The Great Bacterial Reef: #NeoArmory:

“Surgeon’s log. Stardate 2026. Infection, the first and final frontier of orthopaedic surgery. These are the voyages of 5 stage revision surgery to eradicate whatever the petridish grows…”

But, hold on. What if you implant can fight the fight even before the fight has started? That’s where NanoCept, a proprietary antibacterial surface technology from Onkos Surgical. Unlike traditional coatings, this non-eluting, nanoscale surface is designed to actively reduce bacterial contamination deposited during the surgical procedure itself.

It is a Non eluting coating made of quaternary ammonium compound called methacryloyloxydodecylpyridinium bromide (MDPB). (Yep, that one). They claim 99.999% kill rate of bacteria found in OR and excellent biocompatibility. It is already available in their own ELEOS reconstruction system.

If this can show good results in long(-ish) term studies, may be 1 and 1.5 Stage revisions for infections can become more prevalent.

Making a safer window for HTO: #SurgicalPearl:

Medial opening-wedge high tibial osteotomy (OW-HTO) is a joint-preserving option for younger, active patients with varus-aligned medial-compartment knee osteoarthritis. However, releasing the medial collateral ligament (MCL) and protecting the vessels and nerves behind the tibia can be technically stressful—particularly during a surgeon’s learning curve, which has been reported to span 27–42 procedures.

Matthieu Ollivier group describe a “second-window” approach. Instead of working entirely through the standard medial exposure, the surgeon creates an additional window behind the superficial MCL. A periosteal elevator is carefully advanced along the posterior tibial cortex, creating a passage for a posterior tissue retractor. This retractor sits directly against the tibia, shielding the posterior neurovascular structures while the osteotomy is performed.

The deep MCL and its proximal tibial attachment remain intact. The distal superficial MCL is released and retracted separately, improving access to the medial tibia. After the saw cuts, the surgeon can feel the posterior retractor through the osteotomy gap, confirming completion of the posterior cortical cut before opening the wedge. MCL tension can then be fine-tuned using limited posterior-fibre release or pie-crusting.

The proposed advantages are better neurovascular protection, less retractor crowding, reduced tension on the MCL and more controlled ligament release. It may also reduce incomplete osteotomy, which can contribute to tibial plateau fracture—reported in roughly 1–11% of OW-HTOs.

Check out the full video of the technique here

300% mortality rate – is it even possible?

Back in the day when speed is safe and delay is death!

Robert Liston (1794-1847) was the diligent follower of the philosophy! In the early 19^th century when anaesthesia was not even in the cooking pot of thinking. To alleviate the patients suffering or at least decrease the suffering to save the lives through surgery, the faster a surgery is performed, the better. So, there was the question of speed over safety, but they were not fortunate enough ask that question.

Liston was called the “fastest knife in the west end.” Can you imagine that he used to finish a leg amputation under 2 and half minutes, routinely. He even got it at 28 seconds once? Do you remember that recurring scene from the movie series “Equalizer” where Denzel Washington is shown timing his fights? Our man was something like that and it paid him well. While other surgeons had a mortality of 1 in 4, Liston had. 1 in 10, pretty impressive right? He had his fair share of complications and that one surgery became famous, for the right reasons.

Now, our “fast” surgeon was performing a leg amputation and by mistake, he cut off the thumb of his assistant and when he pulled the knife back, accidentally cut of the coat tail of an enthusiastic spectator who was standing too close. The spectator died instantly believing that he was stabbed, which he was not but out of fear, he died of shock. The assistant later died of gangrene and finally the patient on whom the surgery was performed died later, likely of infection, leading to the infamous surgery which had a mortality of 300%.

Coming to the present days, speed is still good, but not at the cost of safety. We are fortunate to have anaesthesia and infection control protocols, and we should remember “safety trumps speed.”

Packed Cell Transfusion, not so soon! #MostCited:

Blood is a limited resource, and there are concerns about risks, including transmitted infections. If a liberal transfusion strategy does not improve clinical outcomes, or if it is equivalent, then adopting a more restrictive approach should be recognised as the standard of care.

JL Carson et al. in their Cochrane review compared 30-day mortality and other clinical outcomes for participants randomised to a restrictive transfusion threshold of 7-8 g/dL versus a liberal transfusion threshold of 9-10 g/dL for all clinical conditions. Upon analysing 61 trials with 27,639 patients, it was noted that restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 42%. When combining all clinical contexts, restrictive transfusion strategies did not modify the risk of 30-day mortality or any other outcomes compared to liberal strategies.

The key takeaway? In most clinical contexts, there was no evidence of harm from a restrictive compared with a liberal transfusion strategy. So, the next time your anaesthetist asks for a transfusion prior to surgery with a higher threshold, this evidence will help you to push the patient into the theatre without an actual transfusion yet.

Events to check out:

• Eurospine 2026 07 – 09^th October 2026 Gothenburg, Sweden

• Indian Arthroscopy Society Annual Meeting 2026 08 – 10^th October 2026 Kolkata, India

• The 41st Annual Orthopaedic Research Meeting of the Japanese Orthopaedic Association 15^th – 16^th Oct 2026 Gifu, Japan

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Have a fabulous month ahead guys. See you all next week.

Scite AI – The tool that Grades those citations!

If you have ever stared at a paper that has a lot of citations and thought “Wow! But is this actually good?” – then welcome to the club. Citation count is not always a good thing; it is more of blunt instrument and Scite.ai tries to sharpen that and it seem to work.

Now, the whole idea is simple, at the same time, clever. What scite does is that it reads the sentence where a particular article is cited and tags as one of the following: Supporting, contrasting or just a passing mention. So, that paper with a huge citation count, you can actually see and understand whether people actually agree with it or quietly thinking it is wrong. The difference between “this is popular” and “this actually holds up”, which has a lot of weight, especially if you do literature reviews.

As you know with all AI platforms, even Scite has an assistant built in. This is a game changer in my opinion. You can ask it in plain English a research question or even a topic in which you are working in interested in working, to look for the present literature and give any gaps that can be dug up for research and it comes up with a clean information regarding the present literature and gives you ideas and even form a protocol of sorts for the proposed studies.

Going forward, always there is a catch, no good thing comes free, as is Scite. It isn’t free – there’s a trial for which you’ll need a card on file and mind you, if you forget to cancel, you’ll be charged (I hope I don’t forget or maybe I will like it so much that I will continue to pay). And, as with all AI tool, mind you, not a substitute for reading the paper yourself.

A Shoulder You Can Experiment On—Without Entering the Lab

Finite element modelling is often discussed as a powerful research tool, but for many orthopaedic researchers, the entry barrier remains high. Building a shoulder model from CT data requires segmentation, mesh generation, tissue-property assignment, boundary conditions, muscle-force inputs and, most importantly, validation. A recently published open-source shoulder finite element model removes much of this groundwork.

The model was created using publicly available CT images from the Visible Human Project. It includes the humerus, scapula, clavicle, glenoid, articular cartilage, labrum and acromioclavicular ligament, with muscle–tendon forces represented for the rotator cuff, deltoid and pectoralis major. The authors validated the model by simulating humeral abduction and comparing the predicted glenohumeral contact forces with published in-vivo measurements. The predicted forces remained within one standard deviation of experimental values through most of the tested abduction range.

For shoulder researchers, this is a useful starting platform rather than a finished answer. It can potentially be adapted to study implant positioning, glenoid components, anchor constructs, cuff tears, cartilage contact, labral mechanics and altered muscle-loading patterns. Researchers can build on an already segmented and mesh-converged model instead of beginning from zero.

There are important limitations. The model was validated only for glenohumeral contact force during controlled abduction. It represents one male shoulder, fixes the scapula, simplifies muscles and does not include the complete capsule or all ligaments. Any major modification will therefore require fresh verification and validation.

The model files are freely available, although running them currently requires Abaqus. Even with that limitation, this is a valuable shared resource—especially for teams looking to begin computational shoulder research without spending months creating the basic model first.

Lost in a sea of papers? Litmaps hands you a map

Every orthopaedic surgeon who has attempted a review knows the drill. You fire a search into PubMed, it flings back four hundred abstracts, and somewhere in that ocean sits the one landmark paper your reviewer will absolutely ask about. You scroll. You squint. You worry. There has to be a better way to brew through the literature — and there is.

Litmaps takes a different route. Instead of another endless list, it draws your field as an interactive picture. You feed it one paper you already trust — your “seed” — say a trial on prophylactic negative-pressure wound therapy or an S2AI screw fixation study, and Litmaps grows a map outward through the citation network. Every paper becomes a dot, every citation a thread, laid out by year and by how often each has been cited. So rather than reading a thousand titles, you literally see how the field hangs together — and spot the gaps nobody has filled yet.

And it does not just sit there looking pretty. Switch on Monitor and Litmaps emails you when fresh papers matching your map appear — handy for fast-movers like orthobiologics, where something new lands every other week. Already living in Zotero? Zotero Sync keeps your library and your maps talking to each other, so you are not copy-pasting references at midnight.

Now, honesty over our brew. Litmaps is a discovery tool, not a reference manager — keep your Zotero or Mendeley handy for the heavy lifting. It leans on citation data, so very new or poorly-indexed work can hide from it, and the interface takes a coffee or two to get comfortable with. Fair trade, we would say.

The best bit for our crowd: the free plan gives you two maps to play with, and if you are at a university, an Educational Licence knocks a hefty 75% off the standard price. Labs and units can grab a team licence and map together.

So next time you are drowning in abstracts, do not scroll harder. Map smarter. ☕

Medable – Breeze through clinical trials

We have all been there. Recruiting for a study can feel like convincing Neo to take the red pill while navigating a bureaucratic desert. Usually, it involves mountains of paper and chasing follow-up data until you question why you didn’t just open a bakery instead. But what if we could simplify patient engagement without them feeling like they are filing tax returns?

Enter Medable, a platform built specifically for decentralized clinical trials. They offer a suite of digital solutions, including eCOA and electronic informed consent, which effectively digitize the research workflow. It allows patients to participate from home, skipping the endless clinic visits.

For those running long-term orthopaedic studies, patient retention is the final boss. Their eClinical platform reports significant boosts in engagement and data quality, lightening the load on site staff while keeping the audit trail pristine.

They claim 90+% participant adherence, 34% reduction in translation timeline and 1 day trial build time. They also have AI agents which are pre-built or custom made to aid you in trials.

Events to check out:

• 46th SICOT Orthopaedic World Congress 29 Sep – 1 Oct 2026 Kyoto, Japan

• IASCON 2026 (23rd Indian Arthroscopy Society Congress) 8 – 10 Oct 2026 Kolkata, India

• NASS 41st Annual Meeting 14 – 17 Oct 2026 San Antonio, USA

• AAHKS 2026 Annual Meeting 5 – 8 Nov 2026 Dallas, USA

Comment about your favorite research tools so that we can write about them. See you all next month guys!

Beyond the Rigid Cage… #NeoArmory:

What do you think about a traditional interbody cage? It’s a bit like forcing an immovable object into an ever-changing environment. If you want the ideal implant, you’d probably want the elasticity of Mr. Fantastic and the strength of The Thing.

Enter Spineology’s OptiMesh^® - Instead of a solid, rigid structure, this system uses an expandable, knitted PET mesh that goes in small and blooms in situ. It’s designed to “conform and expand,” filling the disc space completely and molding to the unique contours of the patient’s endplates rather than forcing them to match the cage.

The data is surprisingly solid, too. The SCOUT IDE trial reported a 99% fusion rate and 92% patient satisfaction at the two-year mark. By enabling an ultra-minimally invasive (OptiLIF) approach, it manages to provide significant distraction without the heavy-duty tissue trauma of traditional open techniques.

Their articulating cutters are a work of art

With the newer HA Nano version hitting the scene to boost osseointegration, it’s a great example of how our implants are finally getting a little more… flexible.

Victor Horseley – Father of Modern Neuro(spine)surgery #FromTheHistory:

Sir Victor Horseley, born in Kensington, London in 1857 was named after Queen Victoria! He was gifted surgeon and social reformer as well. The curious case of Captain Gilby is beautifully described by Horseley in the article he published in 1888 is nothing short of a thriller story!

Captain Gilby started having back pain in 1883 and he went on to be treated by various people from different types of medicine in umpteen different treatments and none were successful for the next 3 years. By the time Horseley saw our patient G, he was almost paraplegic and bed bound. Dr. Gowers helped localize the lesion, a probable tumor compressing the spinal cord in the upper dorsal spine. After thinking through thoroughly, in discussion with the patient (who almost gave up and is ready to try any treatment, even experimental and dangerous ones to get rid of the pain and to stand on his two feet), ventured to do the unthinkable task, an elective spine surgery! He went ahead and opened up the patient’s back in semiprone position, under Ether anaesthesia and cut of 4^th – 6^th thoracic lamina but could not find any tumor. With his keen eye along with the precise knowledge of anatomy, he noted that the dura was pressed on the left side close to the neural canal. Then, he went on to extend the incision proximally and removed two more laminae and successfully removed that culprit causing the patient’s symptoms. All this he did in an era without imaging, good anaesthesia, positioning tools, sterile instrumentation or a sterile field and above something no one has ever even attempted. The success actually was that Captain G was able to walk within a year of the procedure and went on to live for 2 decades from surgery without the symptoms which crushed his spirit and body for 3 years.

Coming to the socialist in our surgeon, he was sent to assess the rabies vaccine developed by Louis Pasteur to Paris by the British government. He went there, validated Pasteur’s work and eventually spearheaded the mission which mandated muzzling and quarantine of dogs which eventually and effectively wiped out rabies from UK!

Turn the Ligament, Not the Facet #Surgical Pearl:

One of the biggest challenges during biportal endoscopic foraminal decompression is achieving adequate nerve root decompression without sacrificing the facet joint. A recent technical note in the Asian Spine Journal introduces an elegant solution—the Non-Facetectomy Ligamentum Flavum (LF) Turn-Down Technique.

1. Position the patient prone on a Wilson frame under general or spinal anesthesia, ensuring the abdomen hangs free to reduce venous congestion.

2. Create two small portals about one pedicle width lateral to the pedicle. The cranial portal is used for viewing, while the caudal portal serves as the working portal.

3. Dock on the transverse process and use a radiofrequency probe to expose the key landmarks—the transverse process, superior articular process (SAP), lateral isthmus, and most importantly, the accessory process.

4. Identify the accessory process. Think of it as your surgical GPS—it reliably guides you to the foramen while keeping you away from the exiting nerve root.

5. Detach the soft tissue from the medial side of the accessory process using a freer elevator. Since the nerve root lies deeper, this step can be performed safely.

6. Slide a curette beneath the SAP, keeping it in constant contact with bone to undermine the ligamentum flavum.

7. Rotate the curette to perform the “turn-down” maneuver, peeling the ligamentum flavum away instead of removing it piecemeal.

