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Papers by Anil Gowtham Manivannan

The common problems seen in distal femoral fractures are communition, articular surface involveme... more The common problems seen in distal femoral fractures are communition, articular surface involvement, fractures in multiple planes and bone loss in compound fractures. They present a challenge to the surgeon to achieve stable fixation and union. With different methods of internal fixation available, the common complications encountered with distal femoral fractures are malunion, varus collapse, delayed union, implant failure and shortening of the limb etc. This necessitates the option of primary bone grafting in treating such fractures. Here, we are presenting our results of 38 cases of distal femoral fractures treated with locking compression plates without primary bone grafting. The functional outcome was excellent in 18 cases and good in 16 cases as per Neer’s rating system. We obtained union in all cases without any primary bone grafting.

IP International Journal of Orthopaedic Rheumatology

WHO declared SARS-CoV-2 as a pandemic disease on 11 th March 2020. Due to global lockdown and res... more WHO declared SARS-CoV-2 as a pandemic disease on 11 th March 2020. Due to global lockdown and restricted social movements, there is a rising curve in the morbidity of health of non-SARS-CoV-2 orthopaedic rheumatology patients and an impairment in the functional quality of life necessitating a pandemic response protocol into action in all fields of patient care. The development of ideal strategies and recommendations for the management of orthopaedic rheumatologically predisposed population and principles to be followed in their practice is the need of the hour. We hereby give a comprehensive list of strategies that can be followed in orthopaedic rheumatology practice by encompassing the recommendations given by the European League Against Rheumatism (EULAR), The American College of Rheumatologists (ACR), and Indian Association of Orthopaedic Rheumatology-Indian Orthopaedic Association (IORA-IOA). SARS-CoV-2 pandemic has put enormous pressure on patients with Rheumatic Diseases (RD) due to their innate weakness and shared treatment protocols in management. Though RD needs a multidisciplinary approach, which remains a challenge in this pandemic scenario, these strategic recommendations would aid in their optimal care amidst the adversity of SARS-CoV-2.

IP International Journal of Orthopaedic Rheumatology

Background: The acromioclavicular joint pathologies are one of the common causes of shoulder pain... more Background: The acromioclavicular joint pathologies are one of the common causes of shoulder pain. The most common of these is the acromioclavicular joint arthritis. The management can be conservative or surgical. The conservative measures include activity modification, physiotherapy, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), and Intra-articular Steroid Injections (ISI). ISI has been used with variable success rates and the long-term effects are doubtful. Materials and Methods: Patients with clinical and radiological evidence of ACJ arthritis and not responding to exercise and NSAIDs for 2 months were enrolled for PRP injection. 1 mL of PRP prepared by the manual double spin method was injected into the ACJ and patients were followed for a minimum period of 6 months. Constant Score was used to measure the functional recovery at 1, 3, and 6 months post-injection therapy. Results: 13 patients including 16 shoulders were followed up for an average of 8 months (6 to 14 months).3 patients had bilateral ACJ involvement. 4 had left ACJ involvement and the rest had right side involvement. The mean pre-injection constant score was 45 (range 28-70). The mean score at the end of 1 month follow up was 69 (range 56-89). At the end of 3 months, the mean score was 81 range (63-93). Both were statistically significant improvements when compared to the pre-injection score (P=0.003,0.0021respectively). At the end of 6 months, the score was 89 range (58-94). This sequential improvement was not however statistically significant. Conclusion: ACJ arthritis is one of the common causes of shoulder pain. In our pilot study, PRP has been a promising option to treat primary ACJ arthritis. Future RCTs are needed to establish it as a superior option in the management of ACJ arthritis.

IP International Journal of Orthopaedic Rheumatology

The therapeutic use of autologous platelet concentrates represents a newer regenerative avenue to... more The therapeutic use of autologous platelet concentrates represents a newer regenerative avenue to stimulate and accelerate complex wound healing. These non-healing ulcers have repercussions in terms of decrease functional outcome and productivity of the patients. Here, we intend to wider the horizon of an alternative approach for treating small-to-moderate-sized complex wounds of lower extremities by using novel Leucocyte Platelet-Rich Fibrin (L-PRF) which embraces healing potentiality over that of bare soft tissue, including bone, tendon, and ligaments respectively. Materials and Methods: A total of 23 cases of non-healing ulcers were receiving L-PRF gel application. The cases with small and large ulcers received L-PRF gel weekly once for 3 and 6 weeks respectively. All the cases were followed up in regular intervals at the end of every week and the end of 3rd month. To document the progress of ulcer healing, we calculated the area and volume of the ulcer at the beginning of the procedure and every week till the size of the ulcer gets contracted. Photographic documentation was performed for all the cases. Results: The duration of non-healing ulcers ranged from 6 months to 24 months with a mean duration of 15.05 ± 2.37 months. According to Wagner's ulcer classification scale, 15 ulcers (65.21%) belong to grade 1 and 8 ulcers (34.78%) belong to grade 2. In grade 1 ulcer cases, the mean area and volume improvement observed was 100% at the end of 3 months whereas, in grade 2 ulcer cases, the mean area and volume improvement observed was 95.67% and 97.31% at the end of 3 months. The volume of 15 ml of venous blood was sufficient to cover an ulcer with a maximum area of 23.12 cm2 with 1 mm thickness of L-PRF. Conclusion: Our study adds to the string of positive evidence for treating complex wounds using L-PRF wherein this autologous preparation is available at greater ease to facilitate the process of granulation tissue formation and epithelization. This serves as a good alternative to manage wounds of small to medium size and minimizes the need to plan for relevant soft tissue surgeries.

