Gaurav Govil

The COVID-19 pandemic impacted the elderly both directly by the affection due to infection and indirectly by the aggravation of the pre-existing medical comorbidities. The management of the chronic diseases took a relative back-seat for an active treatment protocol strategy. The clinicians emphasised on the conservative measures to manage arthritis and osteoporosis. The delayed assessment had a profound negative impact with significant progression of arthritis and osteoporosis amongst the elderly. The crippling effect of COVID-19 pandemic in the elderly presented furthermore with the advanced stages of arthritis and worsened osteoporosis for the management. The delay in timely offer of surgery for the arthritic joint compromised the functional outcomes. There has been a silent worsening with increased morbidity and mortality.The literature review and guidelines formulated emphasized on the timely remedial measures either surgical or conservative for the management of arthritis and osteoporosis in an elderly to halt the silent progression, allow a healthy lifestyle with an improved quality of life. The elderly should have priority for an individualized management strategy even during the pandemic to reduce this “silent” morbidity and mortality.   Keywords: Arthritis, COVID-19, Osteoporosis, Coronavirus, Aging, Older adults, Aged individuals

The crisis of Covid-19 has shaken the world healthcare systems. The intensive care resources to manage the medical conditions associated with Covid-19 are consistently found to be inadequate with exploration and implementation of newer treatment avenues for an early recovery. Presently, the use of Tocilizumab (TCZ) in severe to critical affection of Covid-19 is being practiced as an off-label therapy. A narrative review of present knowledge regarding TCZ pharmacology, indications of its use, and potential side effects with clinical implications for an orthopedic surgeon is presented. The article discusses the clinicopathological factors required to be monitored during the perioperative management of an orthopedic patient who may have received TCZ for Covid-19 related illness. The implications of its usage should alert the orthopaedic surgeons for future management of their arthritic surgical patients. The commonly associated side effects and complications in the post-operative phase following an arthroplasty or any orthopaedic surgery are an area of concern and considerable uncertainty. In the post-Covid-19 recovery phase, when surgeons need to plan a surgical intervention then a thorough evaluation of their Covid-19 medical management history may be warranted. Practical guidelines for the management of arthritic surgical patients have been postulated. With an unregulated increased usage of TCZ during Covid-19 management, an orthopaedic surgeon should worry and needs to be aware of the possible consequences in the perioperative period for the post-surgery management. Future research to gain more insights will confirm the implied concerns.   Keywords: Tocilizumab, Covid19, Orthopaedics, Arthritis, Arthroplasty, Safety, Complications

Introduction: Knee osteoarthritis is a common disabling affection in the elderlies. Rarely the arthritis of knee may be due to ochronotic arthropathy. It is often missed or misdiagnosed as osteoarthritis. An autosomal recessive metabolic disorder characterized by the deficiency of homogentisic acid oxidase enzyme preventing metabolism of homogentisic acid lead to homogentisic aciduria. Alkaptonuria progresses to ochronotic degeneration and arthritis. Early management of ochronotic arthropathy is challenging and is mainly limited to control of symptoms. Advanced cases may necessitate surgery. Case Report: A 65-year-old male presents with persistent progressive pain in both knees, not responding to conservative measures. Patient required simultaneous bilateral cemented total knee arthroplasty for management of arthritic knee pain. Arthrotomy revealed black joints with pigment deposition throughout the articular cartilage and neighboring tissues. Meticulous surgical technique allowed uneventful procedure. Postoperatively patient gained pain-free functional knee movements and was able to ambulate without support within six weeks of arthroplasty. The Knee Society Score improved to 95 bilaterally. At two years, radiologically there was good alignment with no loosening. Discussion: Arthroplasty is an excellent choice for patients with ochronotic arthropathy. However, more information and experience are needed for uniform implant selection and techniques. We report this rare, often missed cause of common knee pain. We review the literature to discuss the specific surgical considerations during knee arthroplasty in such an unusual presentation. Keywords: Alkaptonuria, Ochronosis, Arthropathy, Black joints, Knee arthroplasty..