8. Expose the exiting nerve root and use it as a guide for any remaining decompression. Remove residual ligament or bone with a Kerrison punch or burr only if necessary.

9. Perform a discectomy if required for foraminal or extraforaminal disc herniations, followed by a ball-tip probe check to confirm the nerve root is completely free.

10. Preserve the facet whenever possible. The whole philosophy of this technique is to achieve adequate decompression with minimal bone removal, reducing the risk of postoperative instability while maintaining excellent visualization.

    

Dont hesitate to check the full paper on ASJ

Too much, or Too long — Intraoperative Hypotension isn’t as harmless as it seems!

Managing intraoperative hypotension (IOH) has been a long-standing challenge in spinal deformity surgery. For years, induced hypotension was the go-to strategy to keep the surgical field clean and blood loss in check.

Glassman et al. looked at a retrospective cohort of 539 thoracolumbar fusion cases (>6 levels, >3 hours) and found that the longer the stretch of intraoperative hypotension (MAP <65 mmHg), the higher the risk of postoperative complications. Patients who clocked three or more complications had notably longer hypotensive episodes in the first hour of surgery and required more vasopressor support. The complications weren’t trivial either — SSI, pulmonary failure, PE, ileus, and cognitive dysfunction were all on the list.

The key takeaway? Early intraoperative hypotension is a modifiable risk factor in multilevel lumbar fusion, and one worth taking seriously. So, the next time you’re in theatre, don’t push your anaesthetist for a deeply hypotensive field — especially in that critical first hour. It may cost more than it saves.

Events to check out:

• AOSSM Annual Meeting 2026 08 – 11^th July 2026 Seattle, United States

• 35th Annual Conference of the European Society for Biomaterials – ESB 2026 07 – 11^th Sept 2026 Antwerp, Belgium

• 46th SICOT Orthopaedic World Congress Kyoto 2025 29^th – 01^st Oct 2026 Kyoto, Japan

Ultrasound guided ‘skinning the cat’ #NeoArmory:

‘When there are multiple surgeries described for a single pathology, you can safely say, none of them works the best” – one of our Profs.

But it can’t be more far from true for carpal tunnel syndrome as most of them seem to work (okay-ish). When you have multiple ways to ‘skin-the-cat’ why not try the new Orthopaedic fad, the ultrasound!

Sovereign Medical, have just the right Sono-instruments® (that’s actually the name) for this. Their purpose made blade can be used under USS guidance and a sub 2mm incision for a sutureless procedure.

The procedure can be done in an office setup under local anesthetic. They allow quick return to work and better pain levels immediate post op.

Although USS guided CTRs are not entirely a new concept, having a dedicated instrumentation helps standardize steps. The company is actively collecting PROMs data and hopefully we can get an efficacy study soon.

Fritz Dequervain - a man known for tenosynovitis &……. yup - IODINE: #FromTheHistory:

Dequervain ‘s tenosynovitis is something we all have seen and treated this very common condition. What used to be called washerwoman’s thumb in the 19th century and nowadays with all the gadgets, it has become texting thumb. The man behind this eponym is Fritz Dequervain, son of a pastor in Sion, Switzerland, was brought up in a very religious environment which led him to become quite a stoic (obviously not in a pure sense) and develop a relentless work ethic. Under the shadow of the giant of Medicine, Theodore Kocher, Dequervain was trained and he eventually took over his place.

Actually, if we took a time machine and went back to meet our man in the early 20^th century he surely wouldn’t have spoken about thumbs, but Iodine. His mentor, Kocher as you might already know got a Nobel prize for his study on Thyroid gland. Fritz was seeing a lot of goitres, actually, it was 100% among children in that area at that time. So, Fritz started feeling that operating or treating goitres and cretinism was like a band aid and not sustainable. The idea of Iodine as treatment or the idea that Iodine deficiency as a cause for goitres was not new but was already proposed and proven. But our man, he became an evangelist of public health and proposed something and brought it into reality, Iodine supplementation for the general public with fortification of common salt with Iodine. And voila, goitres, were gone!

Keyhole Fusions #SurgicalPearl:

Have you ever feared addressing scaphoid nonunions in open surgery - too small of a bone to debride/graft, jeopardise vascularity of the remaining bone? Try Arthroscopic fixation - a time tested one at this point of time. Check this evidence from Burnier et al. Read the step wise procedure details below.

• Setup: Regional anesthesia, tourniquet on, wrist put in traction (around 5 kg).

• Take bone graft from distal radius - Small incision near Lister’s tubercle → cancellous bone harvested using a trocar.

• Standard wrist portals (3/4, 6R, midcarpal portals) are created - Check cartilage, ligaments, synovitis – get an idea of joint condition.

• Use probe/feeler → identify exact gap of nonunion.

• Remove fibrous tissue + sclerosis using curette, shaver, drill.

• Important step → you should see bleeding bone (means viable bone).

• If no bleeding → suspect AVN of proximal pole.

• Make a clean cavity ready to accept graft.

• Use trocar through portal → deliver bone into the defect.

• Pack it tightly - Compress graft with probe until defect is fully filled (no gaps).

• Release traction, once grafting is done.

• Fix the scaphoid (osteosynthesis) Either screw or K-wires depending on case.

• Proximal pole → may need scapholunate pinning.

• Stability + graft fill confirmed → close.

Your Hand radiograph says it all!! #MostCited:

Fragility fractures associated with osteoporosis and osteopenia are a common cause of morbidity and mortality. Current methods of diagnosing low bone mineral density require specialised dual X-ray absorptiometry (DXA) scans. Plain hand radiographs may have utility as an alternative screening tool, although optimal diagnostic radiographic parameters are unknown, and measurement is prone to human error.

Luan et al. developed a machine learning model with 1424 hand radiographs with various grades of bone density from normal to osteoporosis, validated with parallel DXA hip T-scores, with a sensitivity of 84.6% at a specificity of 84.6%. This is a start towards the next wave of accessible, cost-effective, automated diagnosis to initiate earlier treatment of osteoporosis/osteopenia.

Events to check out:

5th Madrid Shoulder Course 12 – 14^th Nov 2026 Madrid, Spain

Chennai Sports Injury Conclave 13 – 14^th June 2026 Chennai, India

The Oswestry GAIT Course 2026 10 – 12 June 2026 Oswestry, United Kingdom

Have a Marvelous May ahead mates!

What If You Could Undo the Mistake? #NeoArmory:

What if — in surgery — you could undo a mistake after committing to it? Rotator cuff repair doesn’t usually allow that luxury. A few millimeters off in tension — too tight or too loose — can quietly decide the fate of the repair. And traditionally, once you tension an anchor… you live with it.

Enter the PHANTOM-LP Anchor — and its sibling, the FASE Anchor

What makes these anchors stand out is not just being knotless or PEEK-based. It’s the concept of retensioning. Sutures can be adjusted after implantation - locked, unlocked, and fine-tuned multiple times during surgery. For the first time, we’re seeing intraoperative reversibility becoming part of anchor design.

Most anchor innovations have been about: Strength, Material and Pullout

This is about decision-making under uncertainty. Instead of a binary “set and hope,” we now have: Set → assess → adjust → re-lock. Check the cool video of this technology here

But - and this is important:

Robust independent clinical outcome studies on retensioning technology are still limited.

Long-term comparative data is needed to truly validate whether this translates into lower re-tear rates or better healing.

The Latarjet Encore: More Than Just a Procedure #FromTheHistory:

We’ve spoken about him before — in our deep dive on the Latarjet procedure, and that compelling academic face-off with Albert Trillat. But the more we read about Michel Latarjet… the more it felt like one article just wasn’t enough.

So here’s an encore.

Michel didn’t just grow up around anatomy, he grew up inside it. His father, André Latarjet, carried forward the legendary Testut-Latarjet, the anatomy bible for French medical students. At home, dinner tables weren’t about small talk - they were covered in anatomical diagrams, proofs, and debates that would eventually make their way into textbooks.

For Michel, anatomy wasn’t a subject. It was a way of life. But here’s where it gets interesting. He wasn’t the stereotypical academic. Not even close.

Michel was deeply into skiing and mountaineering — at a serious level. This wasn’t a weekend escape; he chaired the ski commission of the French Alpine Club. And just when you think that’s enough range… He adds music. A professional-level pianist, playing duets with his violinist wife, immersed in Lyon’s cultural scene, eventually becoming president of the Philharmonic Society in 1965.

So what do we see when we step back?

A master anatomist | A surgeon who gave us a game-changing procedure | A competitive sportsman | A refined musician.

All of this — under the shadow of a giant father and a legacy that could have easily boxed him in. But it didn’t. He expanded. He thrived.

Maybe that’s why we keep coming back to Latarjet. Not just for the procedure, or even the Trillat rivalry — but for what he represents. You don’t have to be one thing. You can build depth and range.

“Anchors Aweigh! What to Do When Your Suture Anchor Says ‘I Quit’? #SurgicalPearl

So there you are, cruising through a rotator cuff repair, and your shiny suture anchor decides to pull a Houdini and bail out of the bone. Panic? Nope. The gang at Seoul National Hospital tackled this exact drama in over 1000 surgeries and came up with a few slick bailout moves.

Out of 1076 shoulder cases, 52 anchors misbehaved—48 during surgery, 4 after. Women, older patients, those with pre-op stiffness, and massive tears were repeat offenders when it came to anchor drama. Pullouts were more common with soft anchors (5.4%) than screw-ins (3.3%).

So, what did they do?

1. Buddy Screwing: Basically, tag-teaming two anchors together like conjoined twins—worked okay but had the highest failure rate (3/16 failed).

2. Anchor Re-do at a New Spot: Shift the party to a sturdier neighborhood in the bone—worked decently, though 2/17 failed post-op.

3. Cement Augmentation: Inject some PMMA glue magic into the hole—messy but 100% success (though only tried in 2 cases).

4. BASP (Bar Anchoring with a Steinmann Pin): The showstopper! Slide a threaded pin into the original site, flip it like a ninja baton inside the bone, tie it up, and boom—92% healing rate with 0 failures. Bonus: reuses the original site and looks badass.

Lesson? When the anchor bails, don’t lose your cool. With a few clever tricks (and a trusty Steinmann pin), you can still sail this ship to safe shores

Sling or Brace post cuff repair ?! It doesn’t matter

There is a dilemma between the usage of brace or sling in the post-operative phase of rotator cuff injury since the former is a strict immobilisation protocol with the advantage of suture protection at the risk of joint stiffness, while the latter is more patient friendly that allows early mobilisation.

F Schonweger et al. tested this ambiguity in their randomised controlled trial among 110 patients, where one group used a brace for 6 weeks after surgery (3 weeks day and night, then 3 weeks only at night), while the other group used a simple sling for 2 weeks only. They found at 6 months follow-up that arthroscopic rotator cuff repair using postoperative sling immobilisation was not inferior to immobilisation with a brace, having no differences in terms of functional scores, pain levels, general health, and risk of tendon re-rupture.

Interesting Events to check out:

• 10th Basel Elbow Course 22 – 24^th April 2026 - Basel, Switzerland

• OARSI 2026 World Congress on Osteoarthritis 23 – 26^th April 2026 - West Palm Beach, USA

• 27th EFORT Annual Congress Málaga 2026 04 – 06 May 2026 - Malaga, Spain

BUN-YO-MATIC! #NeoArmory:

We love it when the companies name their product so funky, that we don’t have to do anything creative and just add this as our title.

Again, right from the landing page…

Paragon28, one of our regulars here, have created what appears like a prop from ‘Total Recall’. This jig in combination with their SMART28 planning platform, allows intra-op targeted correction in both axial and rotational planes.

SMART28 works with weight bearing x-rays or CT and can create 3D planning images. Acclaimed as the first device to this and hels surgeons intra-op

Seriously, keep up with the colour schema

Millimeters and half degrees matter..

The tech seems to be from their recent acquisition DISIOR and Paragon28 have been acquired by Zimmer Biomet. There’s always a bigger fish eh…

As interesting as it looks, we do not have real world data or evidence on outcomes. There is no information on clearance for patient use as well.

From Curiosity to Classification: The Story Behind the Patel–Sharma Fragment #FromThePresent:

In orthopaedics, names carry weight. They’re not just labels — they’re stories, discoveries, and sometimes, a bit of legacy. As trainees, most surgeons grow up memorising names like Colles, Barton, Neer, and Volkmann, never really thinking they might one day contribute something of their own. For Dr. Patel and Dr. Sharma, this journey didn’t start with the intention of naming anything. It started, like most meaningful things in surgery, with simple curiosity.

During training at PGI Chandigarh, exposure to a high volume of trauma cases began to change the way fractures were seen. They weren’t just isolated injuries anymore — patterns started emerging. Mechanisms made more sense. Fixation strategies became more intuitive. And occasionally, something didn’t quite fit. That “something” turned out to be a fibular-sided avulsion of the posterior inferior tibiofibular ligament (PITFL). It was subtle, easy to miss, and more importantly — it didn’t have a name.

Now, that’s unusual in orthopaedics.

The syndesmosis has been studied for over a century. The AITFL avulsions? Already named — Chaput-Tillaux and Wagstaff. The posterior side on the tibia? That’s the well-known Volkmann fragment. But the fibular counterpart of the PITFL? Strangely, it had been sitting there, unnamed and often ignored. Recognising this wasn’t just about spotting a “new” fragment. It was about identifying a missing piece in the syndesmotic puzzle.

Getting it accepted wasn’t easy. Reviewers needed convincing. The argument had to be clear — this fragment wasn’t just an anatomical curiosity; it had real clinical implications. Miss it, and you risk syndesmotic instability, poor reduction, and suboptimal outcomes. And that’s where the Patel–Sharma fragment earned its place — not as a name for the sake of it, but as a concept that sharpens how surgeons look at ankle injuries. Interestingly, this wasn’t a one-off contribution. The same line of thinking extended into anterior malleolus fractures as well, leading to newer pattern recognition and the Patel–Dhillon classification — again, with the same goal: simplify, clarify, and improve decision-making.

Because at the end of the day, this isn’t about having your name in a textbook.

It’s about making sure the next surgeon looks at an X-ray just a little more carefully.

Opening Pandora’s Box in Ankle Fractures: Rethinking Syndesmotic Reduction #SurgicalPearl:

Syndesmotic reduction has been a point of concern in ankle fractures for years. Despite advencements about 50% are still malreduced. Tornetta et al. in a cadaveric study, have compared “articular surface reduction method” vs “incisura based redcution method”

Key takeaway

• Look at the joint, not the incisura. Aligning the anterolateral tibial articular cartilage with the anteromedial fibular articular cartilage gives a more anatomical syndesmotic reduction.

• Malreduction >2 mm:

  • 7% with articular method

  • 20% with incisura method

  • At the joint level, tibia and fibula have similar AP depth (~2 mm difference)

  • At the incisura (1 cm above joint), depth mismatch is large (~6 mm), making visual judgment unreliable

How to perform the Articular Surface Method?

