Tocilizumab use during Covid-19 should alert an orthopaedic surgeon for the surgical management of arthroplasty patients: A narrative review

The crisis of Covid-19 has shaken the world healthcare systems. The intensive care resources to manage the medical conditions associated with Covid-19 are consistently found to be inadequate with exploration and implementation of newer treatment avenues for an early recovery. Presently, the use of Tocilizumab (TCZ) in severe to critical affection of Covid-19 is being practiced as an off-label therapy. A narrative review of present knowledge regarding TCZ pharmacology, indications of its use, and potential side effects with clinical implications for an orthopedic surgeon is presented. The article discusses the clinicopathological factors required to be monitored during the perioperative management of an orthopedic patient who may have received TCZ for Covid-19 related illness. The implications of its usage should alert the orthopaedic surgeons for future management of their arthritic surgical patients. The commonly associated side effects and complications in the post-operative phase following an arthroplasty or any orthopaedic surgery are an area of concern and considerable uncertainty. In the post-Covid-19 recovery phase, when surgeons need to plan a surgical intervention then a thorough evaluation of their Covid-19 medical management history may be warranted. Practical guidelines for the management of arthritic surgical patients have been postulated. With an unregulated increased usage of TCZ during Covid-19 management, an orthopaedic surgeon should worry and needs to be aware of the possible consequences in the perioperative period for the post-surgery management. Future research to gain more insights will confirm the implied concerns.

New strategies in regenerative medicine and surgery and their application to orthopedic surgery field: The bio-active composite therapies (BACTs)

Regenerative Medicine and Surgery is a rapidly expanding branch of translational research in tissue engineering, cellular and molecular biology. To date, the methods to improve cell intake, survival and isolation need to comply with a complex and still unclear regulatory frame, becoming everyday more restrictive and often limiting effectiveness and outcome of the therapeutic choices. Thus, the author developed a novel regenerative strategy, based on the synergic action of several bio-active components, called the Bio-Active Composite Therapies (BACTs) to improve grafted cells intake and survival in total compliance with the legal and ethical limits of the current regulatory frame. The rationale at the origin of this new technology is based on the evidence that cells need supportive substrate to survive in vitro and this observation, applying the concept of translational medicine, is true also in vivo. Many different sources have been used in the past for MSCs, molecules and growth factors (GF) isolation and extraction, but the Adipose Tissue and its Stromal Vascular Fraction (SVF) definitely remains the most valuable, abundant, safe and reliable. Bio-Active Composite Mixtures (BACMs) are tailor-made injectable “cocktails” containing several bio-active components to support cells survival and induce a strong regenerative response in vivo by stimulating the recipient site to act as an in-situ real Bioreactor. In this article, the author analyze the main causes of cell’s death and the strategies for preventing it, and outline all the technical steps for preparing the main components of BACMs and the different mixing modalities to obtain the most efficient regenerative action on different clinical and pathological conditions in several surgical specialties. Orthopedic Surgery is definitely the one that most can benefit of these new therapeutic strategies. The final part of this work is anticipating the logical and sequential evolution toward other fundamental technical steps for further supporting and enhancing the most efficient regenerative activity.

Patient on allergen immunotherapy developed systemic lupus erythematosus?– A clinico-pharmacological look out

Drug induced lupus is an autoimmune condition secondary to drug exposure which leads to development of systemic lupus erythematosus (SLE). However, labelling the culprit drug needs a prudent insight into the pharmacological plausibility of each of the offending drugs in suspicion. Here we present a report where allergen immunotherapy was suspected to cause SLE and a deeper clinico-pharmacological evaluation cleared the air.

