Publications by authors named "Rajesh Malhotra"

180 Publications

Respiratory morbidity and mortality of traumatic cervical spinal cord injury at a level I trauma center in India.

Spinal Cord Ser Cases 2021 May 13;7(1):36. Epub 2021 May 13.

Biostatistics, National Drug Dependence Treatment Center, All India Institute of Medical Sciences, New Delhi, India.

Study Design: Descriptive retrospective.

Objectives: To evaluate the burden of respiratory morbidity in terms of ventilator dependence (VD) days and length of stay in neurotrauma ICU (NICU) and hospital, and to determine mortality in patients with traumatic cervical spinal cord injury (CSCI) in a low middle-income country (LMIC).

Setting: Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Methods: A total of 135 patients admitted with CSCI in the NICU between January 2017 to December 2018 were screened. Information regarding age, gender, American Spinal Injury Association (ASIA) impairment scale (AIS), level of injury, duration of VD, length of NICU, hospital stay, and outcome in terms of mortality or discharge from the hospital were obtained from the medical records.

Results: A total of 106 CSCI patients were analyzed. The mean (SD) age of patients was 40 (±16) years and male: female ratio was 5:1. The duration of VD, duration of NICU, and hospital stay was a median of 8 days (IQR 1127), 6 days (IQR 1118), and 15 days (IQR 3127) respectively. Mortality was 19% (20/106). The mortality was significantly associated with poorer AIS score, VD, and duration of ICU and hospital stay. All patients were discharged to home only after they became ventilator-free.

Conclusions: The ventilator burden, hospital stay, and mortality are high in patients with CSCI in LMICs. Poor AIS scores, prolonged VD, ICU and hospital stay are associated with mortality. There is a need for comprehensive CSCI rehabilitation programs in LMICs to improve outcome.
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http://dx.doi.org/10.1038/s41394-020-00371-5DOI Listing
May 2021

The utility of dithiothreitol treatment of periprosthetic tissues and explanted implants in the diagnosis of prosthetic joint infection.

Indian J Med Microbiol 2021 Apr 18;39(2):179-183. Epub 2020 Dec 18.

Department of Microbiology, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Electronic address:

Purpose: The methods used for the processing of periprosthetic tissues and explanted implants to improve culture outcome especially in biofilm mediated prosthetic joint infections (PJIs) are still debated upon. Studies have reported that Dithiothreitol (DTT) pretreatment of infected devices gives similar results as sonication. However, none of them evaluated the DTT treatment of periprosthetic tissues and explanted implants in the same cohort. We evaluated the diagnostic utility of DTT treatment of periprosthetic tissue and explanted implants, as compared to the normal saline treatment of periprosthetic tissues and sonication of explanted implants for the diagnosis of PJI.

Methods: Seventy-three revision arthroplasty cases were prospectively included in this study. Three to five tissue specimens and the explanted implants were collected from each patient. Periprosthetic tissue samples were processed by both normal saline and DTT treatments. Explanted implants were subjected to both DTT treatment and sonication. Musculoskeletal Infection Society (MSIS) PJI criteria was used as the reference standard for the diagnosis of PJI.

Results: Of the 73 cases enrolled, 34 had PJI and 39 were aseptic failures. The sensitivity of DTT treated periprosthetic tissue culture (PTC) and saline treated PTC was similar (66.6% vs 58.8%, P = 0.25). The specificity of both was 100%. Sonication and DTT treatment of explanted implants showed comparable sensitivity (85.3% vs 82.4%) and specificity (100% vs 97.4%), P > 0.99. Compared to DTT treated PTC, culture of DTT treated explanted implants significantly improved the diagnosis of PJI (P = 0.03).

Conclusions: We could verify that DTT can be used to improve culture outcome in laboratories where biofilm detaching sonication techniques are not available for infected implants. In addition, we showed that it is possible to use DTT for treating tissue biopsies, but larger studies are required to confirm our findings.
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http://dx.doi.org/10.1016/j.ijmmb.2020.12.004DOI Listing
April 2021

Profile of co-infections & secondary infections in COVID-19 patients at a dedicated COVID-19 facility of a tertiary care Indian hospital: Implication on antimicrobial resistance.

Indian J Med Microbiol 2021 04 2;39(2):147-153. Epub 2020 Nov 2.

Department of Laboratory Medicine (Microbiology), JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Background: The COVID-19 pandemic has raised concerns over secondary infections because it has limited treatment options and empiric antimicrobial treatment poses serious risks of aggravating antimicrobial resistance (AMR). Studies have shown that COVID-19 patients are predisposed to develop secondary infections. This study was conducted to ascertain the prevalence and profiles of co- & secondary infections in patients at the COVID-19 facility in North India.

Methods: We studied the profile of pathogens isolated from 290 clinical samples. Bacterial and fungal pathogens were identified, and antimicrobial susceptibility was determined by the Vitek2® system. Additionally, respiratory samples were tested for any viral/atypical bacterial co-infections and the presence of AMR genes by FilmArray test. The clinical and outcome data of these patients were also recorded for demographic and outcome measures analyses.

Results: A total of 151 (13%) patients had secondary infections, and most got infected within the first 14 days of hospital admission. Patients aged >50 years developed severe symptoms (p = 0.0004) and/or had a fatal outcome (p = 0.0005). In-hospital mortality was 33%.K.pneumoniae (33.3%) was the predominant pathogen, followed by A. baumannii (27.1%). The overall resistance was up to 84%.Majority of the organisms were multidrug-resistant (MDR) harbouring MDR genes.

Conclusion: A high rate of secondary infections with resistant pathogens in COVID-19 patients highlights the importance of antimicrobial stewardship programs focussing on supporting the optimal selection of empiric treatment and rapid-de-escalation, based on culture reports.
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http://dx.doi.org/10.1016/j.ijmmb.2020.10.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667411PMC
April 2021

Total hip arthroplasty in tubercular arthritis of the hip - Surgical challenges and choice of implants.