Low back pain is one of the commonest symptoms for an orthopaedic consultation. It is also the common first presentation of a rare disorder alkaptonuria. Accumulation of homogentisic acid in connective tissues causes progressive deposition of bluish black pigment causing degenerative changes in ochronotic spine. In this case report, two brothers of Dravidian origin present with alkaptonuria, with clinically more recognizable axial spondyloarthropathy resembling Ankylosing Spondylitis (AS), and the history, clinical presentation, diagnostic techniques, and distinctive diagnosis are reviewed. We suggest for surveillance in clinical practice for this rare, but important cause of back pain. Keywords: Ochronotic Spondyloarthropathy, Alkaptonuria, Familial Ochronosis.

Aneurysmal bone cyst (ABC) is an osteolytic benign tumour, which is usually situated in the metaphysis of long bones and mostly encountered in patients younger than 20 years old. Common treatment modalities include arterial embolization, curettage, intralesional injections and en-bloc resection with instrumentation. We present a case of an eighteen-year old male with an ABC involving lesser trochanter of left femur with impending pathological proximal femur fracture. We discuss treatment modalities and clinical outcome in our case. Keywords: Aneurysmal bone cyst, Expansile lytic cyst, Lesser trochanter tumour, Proximal femur.

The Covid-19 pandemic has affected the health in myriad ways. The direct affection may lead to respiratory infection. An indirect effect of Covid-19 has manifestations on the physical, mental and behavioural attributes in majority of the age groups. The forced restrictions, limited activities, and changed lifestyle have aggravated the deleterious effects of the sedentary lifestyles. The management of the physical activity for all age groups especially pre-adolescents took a relative back-seat during the Covid-19 restrictions with no immediate suggestions for an active treatment protocol strategy. The clinicians in general, emphasised on the conservative measures to manage the increased incidence of vitamin deficiency and osteopenia majorly with consultations based on telecommunication without clinical evaluation. The subsequent delayed assessment showed a profound negative impact amongst the pre-adolescents with significant progression of knee deformation and increased outpatient clinic presentation of genu valgus for management in later phase of pandemic. This has posed a unique Covid-19 post-pandemic manifestation of concern.The trilogy of Covid-19 restrictions induced poor physical activity, vitamin-D deficiency, and deformation of knees to valgus angulation have crippling effect in the pre-adolescent age-group. The delay in timely identification and medical management for the pre-adolescents has aggravated the joint deformation compromising the functional outcomes. The orthopaedic surgeons are now challenged and burdened to manage pre-adolescents knee deformity for corrective medical and surgical measures. On literature review, the guidelines are sparse for the paediatric orthopaedic management. The silent worsening with increased morbidity presents a matter of substantial concerns.An individualized management strategy for pre-adolescents is strongly recommended to manage this “silent” morbidity.   Keywords: Covid­19, Coronavirus, Pre­adolescent, Vitamin­D deficiency, Genu Valgus, Paediatric orthopaedic

The coronavirus (Covid-19) pandemic has ravaged the whole world. It had affected the allied surgical branches that had to reinvent the protocols for patient management. Trauma being inevitable, needed urgent attention. The changing perspectives had a defining role in the direction of arthroplasty too.The pandemic has been considered into three different phases: 1. The acute phase of the lockdown; 2. The intermediate phase of surgical prioritization; 3. The late phase of surgical management post-vaccination.We deliberate on the impact of the pandemic on orthopaedic surgery and the role of Thoracic computerized tomography (Th-CT) imaging during Covid-19 on the surgical practice of orthopaedic surgeons. Th-CT had been useful imaging during the acute phase of lockdown in the pandemic to identify the asymptomatic Covid-19 infection and to gauge the severity of viral infection. We reviewed the guidelines formulated during each step and identified the lessons learned by the practicing orthopaedic surgeon. We further elaborate on the changes in the usage of Th-CT in the subsequent intermediate and late phases of the pandemic for orthopaedic surgeons. The critical consideration remained to achieve an uneventful recovery during the orthopaedic surgical management, to avoid the transmissibility of infection to the surgeon, and to protect the patient from the high morbidity and mortality of Covid-19 related illness. The Covid-19 pandemic has instigated orthopaedists to develop a holistic approach to deal with the new challenges during this pandemic era.   Keywords: COVID­19, Orthopedics, Coronavirus, Trauma, Chest CT scan, Thoracic CT scan, RT­PCR test, Pandemic, Thoracic computerized CT, Orthopaedic surgeon