is not possible as the fracture is complex.

TYPES OF TOTAL SHOULDER REPLACEMENT:

Total Shoulder Replacements are as follows:

Anatomic Total Shoulder Replacement
Reverse Polarity Total Shoulder Replacement
Resurfacing arthroplasty of the shoulder joint.

The choice of procedure depends on number of factors.

A severely destroyed humeral head and glenoid surface with well working rotator cuff muscles would require a Anatomic Total Shoulder Replacement.

If the rotator cuff muscles are not functioning and a person has got severely damaged shoulder joint, then Reverse polarity Total Shoulder Replacement will be the correct option. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder blade bone and a plastic socket is attached to the upper arm bone. This gives a biomechanical advantage by changing the centre of the rotation of the shoulder joint and also tensions the arm muscle called deltoid. These factors allow using the deltoid muscle instead of the torn rotator cuff to lift the arm thus facilitating to regain the lost movement.

If the destruction of the humeral head is not severe and hence if adequate bone stock is available, then Resurfacing arthroplasty of the shoulder joint will be the option.

The above description gives a general outline. Shoulder replacement surgery is highly technical. Each case is individual. The situation will be carefully evaluated before making any decisions. The correct nature of procedure will be determined after physical examination and performing radiological investigations such as X ray and CT Scan.
Preoperative workup

You will be anaesthetized for the surgery. Hence you would have some blood tests and routine check up by an anesthetist for the surgery. The intensity of the pain in first 24 hours is high. Hence during the surgery you will also have an injection to block the nerve supply of the arm. This block helps to get the whole arm numb and you feel a very little pain after the surgery.

A physiotherapist will see you before the surgery and teach you on the exercises that you will have to carry on after the surgery.
Operation

The operation is performed in a position as if you are sitting in a beach chair. The Key surgical steps are as follows

Access into the shoulder joint is performed through an incision of about 10cm from the front of the upper end of arm.
The gap between the arm muscle called deltoid and chest muscle called pectoralis major is explored and kept apart to have deeper access.
Deeper to that is Rotator cuff muscle called subscapularis and lining of the shoulder joint called capsule. Both are divided and the shoulder joint will be accessed.
The humeral head and the glenoid are prepared and correct size implant is fixed in. Stability of the joint is restored to the satisfactory extent
The fixation of the implant can be achieved by bone cement or with implants that have facility for bone growth. This will be determined on the individual case basis depending on the condition of the bone and the disease pathology.
All the layers of the wound that are opened for the access are securely closed.

Postoperative Stage

An inpatient stay in the ward for 2-3 days may be essential to optimize pain and train for getting range of motion before discharge. An adequate pain relief will be provided, wound will be checked, and an X ray of the shoulder joint will be taken. A physiotherapist will teach the exercises that need to be carried on to get satisfactory function. When discharged, a plan of home exercise programme will be taught.
The Success Rates and the Outcomes

The success of the surgery is very high. It is in the order of 90-95%. Most of the patients are satisfied with pain relief and gain of mobility.
Complications

The complications after the surgery are minimal. Infection, Nerve injury, Dislocation and Fracture are the important complications to think about, but fortunately the incidence of these problems is low.
Rehabilitation Post surgery

A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. A sling will be given for comfort during the first four weeks. Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery.

Here are some “do’s and don’ts” for when you return home:

Don’t use the arm to push yourself up in bed or from a chair because this requires forceful contraction of muscles.
Do follow the program of home exercises prescribed for you. You may need to do the exercises 4 to 5 times a day for a month or more.
Don’t lift anything heavier than a glass of water for the first 6 weeks after surgery.
Don’t participate in any repetitive heavy lifting after your shoulder replacement.
Do avoid placing your arm in any extreme position, such as straight out to the side or behind your body for the first 6 weeks after surgery.

Many thousands of patients have experienced an improved quality of life after shoulder joint replacement surgery. They experience less pain, improved motion and strength, and better function.
Article by
Sparsh Hospitals, Bangalore.

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.