Anterior Total hip replacement - A hip replacement surgery with Zero precautions. A hip replacement which can get you back to a completely pain-free life with normal walking. The biggest problem with old techniques of hip replacement are 1. 4 percent patients have high chances of hip dislocation (hip ball coming out & where resurgery is needed to fix). In order to prevent it, patients are adviced multiple precautions & restrictions sometimes for lifetime. 2. The other major problem is unequal length of legs after hip replacement. Leading to permanent abnormal walking & limp. With Anterior total hip replacement both the above issues can be easily managed. With Direct Anterior(surgery from front) Total Hip replacement, patients have the following advantages- 1. Both legs will be completely equal in length- since pt is positioned straight on table & comparison with computerized arm while operating making comparison to the opposite leg easier helping in getting completely equal legs. In other technique like posterior or anterolateral since patient is placed on side, legs end up being unequal since comparison is not possible with opposite leg at all. Even imaging is not possible. 2. Minimal muscle pain due to minimally invasive -mis technique. The entire surgery is performed with an incision of around 10 cms & zero muscle damage. 3. Zero precautions after surgery leading to stress free life. . Patients can sit on floor/use Indian Toilets without worrying about chances of hip dislocation. In older techniques patients are told to follow precautions for atleast 3 months & sometimes even lifetime. 4. No restriction in Sexual activities. 5. Patients have quick recovery due to less pain & can even walk without walker with full weight bearing within 1-2 days. With older techniques, patients still have to use walker or wait upto 1.5 months to put weight & walk. 6. A small 10 cm line incision which gets hidden in groin crease & becomes just like a thin pencil mark in 2-3 months. With Direct Anterior Total Hip replacement, pts can even get Both total hip replacements performed in a single sitting. Even the choice of implants cemented or uncemented & can be dual mobility, ceramic on ceramic , ceramic on poly or metal on poly as per patients preference. Anterolateral & Posterior hip replacement - Both are older techniques of total hip replacements where patients are adviced multiple precautions after surgery. Older techniques posterior/anterolateral (incision of surgery from back- posterior & surgery from side - anterolateral) total hip replacements have limitations such as patients are adviced not to sit on floor or do any activity on ground because of risk of hip ball dislocation & even where patients end up having unequal leg lengths after surgery. Multiple research papers have proven Direct Anterior Hip replacement has significant advantages. In The US, Hip replacement by Direct Anterior technique is preferred by most of the patients due to its significant advantages. Though Direct Anterior Hip replacement technique has excellent advantages, it can be performed in obese patients with weight more than 130 kgs only after proper assessment. We regularly have patients visiting from various parts of the country for Total Hip replacement with Direct Anterior Technique be it cases of hip avn, ankylosing spondylitis or post traumatic hip failure. We have numerous patients from all over the country visiting our centre in Indore & Mumbai who have been suffering from Hip issues & have undergone Total Hip Joint Replacement by Direct Anterior technique. For your benefit, please see the explanation & results regarding anterior hip replacement on our YouTube page- TheJointSurgeon https://youtube.com/@TJSJoints https://youtu.be/mC-Sd52dxsw https://youtu.be/jAKbalLIL4A https://youtu.be/Y3cyQRl5v_U If you are suffering from hip joint issues & need a hip replacement, Anterior Total Hip replacement is the best technique for you to be pain free & walk completely normally. We can help you. For more details or appointment please feel free to contact us. +91 7760547341

A standard total shoulder replacement depends upon muscles and tendons around the shoulder joint to be intact. These muscles and their tendons function to move the shoulder and are together called the rotator cuff. When these tendons become extensively torn so that they do not attach to the bone any longer, the shoulder often does not function normally. The loss of the rotator cuff can produce pain and also loss of motion. A normal shoulder replacement is designed to work only if those tendons are intact. Reverse Shoulder Replacement (Arthroplasty) has emerged as a very attractive alternative for patients with cuff-tear arthropathy, selected proximal humerus fractures and nonunions. Its indications continue to expand, especially for revision surgery. REVERSE SHOULDER ARTHOPLASTY Reverse shoulder arthroplasty is an attractive option in patients. Since this kind of shoulder replacement does not rely on the function of the rotator cuff, it provides predictable results in terms of pain relief and shoulder function in one operation. The results of reverse shoulder replacement are fairly predictable and good especially in patients suffering from chronic shoulder joint problems since the function of the joint is less dependent on healing of the tuberosities. The main reason to consider a reverse prosthesis is when there is arthritis of the shoulder joint and the