Munir Ahmed

09/05/2018

Robotic Knee Replacement!

07/19/2018

My first Robotic Total Knee!
Details to follow

06/16/2018

Certification in Robotic Joint Replacement

02/26/2018

Good read!

Cervical spondylosis, commonly called arthritis of the neck, is the medical term for the wear-and-tear changes that occur in the cervical spine (neck) over time. The condition is common—but many people with cervical spondylosis experience no noticeable symptoms

02/04/2018

Will Biologic Treatments for Cartilage Restoration Become the Standard of Care?

By: Rivka C. Ihejirika, MD
Newer therapies show promise
Prevention of degenerative joint disease and the restoration of articular cartilage through minimally invasive means is a major focus of basic science and orthopaedic sports research. That research has led to advances in technology that enable the long-term storage of cartilage and the replication of “chondroinductive” cells, resulting in cartilage restoration procedures that may potentially set a new standard of care in orthopaedic clinical practice.

For example, there is ongoing research into new options including methods for harvest and transplantation of tissue-forming cells. When combined with bioactive scaffold matrix materials and bioactive molecules, these stem and progenitor cells can differentiate into the appropriate cell lineage for specific tissue repair. Available cell-based strategies may utilize local cells, transplantated autogenous connective tissue progenitor cells derived from bone marrow or other tissues, or autologous growth factors obtained from a patient’s own platelets.

Injections—challenging the status quo
Corticosteroid and hyaluronic acid (HA) injections—the predominant minimally invasive treatments for symptomatic osteoarthritis—are often the bar against which new injectable agents are measured. Corticosteroids work by reducing inflammation and suppressing the immune response within damaged tissue. Often combined with a local anesthetic, steroid injections are inexpensive, reach their peak effectiveness within 4 weeks of injection, and are indicated in treatment of many joint and soft tissue disorders.

HA injections, primarily used for knee arthritis, attempt to replace articular fluid while acting as a shock-absorber and lubricant. Although HA injections provide good pain relief compared to placebo treatment within 8 weeks of injection, they are costly and results are not superior to corticosteroid injections. Although both corticosteroids and HA provide temporary pain relief, neither have been shown in long-term studies to regenerate articular cartilage or delay the onset of arthritis.

Platelet-rich plasma (PRP) is derived from autologous blood in which platelets have been concentrated to 2 to 8 times. The regenerative potential of PRP depends on the amount and viability of the inherent growth factors present in the delivered materials. Large variations exist between the 40 plus commercially available systems; therefore, each system needs to be tested individually for growth factor and cytokine expression. The final platelet concentration of any PRP product depends on several factors, including the initial volume of whole blood to be processed and the platelet recovery efficiency of the chosen technique. Recent randomized control trials support the use of PRP injections in the treatment of mild osteoarthritis disease. As a result, PRP has been used to treat osteoarthritis in the clinical setting. Compared to HA or steroid injections, data suggest that PRP injections may offer better pain relief over a longer period in patients with mild arthritis.

Although mesenchymal stem cell (MSC) therapy is a burgeoning area of interest, it is also controversial due to misrepresentation and misunderstanding among patients, physicians, and distributors. To date, very few high-quality studies support the use of MSC injections to improve joint pain.

Adipose- and bone marrow-derived MSCs have chondrogenic potential and have demonstrated promising results in comparison to HA injections for mild knee arthritis. Some studies have shown bone marrow-derived MSC injection during ligament reconstruction to improve graft incorporation and overall pain scores. However, many purveyors of MSC preparations do not disclose contents of their products or expected yield.

Similarly, bone marrow aspirate concentrate (BMAC), marrow centrifuged to enhance its concentration of MSCs and other trophic factors, has been trialed as an intraarticular injection to treat arthritis with inconclusive results. BMAC preparations vary widely and MSCs make up less than 0.01 percent of cells in the final product, making it difficult to standardize treatment or analyze outcomes. Due to the scarcity of double-blinded, randomized control trials or long-term studies on outcomes of treatment of osteoarthritis or osteochondral defects with MSC injections, it is unclear whether these injections provide any regenerative benefit to articular cartilage over time.

Advertisements regarding expected benefits of MSC injections may mislead patients who often believe the injections will repair their severe degenerative joint disease (DJD) and prevent the need for arthroplasty. Current data is inconclusive regarding the use of MSC or BMAC injections for treatment of DJD or osteochondral defects, and overall, there is insufficient evidence to support the routine use of MSC injections for treating articular cartilage pathology. Further study is needed before definitive conclusions can be drawn and recommendations made.