J Clin Orthop Trauma 2021 Jun 28;17:214-217. Epub 2021 Mar 28.

Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India.

Osteoarticular tuberculosis of the hip joint can be a debilitating disease that can result in severe cartilage degeneration, destruction, and eventual painful arthritis of the hip. Usually, a secondary affliction to a primary lung disease, Tuberculosis (TB) of the hip can be difficult to diagnose due to its indolent natural history and deep-seated nature of the hip joint itself. Untreated, ultimately TB hip leads to disabling arthritis of the hip with limitation of activities of daily living, livelihood, and socio-economic consequences. Historic surgical options such as arthrodesis and excision arthroplasty of TB hip have limitations and several disadvantages. Total hip arthroplasty (THA) is a viable option to restore mobility and relieve pain in patients with severe post-tuberculous arthritis but has been controversial in the past due to the concerns of disease reactivation. We evaluate the current role of THA in TB of the hip, its various applications in different presenting scenarios with a guide to surgical tips and tricks for managing this challenging condition.
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http://dx.doi.org/10.1016/j.jcot.2021.03.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047221PMC
June 2021

Megaprosthesis Versus Allograft Prosthesis Composite for the Management of Massive Skeletal Defects: A Meta-Analysis of Comparative Studies.

Curr Rev Musculoskelet Med 2021 Apr 17. Epub 2021 Apr 17.

Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India.

Purpose Of Review: Megaprosthesis and Allograft Prosthesis Composite (APC) are the established treatment modalities for massive skeletal defects. There are a handful of studies comparing the use of megaprosthesis and APC in the management of substantial bone loss and it has always been a topic of debate regarding the superiority of one modality over the other. Therefore, we aim to compare the functional outcome and implant survivorship of each modality including complications, revision rates, amputation rate and mortality.

Recent Findings: The Allograft Prosthesis Composite (APC) constitutes a skeletal allograft implanted with a revision type prosthesis in it. The biological environment provided by the allograft allows attachment of the muscles and tendons imparting better stability and function. However, the literature is not kind enough with APC due to associated risk of infection, disease transmission and nonunion at the graft-host junction. The megaprosthesis (MP) on the other hand is a nonbiologic modality with better survivorship but subservient functional outcome. Infection has been a major issue in both the modalities. Advancement in metallurgy using silver coated megaprosthesis also failed to provide strong evidence in preventing infection. The functional outcome is better with APC in both the upper and lower limbs. However, the survivorship is better with megaprosthesis, especially in the upper limb when revision rates were compared between the two modalities. Deep infection and mechanical complications were significantly higher in the APC group. There was no significant difference between the two groups in terms of amputation rate, mortality, and local recurrence.

Level Of Evidence (cebm): 2a.
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http://dx.doi.org/10.1007/s12178-021-09707-6DOI Listing
April 2021

Outcomes of Total Knee Arthroplasty in Patients with Prior Hardware: A Case-Control Study Using Handheld Navigation.

J Knee Surg 2021 Apr 14. Epub 2021 Apr 14.

Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.

Presence of hardware in juxta-articular location poses challenge during total knee arthroplasty (TKA). When present in distal femur, it precludes the use of an intramedullary femoral jig during TKA often necessitating removal of hardware leading to prolonged surgery, higher risk of complications, and inferior results. We conducted a case-control study to assess the outcome of TKA among patients with post-traumatic arthritis using a handheld navigation system to perform bone cuts allowing retention of hardware in situ. In 15 patients with post-traumatic arthritis and hardware around the knee (Group A), none or part(s) of hardware were removed while performing TKA. These patients were matched to 15 patients who underwent TKA with handheld navigation for primary OA knee (Group B). The perioperative outcomes assessed were operative time, intraoperative blood loss, length of hospital stay, complications, and 30 days reoperation rate. Clinical outcomes were assessed by using Knee Society Score (KSS) and radiological outcomes using mechanical axis and coronal and sagittal component angles. Mean age of patients at surgery were 65.67 years (Group A) and 66.73 years (Group B). Mean operative time and blood loss were significantly higher in Group A as compared with Group B. At the mean follow-up of 34 months, KSS significantly improved in both the groups. However, there was no statistically significant difference in the clinical and radiological outcomes between the two groups. One patient in Group A developed wound dehiscence and had to undergo debridement and flap coverage within 30 days. The use of navigation helps surgeons in gaining proper limb alignment and implant positioning without complete removal of hardware.
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http://dx.doi.org/10.1055/s-0041-1726419DOI Listing
April 2021

Is It Worth Delaying Total Knee Replacement as Late as Possible? A Cost-Effectiveness Analysis Using a Markov Model in the Indian Setting.

Value Health Reg Issues 2021 Apr 5;24:173-180. Epub 2021 Apr 5.

Department of Orthopedic Surgery, AIIMS, New Delhi, India.

Background: Total knee replacement (TKR) is often delayed in younger patients in an attempt to prolong the longevity of the prosthesis and avoid the risk of revision. But delaying a TKR might compromise the quality of life of young patients who are otherwise active and healthy.

Methods: We built a Markov decision model to study the simulated clinical course of a 50-year-old patient with severe unilateral knee osteoarthritis who could be either treated with conservative therapies or with a TKR at some point in time. An Indian healthcare payer perspective model was used, and lifetime costs (in Indian rupees), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated.

Results: In the base case scenario, patients who did not receive a TKR had a total lifetime cost of ₹216 709 and accumulated 13.59 QALYS in their lifetime. Those who received a TKR without delay (at age 50) accumulated 16.71 QALYS in their lifetime with an ICER of ₹9789 per QALY. When TKR was delayed, the total QALYs decreased, and ICER increased with each year of delay. But the cumulative risk of revision decreased from 27.4% when TKR was performed at 50 years to 10.0% when TKR was done at 70 years.