rotator cuff tendons are torn or gone. This is the most common surgical indication for a patient considering a reverse prosthesis. In this situation this operation will give the patient significant pain relief and may also help with range of motion of the shoulder. Another reason to have a reverse prosthesis is if the rotator cuff tendons are all torn and one cannot lift the arm high enough to function. Typically in this case the shoulder is not painful but the inability to lift the arm is very disrupting to the ability to function in life. When the patient goes to lift the arm there is a prominence on the front of the shoulder, and this is called an anterior-superior migration or subluxation of the shoulder. In these cases pain may or may not be a major factor for the reverse prosthesis, but the main reason for the replacement is to regain motion and function. The third most common reason to have a reverse prosthesis is if the shoulder has already had a replacement prior to the time a reverse prosthesis was available and the patient still has pain and loss of motion. Sometimes the regular shoulder replacement was placed for a fracture or for torn rotator cuff tendons and the shoulder continues to be painful. In this case, if a reverse prosthesis is needed, the surgery to place a reverse prosthesis is a little more complicated. The reason for this is that the first, more traditional shoulder replacement has to be removed at the time of surgery, and the reverse can then be placed in the shoulder. Other reasons to have a reverse prosthesis are some fractures of the shoulder area, particularly ones that involve the proximal humerus (arm bone) where the ball attaches to the shaft of the bone. In some instances, the bone is broken into many pieces or the ball may be split into parts. The last reason to have a reverse prosthesis is because of a tumor in the proximal humerus that involves the bone of the shaft of the bone or the ball of the humerus itself PRE-OPERATIVE STEPS Every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure. 1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed in elderly patients. 2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since shoulder arthroscopy is an elective procedure. If any risk is involved, the patient/ attendants will be informed so. 3. Blood transfusion though rarely required, may be done depending on the reports. 4. X-rays and MRI will be done ideally in order to guide the surgical plan and the prognosis. 5. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. INTRA-OPERATIVE STEPS 1. The patient is positioned in a beach chair position. 2. For this procedure the deltopectoral approach is normally used. 3. It is crucial to evaluate the fracture. The fracture lines are identified as well as the long head of the biceps and the condition of the rotator cuff. 5. The biceps tendon is temporarily attached to the superior border of the pectoralis muscle. A tenotomy of the long head of the bicipital tendon close to the rotator interval is performed. 6. The glenohumeral joint is opened through the fracture. 7. Preparation of the joint for placement of prosthesis is performed. 8. A complete soft-tissue release around the glenoid is performed. 9. The guide plate is placed on to the glenoid surface so that it is flush with the circle of the lower glenoid . The guide plate is fixed with a central K-wire. 10.A cannulated glenoid resurfacing reamer is used to remove the cartilage and to create a smooth surface of the glenoid to provide full contact with the base plate. 11.The glenosphere is implanted. A trial glenosphere may be used instead of the definitive one. 12. The intramedullary canal is prepared with reamers of increasing diameters. 13. The humeral trial prosthesis is inserted as determined by the size of the last reamer. 14. Reduce the prosthesis and confirm proper joint tension and stability. Do not overtension the deltoid muscle. Check if there is any unwanted impingement. 14. After hardening of the cement, reduce the prosthesis. Confirm correct soft-tissue tension and stability. POST OPERATIVE PHASE Care after surgery: • Wear your sling or brace at all times for as long as directed. This helps to remind you not to use the arm. It also allows your shoulder to heal and decreases pain. • Apply ice on your shoulder for 15 to 20 minutes every hour or as directed. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a towel. Ice helps prevent tissue damage and decreases swelling and pain. • Place a small pillow or towel behind your elbow when you lie on your back. This keeps your shoulder in proper position. You may need to sleep in an upright position if you cannot sleep on your back. Place 2 to 3 pillows lengthwise behind your back when in bed. Make sure the pillows do not move your shoulder forward. Instead, you can sleep in a reclining chair. • Avoid moving your shoulder. Do not stretch or shrug your shoulder. Do not do exercises on your own until your healthcare provider says it is okay. • Do not lift with your hand on your surgery side. You put pressure on your shoulder muscles when you lift. • Do not lean on the hand of your surgery side. Pressure will cause pain and may cause damage to your shoulder. • Do not drive until your healthcare provider says it is okay. Shoulder bandage care: Keep your dressing clean and dry. Your healthcare provider will tell you when it is okay to take a bath or shower. Once you are able, let soap and water run