Journal of orthopaedic case reports

Intertrochanteric fracture comprises nearly half of hip fractures occurring in elderly individual... more Intertrochanteric fracture comprises nearly half of hip fractures occurring in elderly individuals with osteoporosis. Considering the age group of its population, they are often associated with multiple comorbidities which warrant optimum management with less surgical. This article reports the case of 56-year-old women with in tertrochanteric fracture associated with the cardiac complication restricting operating duration. Minimal invasive dynamic hip screw (MIDHS) fixation technique with modified instruments was performed which facilitated minimizing the operating time and intraoperative blood loss. MIDHS fixation is an important technique for providing the necessary fixation minimizing soft tissue dissection, operating time, intraoperative blood loss and surgical expense without compromising fixation stability, and rehabilitation protocol.

IP International Journal of Orthopaedic Rheumatology

Knee osteoarthritis (OA) is a chronic, progressive degenerative disease with joint pain, stiffnes... more Knee osteoarthritis (OA) is a chronic, progressive degenerative disease with joint pain, stiffness, and deformity. Knee OA is a common joint disease, with an incidence of 30% of the population older than 60 years. High tibial osteotomy and total knee arthroplasty are the 2 commonly used methods for treating knee OA. Total knee Arthroplasty (TKA), which aims to relieve pain and improve joint function and mobility, primal fibular osteotomy (PFO) is the main surgical alternative in this patient population. Materials and Methods: From September 2017 to September 2019, the PFO was performed for patients presenting with medial compartment osteoarthritis. Preoperative and postoperative weight-bearing whole lower extremity radiographs were obtained to analyze the alignment of the lower extremity and the ratio of the knee joint spaces (medial/lateral compartment) were ascertained. Knee pain was assessed using a visual analog scale (VAS), and knee ambulation activities were evaluated using the Knee Society Score (KSS). Results: A total of 20 patients and 26 knees were followed-up for a minimum period of one year. Of these, 7 were male and 13 were female patient. The average age was 57 years. According to Kellgren Lawrence grading, there were 18 knees of grade 2 and 2 knees of grade 3. The average preoperational VAS score and KSS were 6.3 and 33.5 respectively. The average postoperative VAS score and KSS improved significantly to 2.8 (P<0.01) and 83.7 (p=0.002) respectively. The medial joint space opening has improved significantly from preoperatively 1.15mm to postoperatively 3.4mm. Conclusion : PFO is a promising alternative procedure in the management of medial compartment osteoarthritis of the knee being a simple and cost-effective alternative to the traditional total knee or unicondylar knee replacements. A longer period of follow-up is necessary to evaluate whether the beneficial effects of PFO are sustained over a period of time.

Two points worth noting about osteoporosis in India-high incidence among men and lower age of pea... more Two points worth noting about osteoporosis in India-high incidence among men and lower age of peak incidence compared to Western countries. 1 out of 8 males and 1 out of 3 females in India suffers from osteoporosis. The incidence of hip fracture is 1 woman to 1 man. In Western countries, the peak incidence of osteoporosis occurs at 70-80 years of age, in India it afflicts at age 50-60. But there is a worrying trend of increasing prevalence of osteoporosis among the younger men in India that has been under studied. This cross-sectional study was conducted in a tertiary care centre. With informed consent, male subjects were evaluated clinically including anthropometry and history, biochemically with 25-OH Vitamin D and radiologically with DEXA scan. Calculation of T score and categorization as osteoporosis, osteopenia, and normal BMD was done as per WHO classification and data was analyzed. The male population having decreased bone mass was more than expected. Osteoporosis and osteopenia are prevalent in younger male population too contrary to the popular belief. A significantly large proportion of south Indian men had osteoporosis and vitamin D deficiency. Further interventional studies are needed to look at reduction in end points like fractures and morbidity in these subjects.