Randomized controlled study of proximal fibular osteotomy (PFO) with or without trabeculotomy in early osteoarthritis (OA) knee

This study was conducted to evaluate and compare the clinical and functional outcome of OA knee patients treated with proximal fibular osteotomy with or without trabeculotomy.This was a randomized controlled study amongst patients of osteoarthritis knee for a period of 1 year on patients with early osteoarthritis of knee. All patients were randomly allocated into two groups; group 1 patients were managed using PFO with trabeculotomy whereas group 2 patients were managed with proximal fibular osteotomy alone. All the patients were followed up post operatively at 15 days and at 2, 6 and 12 months post operatively. At each follow up patients were assessed for presence of Pain using Visual analogue scale. Also functional outcome was assessed using WOMAC.In present study, patients of two groups were comparable in their base line characters (p>0.05). Post operatively, mean VAS score and WOMAC score improved significantly in both the groups, the improvement was significantly higher in group 1 as compared to group 2 at all the follow up (p<0.05).Proximal fibular osteotomy with or without trabeculotomy can be used effectively as a promising tool for management of cases with early osteoarthritis of knee. It is safe, effective, and cost effective surgical technique for pain relief and improving functional outcome. PFO with trabeculotomy yields better results in terms of clinical as well as functional outcome as compared to PFO without trabeculotomy.

Teriparatide in fracture healing: Case series and review of literature

Teriparatide (TPTD) (recombinant Parathyroid Hormone 1-34) is one of the pioneer osteo-anabolic agents approved for management of osteoporosis. Being an anabolic agent, it increases bone mineral density by inducing formation of new bone by the action on osteoblasts. As new bone formation is an important aspect of fracture healing as well, Teriparatide has long been a product of interest with respect to its effect on the process of fracture healing. Though fracture healing is not an approved indication for Teriparatide, there is quite a substantial amount of published data related to its effectiveness in fracture healing. With an intent to better understand the role of teriparatide in fracture, we share few case reports of successful fracture healing after giving Teriparatide and also review the published evidences of union taking place in difficult delayed union and non-union cases secondary to mechanical instability, inadequate fixation support or other reasons. This article thus, intended to summarize the accumulating preclinical and clinical evidence for role of TPTD in accelerating fracture healing in various conditions like conservative management of fractures, vertebral fractures, non-unions, delayed unions and atypical femoral fractures.

Functional outcome of autologous platelet rich plasma injection in plantar fasciitis and tennis elbow

Recent developments in cellular and molecular biology have emerged as a potent tool in the management of orthopaedic illnesses and injuries. Upon binding to the target cell receptor, the growth factor from platelets triggers the activation of an intracellular signal transduction system, which results in a biological response that is essential for chemotaxis, cell proliferation, and osteoblastic differentiation. The aim of this study is to determine the efficacy and safety of autologous platelet-rich plasma injection in tennis elbow and plantar fasciitis. We conducted a prospective study with patients who were suffering from plantar fasciitis (n=37) or tennis elbow (n=23) and were given with autologous platelet-rich plasma injection. A short term follow up of all these cases were done at regular intervals for 1, 4, 8, and 12 weeks. The clinical outcomes were analyzed with severity of pain and movements of the pathological part. The functional outcomes were analyzed with VAS and AOFAS scoring for plantar fasciitis and VAS and Mayo’s elbow scoring for tennis elbow. All these patients were statistically analyzed by repeated measures ANOVA test. Our investigation found a statistically significant difference between pre-procedural and post-procedural scores in both the subjective (VAS) and functional (AOFAS and Mayo elbow score) grading systems used in this study. Patients who received an autologous platelet-rich plasma injection experienced a statistically significant (p <0.05) improvement in their ability to combat both of the musculoskeletal illnesses studied. Autologous platelet-rich plasma acts as a promising efficacious biological therapeutic agent for use in musculoskeletal disorders such as plantar fasciitis and tennis elbow without major complications upon its usage.