over your surgery area. Do not scrub the area. Pat the area dry and put on a clean bandage as directed. Pain Management • Some amount of pain is expected after the surgical procedure. • Ice packs can be used for pain reduction • Paracetamol or Nsaids can be considered for pain management especially during the first four weeks. Shoulder rehabilitation protocol The shoulder is perhaps the most challenging joint to rehabilitate both postoperatively and after conservative treatment. Early passive motion according to pain tolerance can usually be started after the first postoperative day. The program of rehabilitation has to be adjusted to the ability and expectations of the patient and the quality and stability of the repair. The full exercise program progresses to protected active and then self-assisted exercises. The stretching and strengthening phases follow. The ultimate goal is to regain strength and full function. Activities of daily living (ADL) can generally be resumed while avoiding certain stresses on the shoulder. Mild pain and some restriction of movement should not interfere with this. The more severe the initial displacement of a fracture, and the older the patient, the greater will be the likelihood of some residual loss of motion. Generally, shoulder rehabilitation protocols can be divided into three phases. Gentle range of motion can often begin early without stressing fixation or soft-tissue repair. Gentle assisted motion can frequently begin within a few weeks, the exact time and restriction depends on the injury and the patient. Resistance exercises to build strength and endurance should be delayed until bone and soft-tissue healing is secure. This may need to be adjusted for each patient. Phase 1 (approximately first 6 weeks) Bandage • Immobilization on a shoulder abduction pillow in neutral position of rotation Range of motion • Passive motion within the pain free interval for abduction, adduction and flexion • No internal or external rotation • Shoulder joint motion up to 90° • ADL for eating and writing allowed Physiotherapy • Passive motion up to 90° • Relaxation/stretching of neck muscles • Training of elbow and hand functions • Specific stabilization therapy for the shoulder joint • Isometric exercises in all directions • CPM up to 90° of abduction Massage • Neck • Shoulder girdle • Thoracic spine Training therapy • Training of the contralateral arm (overflow cardiovascular training) Phase 2 (approximately week 7-11) Bandage • No longer required Range of motion • Assisted/active motion within the pain free interval, also beyond 90° • Careful rotation Physiotherapy • Free motion of shoulder girdle (scapula, clavicle, cervicothoracic junction, cervical and thoracic spine) with specific mobilization • Strengthening exercises especially for ADL • Eccentric muscle activity Massage • As required Ice/warmth • As required Training therapy • Mobilization bath, wound permitting • Training of hand and forearm muscles • Set for shoulder therapy Phase 3 (after week 11) Range of motion • No restrictions on Shoulder movement • Muscle growth for shoulder girdle and all arm muscles Physiotherapy • All physiotherapeutic techniques allowed, active and against resistance • Increasing eccentric muscle activity Training therapy • Handcycling • Training for specific ADL and sports • Machine training • Free weight training

INTRODUCTION A revision knee replacement surgery is a procedure that is performed to replace a knee implant that is no longer functioning properly. Most knee replacements last several decades, some longer. However, there are also times when a knee replacement needs to be redone after years or even just months. Understanding why a knee replacement has worn out is critical to performing a successful revision knee replacement. The average knee replacement lasts more than two decades, and there are reports of implants lasting longer, and new materials and surgical techniques are hoped to provide even longer-lasting knee replacements. That said, there are times when knee replacements may last a very short time, even in otherwise healthy patients. A small percentage of patients (around 1-2%) end up requiring a knee replacement revised within a few years of their initial surgery. Revision replacements are performed for a number of reasons. Some of the more common include: Loosening of the implant Infection of the joint Instability of the knee Malalignment of the components Many people ultimately have a revision knee replacement because the problem is causing significant pain. While pain can be a problem in itself, a revision knee replacement surgery should not be performed without understanding why the pain is occurring. Performing this type of surgery for pain without an identified cause is unlikely to yield good results. Instead, the cause of the problem with the knee replacement needs to be precisely understood, and there needs to be a plan to address that problem with the implant. An operation without a clear plan to address the problem is unlikely to be helpful. Complexity in revision surgeries Revision replacement is difficult for several reasons. First, when someone has had surgery, scar tissue develops, and soft tissues become less identifiable. Performing the second surgery is always more difficult. Second, when performing a knee replacement, bone is removed. When performing a revision knee, often more bone has to be removed, and some may be lost as a result of the problem with the implant. Maintaining adequate bone to support the new implant can be a challenge. Finally, obtaining a knee that is flexible enough to allow for motion, yet stable enough to keep you steady, is also more difficult in revision situations. PRE-OPERATIVE PHASE Your surgeon will send you for routine blood tests to rule out infection, CT scan to look closer at the anatomy, and bone scans to help to determine if a component is loose. X-rays and/or MRI will be considered. Aspiration of the knee joint is occasionally done to diagnose or rule out infection Patient will be asked to undertake a general medical check-up with a physician Patient should have any other medical, surgical or dental problems attended to prior to the surgery in order to prevent a risk of infection. Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding. Any antiplatelet drugs / blood thinners such as clopidogrel, warfarin will be stopped 3-7 days prior to the date of surgery. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. Blood transfusion, if required will be informed and done. Day of surgery You will meet the nurses and answer some questions for the hospital records You will meet your anesthetist, who will ask you a few questions and assess the risk factors for surgery. You will be given hospital clothes to change into and have a shower prior to surgery The operation site will be shaved and cleaned Approximately 45 minutes prior to surgery, you will be transferred to the operating room After explanation of the procedure, you will be asked to sign the consent for surgery. Occasionally, a high risk consent for surgery may be requested depending on the blood reports and clinical examination. SURGICAL PROCEDURE Each knee is individual and knee replacements take this into account by having different sizes for your knee. If there is more than the usual amount of bone loss, sometimes extra pieces of metal or bone are added. Surgery is performed under sterile conditions in the operating room under spinal or general anesthesia. You will be on your back and a tourniquet will be applied to your upper thigh to reduce blood loss. Surgery takes approximately two hours. The patient is positioned on the operating table and the leg prepped and draped. A tourniquet is applied to the upper thigh and the leg is prepared for the surgery with a sterilizing solution. An incision around 7cm is made to expose the knee joint. Old/ damaged components of the implants are removed. The bone ends of the femur and tibia are prepared using a saw or a burr to freshen the bone. Trial components are then inserted to make sure they fit properly. The real components (Femoral & Tibial) are then put into place with or without cement. The knee is then carefully closed and drains usually inserted, and the knee dressed and bandaged. POST- OPERATIVE MANAGEMENT When you wake up you will be in the recovery room with intravenous drips in your arm, a tube (catheter) in your bladder may be inserted, and a number of other monitors to check your vitals. Once stable, you will be taken to the ward. The postop protocol is surgeon dependent, but in general your drain will come out at 24 hours and you will sit out of bed and start moving your knee and walking on it within a day or two of surgery. The dressing will be reduced usually on the second postop day to make movement easier. Your rehabilitation and mobilization will be supervised by a physical therapist. To avoid lung congestion, it is important to breathe deeply and cough up any phlegm you may have. Your surgeon will use one or more measures to minimize blood clots in your legs, such as inflatable leg coverings, stockings, and injections to thin the blood clots or DVT’s. A lot of the long-term results of knee replacements depend on how much work you put into it following your operation. Usually you will be in hospital for 3-5 days and then either go home or to a rehabilitation facility depending on your needs. You will need physical therapy on your knee following surgery. You will be discharged on a walker or crutches and usually progress to a cane at six weeks. Your sutures will be removed at approximately 12-15 days. Bending your knee is variable, but by 6 weeks it should bend to 90 degrees. The goal is to get 110-115 degrees of movement. Once the wound is healed, you may shower. You can drive at about 6 weeks, once you have regained control of your leg. You should be walking reasonably comfortably by 6 weeks. More physical activities, such as sports may take 3 months to be able to do comfortably. You will usually have a 6-week checkup with your surgeon who will assess your progress. You should continue to see your surgeon for the rest of your life to check your knee and take X-rays. This is important as sometimes your knee can feel excellent but there can be a problem only recognized on X-ray. You are always at risk of infections especially with any dental work or other surgical procedures where germs (bacteria) can get into the blood stream and find their way to your knee. If you ever have any unexplained pain, swelling, redness or if you feel unwell you should see your doctor as soon as possible. A Revision Knee replacement is a complex procedure and requires a highly skilled surgeon with adequate expertise. Our Consultant in chief, Dr Vikas Jain is one of the few surgeons in the region who is trained from Europe and has adequate surgical experience in such complex revision procedures.