The common problems seen in distal femoral fractures are communition, articular surface involveme... more The common problems seen in distal femoral fractures are communition, articular surface involvement, fractures in multiple planes and bone loss in compound fractures. They present a challenge to the surgeon to achieve stable fixation and union. With different methods of internal fixation available, the common complications encountered with distal femoral fractures are malunion, varus collapse, delayed union, implant failure and shortening of the limb etc. This necessitates the option of primary bone grafting in treating such fractures. Here, we are presenting our results of 38 cases of distal femoral fractures treated with locking compression plates without primary bone grafting. The functional outcome was excellent in 18 cases and good in 16 cases as per Neer’s rating system. We obtained union in all cases without any primary bone grafting.

IP International Journal of Orthopaedic Rheumatology

WHO declared SARS-CoV-2 as a pandemic disease on 11 th March 2020. Due to global lockdown and res... more WHO declared SARS-CoV-2 as a pandemic disease on 11 th March 2020. Due to global lockdown and restricted social movements, there is a rising curve in the morbidity of health of non-SARS-CoV-2 orthopaedic rheumatology patients and an impairment in the functional quality of life necessitating a pandemic response protocol into action in all fields of patient care. The development of ideal strategies and recommendations for the management of orthopaedic rheumatologically predisposed population and principles to be followed in their practice is the need of the hour. We hereby give a comprehensive list of strategies that can be followed in orthopaedic rheumatology practice by encompassing the recommendations given by the European League Against Rheumatism (EULAR), The American College of Rheumatologists (ACR), and Indian Association of Orthopaedic Rheumatology-Indian Orthopaedic Association (IORA-IOA). SARS-CoV-2 pandemic has put enormous pressure on patients with Rheumatic Diseases (RD) due to their innate weakness and shared treatment protocols in management. Though RD needs a multidisciplinary approach, which remains a challenge in this pandemic scenario, these strategic recommendations would aid in their optimal care amidst the adversity of SARS-CoV-2.

IP International Journal of Orthopaedic Rheumatology

Background: The acromioclavicular joint pathologies are one of the common causes of shoulder pain... more Background: The acromioclavicular joint pathologies are one of the common causes of shoulder pain. The most common of these is the acromioclavicular joint arthritis. The management can be conservative or surgical. The conservative measures include activity modification, physiotherapy, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), and Intra-articular Steroid Injections (ISI). ISI has been used with variable success rates and the long-term effects are doubtful. Materials and Methods: Patients with clinical and radiological evidence of ACJ arthritis and not responding to exercise and NSAIDs for 2 months were enrolled for PRP injection. 1 mL of PRP prepared by the manual double spin method was injected into the ACJ and patients were followed for a minimum period of 6 months. Constant Score was used to measure the functional recovery at 1, 3, and 6 months post-injection therapy. Results: 13 patients including 16 shoulders were followed up for an average of 8 months (6 to 14 months).3 patients had bilateral ACJ involvement. 4 had left ACJ involvement and the rest had right side involvement. The mean pre-injection constant score was 45 (range 28-70). The mean score at the end of 1 month follow up was 69 (range 56-89). At the end of 3 months, the mean score was 81 range (63-93). Both were statistically significant improvements when compared to the pre-injection score (P=0.003,0.0021respectively). At the end of 6 months, the score was 89 range (58-94). This sequential improvement was not however statistically significant. Conclusion: ACJ arthritis is one of the common causes of shoulder pain. In our pilot study, PRP has been a promising option to treat primary ACJ arthritis. Future RCTs are needed to establish it as a superior option in the management of ACJ arthritis.

IP International Journal of Orthopaedic Rheumatology

The therapeutic use of autologous platelet concentrates represents a newer regenerative avenue to... more The therapeutic use of autologous platelet concentrates represents a newer regenerative avenue to stimulate and accelerate complex wound healing. These non-healing ulcers have repercussions in terms of decrease functional outcome and productivity of the patients. Here, we intend to wider the horizon of an alternative approach for treating small-to-moderate-sized complex wounds of lower extremities by using novel Leucocyte Platelet-Rich Fibrin (L-PRF) which embraces healing potentiality over that of bare soft tissue, including bone, tendon, and ligaments respectively. Materials and Methods: A total of 23 cases of non-healing ulcers were receiving L-PRF gel application. The cases with small and large ulcers received L-PRF gel weekly once for 3 and 6 weeks respectively. All the cases were followed up in regular intervals at the end of every week and the end of 3rd month. To document the progress of ulcer healing, we calculated the area and volume of the ulcer at the beginning of the procedure and every week till the size of the ulcer gets contracted. Photographic documentation was performed for all the cases. Results: The duration of non-healing ulcers ranged from 6 months to 24 months with a mean duration of 15.05 ± 2.37 months. According to Wagner's ulcer classification scale, 15 ulcers (65.21%) belong to grade 1 and 8 ulcers (34.78%) belong to grade 2. In grade 1 ulcer cases, the mean area and volume improvement observed was 100% at the end of 3 months whereas, in grade 2 ulcer cases, the mean area and volume improvement observed was 95.67% and 97.31% at the end of 3 months. The volume of 15 ml of venous blood was sufficient to cover an ulcer with a maximum area of 23.12 cm2 with 1 mm thickness of L-PRF. Conclusion: Our study adds to the string of positive evidence for treating complex wounds using L-PRF wherein this autologous preparation is available at greater ease to facilitate the process of granulation tissue formation and epithelization. This serves as a good alternative to manage wounds of small to medium size and minimizes the need to plan for relevant soft tissue surgeries.