Conclusion: Our analysis found that TKR is a cost-effective procedure when the healthcare payer is willing to pay at least ₹9789 ($132) per QALY. The results also suggested that an early TKR is preferred to a delayed TKR despite the higher incidence of revisions.
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http://dx.doi.org/10.1016/j.vhri.2020.12.009DOI Listing
April 2021

Rapid chromatographic immunoassay-based evaluation of COVID-19: A cross-sectional, diagnostic test accuracy study & its implications for COVID-19 management in India.

Indian J Med Res 2021 Jan & Feb;153(1 & 2):126-131

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Background & Objectives: Coronavirus disease 2019 (COVID-19) has so far affected over 41 million people globally. The limited supply of real-time reverse transcription-polymerase chain reaction (rRT-PCR) kits and reagents has made meeting the rising demand for increased testing incompetent, worldwide. A highly sensitive and specific antigen-based rapid diagnostic test (RDT) is the need of the hour. The objective of this study was to evaluate the performance of a rapid chromatographic immunoassay-based test (index test) compared with a clinical reference standard (rRT-PCR).

Methods: A cross-sectional, single-blinded study was conducted at a tertiary care teaching hospital in north India. Paired samples were taken for RDT and rRT-PCR (reference standard) from consecutive participants screened for COVID-19 to calculate the sensitivity and specificity of the RDT. Further subgroup analysis was done based on the duration of illness and cycle threshold values. Cohen's kappa coefficient was used to measure the level of agreement between the two tests.

Results: Of the 330 participants, 77 were rRT-PCR positive for SARS-CoV-2. Sixty four of these patients also tested positive for SARS-CoV-2 by RDT. The overall sensitivity and specificity were 81.8 and 99.6 per cent, respectively. The sensitivity of RDT was higher (85.9%) in participants with a duration of illness ≤5 days.

Interpretation & Conclusions: With an excellent specificity and moderate sensitivity, this RDT may be used to rule in COVID-19 in patients with a duration of illness ≤5 days. Large-scale testing based on this RDT across the country would result in quick detection, isolation and treatment of COVID-19 patients.
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http://dx.doi.org/10.4103/ijmr.IJMR_3305_20DOI Listing
April 2021

Biomarkers of Joint Damage in Osteoarthritis: Current Status and Future Directions.

Mediators Inflamm 2021 9;2021:5574582. Epub 2021 Mar 9.

Department of Integrative and Functional Biology, CSIR-Institute of Genomics & Integrative Biology, Mall Road, -110007, Delhi, India.

Osteoarthritis (OA) is a disease of the whole joint organ, characterized by the loss of cartilage, and structural changes in bone including the formation of osteophytes, causing disability and loss of function. It is also associated with systemic mediators and low-grade inflammation. Currently, there is negligible/no availability of specific biomarkers that can be used to facilitate the diagnosis and treatment of OA. The most unmet clinical need is, however, related to the monitoring of disease progression over a short period that can be used in clinical trials. In this review, the value of biomarkers identified over the past decade has been highlighted. These biomarkers are associated with the synthesis and breakdown of cartilage, including collagenous and noncollagenous biomarkers, inflammatory and anti-inflammatory biomarkers, expressed in the biological fluid such as serum, synovial fluid, and urine. Broad validation of novel and clinically applicable biomarkers and their involvement in the pathways are particularly needed for early-stage diagnosis, monitoring disease progression, and severity and examining new drugs to mitigate the effects of this highly prevalent and debilitating condition.
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http://dx.doi.org/10.1155/2021/5574582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969115PMC
March 2021

Poor Clearance of Free Hemoglobin Due to Lower Active Haptoglobin Availability is Associated with Osteoarthritis Inflammation.

J Inflamm Res 2021 18;14:949-964. Epub 2021 Mar 18.

Department of Integrative and Functional Biology, CSIR-Institute of Genomics and Integrative Biology, New Delhi, 110007, India.

Introduction: Circulating plasma proteins play an important role in various diseases, and analysis of the plasma proteome has led to the discovery of various disease biomarkers. Osteoarthritis (OA) is the most common chronic joint disease, mostly affecting people of older age. OA typically starts as a focal disease (in a single compartment, typically treated with unicompartmental knee replacement), and then progresses to the other compartments (if not treated in time, typically treated with total knee replacement). For this, identification of differential proteins was carried out in plasma samples of OA cases and compared with healthy controls. The aim of this study was to identify circulatory differentially expressed proteins (DEPs) in knee-OA patients undergoing total knee replacement or unicompartmental knee replacement compared to healthy controls and assess their role, in order to have better understanding of the etiology behind OA pathophysiology.

Methods: DEPs were identified with two-dimensional gel electrophoresis (2DE) and isobaric tags for relative and absolute quantification (iTRAQ), followed by liquid chromatography with tandem mass spectrometry. Validation of DEPs was carried out using Western blot and ELISA. Posttranslational modifications were checked after running native gel using purified protein from patients, followed by detection of autoantibodies.

Results: In total, 52 DEPs were identified, among which 45 were distinct DEPs. Haptoglobin (Hp) was identified as one of the most significantly upregulated proteins in OA (=0.005) identified by both 2DE and iTRAQ. Decreased levels of Hp tetramers and increased levels of autoantibodies against Hpβ were observed in OA plasma.

Conclusion: Our data suggest that poor clearance of free hemoglobin and low levels of Hp tetramers may be associated with OA pathogenesis and inflammation.
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http://dx.doi.org/10.2147/JIR.S300801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987317PMC
March 2021

Which one restores in vivo knee kinematics effectively-medial or lateral pivot?

J Clin Orthop Trauma 2021 Feb 21;13:70-73. Epub 2020 Aug 21.

Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India.

Introduction: Total knee arthroplasty (TKA) usually provides good pain relief and improved function but has generally been unable to fully restore normal knee kinematics. Does Medial or Lateral Pivot TKA designs guide us to native knee kinematics needs to be elucidated?