Procedures—old and new
Microfracture is one of the oldest, most inexpensive, and commonly used procedures for treating osteochondral defects. Microfracture, through marrow stimulation using small perforations into subchondral bone, produces a fibrin clot and brings pluripotent stem cells to form fibrocartilage in damaged articular tissue. Although evidence suggests that microfracture improves pain, its use should be restricted to small chondral defects, and pain relief often peaks then wanes after 2 years. Compared to microfracture, newer treatments with autologous and allograft chondral implantation have wider indications and improved outcomes at long-term follow-up.

Osteochondral autograft transplantation (OAT) is one of the oldest cartilage transplant procedures still practiced today for the treatment of osteochondral defects. In a one-stage procedure, osteochondral autografts are obtained from less–weight-bearing sections of articular cartilage in small diameter “plugs” that are then placed directly into the chondral defect. Defects larger than 8 mm may require multiple plugs for coverage (mosaicplasty). This method is useful in addressing small chondral defects where deep subchondral damage, untreatable by microfracture, is present.

Autologous chondrocyte implantation (ACI) has been used to treat larger shallow defects (1 cm – 3 cm) and bypasses the problem of donor size by taking a small arthroscopic biopsy of healthy cartilage and expanding it ex-vivo for up to 6 weeks. The area of damaged cartilage is addressed in a second procedure with débridement, placement of a membrane or patch over the lesion, and an injection of the cultured chondrocytes underneath the patch (Fig. 1).

Fig. 1 MRI of a 25-year-old female with 1x1.5cm patellar chondral lesion after a traumatic patella dislocation. After physical therapy and chondroplasty failed, the patient was successfully treated with autologous chondrocyte implantation.
Courtesy of Rivka C. Ihejirika, MD

Like ACI, matrix-induced autologous chondrocyte implantation (MACI) requires a two-stage procedure where autologous chondrocytes are harvested, expanded, and implanted on a collagen scaffold, which is then placed into an articular defect. Both ACI and MACI have similar results with good integration of “hyaline-like” tissue in the defect and long-term functional results that are improved compared to microfracture.

BMAC is also used in a similar fashion to ACI and MACI. Marrow is harvested, most often from the iliac crest (Fig. 2), and then placed into or under a scaffold/membrane on the débrided defect site. Despite the final centrifuged bone marrow having few MSCs, results are similar to ACI and MACI with good medium-term outcomes. The predominant drawback to the use of BMAC involves the technical aspects of aspiration to obtain a threshold number of progenitor cells.

Fig. 2 Iliac crest bone graft harvest in translational research to understand the role and contribution of mesenchymal stem cells in graft material.
Courtesy of Rivka C. Ihejirika, MD

Osteochondral allografts obviate the need for staged repair and can address large diameter osteochondral defects with fresh or preserved donor tissue. The recipient wound bed is size-matched to donor tissue that is shaped to fit the defect during the surgery. These allografts can treat subchondral defects up to 1 cm deep, with the added benefit of bone integration that provides support for the hyaline cartilage after implantation. Unlike blood products or glandular tissue, osteochondral allografts do not need to be screened for immune compatibility as long as the marrow elements are removed prior to transplant. These grafts perform well at medium-term follow-up, are particularly well-suited for use in the femoral condyles and patellofemoral joint, and have also found use in disorders such as spontaneous osteonecrosis of the knee. The success of these procedures has encouraged research into complete and partial allograft joint replacement surgery.

Summary
Biologic treatments such as PRP, which have the potential to augment tissue regeneration, are changing the face of orthopaedics. However, due to a lack of a standardized harvest and treatment algorithm, efficacy of these new therapies is difficult to quantify. In the absence of long-term evidence, further research is needed to investigate the ultimate risks and cost benefit ratio of biologic treatments for cartilage disease (Table 1).

Rivka C. Ihejirika, MD, is a PGY-2 research resident in the department of orthopaedic surgery at NYU Langone Orthopedic Hospital and a member of the AAOS Biologic Implants Committee.

