Sancheti Institute For Orthopaedics & Rehabilitation

The preferred technique for femoral implant sizing in primary total knee arthroplasty (TKA) is debatable. Sizing is based on the anterior femoral cortex or posterior condylar reference. Using a single knee system, this study compared anterior referencing (AR) versus posterior referencing (PR) in patients undergoing simultaneous bilateral TKA, where one reference technique was randomized to each knee. This prospective study compared the two sizing references using one posterior stabilized knee system. The study included 81 subjects with osteoarthritis and similar varus deformity in both knees. All subjects underwent identical surgical procedures, aside from the selected femoral sizing reference. Subjects were followed for at least 2years. The two sizing techniques did not significantly differ in all measured radiographic, operative, and clinical parameters. The mean posterior condylar offset ratios were similar. Two-year mean knee flexion and Revised Oxford Knee Scores showed no difference. Eighty-four percent of patients stated no preference for either technique. Knees sized with anterior referencing had similar functional outcomes to those sized with posterior referencing. Using a current knee system with multiple sizing options, there is no discernable difference in all measured study parameters. Either reference is acceptable.Level of Evidence 2 (Randomized cohort study).

Background and Aims:Adductor canal block (ACB) has emerged as a selective sensory technique to provide pain relief to the anterior aspect of the knee joint. Despite a large amount of available literature, the ideal site for performing ACB remains debatable. With the use of ultrasound, it is now possible to define the exact location of the adductor canal (AC). The objectives of our cadaveric study were to examine the nerves captured by methylene blue dye (MBD) and the stain pattern of the nerves within the AC following mid-AC injection.Methods:We scanned the thigh area of six lightly embalmed cadavers (12 specimens) and marked the midpoint of the AC using ultrasound and injected 10 mL of (MBD) at this level. Thirty minutes later, all the specimens were dissected to document the frequency and stain pattern of various nerves traversing through the AC.Results:The vastoadductor membrane and saphenous nerve got stained heavily (+3) in all twelve specimens, while the nerve to vastus medialis stained heavily (+3) in four and moderately (+2) in eight specimens. Both the medial cutaneous nerve of the thigh and the intermediate cutaneous nerve of the thigh were stained moderately (+2) in four and two specimens, respectively. There was no spread of the dye into the distal femoral triangle area.Conclusions:Injection of MBD in the sonographically located mid part of the AC consistently involved the saphenous nerve and nerve to vastus medialis, and hence may be the optimal site for performing ACB.