1. Expose the anterolateral corner of ankle joint

2. Identify the anterolateral distal tibial articular cartilage (plafond).

3. Identify the anteromedial fibular articular cartilage.

4. Visually align these two cartilage surfaces perfectly:

   • Smooth continuation, maintenance of Shenton’s line of ankle

   • No anterior or posterior translation

5. Hold reduction manually or with a clamp without levering the fibula posteriorly or anteriorly.

6. While maintaining this alignment, insert provisional fixation (K-wire or reduction clamp).

7. Confirm that the cartilage surfaces remain flush during fixation.

8. Proceed with definitive fixation (screw or suture-button).

9. Fluoroscopy is used only as a secondary check, not the primary reduction guide.

Dont forget to check out the full paper and a surgical demonstration of articular method

Implant Wave Alert, Mg Screws in action now! #MostCited:

Metal plates and screws are used in the management of fractures, but they cause stress shielding and often require removal. In recent years, many studies confirmed that the biodegradable high-purity magnesium (Mg) screws exhibited sufficient mechanical strength with an adequate degradation rate for effective bone healing, avoiding the need for implant removal operations.

Zhao et al. tested it in action in a study of 24 patients comparing Mg screws to traditional Ti screws for ankle fracture management. All patients achieved good fracture alignment, and imaging examination showed that the biodegradable high-purity Mg screws degraded gradually without breakage or displacement. None of the patients experienced infection, failure of internal fixation, malunion or other complications in both groups. Hence, now we have an answer to those patients who ask for disappearing implants.

Events to check out:

• The Association of Bone and Joint Surgeons (ABJS) 78th Annual Meeting - 15 – 19^th April 2026 Napa, USA

• The 99th Annual Meeting of the Japanese Orthopaedic Association 21 – 24^th May 2026 - Kobe, Japan

• 46th SICOT Orthopaedic World Congress 29 September ‐ 1 October 2026 - Kyoto, Japan

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Have a fabulous March guys! See you all next month.

‘Paging Dr Terminator to theatre 1…’ #NeoArmory:

Did you think your job as a surgeon is safe form the AI boom? Well, you may be right. But the Autonomous Robots are here to take over!

What they meant Robotic surgery in 1960s vs What patients think robotic surgery is now?

Monogram technologies have built an autonomous robot ‘mBôs’ which, after registration can complete the cuts without human intervention. Built from scratch, with their 23 patents application, they have built a unique looking robot.

This is them speed running a 6-minute registration and cuts. They have received FDAs 510k clearance and have completed clinical trial in India with 102 cases.

Welcome new kid in the block - the rectus femoris for ACL reconstruction #SurgicalPearl:

Rectus femoris is the new buzz word in ACL circles. Evidence on the superiority of Rectus femoris over routine grafts is poping up in literature as we write this article. Before we start debating on the need for it, it would be handy to learn a technique to harvest it - will be a convinient option in multiligamentous knee injuries as well as revison ACL surgeries

Lee et al. describe a minimally invasive, highly reproducible technique for harvesting a rectus femoris (RF) tendon graft using a bidirectional tendon strip (BTS) approach.

1. Patient supine; knee supported in ~45° flexion.

2. A 2-cm midline incision made ~8 cm proximal to the superior pole of the patella (SPP). This zone has looser tissue planes and better tendon mobility than the suprapatellar region. At 8 cm proximal location, the RF tendon is easier to identify, less crowded by confluence of quadriceps layers, and capsular breach risk is lower.

3. Blunt dissection through subcutaneous fat to expose the glistening rectus femoris tendon, which lies superficial to vastus intermedius. Vastus medialis fibers partially overlying RF are gently swept aside. This allows clear visualization of true RF width and trajectory.

4. Using a No. 15 blade, two longitudinal parallel incisions are made to define graft width. Depth is limited to the fat plane separating RF from vastus intermedius → ensures partial-thickness harvest.

5. The tendon strip is gently lifted using a right-angle clamp. Fascial bands (especially medially) are released to allow smooth passage of harvest instruments.

6. An open tendon stripper is advanced proximally toward the ASIS. This gives controlled proximal length with excellent tactile feedback.

7. Through the same incision, a cylindrical tendon corer is passed distally to harvest an additional 7–9 cm, completing the bidirectional harvest. Capsule and vastus intermedius are preserved, minimizing hematoma and anterior knee pain.

8. Final graft typically measures 8–11 mm diameter and 28–35 cm length, suitable for ACL ± ALL or multiligament reconstructions.

9. Hemostasis achieved; no quadriceps or capsular repair needed. Skin closed in layers.

The bidirectional rectus femoris harvest is a clean, elegant technique but needs access to Corer device of Arthrex. If you want a simpler but less elegant technique check out the one by Rego et al.

The Man behind the Mechanical Axis #FromTheHistory:

As Orthopods, we draw the mechanical axis almost as a reflex. But, do you know the man who steered us away from obsessing anatomical axes and toward the weight bearing mechanical axis? His name is Jan Mikulicz Radecki.

Now, Mikulicz was not our stereotypical 19^th century surgeon. No drinking, no smoking and zero theatrics. He was the serious type, almost intimidating. He got trained under the legendary Theodor Billroth – who for obvious reasons was not really impressed. But over time they grew close and then what helped? Both of them played Piano, they even played alongside the great German composer Johannes Brahms.

In 1882, at just 32, Mikulicz got the prestigious position as Chair of Surgery in Krakow. Billroth may have pulled some strings in Vienna without the knowledge of the medical council. This resulted in a predictable outrage calling “attack on autonomy”. But our man handled it very well and eventually won everyone over. Now comes the relatable twist: his wife, who didn’t speak Polish, was not very happy to be in Krakow and he chose to move out within 5 years. His wife would have played a major part for the change – some dynamics never change!

As a boss, he was feared as a very formal type. He never complimented his assistants as if it was a rule not to. He had what we can call a double life! From 10am to 6pm, he worked in Breslau as Chief medical officer in the government setup where he setup a splendid hospital. He introduced the usage of face mask for surgeons; he was one of the first European surgeons to use surgical gloves. Once Billroth visited this splendid structure created by his disciple as Mikulicz recalls told half jokingly by Billroth “ If it weren’t yours, I would perish out of jealousy”.

Finally another anecdote from his practice which shows how shrewd he was. When a patient once asked him to reduce his fee, he reportedly said: “Certainly, but I have to operate with dull instruments then”!

Serious man, sharp mind and sharp instruments. And a line we still draw every day.

No Starvation Surgery for Diabetics, New ERAS Trend!

Many individuals undergoing surgery involving general anaesthesia are asked to fast for a prolonged period to ensure perioperative safety, yet this can initiate stress reactions and insulin resistance, harming postoperative recovery. Such fasting may be particularly problematic for those who have type 2 diabetes.

Lai et al. performed an RCT where 90 patients who had non-insulin-dependent type 2 diabetes mellitus who were scheduled for elective TKA received oral carbohydrates at two or four hours before surgery, or received a carbohydrate-free “placebo” drink at four hours before surgery. Patients given oral carbohydrates had lower insulin resistance, reduced β‑cell activity, less hunger, and better glycemic control compared with placebo. Administering carbohydrates two hours preoperatively showed the most significant benefit. No aspiration or severe complications occurred, confirming that this approach is safe and effective for non‑insulin‑dependent type 2 diabetes.

Events to check out:

Pediatric Orthopaedic Society of North America (POSNA) 2026 Annual Meeting 6 – 8^th May 2026 Orlando, USA

Barcelona Hip Meeting 2026 27 – 29^th April 2026 Barcelona, Spain

22nd ESSKA Biennial Congress 2026 20 – 22^nd May 2026 Prague, Czech Republic

Have a Fabulous February ahead guys.

Liner change… - For OA! #NeoArmory:

‘THR is so 2025’ is what I would say if I invented a 3D printed Biodegradable liner which can dissolve to form ‘normal’ cartilage.

CytexOrtho, a US based company have designed ReNew^TM Hip implant which has 3D printed porous woven textile to mimic cartilage and a base to facilitate anchorage. Overtime, cells ‘move into the gaps’, implants dissolves and ‘creates 100% healthy tissue’.

They do both femoral head and acetabular components

The ReNew hip clinical trial has commenced and recruiting subjects.

But notably, this would require a safe surgical dislocation to implant. As the implant does not have structural stability, it cannot be used if there is contour mismatch.

Let’s wait for the results!

Adolf Lorenz – A surgery which costed around $75,000 and no blood involved! #FromTheHistory:

All of us would have seen patients who doesn’t want surgical intervention and ask “is there any other way?” Interestingly, there was an Austrian “surgeon” who built his entire career around the same idea.

Adolf Lorenz (1854-1946) was famously known as “Bloodless surgeon of Vienna”. Mind you it was not some gimmick created for marketing, he indeed was a bloodless surgeon and the story behind this is quite fascinating.

Lorenz decided to become a surgeon at 26 after just completing his graduation but fate had other plans. Within 4 years, he developed severe allergy to Carbolic acid which was used extensively in operation theatres to achieve asepsis. Being bitten by the love for surgery, he just could not give up and instead he chose to become a dry surgeon, meaning, not cutting the skin but perform manipulations. He invented manipulation techniques for several conditions like Club foot, scoliosis etc but he was famous for his treatment of congenital hip dislocation.

Lorenz’s most famous case which made him a celebrity is about Lolita Armour, granddaughter of one of the richest man in USA at the time, Philipp D Armour. She was born preterm at 34 weeks weighing barely 3 pounds with congenital dislocation of hip. She even underwent a surgery in the USA which unfortunately was not successful.

At the time, Lorenz’s bloodless surgeries were the talk of the town, or rather talk of the world. Lolita was too fragile to travel to Vienna and so the family requested Lorenz and the team to USA. This created a Media Frenzy and public excitement. It is said that Lorenz and the team have charged around a $100,000 including their travel expenses (This was more than a century ago, now get that!).

There was even a controversy about Lorenz’s license to treat patients in the USA. This, however was swiftly handled when the Illinois State Examination Commission granted him immediate permission to practice, reportedly under pressure from Chicago physicians.

Finally, Lolita, after a trip to Vienna for rehabilitation was said to gain almost normal gait and the parents as well as herself were happy about it.

However, there has always been a skepticism in the orthopaedic fraternity about the complications and success rates with the bloodless surgeries performed by Lorenz and with time, the concerns grew into reality with loads of patients with high complication rates especially Avascular necrosis and redislocation. In hindsight, Lorenz’s story teaches us that however bold your ideas are, what matters is the long-term success not the early results.

The Poller pin technique for subtrochanteric fractures - #SurgicalPearl:

Yoon et al. explain how poller (blocking) screws can be smartly used during intramedullary nailing to guide the nail, improve entry point accuracy, and correct malalignment—especially varus and flexion deformities, which are common in subtrochanteric fractures .

Again the poller pins as traffic dividers inside the bone.

1. Correcting varus deformity (AP plane)

Varus usually happens when the nail starts too lateral or the proximal fragment drifts medially.

• Place a poller pin lateral to the nail path near the greater trochanter. This pushes the nail medially and prevents varus.

• Metaphyseal-level problem (short proximal segment):

  Place a poller pin medially at the metaphysis. This blocks medial drift and restores neck–shaft alignment.

2. Correcting flexion / extension deformity (lateral plane)

Subtrochanteric fractures love to go into flexion because of iliopsoas pull.

• If the proximal fragment is flexed:

  • Place a posterior poller pin → forces the nail anteriorly → corrects flexion.

• For extension deformity (less common):

  • Place an anterior poller pin to redirect the nail posteriorly.

3. Technical pearls

• Insert poller pins before reaming or nail passage

• Use bicortical placement for strength

• Convert Steinmann pin to a 4.5 mm cortical screw if needed

• Avoid blocking the path of proximal recon screws

• Be careful not to blow out the proximal fragment

To read this technique in depth and know about other options esp. subtrochanteric non unions - check the full paper here.

Please close the door after you leave - in Hip arthroscopy! #MostCited:

During hip arthroscopy, closing the capsule is seen as a way to restore the joint’s natural balance and improve outcomes, while leaving it open can help loosen stiff hips but carries a small risk of instability. To weigh these options more clearly, expected‑value decision analysis (EVDA) offers a cool framework that blends probabilities with patient‑valued benefits, helping identify which path brings the most positive energy overall.

Phillips et al. performed an EVDA for this case and their results showed that complete capsule closure carried a higher expected value and greater probability of well outcomes compared with incomplete closure.

Finally, complete closure emerged as the superior management choice, offering better outcomes and fewer complications such as revision surgery or conversion to THA.

Events to check out:

• 27th EFORT Annual Congress Málaga 2026 4 – 6^th May 2026 - Malaga, Spain

• 44th Annual Meeting of the European Paediatric Orthopaedic Society 8 – 10^th April 2026 - Seville, Spain

• Global Spine Congress 2026 27 – 30^th May 2026 - Istanbul, Turkey

Happy New Year Folks!

Let’s Brew with Bones in 2026!

Bone glue is here! #NeoArmory:

REVBIO ‘s TETRANITE® may be the bone glue we have all been waiting for. Comminuted fracture? Just apply this and slap a plate on it. Time for AO principles 2.0.

Combat soldiers in war fields, expeditions in remote conditions, mass casualties and natural disasters where you need immediate solutions for broken bones, we may have something here.

How do they make it?

Science stuff

They claim it to be the first synthetic Bone-to-bone and bone-to-metal adhesive. Forms a cement like adhesive scaffold in minutes which is bioactive and osteoconductive and eventually replaced by new bone all while resisting 3MPa worth force.

RevBio have received a NIH grant for First-in-Human Clinical Trial and have enrolled 5 patients. Are we looking at a fundamental change in fracture management or is it just reinventing the wheel by making it... harder?

The man, the myth and the Legend – Gavril Abramovich Iliarov #FromTheHistory:

In the field of Orthopedics, Ilizarov is a big name, almost a legend. As any good legend goes, there are some myths that float around.

First the name itself! We all know him as Gavril Abramovich Ilizarov but it seems Ilizarov was spelling error by an official of registry of births and it was supposed to be Elizarov! Can you imagine calling him Dr. Eli!

Next is the workshop myth. There is a story floating around that he started his research using bicycle wheel spokes, and making him seem like MacGyver, which he surely was but turns out this story doesn’t have any credible evidence and it is not true. The real story is that he organized a workshop in 1946 with the aim of developing instruments for the war injured people and that’s where the famous Ilizarov circular external fixator was born.

Now, a story which turns out to be true is about the discovery of distraction osteogenesis that was possible with the fixator. The index case in which Ilizarov discovered this was quite intriguing. It was actually a mistake which became a boon to the non unions with bone defects as well as in the development of bone lengthening procedures. The patient underwent fixator application for the lengthening of amputation stump. Ilizarov went for a vacation after the surgery and came back to notice that there was osteogenesis between the bone ends. Mind you Ilizarov was not the first person to describe distraction leads to osteogenesis, but he is the one who described the biologic and histological principles of the process.