Monitoring of bone fractured healing using biochemical markers among patients attending federal teaching hospital abakaliki and bone setter home in onueke ebonyi state, Nigeria

The monitoring of bone fractured healing using Alkaline phosphatase, calcium ion and inorganic phosphate was evaluated among patients with fractured bone in two different centers, Alex Ekwueme Federal University Teaching Hospital Abakaliki and Bone Setters Home, Onueke, Ezza in Ebonyi State between August 2017 and September 2018. : A total of 90 adults patients from 18 years to 78 years were examined using phenolphthalein monophosphate colorimetric end point method. Out of the 90 patients, 30 were healthy normal subjects, another 30 were patients in AE-FUTHA while the remaining 30 patients were in bone setter home. : Patients without bone fracture had the least mean serum level of alkaline phosphatase, 28.5 ± 9.0µl followed by those admitted in bone setter home with a mean serum level of 38.2±17.9µl while patients admitted in AE-FUTHA had the highest mean serum level of 41.4±6.5µl (P<0.05). The mean serum level of calcium was significantly higher 10.9± 2.6mg/dl in healthy normal patients compared to mean serum level of 9.2 ± 3.3mg/dl and 7.4 ± 1.3mg/dl for patients admitted in AE-FUTHA and bone setter home respectively. The mean serum level of inorganic phosphate indicate that patients admitted in bone setter home had the highest mean of 4.1 ± 1.0mg/dl followed by patients admitted in AE-FUTHA 3.4 ± 0.2mg/dl while that of healthy normal individuals had the least mean serum level of 3.2 ± 0.5mg/dl. : Out of the three parameters examined, alkaline phosphatase test was more precise, reliable and patient doctor friendly; hence it can be used as a veritable tool to monitor the process of bone fracture healing effectively.

An experience with Foot Macrodactyly: A case report and review of literature

Macrodactyly is a rare congenital malformation with clinical manifestations such as enlargement of soft tissue and osseous elements. It causes various health issues such as pain, difficulty in wearing shoes, impairment in ambulatory ability and gait development, aesthetic problem, and psychological issues. The aetiology of macrodactyly is ambiguous; however, its association with PIK3CA /AKT1 genes has been reported recently. In the present study, a rare congenital macrodactyly of second and third toe of right foot along with deformed leg in 16-year-old girl has been reported. A progressive increase in the size of the second and third toe of the right foot and deformed reddish swollen area on the same lower leg below knee was seen in the patient. The malformation was present at the time of birth and at the age of one year the patient was operated for macrodactyly, but again the toe progressively increased to the previous size. She was presented with multiple health problems. There was no positive family history and/or other congenital malformation. Thus, it was suggested that due to variable phenotypic manifestations, appropriate treatment should be chosen for the patient individually.

Role of Vitamin D3 in fracture union in adults

Fractures play an important role in morbidity and often premature mobility among the elderly population. Because inactivity as a result of a fracture is harmful both to bone healing and health, it appears early or rapid fracture healing would be highly recommendable for returning fracture patients to come back to normal as soon as possible with minimal side effects. The literature remains unclear regarding supplementation required for promoting bone healing in fracture cases. Hereby we evaluated the advantages and disadvantages of vitamin D3 supplementation in fracture cases along with the quantitative analysis of vitamin D3 at the time of fracture and after fracture union.: A total of 200 patients were assessed clinically, biochemically (serum alkaline phosphatase, serum vitamin D3, and serum parathormone), and radiologically. All patients who satisfy inclusion criteria are followed up and vitamin D3 levels were measured up within 1 day of fracture and at the interval of 6 months after the orthopaedic intervention. The outcomes were monitored by the 5 points radiographic scoring system by Warden et al. With the majority of patients falling under the vitamin insufficiency group i.e. 53% of all patients were found to be vitamin insufficient at the time of fracture. 33% of patients found to be vitamin D deficient while 14% found to be insufficient stage. No patient was found to be in a toxicity state. According to Warden’s scoring., 50% of patients were in grade 3, 15% in grade 4, 33% in grade 2, and only 2% in grade 1. Regarding the prevalence of vitamin D deficiency or insufficiency in the general population, this study shows an alarming rate of vitamin D insufficient patients in a group of 200 patients, which indicates the need for attention towards vitamin D status not only for bone-related issues but for other issues related to vitamin D deficiency.