Methods: Kinematic assessment of 13 knees with Medial Pivot TKA and 13 knees with Lateral Pivot TKA was done. The subjects were asked to perform step-up and weight bearing deep knee bend exercise under fluoroscopy for kinematic assessment. Patellar Tendon Angle (PTA) was measured after correcting f luoroscopic images for distortion against Knee Flexion Angle (KFA).

Results: During the weight bearing deep knee bend, the average active maximum flexion achieved with Medial Pivot design was 113.8 ͦ as compared to 102.9 ͦ with Lateral Pivot design. There was no significant difference in PTA in step up and deep knee bend exercise between both the designs.

Conclusion: The kinematic assessment of both the Medial and Lateral Pivot TKA designs revealed linear trend of PTA with increasing KFA as described for normal knee. Both the designs were able to achieve functional knee range of motion.
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http://dx.doi.org/10.1016/j.jcot.2020.08.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920103PMC
February 2021

Influence of Etiology and Onset of Deformity on Spatiotemporal, Kinematic, Kinetic, and Electromyography Gait Variables in Patients with Scoliosis-A Prospective, Comparative Study.

Spine (Phila Pa 1976) 2021 Mar;46(6):374-382

Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.

Study Design: Prospective comparative study.

Objective: The aim of this study was to compare the spatiotemporal, kinematic, kinetic and electromyographic (EMG) gait variables in patients with adolescent idiopathic scoliosis (AIS) and congenital scoliosis and to compare these gait variables of scoliosis patients with healthy controls.

Summary Of Background Data: Earlier studies have solely focussed on the possibility of altered gait patterns in AIS patients; not much light has been shed on the differences in gait patterns in congenital and adolescent scoliosis patients.

Methods: Forty scoliosis patients (20 each with AIS and congenital scoliosis) and 20 healthy volunteers were prospectively recruited. After thorough clinical and radiological examination, all patients underwent gait analysis in accordance with standard protocols.The outcome measures included spatiotemporal, kinetic, kinematic and EMG activity. Composite indices for gait analysis-Gait Profile Score (GPS) and Gait Deviation Index (GDI)-were also calculated. Relevant statistical tests were applied to compare the different groups.

Results: No significant difference was found between the AIS and congenital scoliosis groups with respect to baseline demographic and radiological parameters. The two subgroups of scoliosis patients (AIS and congenital) did not differ significantly with respect to any of the measured gait analysis parameters. However, when compared to the healthy age-matched control group, the scoliosis patients differed significantly with respect to gait speed, stride length, step length, GDI, GPS and peak EMG activation for erector spinae, biceps femoris, semimembranosus, rectus femoris, gastrocnemious, and tibialis anterior.

Conclusion: Our findings confirm the previous findings of literature regarding the alteration in gait patterns in scoliosis patients when compared to normal individuals. However, the lack of difference in gait analysis variables between AIS and congenital scoliosis patients suggests that this alteration in gait is secondary to the existence of the deformity and does not correlate with the onset or etiology of deformity.Level of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003796DOI Listing
March 2021

Device associated infections at a trauma surgical center of India: Trend over eight years.

Indian J Med Microbiol 2021 Jan 4;39(1):15-18. Epub 2020 Nov 4.

Department of Orthopaedics, Chief, JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India. Electronic address:

Background: Device-associated infections (DAIs) are an important cause of excessive stay and mortality in ICUs. Trauma patients are predisposed to acquire such infections due to various factors. The prevalence of HAIs is underreported from developing nations due to a lack of systematic surveillance. This study reports the rates and outcomes of DAIs at a dedicated Trauma Center in trauma patients and compares the rates with a previous pilot observation.

Methods: The study reports the finding of ongoing surveillance and the use of an indigenous software at a level-1 trauma center in India. Surveillance for ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections was done based on standard definitions. The rates of HAIs and the profile of pathogens isolated from June 2010 to December 2018 were analyzed.

Results: A total of 7485 patients were included in the analysis, amounting to 68,715 patient days. The rates of VAP, CLABSI, and CA-UTI were respectively 12, 9.8 1st 8.5/1000 device days. There was a significant correlation between device days and the propensity to develop infections. Of the 1449 isolates recovered from cases of DAIs, Acinetobacter sp (28.2%) was the most common isolate, followed by Candida sp. A high rate of multi-resistance was observed.

Conclusion: Automated surveillance was easy and useful for data entry and analysis. Surveillance data should be used for implementing preventive programs.
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http://dx.doi.org/10.1016/j.ijmmb.2020.10.015DOI Listing
January 2021

Total Hip Arthroplasty in Patients With Postpolio Residual Paralysis: A Systematic Review.

J Arthroplasty 2021 Jan 23. Epub 2021 Jan 23.

Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Background: Patients with postpolio residual paralysis can develop disabling hip arthritis in paralytic as well as a nonparalytic limb, warranting total hip arthroplasty (THA). Limited literature is available on the results of THA among these patients in the form of small series or case reports. We have undertaken a systematic review to evaluate the clinical outcome of THA in patients with poliomyelitis with hip pathologies.

Methods: A systematic search of electronic databases of PubMed, Scopus, and Web of Science pertaining to English literature was undertaken from 1945 to August 2020 to assess the results of THA in patients with poliomyelitis. Information was gathered about demographics, indication, clinical course, complications, functional outcome, survival, and need for any revision surgery in these patients.

Results: The literature search revealed 81 articles. Finally, after deduplication and manual selection, 16 relevant articles (128 hips) were included for evaluation. There is a paucity of literature evaluating THA in patients with poliomyelitis over the last 2 decades. The principal reason for arthroplasty was osteoarthritis of the hip in the ipsilateral (paralyzed) limb. A combination of cemented, uncemented, and hybrid implant fixation system was found to be used by surgeons. Addressing instability and perioperative management of limb length discrepancy were found to be challenging propositions.

Conclusion: THA remains an effective intervention to relieve pain and improve quality of life in patients of poliomyelitis afflicted with either primary or secondary arthritis of the hip. The use of uncemented nonconstrained hip implant designs appears to demonstrate better results than constrained implants.
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http://dx.doi.org/10.1016/j.arth.2021.01.046DOI Listing
January 2021

Artificial Intelligence-assisted chest X-ray assessment scheme for COVID-19.