All in One posterior approach for ankle fractures - The Modified Posteromedial Approach #SurgicalPearl:

This approach was described by Assal et al. for complex pilon fractures with a major posterior column component, where restoring posterior length and alignment is critical before anterior articular reconstruction.

Begin surgery in the prone position with a support under the anterior tibia to allow free ankle motion and fluoroscopy. Make a longitudinal incision ~1 cm medial to the Achilles tendon, starting just proximal to its calcaneal insertion and extending ~12 cm proximally.

Superficial Dissection – Open the fascia, retract the Achilles tendon laterally (preserving its sheath), retract the tibialis posterior, identify the transverse intermuscular septum.

Deep Interval – Incise the septum to enter the deep posterior compartment; identify the FHL tendon/muscle and note the tibial nerve along its medial border.

Exposure of Posterior Column – Develop the interval between the tibial nerve and FHL, retracting FHL laterally to expose the posterior plafond, metaphysis, syndesmosis, and malleoli.

Posterior Reduction & Fixation – Reduce posterior fragments under direct vision, restoring length and alignment; fix using a posterior plate (locking T-plate or recon plate), ensuring distal screws are short.

Fibular fractures - If fibular fracture fixation is need, go in the interval between the FHL and peroneal muscles to expose the posterior fibula and plate it.

This is quite a handy all in one posterior approach for tibial plafond fractures.

Check out the full technique here

Finite Element solution to Screw Loosening in FNF #MostCited:

Despite several surgical options, there has yet to be a consensus on the best treatment for femoral neck fracture (FNF) due to higher complication rates compared to other bone fractures. Güvercin et al. examined the possible consequences and solution suggestions of changing screws during surgery for various reasons in FNF surgical treatment from a biomechanical perspective.

The key findings of the study were as follows:

• The best results were obtained by using the CCS (Cannulated Cancellous Screws) with the MBP (Medial Buttress Plate). However, using CCS in the appropriate position and length at once is sufficient.

• The DHS (Dynamic Hip Screw) plate provides sufficient compression when applied at once and positioned appropriately. However, it cannot provide as much stability as a CCS.

• It is unnecessary to support the DHS plate with double anti-rotation screws

• MBP increases the stability of all constructs.

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Events to check out:

• IOACON 2025 15 – 20^th December 2025 Guwahati, India

• 7th Athens Shoulder Course 2026 13 – 15^th March 2026 Athens, Greece

• Mayo Clinic Advancements in Surgical and Medical Management of the Spine 2026 26^th Feb – 01^st March 2026 Hawaii, USA

Have a fabulous month ahead folks. See you all next year.

SI joint would like to be loved too… #NeoArmory:

SI joint is like the Spine’s forgotten little child left Home Alone before a big European holiday. Studies estimate SI joint dysfunction can be behind 15-35% of LBAs. Although we are picking this up more recently, we need more modalities of management.

The Catamaran® SI Joint Fusion System from Tenon Medical (CA, USA), aims to address the Kevin Mcallister (Homealone) situation. It is a Robust Titanium peg type implant to transfix and help fuse the SI joint. Uses an inferior-posterior approach and transfixes along a longitudinal axis.

Mechanical testing shows it being a reliable stabilization system and a single centre study concluded a good reduction in SI joint pain.

MAINSAIL study has given out interim 6 month result that suggests 61% pain reduction(VAS), 93% patient satisfaction, No re-operation, No reintervention and 80% success rate.

The “Crazy” Surgeon Who Straightened Spines - The Hidden Chapters from Dr. Paul Harrington’s Legacy: #FromTheHistory

Most orthopedic surgeons have heard of the Harrington Rod, the pioneering spinal implant that changed scoliosis treatment and posterior instrumentation forever. But only a few know the backstory of the man behind it - Dr. Paul Randall Harrington, the orthopedic maverick from Kansas who literally built modern spine surgery from scratch.

Back in the 1950s, when polio was leaving children with severe spinal deformities, Harrington wasn’t satisfied with braces and casts. He wanted internal fixation—something unheard of back then. So what did he do? He started crafting metal rods with hooks and ratchets for internal use. Before each surgery, he would hand-fashion the instruments himself—and after each case, he’d tweak the design based on what worked or didn’t. It was surgical innovation in real-time, one patient at a time. But the medical community wasn’t impressed at first. In 1958, when he presented his technique at the AAOS meeting, he was met with “astonishment and deep skepticism. Some even wanted him expelled from the society. He was denied residents, sidelined by colleagues, and nearly booted from his local medical society after early failures. They called him a “crazy man.” He kept going anyway.

Eventually, he convinced the society with his results and partnered with Zimmer Inc. to manufacture the rods - but only allowed sales to surgeons who had personally trained under him. For the first two years, no one could buy a Harrington rod without seeing it in action first. He believed patient safety and proper training were non-negotiable. And those royalties? Until 1970, he donated every cent—$0.50 per rod, $0.25 per hook—to research. Only later, when peripheral vascular disease limited his mobility, did he accept payment.

From basement tinkering to global impact, Dr. Harrington’s legacy is more than metal. It’s about grit, guts, and the belief that a single surgeon, even a ridiculed one, can reshape medicine.

Leverage Technique Using Monoaxial Pedicle Screws for Thoracolumbar Compression Fractures #SurgicalPearl

#SurgicalPearl:

This technique by Zhu et al. enables direct vertebral body reduction by leveraging monoaxial screws, minimizing distraction-related complications such as screw loosening and implant failure. It is particularly effective for AO Type A3 fractures.

Let us provide you with the pearls:

- Posterior midline approach is used to expose the transverse and articular processes of the injured and adjacent vertebrae.

- Monoaxial screws are inserted into the fractured vertebra, parallel to its superior endplate.

- Multiaxial screws are placed in the vertebrae above and below.

- Rods are contoured to match the physiological sagittal profile.

- Rods are seated and caudal nuts are tightened to anchor the rod.

- A rod gripper is locked onto the rod, contacting the inferior edge of the monoaxial screw heads.

- As the monoaxial screw nuts are tightened, the screw tail shifts caudally and the tip elevates cranially.

- This fulcrum-based action lifts the superior endplate of the fractured vertebra.

- Reduction is confirmed when the screw and rod are perpendicular.

- Cranial nuts are then locked without applying distraction. C-arm fluoroscopy confirms reduction and hardware positioning.

Should we operate discs early #InTrials:

Mutubuki et al conducted an RCT and an economic analysis that followed 72 adults who were stuck on a waiting list for surgery for lumbar herniated discs. The researchers randomly divided them into two groups: one got the traditional care approach, while the other received a two-pronged strategy combining Mechanical Diagnosis & Treatment (MDT, a targeted exercise-based therapy) alongside a transforaminal epidural steroid injection (TESI). Over a year, the combo group showed impressive results: vastly fewer of those patients ended up needing surgery, and they saved around €1,700–€2,300 per person, depending on whether you’re looking at healthcare costs or broader societal costs. In short, this combo intervention didn’t just ease pain and avoid surgery—it also made serious economic sense.

It’s the kind of study that might change how we tackle lumbar disc issues, especially when surgical resources are tight or patients prefer to skip cutting altogether.

Don’t forget to check the full study!

Restoring the Curve: Segmental Lordosis and Its Ripple Effect on Adjacent Segment Disease: #MostCited:

Restoring alignment is an important consideration in spinal fusions. Failure to correct to level-specific alignment goals could promote the development of adjacent segment disease (ASD). Singh et al. explored the consequences of inadequate L4–S1 lordosis correction during short lumbar fusions. The findings are sobering: failure to restore segmental alignment within the optimal 35°–45° range significantly increases the risk of ASD and revision surgery within two years.

Among 168 patients with 1–3 level TLIF and two-year follow-up, 32.7% developed ASD and 19.6% required revision. When stratified by adequacy of L4–S1 lordosis restoration, those with optimal correction had markedly lower ASD (6.7% vs. 33.3%) and revision (5.7% vs. 25.9%) rates. Notably, ASD patients had higher implant-related complications (36.8% vs. 8.0%) and were more likely to undergo subsequent revision (61.1% vs. 8.7%).

Hence, sagittal alignment isn’t just aesthetic—it’s biomechanical insurance. In degenerative spine fusion, restoring segmental lordosis may be the difference between durable outcomes and downstream complications

Events to check out:

• IMAST 2026 – International Meeting on Advanced Spine Techniques 15 – 17 April 2026 Toronto, Canada

• EFORT Annual Congress 2026 04 – 06 May 2026 Malaga, Spain

• BioSpine 9 20 – 22 May 2026 Berlin, Germany

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  Have A fabulous month ahead folks!

OrthoSearch: the PubMed of Orthopaedics?

In today’s rapidly evolving scientific ecosystem, researchers are often overwhelmed by the sheer volume of published literature. Finding precise, high-quality, and clinically relevant information can be like searching for a needle in a haystack.

Enter OrthoSearch, a new-age research platform built exclusively for the orthopaedic and musculoskeletal community. Positioned as a next-generation research tool, OrthoSearch combines the precision of medical indexing with the speed and intelligence of AI-driven search engines. Unlike conventional databases that are broad and often cluttered, OrthoSearch is designed with focus and specialization at its core. It brings together peer-reviewed journals, clinical trials, conference abstracts, meta-analyses, and even preprints under one roof—streamlined for orthopaedic surgeons, researchers, and trainees. By leveraging machine learning algorithms, the platform doesn’t just retrieve articles; it curates context-aware results—highlighting methodologies, outcomes, and relevance to clinical practice.

One of the standout features of OrthoSearch is its smart filtering system. Users can refine results by anatomical site, type of study (RCT, cohort, case series), level of evidence, or even keywords like “rotator cuff repair” or “arthroscopic innovations.” In addition, the platform integrates citation analytics and research impact metrics, allowing users to quickly gauge the significance of a study within the orthopaedic landscape. What makes OrthoSearch truly unique is its collaborative edge. The platform encourages knowledge-sharing by enabling users to create research collections, annotate studies, and collaborate with peers globally. In a market saturated with generic search engines, OrthoSearch distinguishes itself as a specialized, intelligent, and clinically aligned tool.

OrthoSearch isn’t just another research tool—it’s the future of orthopaedic knowledge navigation.

Consensus: Your Research Co-pilot or Just Hype?

If you’ve ever wished for a shortcut through the maze of peer-reviewed papers, Consensus might be the tool you didn’t know you needed.

This AI-powered academic search engine pulls evidence straight from over 200 million peer-reviewed articles and distils them into digestible, citation-linked answers — no fluff, just facts. Want to compare THR vs. HA in elderly femoral neck fractures? Consensus doesn’t just guess — it shows you what the literature says, complete with percentages and links to real studies.

But here’s the catch: it’s not a substitute for deep reading or meta-analysis. Think of it as your lit review pre-check: fast, traceable, and surprisingly useful when prepping protocols or shaping hypotheses.

So is it validated? Not officially like Cochrane or PRISMA — but it’s trusted by researchers, and every output links to original publications. Just don’t forget your own judgment along the way. 😉

Try it yourself here

From Lab Rabbits to Research Rabbit: ?!Evolution

Writing an academic article is not a simple feat and almost all of us went through that struggle. Even with the internet, it used to be a struggle especially to find the relevant studies for the specific topic you are working on. But now, if you give an article to this AI driven web application called “Research rabbit”, it will dig through the literature available and bring you the articles which are similar to your work. Something like a bunny digging through fields and finding carrots, pun intended!

The articles that this great AI tool digs out of the literature is nicely curated into a nice mind map where you can see the connections as well as the timelines of that topic. It’s like the carrots are nicely sorted out according to the size and quality for us to pick what we need. Sounds yummy, right?

Great thing is you don’t need to start from scratch when you start using this app. You can import your data from Zotero. Mind you, our rabbit is not a replacement for Zotero, but they both work together. Something like, Zotero is cabinet where you fill things and take them when you need them, but our Rabbit here is like a DJ which takes the available tracks (read articles) and mixes and matches them to your liking.

So, why delay, try it out and see if this helps progress your research.

The Online data analyst - How AI is breaking the Research (barrier)

Gone are the days when we had to find(beg) a ‘data-person’ (or a statistician as the normies would say) to help with our research and dissertation. I still remember mine was third on the queue on her table with deadline in 8 days.

With AIs doing most of the heavy lifting in research ever since LLMs came into the picture, it is no wonder they have taken over most aspects. One of the areas where they lagged was data visualization. Ask Sam Altman. He knows better.

Image published during GPT5 release. 52.8>69.1=30.8 AI math!

Julius.ai is one of them few which can visualize your data for you. They claim 10x faster research and no need to know any coding. Comes with a good app to work with.

I appreciate the effort taken on the prompt

Julius.ai helps with most of your data management and provides insight on the data as well. Supposed to be better than ChatGPT and it can handle files upto 32GB. There is a free version to try out and priced around $30 a month for premium versions.

Events to check out:

• AAOS Annual Meeting 2026 02 – 06^th Mar 2026 - New Orleans, USA

• Orthopaedic Research Society (ORS) Annual Meeting 27 – 31^st Mar 2026 - Charlotte, USA

• WCO-IOF-ESCEO 2026 – World Congress on Osteoporosis, Osteoarthritis & Musculoskeletal Diseases 16 – 19^th Apr 2025 - Prague, Czech Republic

NB: None of these are promotoed contents! Do mention your experience with these tools in the comments.

Have a marvellous month ahead guys!

Nanobots? Nope. Just a Gel That Sticks Around for 5 Years

Where do sci-fi movies turn to when the plot is thrown into a corner? ‘Nanobots’. They inject something into the blood stream and the little ‘bots’ do all the work and create a superhero.

What if, we say that there is a similar injection similar to treat knee osteoarthritis! (Well, except for the nanobot part)(and the superhero part).

Contura Orthopaedics have created Arthrosamid a first “injectable synovial implant”. It a 2.5% PolyAcrylamide gel(iPAAG) which coats the synovial membrane and gives pain relief upto 5 years!

When injected, the compound integrates into the synovial membrane and remains as non biodegradable, non absorbable and non migratory, although we don’t yet know how the pain relief is achieved.

The compound itself is not new, been used up for soft tissue augmentation and bilking agent in stress incontinence almost for 40 years. Also, been injected into race horse knees with excellent effects.

This is not yet FDA approved but CE approved for use in Europe and being used in the UK and Canada. Does it cause any short or long term issues with knee replacement after injection? We don’t know yet.

(Stetho)Scope in trauma - Ah! Come on! #FromTheHistory:

How did our forefathers identify and treat the not so easily identifiable fractures, without X rays? Did you ever wonder? It is not just before the discovery and introduction of X rays in the market, even after that, not every place was able to procure a machine. So, how did they manage, especially the ones like impacted neck of femur fractures?