Journal of orthopaedic case reports

Intertrochanteric fracture comprises nearly half of hip fractures occurring in elderly individual... more Intertrochanteric fracture comprises nearly half of hip fractures occurring in elderly individuals with osteoporosis. Considering the age group of its population, they are often associated with multiple comorbidities which warrant optimum management with less surgical. This article reports the case of 56-year-old women with in tertrochanteric fracture associated with the cardiac complication restricting operating duration. Minimal invasive dynamic hip screw (MIDHS) fixation technique with modified instruments was performed which facilitated minimizing the operating time and intraoperative blood loss. MIDHS fixation is an important technique for providing the necessary fixation minimizing soft tissue dissection, operating time, intraoperative blood loss and surgical expense without compromising fixation stability, and rehabilitation protocol.

IP International Journal of Orthopaedic Rheumatology

Knee osteoarthritis (OA) is a chronic, progressive degenerative disease with joint pain, stiffnes... more Knee osteoarthritis (OA) is a chronic, progressive degenerative disease with joint pain, stiffness, and deformity. Knee OA is a common joint disease, with an incidence of 30% of the population older than 60 years. High tibial osteotomy and total knee arthroplasty are the 2 commonly used methods for treating knee OA. Total knee Arthroplasty (TKA), which aims to relieve pain and improve joint function and mobility, primal fibular osteotomy (PFO) is the main surgical alternative in this patient population. Materials and Methods: From September 2017 to September 2019, the PFO was performed for patients presenting with medial compartment osteoarthritis. Preoperative and postoperative weight-bearing whole lower extremity radiographs were obtained to analyze the alignment of the lower extremity and the ratio of the knee joint spaces (medial/lateral compartment) were ascertained. Knee pain was assessed using a visual analog scale (VAS), and knee ambulation activities were evaluated using the Knee Society Score (KSS). Results: A total of 20 patients and 26 knees were followed-up for a minimum period of one year. Of these, 7 were male and 13 were female patient. The average age was 57 years. According to Kellgren Lawrence grading, there were 18 knees of grade 2 and 2 knees of grade 3. The average preoperational VAS score and KSS were 6.3 and 33.5 respectively. The average postoperative VAS score and KSS improved significantly to 2.8 (P<0.01) and 83.7 (p=0.002) respectively. The medial joint space opening has improved significantly from preoperatively 1.15mm to postoperatively 3.4mm. Conclusion : PFO is a promising alternative procedure in the management of medial compartment osteoarthritis of the knee being a simple and cost-effective alternative to the traditional total knee or unicondylar knee replacements. A longer period of follow-up is necessary to evaluate whether the beneficial effects of PFO are sustained over a period of time.

Two points worth noting about osteoporosis in India-high incidence among men and lower age of pea... more Two points worth noting about osteoporosis in India-high incidence among men and lower age of peak incidence compared to Western countries. 1 out of 8 males and 1 out of 3 females in India suffers from osteoporosis. The incidence of hip fracture is 1 woman to 1 man. In Western countries, the peak incidence of osteoporosis occurs at 70-80 years of age, in India it afflicts at age 50-60. But there is a worrying trend of increasing prevalence of osteoporosis among the younger men in India that has been under studied. This cross-sectional study was conducted in a tertiary care centre. With informed consent, male subjects were evaluated clinically including anthropometry and history, biochemically with 25-OH Vitamin D and radiologically with DEXA scan. Calculation of T score and categorization as osteoporosis, osteopenia, and normal BMD was done as per WHO classification and data was analyzed. The male population having decreased bone mass was more than expected. Osteoporosis and osteopenia are prevalent in younger male population too contrary to the popular belief. A significantly large proportion of south Indian men had osteoporosis and vitamin D deficiency. Further interventional studies are needed to look at reduction in end points like fractures and morbidity in these subjects.