Introduction: Longer life expectancy, the rising burden of osteoarthritis, increasing obesity, and a growing desire among older adults to maintain active lifestyles have all contributed to a significant surge in joint-related health needs; as a result, the demand for total hip and knee arthroplasties is expected to increase substantially by 2026 [1,2]. A recent survey estimated that roughly 200,000 knee replacements were performed in 2020 alone, reflecting rapid growth driven by demographic and lifestyle changes [3]. Despite the expanding volume of total hip and knee arthroplasties, India still lacks a centralized, fully operational National Joint Registry (NJR). In many countries, NJRs are a vital part of orthopedic practice, helping surgeons monitor implant outcomes, improve techniques, and guide health policy [4]. In the Indian context, establishing an NJR is no longer optional; it has become an urgent necessity. For example, the 2010 recall of a faulty metal-on-metal hip implant (DePuy ASR) highlighted the consequences of not having a registry: of the 4,700 ASR implants done in India, only 882 patients could be traced for remedial action [2]. This incident highlighted serious shortcomings in India’s medical device regulations, such as delayed action on international recalls and the lack of systems to effectively trace affected patients. A robust NJR would have enabled health authorities to identify all affected patients, thereby mitigating harm promptly. This editorial discusses the global success of joint registries, reviews India’s progress so far, and outlines strategic imperatives to develop a comprehensive Indian Joint Registry (IJR). Global Context: Lessons from Established Joint Registries Around the world, national joint registries have demonstrated immense value in improving orthopedic outcomes and patient safety (Table 1). The United Kingdom’s NJR, established in 2002, now has over 96% of hospitals participating and covers more than 2 million procedures [5]. Its large-scale data enabled early identification of underperforming implants – notably the metal-on-metal hip replacements that showed a re-revision rate above 6% within 5 years, prompting regulatory actions and a global alert on these devices [6]. Likewise, the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) detected high-failure implant designs and facilitated their withdrawal, leading to a 25.8% reduction in revision surgeries nationwide [7]. Countries with well-organized registries have not only improved patient outcomes but also reduced healthcare costs. For example, analyses in the United States estimated that using registry data to refine practices saved around $2 billion in hip replacement expenditures by averting failures and revisions [8]. In Scandinavia, the national registry, The Nordic Arthroplasty Register Association (NARA) for hip and knee replacement has been in place for decades and is considered a global benchmark, has shown that systematic data collection over time correlates with lower complication and revision rates [9]. These registries not only gather data but also actively empower surgeons with real-world evidence on implant longevity, complication trends, and best practices [2]. The collective global experience makes it clear that a national registry is indispensable for delivering high-quality, evidence-based care for joint replacement. India can draw important lessons from these models as it strives to implement its NJR. India’s Registry Progress Early initiatives India’s journey toward a joint registry began in 2006, when the Indian Society of Hip and Knee Surgeons (ISHKS) launched a preliminary registry for hip and knee arthroplasties [10]. That early effort provided a proof of concept, capturing tens of thousands of cases over the next few years. By 2012, the registry had recorded over 34,000 total knee arthroplasties (TKAs) and 3,600 total hip arthroplasties (THAs), yielding insights into patient demographics and implant usage (e.g., mean age ~64 for TKA, with 75% of TKA patients being women) [10]. The IJR Building on the ISHKS pilot, a more comprehensive IJR was later established to systematically collect data on joint replacement surgeries across the country [2,10]. The IJR is designed as a national database to track every hip or knee replacement case, including patient demographics, diagnosis, surgical details, implant specifics, and outcomes. Data submission is done by participating surgeons and hospitals either through a secure online portal or through integration with hospital electronic record systems. All patient information is anonymized to ensure privacy and confidentiality [11]. This structure allows the registry to function as a real-time surveillance and quality improvement tool – monitoring implant performance and supporting research to identify best practices in arthroplasty. Importantly, the IJR was initiated and is maintained by professional bodies (ISHKS and the Indian Orthopaedic Association), reflecting a surgeon-led approach in its governance and priorities. Current status and growth Participation in the IJR has grown steadily, though it remains voluntary. By June 2020, the registry had enrolled data from 712 orthopedic surgeons nationwide [2]. The number of procedures being captured has increased dramatically: 1,019 knee replacements were reported in 2006, whereas about 27,000 knee replacements entered into the registry in 2019 [2]. This exponential rise mirrors the overall growth of arthroplasty in India and indicates improving engagement with the registry. The IJR’s dataset has expanded to include not only primary THAs and TKAs but also more specialized procedures, for example, between 2016 and 2022, over 1,000 unicompartmental knee replacements (UKRs) were documented, reflecting the gradual adoption of partial knee replacement techniques in the country [12]. Such data help identify emerging trends and outcomes for newer procedures in the Indian population (Table 2). Despite these advances, the IJR is still far from reaching its full potential. Coverage of cases is incomplete – many surgeries across India are never entered into the registry. To put this in perspective, an estimated ~200,000 knee arthroplasties were performed in India in 2020, whereas only ~27,000 knee cases from 2019 were recorded in the registry [2,13]. In other words, likely only a small fraction of total procedures is being captured. In addition, the registry’s participation is largely concentrated among certain hospitals and surgeons who volunteer data, which may introduce reporting bias. Nonetheless, the IJR stands out in the region: a recent review identified six national arthroplasty registries across Asia, but only three countries – India, Japan, and Pakistan have fully established registries with official websites and published annual reports for public data sharing [14]. This highlights both the progress India has made and the gap that remains. The challenge now is to transition the IJR from a voluntary, limited initiative to a truly nationwide, mandatory registry that can capture all joint replacement surgeries in India. For a registry to generate meaningful and valid data, participation of at least 90% of arthroplasty surgeons is essential. Current voluntary reporting falls well short of this standard, limiting the registry’s reliability and impact. Strategic Imperatives for a Robust National Registry Establishing an effective, sustainable NJR in India will require concerted action on multiple fronts. The following strategic imperatives should be prioritized: Mandatory Nationwide Participation: Broaden registry coverage by making data submission compulsory. Voluntary participation has yielded suboptimal data capture – many centers still opt out, leaving significant gaps [15]. To address this, reporting every joint replacement to the IJR should become standard protocol across all hospitals performing these surgeries. Tying registry participation to hospital accreditation, surgeon credentialing, or insurance reimbursement can powerfully incentivize compliance. For instance, including registry data reporting as a criterion for NABH hospital accreditation or as a requirement by insurance providers (for procedure coverage) would ensure that centers routinely contribute data. International experience shows that near-universal compliance is achievable; the UK’s NJR reached 96% coverage after implementing systematic enrollment and data quality audits (DQAs). India must likewise move from a voluntary system to a mandated one to capture a truly national dataset (Table 3). Professional Leadership and Governance: The IJR should continue to be managed by orthopedic professional bodies such as ISHKS and the Indian Orthopaedic Association, which ensure that it reflects clinical priorities and maintains the trust of surgeons [2]. A surgeon-led governance model can better promote buy-in, as clinicians are more likely to participate when they see the registry is run for and by their peers [14]. At the same time, strong support from health authorities is needed – for policy backing and funding. A joint governance council could be formed, comprising leaders from ISHKS/IOA and representatives of the Ministry of Health, to institutionalize the registry within national healthcare plans. This collaboration can help align the IJR with public health objectives and possibly make registry reporting a legally endorsed requirement (similar to notifiable diseases or device tracking programs) [2,14]. Digital Infrastructure and Data Quality Assurance: A user-friendly digital infrastructure is crucial to facilitate seamless data entry without overburdening surgeons. The registry should integrate with hospital information systems and electronic medical record platforms so that data can be uploaded with minimal manual effort. Modern registries are increasingly adopting semi-automated data capt