Two words: Percussion and Auscultation!

Josef Leopold Auenbrugger (19 November 1722–17 May 1809) learnt this technique in the wine cellars of his father’s collection and used it to describe shoulder dislocation with percussion technique - Learnt the technique and brought it into his practice from a wine cellar, think about that! He taps on the olecranon process and immediate auscultation, viz., keeping his ear on the manubrium and hearing the conducted sound and it is called Auenbrugger sign and later became Heuter’s sign if you placed the bell of the stethoscope on the manubrium.

Rene Theophile Hyacinthe Laënnec (1781–1826) is the one we all know who invented the stethoscope. But do you know that he invented in order to avoid leaning on and hearing to the heart of a young lady with a heart condition? Yes, he wanted to avoid the awkward moment and at the same time he remembered some children playing with a wooden tube to amplify a sound and he thought can I do the same to hear the chest sounds and voila, we have a stethoscope. Though Laënnec didn’t write explicitly about using the stethoscope for identifying fractures, Jacques Lisfranc (12 April 1787–13 May 1847) wrote about the brilliance of Laënnec in identifying even those impacted neck of femur fractures, and even when patient is able to walk.

Finally, can you fathom that Kuntscher, Lipman and several other surgeons have just used percussion and auscultation not just to identify the fractures but also to understand if there was a good reduction and even placed intramedullary nails with closed technique without X rays!

No, X rays are needed, but when we don’t have them, take out that old stethoscope and dust it off and start using it.

Genicular Nerve Radiofrequency Ablation (GNRFA) - #SurgicalPearl

Genicular Nerve Radiofrequency Ablation (GNRFA) is an outpatient pain procedure gaining ground in the treatment of moderate to severe knee osteoarthritis, especially in patients who’ve failed conservative treatments, had an unsatisfying knee replacement, or aren’t ideal surgical candidates.

Here’s how the technique works step-by-step:

1. Diagnostic Block: First, a test injection with 1 mL lidocaine is given near three sensory nerves—superior medial (SM), superior lateral (SL), and inferior medial (IM) genicular nerves. If pain relief >50% lasts 24 hours, the patient proceeds to ablation.

2. Positioning: Patient lies supine with 30° knee flexion. The knee is sterilized and draped. A ground pad is placed to avoid skin burns.

3. Landmark Identification:

   • SL nerve: Junction of femoral shaft and lateral epicondyle (AP view).

   • SM nerve: Just anterior to the adductor tubercle on the medial distal femur.

   • IM nerve: At the junction of the medial tibial metaphysis and diaphysis, along the tibial flare.

4. Cannula Insertion: 20G radiofrequency cannulas (3.5-inch, 10-mm active tip) are advanced percutaneously to contact bone at these landmarks under fluoroscopy.

5. Confirm Position: On lateral view, all cannulas should lie at the midpoint of the diaphysis. Adjust 3–5 mm if needed.

6. Nerve Testing: Sensory testing at 50 Hz reproduces typical pain. Motor testing (2 Hz) confirms no motor involvement.

7. Ablation: Each site is injected with lidocaine, then ablated at 80°C for 90 seconds. Cannulas are advanced slightly, and ablation is repeated.

8. Steroid Injection & Wrap-Up: 1 mL methylprednisolone is given post-lesion. Cannulas removed, sites bandaged.

The result? Months of relief for patients with limited options—no incision, no implant, and no general anaesthesia required. Read the detailed description of the technique here.

💉 Big Dose or Small Dose? Turns Out, It Doesn’t Matter Much for CTS

Carpal Tunnel Syndrome (CTS) is one of those sneaky little conditions that can really mess with daily life—and steroid injections are often the go-to relief plan. But how much steroid is really needed? A recent randomized controlled trial put that exact question to the test.

Researchers compared 10 mg vs. 40 mg doses of triamcinolone acetonide (TA)—both mixed with lidocaine—given under ultrasound guidance for patients with mild to moderate CTS. Over 12 weeks, they tracked pain levels, symptoms, function, and even nerve conduction studies. Spoiler: both groups did equally well across the board.

So what’s the takeaway? You can likely get the same bang for your buck—and symptom relief—with just 10 mg of steroid. That means less drug, potentially fewer side effects, and more cost-effective care. It’s a win for patients and a win for resource-conscious clinicians.

This study reinforces the idea that in medicine, more isn’t always better. Sometimes, keeping it minimal does the job just fine.

Ponseti’s Clubfoot Protocol: Tenotomy Timing Makes the Difference

In the stiff clubfoot game, timing is everything, especially when it comes to Achilles tenotomy. So, should we snip sooner rather than later?

A randomised trial by Ghanem et al. put the method to the test: 140 stiff feet, split evenly into early and late tenotomy groups, all treated with the Ponseti method. The verdict? Early tenotomy at the first cast not only reduced technical hiccups (just 3% vs. 38%), but also scored better long-term outcomes — more “excellent” feet and fewer talar dome issues.

Why does it work? Easier access to the tendon on an untouched foot and less joint compression after an early release appear to provide both surgeons and neonates a smoother experience.

Moral of the story: If you’re in the early intervention camp, science is backing you — early may just be the new gold standard.

Events to watch out:

• Ranawat Orthopaedic Conference (ROC 2026) 08 – 10^th Jan 2026 - Bengaluru, India

• Global Knee Innovation Summit 22 – 24^th Jan 2026 - Dubai, UAE

• Asia Pacific Orthopaedic Association (APOA) 25^th Congress 04 – 07^th Feb 2026 - Jaipur, India

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  Answer to last month question:

  Which bone sarcoma subtype had the highest pooled 5‑year overall survival rate?

  A. Chondrosarcoma

  B. Ewing’s sarcoma

  C. Osteosarcoma

  D. Metastasis

Answer: Ewing’s sarcoma according to a systematic review by Hosseini et al.

Have a fabulous month ahead guys!

Can we get a Watt Watt?! - #NeoArmory:

What do you get when you mix a bit of problem-at-hand, interest-in-photons, out-of-the-box-thinking, a buddy from IR, and of course lytic bone lesion? You give the world – the “IlluminOss”

The IlluminOss system has its proprietary Balloon catheter made of Dacron-like material, which is inserted into the medullary canal and filled with its light-sensitive Monomer. This is cured with light (436nm), which makes the construct rigid and provides longitudinal and some rotational stability. Additional fixation can be done on top of this if needed.

We know what you’re thinking. Looks good, does it work? Yes, it does. LightFix trial concluded, saying it reduced pain and improved function in the first year. It can be used alone in impending fractures, but it is recommended to add fixation in pathological fractures.

FDA approved for almost all long bones; this has been a perfect NeoArmory storage on the shelves in some parts of the world. Yet to be widely available, but most of us have been in the dark until the light shines! Haha

Out-of-the-box awesomeness: Van Nes – Borggreve knee rotationplasty #FromTheHistory:

Can you imagine a person whose leg was amputated, and his ankle and foot were attached to the stump, in the wrong way, feet pointing backwards, 180° to what we usually have—— jumping over six feet high? That sounds like some out-of-this-world story, right? But, no, this is how the life-changing surgery called rotationplasty could work!

It all started with Joseph Borggreve, a German surgeon who thought out of the box and did an amputation above the knee for a 12-year-old kid with tuberculosis and thought it would help him if the healthy ankle and foot could be fixed to the stump, providing what is essentially a knee joint. It was Cornelis Pietr Van Nes, a Dutch surgeon, who popularised the procedure where he gave hope to a lot of children with congenital deformities of the lower limb.

Over time, this surgery was incorporated in treating children with lower thigh tumours where above knee amputation was the only choice and voila, it gave excellent results. Samuel Grewe has become a poster boy for the rotationplasty for malignant tumours in recent times. He underwent rotationplasty at the age of 13 in 2011 and instead of going through despair, he decided to jump into action, quite literally. He started high jumping in 2014 and didn’t stop. He went on to earn two medals in the Paralympics. First, a silver in Rio, 2016 followed by a Gold for a jump which was 1.86m high in Tokyo, in 2020.

When life gives you a tumour, just make a turn-around and jump high!

The ‘Living Sleeve’ Technique for Pediatric Humerus Reconstruction” - #SurgicalPearl:

In the world of upper-limb oncology surgery, this one’s a game-changer—especially for growing kids. When large segments of the humerus are resected for tumours like osteosarcoma, traditional megaprostheses can be too bulky, too rigid, and too dead (literally—they don’t grow or heal). Enter the “Living Sleeve” technique, a clever hybrid of modern 3D printing and good ol’ biology.

What’s the idea?

A custom-made, 3D-printed hollow titanium prosthesis is designed to replace the lost humerus segment. But it’s not just any implant—it’s porous, lightweight, and hollow for a reason. Surgeons pack the hollow core with autologous bone graft, harvested from the remaining proximal humerus or iliac crest. This converts the prosthesis into a scaffold that facilitates genuine biological integration.

Surgical Steps:

1. Wide tumour resection, preserving joints when possible.

2. CT-based design and printing of a porous titanium hollow sleeve with flanged ends.

3. Grafting: Cancellous bone is packed into the hollow interior.

4. Internal fixation: The prosthesis is secured to the host bone with locking screws through side flanges.

5. Layered closure and standard post-op rehab.

Merits:

• The porous structure allows bone ingrowth.

• Hollow design = less weight and more biology.

• Custom-fit improves stability and cosmetic results.

• Ideal for young, growing patients where motion and long-term integration matter.

3D-Printed Pelvic Reconstruction: Sculpting Precision, Stressing Function - #MostCited:

Hu et al. delivered compelling data comparing 3D-printed versus modular hemipelvic prostheses for pelvic reconstruction post-tumour resection. In their retrospective cohort, 3D-printed implants demonstrated more natural biomechanical stress patterns, improved osteointegration, and higher functional scores. Finite element modelling revealed that these implants better mimic native pelvic biomechanics, while modular devices showed stress hotspots linked to mechanical failure and screw loosening.

Clinically, the modular group faced more complications—loosening, infection, poor integration—whereas 3D-printed counterparts, though demanding longer operative time and more blood loss, provided durable reconstructions with precise anatomic fit. The study underscores a paradigm shift: from adaptable modularity to personalised precision. For the reconstructive surgeon, it's a nudge to rethink “fit-for-all” and embrace the pelvic ring’s biomechanics as a blueprint—not a boundary.

Longer Isn’t Always Better - Antibiotics After Tumor Surgery #InTrials:

A multi-centre RCT by Ghert et al. compared short (24-hour) versus extended (5-day) intravenous antibiotic regimens after endoprosthetic reconstruction for lower extremity bone tumours. Conducted across 36 sites and involving 604 patients, the study aimed to reduce deep postoperative infections—a major complication after limb salvage surgery. Surprisingly, the longer antibiotic course did not lower infection rates. The 5-day group had a slightly higher (though not statistically significant) infection rate: 16.7% vs. 10.9% in the 24-hour group. Adverse events, such as antibiotic-related side effects, were also more frequent with prolonged use. The study’s findings challenge the assumption that “more is better” when it comes to post-op antibiotics in oncologic limb reconstructions. The results support using a single-day prophylactic antibiotic protocol, which is equally effective and comes with fewer risks—streamlining care while maintaining safety in a high-risk surgical population.

Events to check out:

• AO Spine Asia Pacific Regional Conference 2025 18 – 21 September 2025 Bangkok, Thailand

• 18th ICRS World Congress Joint Revolution 11 – 14^th Oct 2025 - Boston, USA

• AANA 2026 14 – 16^th May 2026 - Phoenix, USA

Answer for the last month’s question:

Which of the following statements best reflects the evidence regarding the management of elderly patients with femoral neck fractures on clopidogrel?

A) Surgery should be delayed for at least 5 days after stopping clopidogrel to reduce bleeding risk.

B) Early surgery on patients taking clopidogrel significantly increases the need for blood transfusion.

C) Early surgery on patients taking clopidogrel is safe and does not significantly increase bleeding risk.

D) Clopidogrel should always be withheld in the perioperative period to avoid complications.

Answer: C) Early surgery on patients taking clopidogrel is safe and does not significantly increase bleeding risk according to a systematic review and meta-analysis by Soo et al.

Question of the month:

Which bone sarcoma subtype had the highest pooled 5‑year overall survival rate per the review?

A. Chondrosarcoma

B. Ewing’s sarcoma

C. Osteosarcoma

D. Metastasis

Hold your curiosity till our next issue. Have a wonderful month ahead, folks.

Warp speed wrap! #NeoArmory:

“I am Flash” – Flash (DC comics)

We all like speed and precision while operating. Reducing the knife to closure time means bragging rights (also, the patient benefits, etc.. etc). That can happen incrementally by reducing the time taken in each step of the procedure,our and we will employ any device at our disposal.

Nerve repairs in complex reconstructions can themselves take upwards of 10 minutes. Biocircuit have devised Nerve tape^®, which can cut down this time tremendously. It is a Porcine small intestine submucosal wrap with Nitinol hooks on it. Just get the nerve ends together, wrap the tape around them and move on to the next step.

...and Bob’s your uncle.

They claim a 97% success rate with repairs, 4.8 times faster and 2.6 times stronger than the microsuture. There is also evidence for better or equal regeneration with data from electrophysiological studies.

This is one of the devices that we expect will become as essential as a skin clip or a bone wax. If you’re not a trauma reconstruction surgeon, get it to your shelf and hope and pray you don’t get to use it.

A psychotic breakdown after Hip surgery –The story of Arthroprosthetic cobaltism #FromTheHistroy:

Dr. Stephen Tower, a hip replacement surgeon from Alaska, USA, an avid cyclist, developed hip arthritis and was finding it difficult day by day. So, he went ahead and underwent Metal on Metal-on-Metal Articular surface replacement (MoM ASR) in 2006, as that was promoted as the one for “highly active individuals. Guess what, he did a 200-mile cycling road race without much difficulty, within 6 weeks of surgery and was on cloud nine as everything seemed great.

Then, after a year and a half, he started feeling these new-onset neurological symptoms like tremors in his hands, ringing in his ears, and he was repeating himself and did not realize he was doing that. Finally, on a fine day, he was supposed to give a talk about Sign nail program that was introduced in Liberia, in Hanford and was staying in a hotel. But now, he went on to have a full-on breakdown and did not leave the hotel room and get this, he wrote on the walls, ceiling, even on the bathroom mirrors with pens, sharpies and when they went out, he even used soap as ink! He was treated by a psychiatrist as bipolar disorder for almost a year and a half.

Tower couldn’t give up on himself and started checking his blood and urine samples and his Cobalt levels were sky high, they were like around 100 times that of known safe blood levels! He called DePuy people (manufacturers of MoM ASR) for no avail and finally, he gave in and went for a revision hip replacement, this time with a Ceramic on poly and unsurprisingly, his symptoms were gone within a month. His surgeon later told him how the prosthesis was virtually a crankcase of metal sludge!