Eur Radiol 2021 Jan 20. Epub 2021 Jan 20.

Indian Institute of Technology, Delhi, New Delhi, India.

Objectives: To study whether a trained convolutional neural network (CNN) can be of assistance to radiologists in differentiating Coronavirus disease (COVID)-positive from COVID-negative patients using chest X-ray (CXR) through an ambispective clinical study. To identify subgroups of patients where artificial intelligence (AI) can be of particular value and analyse what imaging features may have contributed to the performance of AI by means of visualisation techniques.

Methods: CXR of 487 patients were classified into [4] categories-normal, classical COVID, indeterminate, and non-COVID by consensus opinion of 2 radiologists. CXR which were classified as "normal" and "indeterminate" were then subjected to analysis by AI, and final categorisation provided as guided by prediction of the network. Precision and recall of the radiologist alone and radiologist assisted by AI were calculated in comparison to reverse transcriptase-polymerase chain reaction (RT-PCR) as the gold standard. Attention maps of the CNN were analysed to understand regions in the CXR important to the AI algorithm in making a prediction.

Results: The precision of radiologists improved from 65.9 to 81.9% and recall improved from 17.5 to 71.75 when assistance with AI was provided. AI showed 92% accuracy in classifying "normal" CXR into COVID or non-COVID. Analysis of attention maps revealed attention on the cardiac shadow in these "normal" radiographs.

Conclusion: This study shows how deployment of an AI algorithm can complement a human expert in the determination of COVID status. Analysis of the detected features suggests possible subtle cardiac changes, laying ground for further investigative studies into possible cardiac changes.

Key Points: • Through an ambispective clinical study, we show how assistance with an AI algorithm can improve recall (sensitivity) and precision (positive predictive value) of radiologists in assessing CXR for possible COVID in comparison to RT-PCR. • We show that AI achieves the best results in images classified as "normal" by radiologists. We conjecture that possible subtle cardiac in the CXR, imperceptible to the human eye, may have contributed to this prediction. • The reported results may pave the way for a human computer collaboration whereby the expert with some help from the AI algorithm achieves higher accuracy in predicting COVID status on CXR than previously thought possible when considering either alone.
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http://dx.doi.org/10.1007/s00330-020-07628-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816060PMC
January 2021

Factors associated with delayed surgery in elderly hip fractures in India.

Arch Osteoporos 2021 01 6;16(1). Epub 2021 Jan 6.

Department of Orthopaedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Early hip fracture surgery is recommended to decrease the morbidity and mortality. The extent to which such guidelines are being followed in developing countries like India is unknown. About 20% of the patients presented to hospital after 24 hours of injury, and only one-third had surgery within 48 hours of presentation.

Introduction: Early hip fracture surgery is recommended to decrease the morbidity and mortality following hip fractures. Understanding the factors responsible for delay in surgery is important to improve the quality of hip fracture care. This study was conducted to study the factors causing delay in elderly hip fracture surgery in India.

Methods: In this prospective study, 272 consecutive hip fracture surgeries at a single hospital were included. Delayed surgery was defined as when the time to surgery (reaching hospital to start of incision) was more than 48 hours. Additionally, the total time to surgery (including time taken for patients to reach hospital after injury) was studied. Factors associated with delayed surgery were assessed using regression models.

Results: Eighty-seven (32%) patients had a surgery within 48 hours of presentation. Majority of the patients had a delay (82%, N = 151/185) due to one or more medical reasons. Fifty-four (20%) patients presented to hospital after 24 hours of injury. The mean total time to surgery was 112 ± 90 hours with time after reaching hospital contributing to 78% of the total time. Multiple comorbidities (odds ratio, OR = 3.47 [1.42-8.45]), fall as mode of injury (OR = 3.54 [1.61-7.80]), requiring an additional investigation (OR = 10.4 [3.4-31.81]), and requiring arthroplasty (OR = 40.57 [7.01-234.97]) were independently associated with delayed surgery.

Conclusion: Only about one-third of the patients received surgery within 48 hours of reaching the hospital, and about 20% of the patients presented to hospital after 24 hours of injury. Delayed surgery was primarily due to medical comorbidities. Hospitals should establish protocols to ensure faster optimization of patients.
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http://dx.doi.org/10.1007/s11657-020-00858-6DOI Listing
January 2021

Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients.

Indian J Crit Care Med 2020 Nov;24(11):1037-1044

Department of Laboratory Medicine, JPNA Trauma Center, All India Institute of Medical Sciences, New Delhi, India.

Purpose: One of the leading causes of morbidity and early-age mortality across the globe is trauma. It disrupts immune system homeostasis and intensely affects the innate and adaptive immune responses, predisposing patients to posttrauma complications and poor outcomes. Most of the studies on posttrauma cellular immune response have been centered on the T helper-1-T helper-2 imbalances after trauma. This study was conducted to understand the role of circulating novel T helper cells in the acute posttraumatic period and clinical outcome of trauma patients.

Materials And Methods: Signature cytokines and transcription factors of circulating Th (T helper)-9, Th-17, Th-22, and regulatory T helper cells were studied using flowcytometry along with serum biomarkers in 49 patients with polytraumatic injuries admitted to a tertiary care hospital. The patients were followed up until their outcome. The results were correlated with their clinical outcomes.

Results: In patients who died, higher nTreg, iTreg, Tr1 (early-phase), and higher IRF4+Th-9, IL17+ Th-17, and RORγT+ Th-17 (mid-phase) were seen. However, by the late phase, only RORγT+ Th-17 remained higher. Serum IL-6 and PCT were found to be consistently higher. In survivors, higher Th-3 (early phase), Th-22 (mid-phase), and IRF4+Th-9, IL17+ Th-17, nTreg, Th-3 (late phase) were observed to have played a protective role. Serum IL-2, IL-4, IL-17A and IL-22 were significantly higher in survivors.