Shoulder Arthroscopy- Dislocation Bankarts Repair Surgery To better understand what shoulder dislocation is, an overview of the shoulder is needed. The humeral head (ball of the shoulder joint) is centered in the glenoid (the socket of the joint), which stabilizes the shoulder. If the shoulder becomes dislocated, it can tear the glenoid labrum and ligaments that help reinforce its structure. Bankarts repair surgery is a minimally invasive surgery to repair instability and restore function of dislocated shoulders. The goal of Bankart repair surgery is to re-attach the torn labrum and ligaments to the tip of glenoid from which they were detached. Symptoms of Bankart tear or lesions are: • Severe shoulder pain • Shoulder dislocation, single or multiple episode. • Repeated instances where the shoulders give out during activity • Sensation of the shoulder feeling loose, slipping out of the joint or “hanging there” PRE-OPERATIVE STEPS Every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure. 1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed in elderly patients. 2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since shoulder arthroscopy is an elective procedure. If any risk is involved, the patient/ attendants will be informed so. 3. Blood transfusion though rarely required, may be done depending on the reports. 4. X-rays and/or MRI may be done depending on the surgeon’s choice and the surgical indication. 5. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. INTRA OPERATIVE STEPS 1. After anesthesia induction and patient positioning your surgeon will make two small incisions in the front and one small incision in the back of the shoulder. 2. The surgery is considered minimally invasive thanks to the small incisions resulting in less discomfort and shorter recovery time. 3. The surgery is performed using a small fiberoptic camera (an arthroscope) and other small instruments. 4. The labrum tissue which is attached due to fibrosis at abnormal position (after shoulder dislocation) is released from the underlying glenoid. 5. Small holes are drilled near the detached labrum, once it has been cleared of loose particles. 6. The surgeon will then attach sutures to the released labrum and pull them tightly across the anchors so the labrum can be reattached to the glenoid. 7. Once the ligaments are firmly in place, the incisions are then closed with small bandages and the surgery is complete. POST OPERATIVE STEPS The first few days following surgery may be painful, but is typically managed by minimal amounts of pain medication. Seven to 10 days after the surgery, patients should have a follow-up with their surgeon.. Physical therapy helps to improve physical strength, range of motion, and assists with normal activities of daily living. 1. After surgery the arm is placed in a sling immobilizer. The sling is worn for at least the first two weeks after the operation. It should be removed when bathing/showering, or to do exercises. The sling is worn to sleep, and when in big crowds for at least four weeks after surgery. 2. Physical therapy should begin 7 to 10 days after surgery. Your surgeon will guide you through the exercises required after the surgery. The exercises are necessary to strengthen the muscles around the shoulder joint. 3. 1-2 week: passive shoulder motion and passive/active elbow motion 4. 2-8 weeks: active-assisted range of motion 5. 8-12 weeks: isometric rotator cuff strengthening 6. 3-6 months: sports- and work-related exercises 7. Return to sport: conditioning at 12 weeks but full return to contact sports at 6 months For the first four to six weeks following surgery, the focus should be on rehabilitation and regaining as much range of motion as possible (keeping surgical repair in mind). Depending on the progress of the patient, the next four to six weeks the focus will be on increasing the strength of the shoulder. As the strength of the shoulder improves any pain should decrease. Patients should visit their physical therapist six-eight times over a period of 12 weeks. Depending on the recovery, a patient can return to normal activity within a short period.