After this, Tower started his research into Cobaltism associated with orthopaedic implants and now an expert in the topic. Can you believe his story was featured in the Netflix documentary “Bleeding edge”.

Cement-Augmented Fixation - a must-know #SurgicalPearl

Here’s a cool surgical tweak that’s making life easier for elderly patients with tricky shoulder fractures. The usual story with locking plates in proximal humerus fractures is that in older bones, the screws can fail, back out, or even poke into the joint—ouch! But in this technique, surgeons added a smart twist: they used shorter locking screws and pumped bone cement through some of them right into the humeral head to improve grip and reduce failures.

The approach is clean and methodical. After a beach-chair setup and a deltopectoral approach, the head and tuberosities are reduced with sutures and wires. Then a PHILOS plate is carefully positioned on the lateral humerus, and screws are placed to engage as much of the humeral head as possible—but here’s the kicker: instead of going long and risking screw penetration, surgeons went short and added cement to the tips of the screws using a special delivery system. Cement was injected through cannulated screws, especially in rows B and D, avoiding rows A (to prevent necrosis) and E (to avoid cement leakage).

What did Foruria et al. find? A dramatic drop in implant failure—from 9% down to just 1%! Patients also showed better function and fewer complications overall. Although a few patients experienced minor issues, such as partial bone necrosis around the cemented screws, the technique appears solid (pun intended). All in all, cement augmentation in the right screws, with the right technique, is proving to be a game-changer for osteoporotic shoulders

Proficiency in Endoscopic Discectomy, when do I reach it? #MostCited:

Given the current trend towards endoscopic discectomy, every spine surgeon aims to master this addition to their spine surgery skillset. However, when is such mastery reached? Li et al. in their work analysed the number of cases needed to bypass the learning curve in percutaneous endoscopic transforaminal discectomy (PETD) and interlaminar unilateral biportal endoscopic discectomy (UBED) in the treatment of lumbar disc herniation. They found that although PETD and UBED surgery are effective in the treatment of LDH with a low incidence of complications, achieving mastery in PETD necessitates a learning curve of 40 cases, while UBED requires a minimum of 15 cases to reach proficiency. So train well to treat well.

A new way to handle the pressure! #InTrials:

Compartment syndrome is a major worry after high-velocity tibial fractures, and while fasciotomy is the go-to treatment, it’s not ideal and comes with risks. This randomised, double-blind study by Jerry et al. explored whether IV Mannitol, a common brain oedema medication, could lower leg compartment pressure and help prevent full-blown compartment syndrome. Forty patients with closed tibial fractures received either 20% Mannitol or saline. Overall, there wasn’t a huge difference in pressure drop between the two groups, but in patients who started with high pressures (≥30 mmHg), Mannitol made a real difference, dropping pressures by about 8.5 mmHg at 1 hour. No side effects were reported. While it’s not ready to replace surgery yet, Mannitol showed early promise, especially for high-risk cases. More studies are needed, but this could pave the way for a simple, low-cost alternative in resource-limited settings.

Events to check out:

• IOACON 2025 15 – 20^th December 2025 - Guwahati, India

• Japan Sports Orthopaedic Association Annual Meeting 12 – 13^th Sept 2025 - Tokyo, Japan

• 18th ICRS World Congress Joint Revolution - 11 – 14^th Oct 2025 Boston, USA

Answer to the previous month's question:

What is the standard of care in paediatric ACL injuries?

• Early surgical intervention

• Delayed Surgery

• Conservative Management

Early surgical intervention is better. According to Jin et al’s systematic review of 105 studies on paediatric ACL injuries, Conservative management of ACL injuries in children and adolescents is linked to higher rates of knee instability, secondary meniscal and cartilage damage, and degenerative changes. In contrast, surgical interventions, such as physeal-sparing and transphyseal techniques, yield better outcomes in knee stability and complications reduction.

Question of the month:

Which of the following statements best reflects the evidence regarding the management of elderly patients with femoral neck fractures on clopidogrel?

A) Surgery should be delayed for at least 5 days after stopping clopidogrel to reduce bleeding risk.

B) Early surgery on patients taking clopidogrel significantly increases the need for blood transfusion.

C) Early surgery on patients taking clopidogrel is safe and does not significantly increase bleeding risk.

D) Clopidogrel should always be withheld in the perioperative period to avoid complications.

Wait for our next issue to know the answer

Have a Joyous July folks.

The Schrödinger’s operation: #NeoArmory:

What do we, Orthopaedic Surgeons, hate the most? Correct! Those pesky ECGs. Second most? Metal removal – Schrödinger’s operation. They are the easiest and the most difficult surgery at the same time. Even more Schrödinger-ery when we must take them off the kids.

Shaheer Maher’s paper (Yep, we completely understood it) shows an alternative method of manufacturing Titanium (Ti) implants with anodization that makes them less susceptible to cell attachment and proliferation.

Invitro testing showed reduced attachment and proliferation of Osteoblasts. They also added Gallium to the mix, and it showed antibacterial properties against S. aureus and P. aeruginosa.

(A very useful photo)

If any of the major manufacturers integrate this into implant manufacturing, that will be great!

The story of Wick Harness #FromTheHistory:

Having been born and studied Medicine in his hometown, Brno, Czechoslovakia, Arnold Pavlik worked under Dr. Bedrick Fejka, also in the same town. Finally, in 1939, Pavlik got “wings” when he was appointed as chief of Orthopaedics in Olomouc, a town around 60 miles away.

Now, now, fate rolled the dice, and his hands were tied as the World War II started and Nazis occupied Czechoslovakia. But, after treating numerous kids with congenital hip dislocations and seeing them end up with Avascular necrosis, he could not sit idle. He started working on a new philosophy, which he called “functional treatment”. To bring it to life, he wanted leather straps, but welcome to the war, he could only find wicks used in petroleum lamps, believe me, that didn’t stop him from glowing. He made a harness which followed his philosophy with those wicks till the war was over, and then got to make with leather. He found that the outcomes with his harness were excellent, with almost negligible incidence of AVN, and he published his findings.

He was being called a forger, and he had to defend himself. Can you imagine that? Having thought out of the box, formulated his principles, made a harness which follows those principles and overall, gives excellent results, only to get hurled insults upon? As refiner’s fire brings out gold, as you know, Pavlik harness with his principles makes the basis of how DDH is treated around the world, even after 3 quarters of a century!

Resurrecting the Lost Art for common upper limb fractures #Clinical Pearl:

Let’s go through the key takeaways from Bryson et al.'s paper regarding the conservative management of distal radius fractures

1. Clavicle Fractures

• Treatment: Broad-arm sling for 10–21 days for pain relief.

• Mobilisation: Begin gentle mobilisation after sling; avoid contact sports for 5 weeks.

2. Proximal Humerus Fractures

• Remodelling potential: High (80% of humeral growth from proximal physis).

• Treatment: Collar and cuff for symptom control for 3 weeks.

• Mobilisation: Start gentle movements at 10 days, full at 3 weeks.

• Exceptions: Only intervene surgically if the epiphysis is rotated >90° and locked.

NB: Full displacement is acceptable if >2 years of growth remain.

3. Supracondylar Humerus Fractures

AO Type I and II:

• Treatment: Collar and cuff in flexion beyond 100°.

• Mobilisation: After 3 weeks.

Type III and IV:

• Treatment: Closed reduction + K-wire fixation.

• Alternative in failed reduction: External fixation or traction (e.g., straight-arm or olecranon screw traction).

NB:

• Posterior angulation can remodel; varus/valgus typically doesn’t.

• Type I/II treated non-operatively unless instability/neurovascular issues.

4. Distal Radius Fractures

Buckle Fractures: Futura splint for 3 weeks; no follow-up required.

Salter-Harris I/II, Metaphyseal, Diaphyseal:

• Treatment: Manipulate in ED using Entonox and diamorphine.

• Plaster: Below-elbow cast.

• Acceptable post-reduction angulations:

• <10 years: ≤20° (metaphyseal/Salter-Harris).

• ≥10 years: ≤10°.

Off-ended Fractures: Manipulation under anaesthesia, plaster; pinning optional.

NB: Avoid manipulation after 10 days (risk of growth arrest); below-elbow cast preferred for function and convenience.

A PePCI for the Injured Child, Please! #MostCited:

Here, PePCI is not the misspelt cola; instead, it’s the newly designed screening tool that necessitates the need for Whole Body CT in injured children, the Paediatric Polytrauma CT-Indication (PePCI) score, as described by Strahl et al. Given the risks of radiation exposure with rampant use of whole body CT, there is a need to rationalise the use of this hazardous investigation, and here it is, PePCI. It considers cGCS, base excess (BE), medically abnormal results from eFAST screening, initial unconsciousness, and injuries involving three or more body regions as significant predictors for a screening tool for decision-making to perform WBCT or selective CT.

Cartoons to the Rescue: Easing Pain and Anxiety in Kids During Pin Removal - #InTrials

Akan et al. aimed to see how much pain and anxiety kids aged 4–12 feel during pin removal after surgery for humeral supracondylar fractures, and whether watching a fun animated video could help. In a randomised controlled trial with 180 kids, four groups were tested: Group 1 had no prep, Group 2 watched an animation before the procedure, Group 3 got ibuprofen (10 mg/kg), and Group 4 got both the animation and the ibuprofen. Pain was measured using the Wong-Baker Scale, Modified CHEOPS, and heart rate; anxiety was assessed using CAM, SAIS, and CEMS. Results showed that watching the animation made a significant difference in lowering pain and anxiety (p < 0.001). Interestingly, animation alone worked just as well as when combined with medication.

Bottom line: A short animated video before pin removal can go a long way in calming kids and reducing pain, making a tough moment just a little easier.

Events to check out:

• Japan Sports Orthopaedic Association Annual Meeting 12 – 13^th Sept 2025 Tokyo, Japan

• AOSSM Annual Meeting 10 – 12^th July 2025 Nashville, USA

• 18th ICRS World Congress Joint Revolution 11 – 14^th Oct 2025 Boston, USA

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Answer to last month’s question:

Among the following treatments, which is better for conservative management of carpal tunnel syndrome?

• Corticosteroid injection

• Wrist splint

• Placebo injection

• All are similar in efficacy

A network meta-analysis by Adindu et al. showed that all the above modalities are similar in efficacy, with corticosteroids doing slightly better in pain control and nerve conduction during the early follow-up.

Question of the month:

Which is the standard of care in paediatric ACL injuries?

• Early surgical intervention

• Delayed Surgery

• Conservative Management

  ---

Wait for our July Issue to know the answer. Have a joyous June guys!

WristArt!

This quote is not related to our Neo-armory post today. We are just filling out the minimum 200-word limit set by our Editor. Our product in the spotlight today is the winner of ‘Best device named by 10-year-old’ award- WristArt.

WristArt (Guys, seriously.. please reconsider)

Developed by Fibioseq medical Ltd (Acre, Israel), WristArt is a ‘bone sparing’, ‘interim prosthesis’ before the patient undergoes Total wrist arthroplasty. Implant has a double centre of rotation to improve range of motion.

They claim the intramedullary component along with the Extracortical plate helps distribute the forces. It is one-size-fits-all design and non-side specific. Bone preservation allows future revisions easier.

This implant is in very early stages and has had the first human patient implantation. It is a 54 year old with traumatic wrist OA and the follow up shows good ROM. They have just recruited 5 more patients and trial is ongoing. Watch this space for any updates.

PS: Is the quote relevant to this implant now? We’ll let you decide.

A firm handshake that changed the perception of Leprosy #FromTheHistory:

Back around the time India got its independence, Dr. Paul Brand got a call from Dr. Robert Cochrane, the then-principal of Christian Medical College (CMC) in Vellore, Tamil Nadu. Cochrane wanted Brand to join as a teacher. Brand wasn’t too sure at first — he was kind of hesitated, thought about it, and finally said, “Alright, let’s give it a shot for a year.”

Now, Dr. Cochrane was no ordinary guy. He was a well-known dermatologist, especially for his work in leprosy. So, not long after Brand arrived, Cochrane took him on a little field trip — to a leprosy sanatorium near Chennai, about 100 km from Vellore. And that trip? It changed Brand’s life… and ended up transforming the lives of millions of people with leprosy.

Brand wasn’t really into skin diseases — he was more of a “hands guy.” So, he and Cochrane would joke around calling each other the “skin man” and the “bone man.” But their banter led to some serious breakthroughs. During one visit, Brand gave a handshake to a man with leprosy — the man’s hands were badly deformed. Brand asked him to squeeze as hard as he could. And the guy did — so hard that Brand nearly yelled in pain!

That’s when the lightbulb moment happened. Brand realised: the man wasn’t weak… he just couldn’t feel. It wasn’t paralysis — it was loss of sensation, especially pain. Without pain as a warning system, people with leprosy would keep injuring themselves without even realizing it. That insight led to his famous idea — pain, as awful as it feels, is actually a gift. He even wrote a book about it called The Gift of Pain.

Before all this, doctors believed that leprosy caused deformities because of “bad flesh” or flesh-eating bacteria. No one really investigated why the limbs got deformed or how to actually help. But Brand dug in. He researched, experimented, and made huge contributions to hand reconstruction surgery in leprosy patients.

One of his coolest moments? He figured out that the classic “claw hand” in leprosy came from the paralysis of certain hand muscles controlled by the ulnar nerve. He found an old technique by Bunnell (used in war injuries and polio cases) and decided to try it on a young patient named Mr. Krishnamurthy.

Fast-forward a few months and some corrective surgeries later… and boom! One day, Krishnamurthy walked up to Brand, beaming with pride, holding a ball of rice and curry in his hand — something he couldn’t even dream of doing before. It was a small moment, but a giant leap in the world of leprosy treatment.

And to think… all this started with a skeptical visit, a “let’s try it for a year,” and one very, very strong handshake.

Arthroscopic SL lig repair with capsulodesis - #SurgicalPearl:

Want to know a cool way to treat acute and subacute Scapholunate ligament injuries? Know a simple arthroscopic method.

• Prone position, wrist in traction, using standard 3-4, 6R, MCU, and MCR portals. Begin with dry arthroscopy to assess the scapholunate ligament (SLL) tear, remove scar tissue, and prepare the scaphoid/lunate for repair.

• Use K-wires as joysticks to achieve the precise reduction of the scapholunate interval.

• Once aligned, place a 2.2-mm Micro Corkscrew anchor at the dorsal edge of the scaphoid or lunate via the 3-4 portal. Pass sutures through the SLL using a SutureLasso, retrieve them, and secure them with a sliding knot. A second anchor may be added for extra reinforcement.

• For dorsal capsular reinforcement, thread a nylon suture through the dorsal capsule, retrieving it via the MCR portal. Shuttle it with sutures from anchor, Knot the sutures securely to reinforce the scapholunate interval while ensuring no tendon impingement.