References:

Insall, John N. Insall & Scott surgery of the knee. Elsevier Health Sciences, 2018. Online Version
Goodman, Stewart. Let’s Discuss: Biologics in Orthopaedics. AAOS, 2016.
Laver, Lior, et al. “PRP for Degenerative Cartilage Disease: A Systematic Review of Clinical Studies.” Cartilage (2016): 1947603516670709.
Moatshe, Gilbert, et al. “Biological treatment of the knee with platelet-rich plasma or bone marrow aspirate concentrates: A review of the current status.” Acta Orthopaedica 88.6 (2017): 670-674.
Tírico, Luís EP, et al. “Fresh Osteochondral Allograft Transplantation for Spontaneous Osteonecrosis of the Knee: A Case Series.” Orthopaedic Journal of Sports Medicine 5.10 (2017): 2325967117730540.
Khoshbin, Amir, et al. “The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 29.12 (2013): 2037-2048.
Dai, Wen-Li, et al. “Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 33.3 (2017): 659-670.
Campbell, Kirk A., et al. “Is local viscosupplementation injection clinically superior to other therapies in the treatment of osteoarthritis of the knee: a systematic review of overlapping meta-analyses.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 31.10 (2015): 2036-2045.
Campbell, Andrew B., et al. “Return to sport after articular cartilage repair in athletes’ knees: a systematic review.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 32.4 (2016): 651-668.
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10/18/2017

https://vimeo.com/235389919/e1d6edbafd

This is "DR MUNIR AHMED" by Martin Salowey on Vimeo, the home for high quality videos and the people who love them.

09/15/2017

Hopefully this will be approved soon in USA

03/31/2017

http://orthoinfo.org/topic.cfm?topic=A00771

Bone and joint conditions, injuries and surgeries can be painful. Orthopaedic surgeons are committed to helping their patients recover and live as comfortably and pain free as possible, while also ensuring overall health and safety.

05/26/2016

Study Asks, “Where are the Women in Orthopaedics?”





Although women account for approximately half of medical students in the United States, they represent only 13 percent of orthopaedic surgery residents and 4 percent of AAOS members. According to survey results to be presented Friday, the few women who are practicing orthopaedic surgery today became interested in the field due to factors such as the professional satisfaction and intellectual stimulation it offers, despite the lack of female role models and their limited exposure to orthopaedics prior to residency.

The authors contend that programs designed to improve mentorship and increase early exposure to orthopaedics play an important role in attracting the best and brightest of both sexes to orthopaedic surgery.

Study methods
The objective of this study was to understand why female orthopaedic surgeons chose the specialty, what perceptions they think might deter other women from pursuing this field, and the roles early exposure to orthopaedics and mentorship might play in this choice.

A 21-question survey was emailed to all members of the Ruth Jackson Orthopaedic Society (n = 556). Questions were formulated to determine demographics, practice patterns, and lifestyle choices of female orthopaedic surgeons. Specific questions evaluated the respondents’ selection of orthopaedics and their opinions of why more women do not choose this field.

Results
Responses were received from 232 members (41.7 percent).

The following were the most common reasons proposed for why women might not choose orthopaedics:

•perceived inability to have a good work/life balance
•perception that too much physical strength is required
•lack of strong mentorship in medical school or earlier

The most common specialties among respondents were hand (24 percent), general orthopaedics (20 percent), pediatric orthopaedics (19 percent), and sports medicine (15 percent). A majority of respondents reported practicing in an academic (42 percent) or hospital employed (21 percent) setting. Seventy-five percent of respondents considered themselves to be in a committed relationship, and 52 percent have children.

“Our key findings suggest that lack of exposure to musculoskeletal medicine, lack of mentorship, and lack of female role models may play a prominent role in the paucity of women entering orthopaedics,” said Julie E. Adams, MD, one of the study’s authors.

“In addition,” she asserted, “stereotypes—such as the perception that ‘too much strength” is required—or perceptions regarding poor work-life balance may deter women from pursuing orthopaedic surgery. Future work is needed to understand and improve the pipeline of qualified medical students who enter the field of orthopaedic surgery. Promoting mentorship and female role models in orthopaedics will ensure the future of orthopaedic surgery and that we will continue to attract the best and brightest of both sexes to enter our field.”

Dr. Adams’ coauthors of Paper 862, “Where are the Women in Orthopaedic Surgery? Examining Reasons for the Persistent Gender Gap” are Rachel S. Rohde, MD; and Jennifer M. Wolf, MD.

Details of the authors’ disclosures as submitted to the Orthopaedic Disclosure Program can be found in the Final Program; the most current disclosure information may be accessed electronically at www.aaos.org/disclosure

05/26/2016

Improving Transfer of Information to Optimize Patient Safety





By: Andrew W. Grose, MD


The competing demands of mastering minutiae and working expeditiously create tension for many healthcare providers. Efforts to satisfy both these goals often involve negotiating "efficiency-thoroughness trade-offs," a normal process wherein providers strike a balance between productivity and safety. This is particularly evident when providing patient information during transitions of care.