Conclusion: Different T helper subsets were observed to be playing pathogenic and protective roles in different phases of trauma and could be used for early prognostication and make way for noninvasive management of critically injured trauma patients by immunomodulation.

How To Cite This Article: Khurana S, Bhardwaj N, Kumar S, Sagar S, Pal R, Soni KD, Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients. Indian J Crit Care Med 2020;24(11):1037-1044.
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http://dx.doi.org/10.5005/jp-journals-10071-23577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751033PMC
November 2020

Comparison of Genotypic and Phenotypic Methods of Metallo-β- lactamase Detection in spp.

J Glob Infect Dis 2020 Jul-Sep;12(3):141-143. Epub 2020 Aug 29.

Department of Orthopaedics, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

Introduction: MBL containing genes have been reported in all GNBs including spp since 1990s which are worrisome as they are transmitted by mobile genetic elements. Thus, early detection of MBL encoding organisms is necessary. The current study was designed to identify the most sensitive cost-effective test which could be used as a screening test for detection of cabapenamase producing isolates.

Methodology: All consecutive strains of spp isolated from various clinical samples were included. All isolates found resistant to any of the carbapenems were tested for MBL production using MHT (on MacConkey Agar and Mueller Hinton Agar), Etest (using Imipenem/Meropenem-EDTA) and Combined Disc Test (using EDTA and 2 MPA as inhibitors and Ceftazidime/Imipenem/Meropenem as substrate discs). PCR was performed for representative strains for IMP, VIM, KPC, OXA and NDM-1 gene.

Results: Total of 154 non-duplicate strains of spp were isolated and identified, of which, 134 (88%) and 126 (82%) were resistant to meropenem and imipenem respectively. All 134 meropenem resistant strains were tested for MBL production and PCR was performed on 100 strains. 3(3%), 5(5%), 7(7%), 26(26%), and 51(51%) strains had IMP gene, VIM gene, KPC gene, OXA gene and NDM-1 gene. MHT on MAC had better performance than on MHA and dilution to 0.05 McFarland was not required.

Conclusion: MHT on MAC had best sensitivity when compared with gold standard PCR and was also cost effective. With ROC curve, we found that 2MPA was not a good MBL inhibitor when compared with EDTA..
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http://dx.doi.org/10.4103/jgid.jgid_38_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733430PMC
August 2020

A multi-responsive pyranone based Schiff base for the selective, sensitive and competent recognition of copper metal ions.

Spectrochim Acta A Mol Biomol Spectrosc 2021 Mar 16;249:119221. Epub 2020 Nov 16.

Department of Chemistry, Guru Jambheshwar University of Science and Technology, Hisar 125001, India. Electronic address:

Exploring a new multi-responsive pyranone chemosensor capable of sensing copper ions specifically and selectively through colorimetric, UV-Vis absorption and fluorescence methods is of great importance. In this piece of work, a novel pyranone based Schiff base ligand 4-Hydroxy-6-methyl-3-[1-(2-morpholin-4-yl-ethylimino)-ethyl]-pyran-2-one (DM) was synthesized by the condensation of dehydroacetic acid and 4-(2-aminoethyl) morpholine. The structural determination of ligand DM was executed using distinct spectral techniques i.e.,H NMR, C NMR, FT-IR and HR-MS techniques. The reported Schiff base DM showed an immediate colorimetric change from pale yellow to colorless accompanied by a strong change in the UV-Vis absorption band onto the addition of Cu (II) ions. This metal ligand chelation leads a decrease in ICT process. Also the decrease in fluorescence emission intensity of Schiff base DM with Cu (II) ions addition showed its turn-off behavior towards copper ions. Further absorption/ emission titration studies, Job's plot, HR-MS and H NMR titration data designated 2:1 stoichiometric ratio between DM and Cu (II) ions respectively. Density functional theory studies were also performed to authenticate the binding mechanism theoretically. The sensitivity of Schiff base DM towards Cu (II) ions was applicable at every pH conditions and at the same time DM exhibited selectivity towards Cu (II) ions with a negligible interference of other metal ions. DM showed a detection limit of 7.7 nM towards copper ions via fluorescence emission studies. The best part about DM is that it has good stability but showed an instant chemical reversibility when titrated with EDTA solution.
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http://dx.doi.org/10.1016/j.saa.2020.119221DOI Listing
March 2021

Atypical case presentations of from level 1 trauma centre in India -A case series.

J Family Med Prim Care 2020 Sep 30;9(9):5058-5061. Epub 2020 Sep 30.

Department of Microbiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

is a rare cause of appendicitis, skin soft tissue, and bloodstream infections. The clinical significance of its isolation from samples of skin or soft tissues and pus from the appendix is poorly understood. Invasive pneumococcal disease (IPD) continues to be a problem in India, associated with a high case fatality rate despite treatment facilities available in the hospital settings. In the present study, we report three adult cases, one presented as acute appendicitis, the other had skin and soft tissue infection, and third presented with bloodstream infection caused by from our level 1 trauma center. The patients with acute appendicitis and soft tissue infection recovered when treated with appropriate antimicrobial therapy, however, the one with pneumococcal sepsis could not be revived.
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http://dx.doi.org/10.4103/jfmpc.jfmpc_529_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652198PMC
September 2020

Total hip arthroplasty in acetabular fractures.

J Clin Orthop Trauma 2020 Nov-Dec;11(6):1090-1098. Epub 2020 Oct 17.

All India Institute of Medical Sciences, Jai Prakash Narayan Apex Trauma Centre, Ansari Nagar, New Delhi, Delhi, 110029, India.