• Final check under arthroscopy to confirm stability and capsular reinforcement. If everything looks good, insert a 1.5-mm K-wire for temporary stabilization and close the portals.

Check the article with beautiful illustrations and original video technique here.

“To Cast or Not to Cast?” – The Wrist Dilemma Gets a Shake-Up!

Ever hurt your wrist, got X-rays, and were told, “It might be a scaphoid fracture, so let’s cast it… just in case”? This study from the Netherlands says — hold up! They looked at 180 adults with wrist pain and totally normal X-rays (the usual “maybe scaphoid” crowd) and split them into two groups: one got the usual 2-week cast, and the other just got a chill 3-day bandage.

What happened? Three months later, both groups had pretty much the same wrist function (measured by QDASH scores). No big differences in pain, grip, or long-term problems. Even better, only 9% actually had a real fracture — and zero nonunions! Bonus points: the bandage group had better wrist movement at 2 weeks and liked their treatment more.

So here’s the twist — if the X-ray is clean, we might be overdoing it with the casts. A bandage and a 2-week recheck might just do the trick. Less fuss, more flex.

Takeaway: Skip the unnecessary cast, save the hassle, and let your wrist breathe — as long as there’s a solid follow-up plan.

Make the releases even more precise #MostCited:

Trigger finger is a common hand condition that can be treated with percutaneous pulley release. Garcia et al. upon analysis 8 RCTs with 555 patients found that ultrasound-guided release significantly reduced postoperative DASH scores, shortened time to resume activities, hastened discontinuation of oral analgesics, and improved patient satisfaction scores. However, there were no significant differences in VAS scores, time to movement recovery, or surgical success rate.

Events to check out:

• Minnesota Anatomic Complex Knee International Symposium (MACKIS) - 28 to 30 May 2025, Eagan, USA

• 10^th Stockholm Arthroscopy and Rehabilitation Conference - 16 to 17 Oct 2025, Stockholm, Sweden

• 18^th ICRS World Congress - 11 to 14 October 2025, Boston, USA

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Answer for the previous month question:

Which surgery has low reoperation rate and less complications for patients with glenohumeral osteoarthritis and intact cuff?

A. Total Shoulder Replacement

B. Reverse Shoulder Replacement

Answer: Reverse Shoulder Replacement - according to a meta-analysis of 14 studies by Daher et al.

Question of the month:

Among the following treatments, which is better for conservative maangement of carpal tunnel syndrom?

• Corticosteroid injection

• Wrist splint

• Placebo injection

• All are similar in efficacy

Watch this space next month for the answer!

Have a Merry May guys!

Screw the cuff please… #NeoArmory:

How would a trauma surgeon fix the cuff? They’ll nail it! (ta da). Just kidding... They’ll fix the cuff… with plate… and screw. Nope, not joking this time.

Inovedis, a Minnesota based company have an interesting device that was may be ideated by a trauma surgeon who said ‘Let’s plate the cuff’ (pun intended… ha..haa). SINEFIX is a PEEK based implant designed to be used in rotator cuff ruptures. It has a plate and 2 anchors to hold the cuff tendon in place.

It is supposed to simplify the repair process, minimize post op gap formation and loosening while ensuring blood flow and facilitate healing. This Poster shows, in cadaveric animal testing, Sinefix has higher pull out strength than double row cuff repair. Recently, first patients have had this implanted and watch this space for any updates on those results.

The Surgeon, The Dentist and The Shoulder – That made history! #FromTheHistory:

Back in the early days of germ theory and antisepsis, there was this guy, Jules Pedoux from Paris. He had tuberculosis in his shoulder joint, which led to a nasty abscess. His doctor suggested the usual radical treatment at the time—amputating the whole shoulder! But Pedoux wasn’t on board with that plan.

So, he turned to a surgeon named Jules Émile Péan, who had a wild idea: “What if we just remove the dead, infected part of the bone and replace it with a metal prosthesis?” Sounds futuristic, right? To make this happen, he teamed up with his dentist friend, J. Porter Michaels, to design the prosthesis.

Michaels, being a true craftsman (think Celebrimbor forging the master rings), created the shoulder prosthesis using Vulcanite and Platinum—materials commonly used for dentures since they didn’t rust or irritate tissues. He made it so precise that Pedoux could move his shoulder like normal!

Fast forward to March 11, 1893—Péan went ahead with the first-ever attempt at shoulder arthroplasty! He removed the infected tissue and the humeral head, then implanted the prosthesis. And guess what? It worked! Pedoux even went back to work as a waiter, smoothly opening wine bottles and pouring drinks like nothing ever happened!

Sadly, things took a turn when he developed an infection with multiple sinuses, and the prosthesis had to be removed in 1895. But still, this was a groundbreaking moment in surgical history—Péan’s bold innovation paved the way for modern joint arthroplasty in the early and mid-20th century. And icing on cake, the original prosthesis used by Péan is still up as an exhibit in Smithsonian Museum!

Crazy, right? Who knew a dentist and a surgeon would kickstart the future of joint replacements!

A Three-Step Approach to Brachial Plexus Decompression – #SurgicalPearl:

Neurogenic Thoracic Outlet Syndrome (nTOS) is a pain to diagnose and treat. When the patients don’t respond to conservative treatment, we don’t have a lot of options to try. Arthroscopic decompression of the Brachial Plexus is one surgical option to try

1. Patient Selection – No Shortcuts Here

• Only neurogenic TOS cases qualify. If there’s a cervical rib or vascular involvement, let the thoracic surgeons handle it.

• Start with six months of physio. If symptoms persist or worsen, bring out the scope.

2. The Patient is in a beach chair position, arm in mild traction, and arm in slight flexion/abduction. Anterior, anterolateral, lateral, medial, and trans-trapezial posterior portals are made.

3. Suprascapular Nerve Release – Unlock the First Gate

• Follow the anterior border of the Supraspinatus - Identify the conoid ligament (your lighthouse for the day). Use the outside-in technique to approach the suprascapular notch. Transverse scapular ligament (TSL) = target. Snip it, but watch out for the suprascapular artery hovering above.

4. Step 2: Pectoralis Minor Release – Free the Infraclavicular Space

• Find the coracoid and conjoint tendon. Use radiofrequency ablation to cut the pectoral fascia and release the pectoralis minor. Watch for the musculocutaneous nerve sneaking around.

5. Step 3: Brachial Plexus Release – The Grand Finale

• Locate the costoclavicular space and subclavius muscle. Use RF cautery to clear out fibrous bands strangling the brachial plexus. Be extra cautious with lateral and posterior cords—don’t fry them!

6. Be Ready to Convert - If you hit complications (severe bleeding, nerve injury), switch to open surgery immediately.

#Firstfewcases? Go slow, stay sharp, and have a backup plan. Check out the article and video here.

Active Seniors with Shoulder Fractures - RSA vs Conservative management: #InTrials:

Miquel et al explored whether reverse shoulder arthroplasty (RSA) offers better outcomes than non-surgical treatment for active people over 70 with 3 and 4 part proximal humerus fractures. Eighty-one patients were split into two groups: 41 underwent RSA, while 40 were treated conservatively. After one year, those who had RSA showed noticeably better shoulder function, scoring higher on the Constant-Murley scale (61.2 vs. 52.4). While there were a few complications in the surgical group, including one revision surgery, the overall benefits in mobility and function were clear. The non-surgical group had fewer risks but didn’t recover as much shoulder movement. Overall, RSA stands out as a solid, effective option for older adults who want to stay active —especially when returning to independence is a top priority.

Let’s button up the Latarjet! #MostCited:

Hali et al looked at how two different fixation methods for Latarjet procedure —traditional screws (SF) and newer suture buttons (SB). After analyzing 11 studies with over 1,100 patients, the results were pretty clear: both options work well when it comes to restoring shoulder function, motion, and reducing pain. However, suture buttons had a few perks. They showed fewer complications, especially hardware-related issues, and significantly less bone resorption over time. In terms of strength, both techniques were on par in biomechanical testing. While one study noted a slightly higher rate of redislocation with suture buttons, this didn’t lead to more surgeries. Overall, SB seems like a solid, low-hassle alternative to screws—offering the same stability with potentially fewer problems down the road.

Events to check out

• 9^th Basel Elbow Course 07 – 09 May 2025 - Basel, Switzerland

• 42nd Annual San Diego Course: Arthroplasty, Arthoscopy and Fractures 11 – 13 June 2025 - Coronado, USA

• ISHA 2025 Annual Scientific Meeting 02 – 04 Oct 2025 - Fukuoka, Japan

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Answer for the last month question:

What is the best treatment method for syndesmotic ankle injuries?

• Dynamic fixation

• Static screw fixation

• fibular nails

• Any of the above

According to a meta-analysis by Cho et al comparing 19 studies dynamic fixation seems to be the superior method of fixation of syndesmosis.

Question of the month:

Which surgery has low reoperation rate and less complications for patients with glenohumeral osteoarthritis and intact cuff?

A. Total Shoulder Replacement

B. Reverse Shoulder Replacement

Wait for our next issue to get an evidence based answer!

Have an amazing April guys.

Navigation? Check!

Navigation, as a technology, was a logical step in the evolution of joint arthroplasty. Although it is more than a decade old in knees, it paved the way for the current generation of Robotics.

Although the current generation of Ankle arthroplasty implants has improved survivorship, the management of deformities plays a key role in longevity. One important factor is the placement of cuts and Exatech have achieved the next logical step in evolution.

GPS Ankle (DOGE has taken off the creativity fund I suppose)

‘GPS ankle’ touted as the world’s first Navigation system for ankle arthroplasty, the system allows everything you expect from a standard Navigation. Resection height, angle, intra-op implant size planning and pre- and post-op joint Kinematics measurement.

Preclinical studies (bench testing and sawbones) show accuracy close to 2mm and 2 degrees relative to the surgical plan. However, we haven’t been able to verify this claim as the quoted papers are not to be found. There is no literature yet to suggest Navigation is superior but steps like these will enable us to move on to Robotics next.

But is Robotic joint replacement any better? We let you decide.

Be not only a good Clinician but also a great showman!

Charcot’s foot—named after the French surgeon Jean-Martin Charcot—is probably one of his most famous discoveries. Back in the day, he was working at the Salpêtrière hospital in Paris, which mainly treated the poor. As a neurologist and rheumatologist, he was the first to describe joint problems linked to Tabes dorsalis (a complication of neurosyphilis), which was then called progressive locomotor ataxia. But like many doctors of his time, he believed most neurological disorders were hereditary—after all, germ theory was still in its early days!

Most surgeons just assumed that the changes in the feet of ataxic patients were caused by ataxia itself. But he was a sharp clinician and noticed what others had missed – the bone and joint changes started before the well-known motor incoordination and locomotor ataxia. He described how the heads of bones wore down, ligaments became extremely loose, and subluxations were common. He even pointed out that while sensations like touch, pressure and temperature were reduced but not completely abolished! Now think how keen observational skills were!

Charcot wasn’t just a brilliant doctor; he was also a bit of a showman. His medical demonstrations were legendary, drawing crowds that included not only students and doctors but also regular folks just curious to see the spectacle.

One of his most famous "performances" took place in 1881 at the 7th International Medical Congress in London. Picture this: a room full of medical legends like Joseph Lister, Louis Pasteur, Robert Koch, and Rudolf Virchow, all watching as Charcot put on a show. He even brought a life-size wax model of a 60-year-old woman named Berthelot—complete with her entire skeleton who had Charcot’s foot! He showcased her disease progress with various clinical photographs as well. His presentation was so detailed and visually impressive that it was the 19th-century version of a multimedia experience. Sir James Paget, another big name in medicine, was so impressed that he declared, "This … a distinct pathological entity, deserves the name by which it will be known—Charcot’s disease."

Pretty cool, right? Charcot was more than just a doctor—he was a pioneer who knew how to make science interesting!

TENDINS-A – Hot Tool in the box that’s worth a try !!

Achilles tendinopathy is a common condition in foot and ankle clinics, however, no specific patient-reported outcome measures (PROMs) are commonly used in clinical practice. This may be due to the concern that the existing PROMs such as Foot and Ankle Outcome Score (FAOS) or Victorian Institute of Sport Assessment–Achilles (VISA-A) have insufficient content and structural validity specific to the condition. However, the new Tendinopathy Severity Assessment –Achilles (TENDINS-A) appears to have sufficient content validity, construct validity, and test-retest reliability.

The TENDINS-A was co-designed by people with Achilles tendinopathy, expert clinicians, and researchers to evaluate the level of disability that results from the condition. The TENDINS-A consists of 13 questions that address the subdomains of disability—Pain, Symptoms, and Function—yielding a total score out of 100, whereby a higher score indicates a higher level of disability. It is available for free.

Simple ways to manage your OCDs - #SurgicalPearl

Check out this simple technique of Torres et al. to manage talar OCDs

1. The patient is put prone, with the ankle hanging freely over the table edge.

2. Standard posterior endoscopic portals (van Dijk technique) are used, with an extra posterolateral portal (1 cm proximal).

3. A 3.5-mm shaver clears fatty tissue and the subtalar joint capsule, exposing the flexor hallucis longus tendon.

4. A 1.2-mm K-wire is inserted through the posterolateral talus under fluoroscopy. It’s over-reamed with an 8-mm cannulated reamer, avoiding cartilage damage.

5. The arthroscope enters the tunnel to visualize necrotic bone. The lesion is cleaned with a curette, spoon, or mini-shaver, keeping the cartilage intact.

6. Bone Graft Harvesting: A cylindrical cancellous bone graft is taken from the distal tibia via the posteromedial portal using a trephine.

7. Bone Graft Placement: The bone plug is inserted through the posterolateral portal into the talar defect and tapped press-fit under the chondral layer.

Simple. Clean. Effective. 💡

Check out the video of the technique here.

Should you walk on your operated ankle sooner?

Ankle fractures are pretty common, and the usual advice after surgery is to avoid putting weight on the leg for about six weeks. But what if patients could start walking earlier—say, just two weeks after surgery? Would it be safe, and could it even help recovery?

The WAX Trial, a randomized controlled study across 23 hospitals in the UK, tested this by comparing early (2 weeks) vs. delayed (6 weeks) weight-bearing in 561 patients who had any surgery for unstable ankle fractures other than nailing. The goal was to see if early weight-bearing was at least as good as (non-inferior to) the standard delayed approach.

After 4 months, patients who started walking earlier had slightly better ankle function scores (OMAS: 65.9 vs. 61.2), though the difference was small. Complication rates were similar (16% early vs. 14% delayed). Plus, early weight-bearing was more cost-effective, saving money for both patients and the healthcare system.

Bottom line? Walking sooner doesn’t cause more harm, might help recovery a bit, and is likely the better option overall. This study gives surgeons the confidence to tell patients: “You don’t have to wait—start walking!” 🚶‍♂️💪

Answer to the last month question:

Which nerve block provides effective pain control after TKA?