Knee arthroscopy, keyhole surgery, is a technique used to inspect the inside of the joint cavity to diagnose and assess damage and, where possible, to treat this damage. Arthroscopic knee surgery involves putting a small telescope and special instruments into the knee, with the ability to photograph and video the operation. At the same time all of the other structures within the knee can be clearly viewed and probed. . Arthroscopic knee surgery is used to treat any number of conditions that occur within the knee from simple cartilage tears to removal of loose bodies, meniscal surgeries and anterior/ posterior cruciate ligament reconstructions. The meniscus is a piece of cartilage that provides cushion between the Femur (thigh bone) and Tibia (shin bone). In many ways, meniscus acts as shock-absorbers of the knee joint. They can be damaged or torn during activities that put pressure on or rotate the knee joint. If a meniscus is torn, it is ideal to get it repaired at the earliest since neglected meniscal damage leads to onset of osteoarthritis of the knee. WHAT IS DONE? The entire procedure is done with the help of 2-3 small keyhole sized incisions from which the instruments and the small laser/telescopic camera is inserted and the procedure is visualized on a high definition screen. Arthroscopic Meniscectomy: A minor surgery where the torn part of the damaged meniscus is removed and the remaining part of the meniscus is smoothened/ balanced in order to prevent any further damage to knee cartilage and ensure smooth functioning of the joint. Arthroscopic Meniscal repair: Depending on the pattern, some of the meniscal tears can be repaired. The torn portion of the meniscus is repaired with the help of specialized meniscal sutures. PRE-OPERATIVE STEPS Though the procedure is a very minor procedure, every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure. 1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed. 2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since it is an elective procedure. If any risk is involved, the patient/ attendants will be informed so. 3. X-rays and MRI may be done depending on the surgeon’s choice and the surgical indication for the procedure. 4. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. INTRA-OPERATIVE STEPS- MENISCAL REPAIR/ MENISCECTOMY A meniscal injury is most commonly associated with another ligamental injury, though it is not uncommon to find an isolated meniscal injury. Meniscal tears are majorly of 2 types repairable and irreparable. Depending on the type of pattern two procedures which are performed commonly are described. 1. 2-3 small key hole incisions are made on the front aspect of the knee. 2. A small 1 mm Arthroscopic Camera is inserted into the knee joint to visualize the torn meniscus. 3. If the meniscus part is damaged and irreparable, a Debrider is inserted into the joint to remove the damaged portion of the meniscus and remaining part is smoothly balanced. The meniscectomy is complete. 4. If the Meniscus part which is torn is radial in shape or is large, an attempt is made to perform the meniscal repair. 5. An all inside suture with needle is inserted into the joint and is released after obtaining a hold in both the cut ends of the torn meniscus. 6. After checking that the torn portions are again in continuity, meniscal repair is complete. 7. Wound is closed with 2 or 3 small sutures followed by dressing. POST-OPERATIVE MANAGEMENT/ REHABILITATION Meniscectomy- patient is allowed to resume all the daily activities from the next day itself including full weight bearing. Patient needs to follow up for suture removal at 10th day after surgery Meniscal repair- patient is advised to continue non-weight bearing for a period of 6 weeks in order to allow for the torn meniscus to heal adequately.