Total Hip Arthroplasty (THA) is a well-accepted treatment for established hip arthritis following acetabular fractures. If a conservatively managed or operated case progresses to non-union/mal-union failing to restore the joint integrity, it may eventually develop secondary arthritis warranting a total hip arthroplasty. Also, in recent years, acute total hip arthroplasty is gaining importance in conditions where the fracture presents with pre-existing hip arthritis, is not amenable to salvage by open reduction and internal fixation, or, a poor prognosis is anticipated following fixation. There are several surgical challenges in performing total hip arthroplasty for acetabular fractures whether acute or delayed. As a separate entity elderly patients pose a distinct challenge due to osteoporosis and need stable fixation for early weight bearing alleviating the risk of any thromboembolic event, pulmonary complications and decubitus ulcer. The aim of surgery is to restore the columns for acetabular component implantation rather than anatomic fixation. Meticulous preoperative planning with radiographs and Computed Tomography (CT) scans, adequate exposure to delineate the fracture pattern, and, availability of an array of all instruments and possible implants as backup are the key points for success. Previous implants if any should be removed only if they are in the way of cup implantation or infected. Press fit uncemented modern porous metal acetabular component with multiple screw options is the preferred implant for majority of cases. However, complex fractures may require major reconstruction with revision THA implants especially when a pelvic discontinuity is present.
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http://dx.doi.org/10.1016/j.jcot.2020.10.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656485PMC
October 2020

Superior patient satisfaction in medial pivot as compared to posterior stabilized total knee arthroplasty: a prospective randomized study.

Knee Surg Sports Traumatol Arthrosc 2020 Nov 5. Epub 2020 Nov 5.

Chapel Allerton Hospital, University of Leeds, Leeds, UK.

Purpose: Medial pivot (MP) total knee arthroplasty (TKA) aims to restore native knee kinematics due to highly conforming medial tibio-femoral articulation with survival comparable to contemporary knee designs. Posterior stabilized (PS) TKAs use cam-post mechanism to restore native femoral rollback. However, there is conflicting evidence regarding the reported patient satisfaction with MP TKA designs when compared to PS TKAs. The primary aim of this study is to compare the patient satisfaction between MP and PS TKA and the secondary aim is to establish potential reasons behind any differences in the outcomes noted between these two design philosophies.

Methods: In this IRB-approved single surgeon, single centre prospective RCT, 53 patients (mean age 62 years, 42 women) with comparable bilateral end-stage knee arthritis undergoing simultaneous bilateral TKA were randomized to receive MP TKA in one knee and PS TKA in the contralateral knee. At 4 years post-surgery, all patients were assessed using Knee Society Score (KSS)-Satisfaction and -Expectation scores, and Oxford Knee Score (OKS). In addition, all the patients underwent standardized radiological and in vivo kinematic assessment.

Results: Patients were more satisfied with the MP TKA as compared to PS TKA: mean KSS-Satisfaction [34.5 ± 3.05 in MP and 31.7 ± 3.16 in PS TKAs (p < 0.0001)] and mean KSS-Expectation scores [12.5 ± 1.39 in MP TKAs and 11.2 ± 1.41 in PS TKAs (p < 0.0001)]. No significant difference was noted in any other clinical outcomes. The in vivo kinematics of MP TKAs was significantly better than those of PS TKAs.

Conclusion: MP TKAs provide superior patient satisfaction and patient expectations as compared to PS TKA. This may be related to better replication of natural knee kinematics with MP TKA.

Level Of Evidence: I.
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http://dx.doi.org/10.1007/s00167-020-06343-4DOI Listing
November 2020

Rapid chromatographic immunoassay-based evaluation of COVID-19: A cross-sectional, diagnostic test accuracy study & its implications for COVID-19 management in India.

Indian J Med Res 2020 Oct 31. Epub 2020 Oct 31.

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.

Background & Objectives: : Coronavirus disease 2019 (COVID-19) has so far affected over 41 million people globally. The limited supply of real-time reverse transcription-polymerase chain reaction (rRT-PCR) kits and reagents has made meeting the rising demand for increased testing incompetent, worldwide. A highly sensitive and specific antigen-based rapid diagnostic test (RDT) is the need of the hour. The objective of this study was to evaluate the performance of a rapid chromatographic immunoassay-based test (index test) compared with a clinical reference standard (rRT-PCR).

Methods: : A cross-sectional, single-blinded study was conducted at a tertiary care teaching hospital in north India. Paired samples were taken for RDT and rRT-PCR (reference standard) from consecutive participants screened for COVID-19 to calculate the sensitivity and specificity of the RDT. Further subgroup analysis was done based on the duration of illness and cycle threshold values. Cohen's kappa coefficient was used to measure the level of agreement between the two tests.

Results: : Of the 330 participants, 77 were rRT-PCR positive for SARS-CoV-2. Sixty four of these patients also tested positive for SARS-CoV-2 by RDT. The overall sensitivity and specificity were 81.8 and 99.6 per cent, respectively. The sensitivity of RDT was higher (85.9%) in participants with a duration of illness ≤5 days.

Interpretation & Conclusions: : With an excellent specificity and moderate sensitivity, this RDT may be used to rule in COVID-19 in patients with a duration of illness ≤5 days. Large-scale testing based on this RDT across the country would result in quick detection, isolation and treatment of COVID-19 patients.
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http://dx.doi.org/10.4103/ijmr.IJMR_3305_20DOI Listing
October 2020

Sn-MOF@CNT nanocomposite: An efficient electrochemical sensor for detection of hydrogen peroxide.

Environ Res 2020 12 12;191:110005. Epub 2020 Sep 12.