• Continuous adductor canal block

• Genicular nerve block

• Infiltration between the popliteal artery and capsule

• A combination of these

A combination of continuous adductor canal block with either genicular nerve block or Infiltration between popliteal artery and capsule is better in TKA pain management according to a network meta-analysis by Wang et al. including 30 studies

Events to check out:

• 42nd Annual San Diego Course: Arthroplasty, Arthroscopy and Fractures 11 – 13 June 2025, Coronado, USA

• Minnesota Anatomic Complex Knee International Symposium (MACKIS) 28-30 May 2025, Eagan, USA

• Knee 360⁰ 12 – 13 July 2025 Lima, Peru

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  Question of the month:

  What is the best treatment method for syndesmotic ankle injuries?

• Dynamic fixation

• Static screw fixation

• fibular nails

• Any of the above

Wait for our next issue to know the correct answer.

Have a marvellous March guys.

Redefining the Script: #NeoArmory

Remember when Avengers: Endgame pulled off the ultimate plot twist with the time heist? They didn’t follow the old rules but rewrote them entirely to achieve something bigger. That’s exactly what hit us in today’s Neo-Armory section.

Enter Medacta’s GMK SpheriKA, their groundbreaking take on knee arthroplasty. Like the Avengers’ daring plan to change the past for a better future, the SpheriKA flips the script on traditional knee replacements with its bold kinematic alignment design.

The GMK SpheriKA System

This implant isn’t just an upgrade; it’s a whole new approach.

• Medial ball-in-socket stability offers rock-solid support while allowing the lateral compartment to move freely, mimicking natural knee motion.

• The funnel-shaped trochlear groove adjusts to various Q-angles, improving patella tracking and minimizing alignment issues.

• Designed for Kinematic Alignment (KA), it respects the knee’s unique anatomy instead of forcing it into a generic mechanical alignment.

Performance Check:

Early research shows that KA-based systems like SpheriKA have improved functional outcomes, delivering smoother, more natural movement for patients. The Neo-Armory debate is on: Is the GMK SpheriKA a “heroic move” to redefine knee arthroplasty or just a bold gamble with the status quo? You decide—are we looking at the Endgame of outdated alignment techniques?

Going against the Tide: Meniscus repair #FromTheHistory:

Did you know that for thousands of years—basically from Hippocrates in the 5th century BC up until the 19th century, more than a couple millennia — surgeons believed in sticking to conservative treatment for meniscal tears?

Then came along Sir Thomas Annandale, a Scottish surgeon who changed the game in 1883. Back in those days, they used to call the meniscus the "semilunar cartilage" (sounds fancier, right?). Fun fact: Annandale was already helping his dad in surgeries at the age of 15—impressive, right? Later, he worked with James Syme until 1870 and eventually became a Professor in Edinburgh.

Now let’s talk about the real breakthrough. A 30-year-old miner from North England showed up with sharp knee pain and a joint that would lock up whenever he bent it. Annandale, being the innovator he was, decided to go against the grain. Instead of the usual non-surgical treatment, he tried something revolutionary—repairing the torn "internal semilunar cartilage". He performed an open repair of the torn meniscus with 3 chromic catgut stitches. After immobilizing the knee for seven weeks, the patient fully recovered within six months. Amazing, right? He published this in 1885 explaining the whole operation.

This bold move by Annandale laid the foundation for modern meniscus repair techniques. Thanks to him, repairing meniscus tears is now the gold standard in treatment.

Best of both worlds - The NAIL PLATE construct #SurgicalPearl:

Are you worried about osteoporosis, metaphyseal comminution and obesity when you fix distal femur fractures? - It seems there is a single solution to address all three issues - the nail-plate construct (NPC) combining the retrograde intramedullary nail (rIMN) and locking compression plate (LCP). Both biomechanical and clinical evidence are coming up to support this.

Surgical Technique

1. The affected lower extremity and hip region are freely draped, with the knee placed over a sterile bolster at ~30° flexion.

2. A 3 cm midline incision is made from the inferior pole of the patella to the tibial tubercle.

3. The entry point for the guide wire is confirmed using fluoroscopy. A proximal entry reamer with a retrograde protection sleeve is used, and a long femoral guide wire is inserted.

4. The appropriate length of the retrograde nail is selected to reach the lesser trochanter level for optimal support and splinting.

5. An undersized retrograde nail is inserted into the femoral canal after canal preparation.

6. A separate direct lateral approach is performed to visualize the fracture site if the fracture seems still displaced after nail insertion. Otherwise, a plate of appropriate length is slid through the MIPO technique.

7. The plate’s provisional position is confirmed with fluoroscopy and fixed with K wires

8. The condylar screw (compression bolt) of the retrograde nail is inserted first using the “perfect circle” technique under fluoroscopy, linking the retrograde intramedullary nail (rIMN) and lateral plate. If this is not possible, a condylar screw is inserted and buried into the metaphysis and the plate is placed over it

10. Separate distal interlocking screws are inserted for the rIMN, along with multiple distal locking screws for the lateral plate. Proximal screw holes of the lateral plate are filled with unicortical screws.

11. The rIMN is secured proximally with an anteroposterior screw at the level of the lesser trochanter.

Injectable Blood-Based Biologics for Knee OA: Here’s the Tea 🍵

The ESSKA-ORBIT Group has dropped their verdict on PRP for knee osteoarthritis (OA), cutting through the noise with expert-backed consensus. PRP has legit benefits for knee OA but comes with some dos and don’ts. Let’s break it down:

The Green Flags: PRP’s Winning Moments ✅

• Does it work for knee OA? YES! Clinical evidence supports PRP’s use.

• Severe OA (KL-4)? PRP can still help!

• Patellofemoral OA (PFOA)? PRP is in.

• Post-effusion aspiration inflammatory phase? PRP works here too.

• Repeat treatments? If PRP worked before and symptoms reappear, go for it again.

• Better than hyaluronic acid? Yep. PRP takes the crown. 👑

• Better than corticosteroids? Another yes—PRP has clear advantages.

The Red Flags: No-Go Zones for PRP 🚫

• Asymptomatic early OA? Nope, no rationale for PRP here.

• Disease-modifying effects? Sorry, PRP isn’t magic—it won’t reverse OA.

• NSAIDs, local anesthetics, antibiotics around PRP? Hard no on all three.

• Other injectables like autologous conditioned serum or alpha-2-macroglobulin? There is not enough evidence to support these yet.

The Extras: FYI About PRP 📝

• Best for KL 1-3 OA.

• Contraindications? Infection or cancer.

• Leukocyte-rich or poor PRP? Either works.

• Dosage? 2-4 injections, spaced 1-3 weeks apart.

• Post-steroid timing? Wait at least 6 weeks.

• Patient prep? No high-fat foods or alcohol for 48 hours prior.

PRP is a strong player in knee OA treatment, but knowing when (and how) to use it makes all the difference. Play by the rules for the best results! 💉🦵✨

Another alignment debate #InTrials:

A recent study by Max et al. compared two different techniques for total knee replacement—restricted kinematic alignment (rKA) and mechanical alignment (MA)—using a medial pivot (MP) prosthesis. The results? rKA came out on top, especially for patients with varus knee alignment (where the knees bow slightly inward).

The study, which followed 98 patients with severe knee arthritis for up to two years, found that those who had rKA were more satisfied and had better knee function compared to those who had the traditional MA approach. Scores measuring knee function and how “natural” the knee felt (like the Forgotten Joint Score and Knee Society Score) were significantly better with rKA.

Bottom line? rKA with an MP prosthesis seems to be a game-changer for knee replacements, especially for varus knees. It could mean happier patients, better function, and a quicker return to normal life.

Events to check out:

• 4^th Annual Meeting SIAGASCOT 27^th March 2025 Naples, Italy

• MIKS 2025 – International Congress on Biological Therapies 3-5 April 2025 Vitoria Gasteiz, Spain

• 22nd ESSKA Congress 20 – 22 May 2025 Prague, Czech Republic

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Answer to last month's question:

Which approach to hemiarthroplasty after femoral neck fractures has minimal complications?

• Posterior approach

• Direct anterior approach

• Direct lateral approach

• Anterolateral approach

There is no clinical difference in any of these approaches according to a network meta-analysis by Gusho et al.

Question of the month:

Which nerve block provides effective pain control after TKA?

• Continuous adductor canal block

• Genicular nerve block

• Infiltration between the popliteal artery and capsule

• A combination of these

Wait till our next issue for the answer.

Have a fabulous February folks.

What if…? #NeoArmory:

‘What if’ breaks the Marvel’s mould of superheroes and does a 180 in the storyline, the best one being T’challa’s Quill. Was he any better? That's for you to decide. (We won’t bias your idea) That’s exactly how we felt at today’s Neo-armory section.

Hip Innovation technology, a Georgia (the US one) based venture, has done a ‘what if’ episode. We introduce to you, the brainchild of Dr Termanini, their take on reinventing THR prosthesis.

The Reverse Hip Replacement System

A Cobalt Chrome ball inside the Acetabular cup which articulates with a poly liner attached to the stem. They claim, this design maintains stability with extended Hip ROM, lowers chance of dislocation, reduces contact stresses and minimizes edge loading.

This study shows excellent PROMs data in a 2 year follow up period in 23 patients. We, at the Brewery, are still debating on where to file this? ‘Lesson learnt’ or ‘historical milestone’. What do you think?

Did we steal one of their machine tools? #FromTheHistory:

Did you know that Morse taper that is ubiquitous now in total hip replacement was actually designed to be used in machine tools, that too around a century and a half ago! Stephen A. Morse developed it to join two rotating components reliably in 1864 and got a patent for the same. Morse started a Morse Twist Drill and Machine company in the same year with an investment of $30,000 from the stockholders.

Like all relationships, things didn’t stay smooth for long—Stephen Morse had a fallout with the company board and ended up resigning just four years after starting the company. There’s not much info about what he did after that, but his legacy definitely lived on. The company grew into a giant in machine tool manufacturing, earning international fame.

However, it took a whopping 110 years for Morse’s brilliant idea to find its way into total hip replacements. And that too, only when ceramic heads came into play. Before that, monoblock metal implants were the norm, so there wasn’t even a need for a fancy coupling mechanism like the Morse taper.

One can think then “how did they fix the ceramic head on the stem” before Morse taper was inducted… yeah, they used to do it with glue or screw, the carpenter inside seems to be always at work! Prof. Mittlemeier, in 1974, was the first one to adapt Morse taper which unsurprisingly reduced the fractures of the head. Further developments were done Daniel Blanquaert in association with Ceraver in 1977. Even now, the reliable impacted fit we get between the trunion (male portion) and the bore (female portion) in our total hip prosthesis is the result of one man trying to make using machine tools easier a century and a half ago.

SuperPATH - #SurgicalPearl:

People are now moving from minimally invasive approaches to micro-invasive approaches for THA. SuperPATH is one such approach and is super interesting.

Supercapsular percutaneously assisted total hip (SuperPath) approach is a direct superior portal-assisted approach to total hip arthroplasty (THA) that utilizes the interval between the gluteus minimus and the piriformis to access the hip. The major steps of this procedure:

• The patient is in the standard lateral decubitus position with the involved leg in the“home position,” that is,45° to 60° of flexion, 20° to 30° of internal rotation, and slight adduction elevating the foot on a padded Mayo stand.

• Exposure - Incision is from the tip of the GT 6 to 8 cm proximally in line with the femur in the home position, the gluteus maximus muscle is split by blunt dissection in line with the fibres, and the gluteus medius and minimus are retracted anteriorly, and the piriformis tendon is retracted posteriorly to access to the capsule.

• Capsule is incised along the path of the skin incision from the saddle of the femoral neck to 1 cm proximal to the acetabular rim.

• Femoral preparation - A channel is created in the superior aspect of the femoral neck from the femoral canal to the centre of the femoral head, using reamers, a round osteotome, and a curet.

• Femoral broaching - Sequential femoral broaches are then used to complete the preparation and size of the proximal femoral canal while the head and neck remain intact.

• Neck resection - The femoral neck osteotomy is performed level with the broach neck, and Schanz pins are used to rupture the ligamentum teres and remove the femoral head.

• Acetabular preparation and placement - Acetabular preparation and cup impaction are done through a portal without needing the release of the iliotibial band or remaining external rotators.

• Trial reduction - Trial reduction is completed using a bone hook and a T-handle to gently manipulate the femur.

• Final implant assembly - Liner impaction is completed through the portal, and the remaining components are implanted.

Difficulty in following the technique? Check out the video here.

The Holy Grail for hip surgeries? #MostCited:

Spinal anaesthesia is a concern in elderly with multiple comorbidities. It is not always risk free. Sacral erector spinae plane block is now potentially considered as an alternative to conventional anaesthetic approaches in frail individuals with significant cardiovascular and respiratory comorbidity in procedures such as intramedullary nailing for proximal femoral fractures. A unilateral injection of local anaesthetic at the intermediate crest of the second sacral vertebra resulted in bilateral sensory block of the T12 to S2 dermatomes. The technique did not result in hypotension or motor block of the limbs, and the surgery was completed uneventfully.

Though this technique warrants further investigation to be considered as an alternative to spinal and general anaesthesia for hip and lower limb surgery, it now the hot cake over the table on New Year for the frail individuals sustaining hip fractures.

Shoulder I change my approach? - #InTrials:

A study by Roberts et al. compared the Direct Anterior Approach (DAA) and Mini-Posterior Approach (MPA) for total hip replacements, and the results are pretty much neck and neck. Early on, DAA showed slightly quicker recovery, but by a few weeks in, those perks were gone, and both approaches performed about the same. Fast forward 7.5 years, and there’s still no big difference between the two in terms of function, X-rays, or overall quality of life.

The scores for things like hip health (Harris Hip Scores, SF-12, HOOS) were super similar, and none of the numbers hit the “wow, that’s a huge improvement” mark. Complications? DAA had 4, MPA had 6—stuff like dislocations, wound problems, and a couple of rare re-dos.

Bottom line: Both approaches are solid for hip replacements. Surgeons can choose whichever method works best for their vibe and the patient’s needs, knowing the long-term outcomes are basically the same.

Answer to previous month question:

Spinous process osteotomy seems to be the most effective technique according to the meta-analysis by Wu et al.

Question of the month:

Which approach to hemiarthroplasty after femoral neck fractures has minimal complications?

• Posterior approach

• Direct anterior approach

• Direct lateral approach

• Anterolateral approach

Events to check out:

25^th Annual Meeting of Arthroscopy Association of North America (AANA)

8 – 10 May 2025

Washington DC, United States

ISAKOS Congress 2025

8 – 11 June 2025

Munich, Germany

Global Spine Congress 2025

28 – 31 May 2025 Rio-de-janeiro, Brazil

Cheers to a bright and beautiful year ahead guys