Background: Normal scapulo-humeral rhythm relies on coordinated scapular upward rotation, posterior tilt and external rotation to maintain optimal shoulder mechanics. Stroke-related weakness, spasticity and trunk posture changes can cause scapular dyskinesia and understanding its prevalence in stroke can guide targeted rehabilitation programs. Objective: To determine the prevalence of scapular dyskinesia in individuals with stroke using the Scapular Balance Angle (SBA) and Lateral Scapular Slide Test (LSST). Methods: A cross-sectional observational study was conducted on 88 individuals with subacute and chronic middle cerebral artery stroke which were selected via purposive sampling. SBA was measured using goniometer and values ≥7° were considered as dyskinesia. LSST was performed at 0°, 45° and 90° of shoulder abduction and a side-to-side difference >1.5cm was considered as dyskinesia. Results: The sample comprised of 69 males and 19 females with a mean age of 57.74 ± 5.37 years. SBA ≥7° was observed in 42 participants (47.73%) with a mean SBA of 8.93 ± 1.09°. LSST scores revealed increasing dyskinesia prevalence with shoulder elevation: 32.95% at 0°, 43.18% at 45° and 53.41% at 90° of shoulder abduction. Participants at risk (1.0-1.5 cm difference) were most common at 90° (43.18%). Mean LSST values for dyskinesia group were highest at 90° (2.47 ± 0.27 cm) Conclusion: The findings of the present study revealed high prevalence of scapular dyskinesia in individuals with stroke, particularly at higher degrees of shoulder elevation reflecting underlying muscular weakness and altered neuromuscular control. Keywords: Scapular Dyskinesia, Scapular Balance Angle, Lateral Scapular Slide Test, Stroke.

To elucidate the implications of restoring larger percentage of native ACL tibial insertion area on the functional outcomes and stability of the knee joint after arthroscopic ACL reconstruction. Prospective study of 201 patients with clinical and radiological signs of ACL insufficiency, while individuals with multi-ligamentous injuries, concomitant intra-articular fractures, and revision ACL cases were excluded. Intraoperatively arthroscopic ruler was used to measure the native footprint dimensions and the percentage of native ACL footprint area restored was calculated. The patients were divided into two groups depending upon the percentage of native ACL tibial footprint area restored. Group A patients had > 70% area restored and group B < 70% area was restored. Pre- and postoperatively, patients were assessed using KT1000, Lysholm score, and IKDC score. At 1year follow-up, mean IKDC scores at 12months for group A and group B were 89.28 ± 4.74 and 79.22 ± 4.98, respectively (p value < 0.05). The mean Lysholm scores at 12months for Group A and B were 93.68 ± 2.71 and 88.02 ± 2.8, respectively (p value < 0.05). The mean KT1000 scores at 12months for group A (> 70% footprint area restored) and group B (≤ 70% footprint area restored) were 0.37 ± 0.66 and 0.39 ± 0.53, respectively. The functional outcomes in terms of IKDC and Lysholm scores were better, while there was no objective difference in the knee laxity when the ACL reconstruction procedure was able to restore more than 70% of the native ACL tibial footprint size.