Department of Bio and Nano Technology, Guru Jambheshwar University of Science and Technology, Hisar, 125001, India. Electronic address:

A novel approach for the assembly of Sn-based metal organic framework (Sn-MOF) via solvothermal method and its composite (Sn-MOF@CNT) with electroactive material, carbon nanotubes (CNT) by sonochemical means, is described that is useful for hydrogen peroxide sensing; large surface area and pore volume of Sn-MOF were exploited where in the crystallinity of the Sn-MOF was preserved upon inclusion of CNT over its surface. The surface morphology and structural analysis of Sn-MOF and its composite form, Sn-MOF@CNT, were determined analytically through Fourier-transform infrared spectroscopy (FT-IR), X-ray powder diffraction (XRD), Scanning electron microscopy (SEM), Brunauer-Emmett-Teller and Energy-dispersive X-ray spectroscopy (EDX). The developed Sn-MOF@CNT sensor was expansively used to determine and optimize the effect of scan rate, concentration and detection limits including the EDX and SEM analysis of used Sn-MOF@CNT nanocomposite's post hydrogen peroxide sensing. The electrochemical sensing with Sn-MOF@CNT revealed a lower limit of detection ~4.7 × 10 μM with wide linear range between 0.2 μM and 2.5 mM. This study has explored a new strategy for the deposition of CNT over Sn-MOF via a simple sonochemical methodology for successful electrochemical detection of HO, an approach that can be imitated for other applications.
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http://dx.doi.org/10.1016/j.envres.2020.110005DOI Listing
December 2020

Robotic spine surgery: Ushering in a new era.

J Clin Orthop Trauma 2020 Sep-Oct;11(5):753-760. Epub 2020 May 23.

All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

The endeavour to make spine surgery safe with reproducible, consistent outcomes has led to growing interest and research in the field of intraoperative imaging, navigation and robotics. The advent of surgical robot systems in spine surgery is relatively recent - with only a few systems approved for commercial use. At present, pedicle screw insertion remains the primary application of robotic systems in spine surgery. The purported advantages of robot-assisted pedicle screw insertion over other conventional techniques are its increased accuracy, reproducible consistency and reduced radiation exposure. Many of these claims have been supported or refuted by individual studies - and high quality evidence for the same is lacking. Robotic spine surgery also has its share of limitations which include increased operative time, considerable learning curve and technical pitfalls unique to the robotic systems. The applications of robotic spine surgery are evolving and expanding to spinal deformity, spine oncology and needle-based interventional treatments. This review provides an overview of the evolution and current status of robotic spine surgery along with an evidence-based discussion of its current applications in spine surgery.
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http://dx.doi.org/10.1016/j.jcot.2020.04.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452360PMC
May 2020

EOS® imaging: Concept and current applications in spinal disorders.

J Clin Orthop Trauma 2020 Sep-Oct;11(5):786-793. Epub 2020 Jul 6.

Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.

EOS® imaging is a proprietary imaging technology that was launched in 2007. Based on a gaseous particle detector with a multi-wire proportional chamber, it offers several advantages over other imaging modalities: low dose of radiation, ability to create 3D reconstructions, ability to conduct whole body imaging, high reproducibility in measuring various parameters of alignment and faster imaging time. EOS® imaging is slowly gaining widespread acceptance as its applications in various disorders continue to evolve. It has been found to be particularly useful and has opened up new avenues of research in the field of spinal deformities. This narrative review seeks to provide an overview of the proprietary technology behind EOS® imaging, compare it to existing imaging modalities, summarize its current applications in various spinal disorders and outline its limitations.
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http://dx.doi.org/10.1016/j.jcot.2020.06.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452333PMC
July 2020

Letter to the Editor on "Patient Characteristics and Surgical Start Time Affect Length of Stay Following Anterior Total Hip Arthroplasty".

J Arthroplasty 2020 11 6;35(11):3425-3426. Epub 2020 Aug 6.

Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India; Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India; Indian Orthopedic Association and Delhi Orthopaedic Association, New Delhi, India.

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http://dx.doi.org/10.1016/j.arth.2020.07.077DOI Listing
November 2020

Conducting orthopaedic practical examination during the Covid-19 pandemic.

J Clin Orthop Trauma 2020 Jul 10;11(Suppl 4):S448-S455. Epub 2020 Jul 10.

Additional Professor of Orthopedics, All India Institute of Medical Sciences, New Delhi, India.

Background: As the coronavirus disease (COVID-19) pandemic is expected to stay for a longer time, educational activities including residency training have gradually resumed with the aid of virtual tools. In addition to continuing the residency education during COVID-19, it is also important to conduct their examination so that the graduations of final year residents are not delayed. The conventional exam pattern involved clinical case presentations and required resident interaction with a number of patients. However, in view of the COVID-19 pandemic we conducted a "zero-patient contact virtual practical exit examination" for orthopaedic residents.

Methods: In order to replicate the conventional exam case-scenarios, clinical cases were prepared in a digital presentation format. The candidate used N-95 facemasks and gloves, and adequate social distancing was maintained in the examination area. We also designed a 10- item questionnaire aimed at assessing the quality and satisfaction with the exam pattern.

Results: The mean score for overall satisfaction with the virtual pattern was 4.5 (out of 5) in examiner group while it was 4.1 in examinee group. Higher scores were also reported for questions related to safety of the exam, relevance and quality of the virtual cases, etc. The mean total feedback score for the examiner and examinee group was 48 and 43.4 respectively (out of 50).

Conclusion: Orthopaedic residency end-of-training examinations can be successfully conducted during the COVID pandemic, and we hope our experience will be helpful to other residency programs.
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http://dx.doi.org/10.1016/j.jcot.2020.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347501PMC
July 2020

Management of metacarpal fractures.

J Clin Orthop Trauma 2020 Jul-Aug;11(4):554-561. Epub 2020 Jun 6.

Department of Orthopaedics, All India Institute of Medical Sciences, Delhi, India.

The metacarpal fractures are common fractures which are treated by orthopaedic surgeons, plastic surgeons and hand surgeons equally. These are seen in young adults who have active life style. These have a major impact in life style of the patients if these are not treated adequately. The management of the fractures vary among surgeons to surgeons; two surgeons in the same centre can have a different treatment plan for a fracture. There are no standard guidelines for the treatment and it ranges from conservative management, Kirschner's wire (K-wires), plates and screws. This review article is about the management of metacarpal fractures where the commonly done procedures are reviewed.
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http://dx.doi.org/10.1016/j.jcot.2020.05.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355092PMC
June 2020