Data are often lost or degraded when information is transferred and, paradoxically, attempts to maximize thoroughness often only worsen the situation. Recognition of this, therefore, needs to be an integral part of care transition discussions. Most importantly, how to best manage conflicting goals to minimize the potential for patient harm must be addressed.

This article, the first of a two-part series on patient handoffs and sign-outs, explores the breakdowns in information transfer that can occur during a patient's transition of care.

Communication breakdown
In a hypothetical situation, a patient presents to the emergency department (ED) at 4:00 a.m. with a distal femur fracture caused by a simple fall from standing. The fracture is associated with a 4-mm to 5-mm clean wound at the anterior knee. Because the patient has complex medical problems (body mass index greater than 70, noninsulin-dependent diabetes mellitus, hypertension, and is on immunosuppressives for rheumatoid arthritis), the ED attending physician consults the medicine hospitalist and the patient is admitted to the medical service.

The patient is also assessed separately by the physician's assistant (PA) working for the on-call orthopaedist. Convinced that the fracture is open, the PA alerts the attending orthopaedic surgeon of the open fracture and recommends a plan for tetanus prophylaxis, antibiotics, and rapid surgical management. The attending orthopaedist agrees, so the orthopaedic PA also calls the admitting hospitalist and explains that the patient "needs to go to the operating room (OR) for an urgent repair today." No conversation takes place between the orthopaedic service and the ED physician.

While the orthopaedic team arranges for the case to go to the OR, the overnight hospitalist hands off to the oncoming hospitalist, explaining the patient's medical issues and the need for urgent fracture repair. The new hospitalist considers the patient at high risk for complications and therefore plans a 2-day stress-test; the hospitalist also orders heparin and a diet for the patient. As a result, the patient receives 5,000 units of heparin as well as breakfast early in the morning, just prior to a planned surgical treatment of the open distal femur fracture.

Unfortunately, outcomes such as these are frighteningly common. Hindsight, however, is of little use when determining what to do in real time. Rather than attempt to point to what people should have done, it is more useful to consider the world from their point of view. As providers working in vivo, we need to keep in mind what information will be required by others and when. Often the "when" is dictated to us by a formal transition of care, but that is not always the case.

Enhancing information exchange
Diverse teams with varying expertise can result in better patient care, but also bring increasingly narrow viewpoints that can pursue divergent paths with conflicting goals. As practitioners working at the sharp end of the stick, our role is to manage those conflicts. "Threat Management & Task Adaptation" is an excellent model of how this can be accomplished. This model assumes that some tasks involve events—or threats—outside the control of the team, yet team management is required for these tasks to be successfully completed. For example, the patient described above presented to the ED with threats of open fracture, morbid obesity, medical comorbidities resulting in immunosuppression, and cardiovascular risk—all of which needed to be managed. In addition, each team involved in a patient's care follows its own pathway, creating another category of threats.

Effective communication between providers is not only a safety buffer, but also a way to minimize redundant work (where possible) and maintain balance between goal conflicts. Unfortunately, effective communication—which needs to be precise, concise, and timely—can be hindered by significant barriers. These include hierarchy, jargon, turf or silo mentalities, fear, distractions, and assumptions. As a result, some information will undoubtedly be lost in transfer. Adhering to the following standard requirements for exchanging information between providers can help minimize this risk:
•The information exchange should occur in a "sterile" environment, meaning a place without distractions.
•The information should be delivered in a standardized fashion.
•Both providers should know each other's names and contact information.
•The receiver should repeat all information back to the sender to ensure accuracy.
•The sender should ask the receiver if he or she has any questions.

Andrew W. Grose, MD, is a member of the AAOS Patient Safety Committee.

References:
1.Hollnagel E: The ETTO Principle: Efficiency-Thoroughness Trade-off. Surrey, England, Ashgate, 2009.
2.Merritt A, Klinect J: Defensive Driving for Pilots: An Introduction to Threat and Error Management. Austin, The LOSA Collaborative, 2006.
3.https://psnet.ahrq.gov/search?topic=Structured-Hand-offs&f_topicIDs=633,631&f_resource_typeID=7
4.https://psnet.ahrq.gov/resources/resource/28485

04/14/2016

03/10/2016

My First successful Outpatient TOTAL KNEE REPLACEMENT !