TOTAL SHOULDER REPLACEMENT/ PARTIAL SHOULDER REPLACEMENT The primary indication for a Total Shoulder Arthroplasty or Hemiarthroplasty is Inability to reconstruct the fracture. A repairable rotator cuff is a pre-requisite for this type of surgery. Replacement of the humeral head along with the glenoid surface constitutes Total Shoulder Arthroplasty whereas replacement of only the humeral head constitutes Hemiarthroplasty of the shoulder joint. Supporting indications • Poor bone quality • Humeral head ischemia in the elderly patient • Intraoperative failure of osteosynthesis • Osteoarthritis of the shoulder joint ( Though reverse shoulder replacement is a preferred procedure) Advantages • Provides a replacement for unreconstructable humeral head • If failure of fixation and/or avascular necrosis (AVN) are highly likely, primary arthroplasty may avoid a second surgery Introduction Arthroplasty is indicated in all cases where a stable fixation is not achievable especially in situations with poor bone quality like severe osteoporosis. In the elderly, the indication might be extended to head-splitting fractures and situations with a probably ischemic humeral head (e.g., a displaced anatomical neck fracture with no capsular attachment remaining). PRE-OPERATIVE STEPS Every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure. 1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed in elderly patients. 2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since shoulder arthroscopy is an elective procedure. If any risk is involved, the patient/ attendants will be informed so. 3. Blood transfusion though rarely required, may be done depending on the reports. 4. X-rays and MRI will be done ideally in order to guide the surgical plan and the prognosis. 5. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. INTRA-OPERATIVE STEPS 1. This procedure is performed with the patient in a beach chair position. 2. For this procedure the deltopectoral approach is normally used. 3. It is crucial to evaluate the fracture. Identify the fracture lines, the long head of the biceps and the condition of the rotator cuff. 4. Sutures are inserted into the subscapularis tendon and the supraspinatus tendon just superficial to the tendon’s bony insertions. These provide anchors for reduction, and temporary fixation of the greater and lesser tuberosities. 5. The biceps tendon is temporarily attached to the superior border of the pectoralis muscle. A tenotomy of the long head of the bicipital tendon close to the rotator interval is performed. 6. Any remaining medial capsular attachment to the head should be carefully released with special attention not to damage the axillary nerve medial to the proximal humerus. 7. Insert a suture into the infraspinatus tendon. 8. The correct prosthesis head size can be measured on the retrieved humeral head. 9. In general, the reattachment of the tuberosities can be performed with sutures or cables. 10. Preparation of the humeral shaft is performed after opening the medullary canal and gently enlarging the humeral canal with rasps of increasing sizes. 11. Determine humeral head retroversion 12. Preparation of the Glenoid is performed and an appropriate sized trial is used to see the alignment. 13. Implantation of the prosthesis is performed, respecting the proper insertion height and the retroversion. 14. Depending on the prosthesis type and the remaining bony situation, bone cement may be necessary to fix the implant. Certainly it is wise to use cement if the prosthesis does not fit securely in the humerus. 15. Once the prosthesis is inserted, stability of the shoulder joint is assessed. After stability assessment, wound wash is given followed by wound closure and dressings. POST OPERATIVE PHASE Care after surgery: • Wear your sling or brace at all times for as long as directed. This helps to remind you not to use the arm. It also allows your shoulder to heal and decreases pain. • Apply ice on your shoulder for 15 to 20 minutes every hour or as directed. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a towel. Ice helps prevent tissue damage and decreases swelling and pain. • Place a small pillow or towel behind your elbow when you lie on your back. This keeps your shoulder in proper position. You may need to sleep in an upright position if you cannot sleep on your back. Place 2 to 3 pillows lengthwise behind your back when in bed. Make sure the pillows do not move your shoulder forward. Instead, you can sleep in a reclining chair. • Avoid moving your shoulder. Do not stretch or shrug your shoulder. Do not do exercises on your own until your healthcare provider says it is okay. • Do not lift with your hand on your surgery side. You put pressure on your shoulder muscles when you lift. • Do not lean on the hand of your surgery side. Pressure will cause pain and may cause damage to your shoulder. • Do not drive until your healthcare provider says it is okay. Shoulder bandage care: Keep your dressing clean and dry. Your healthcare provider will tell you when it is okay to take a bath or shower. Once you are able, let soap and water run over your surgery area. Do not scrub the area. Pat the area dry and put on a clean bandage as directed. Pain Management • Some amount of pain is expected after the surgical procedure. • Ice packs can be used for pain reduction • Paracetamol or Nsaids can be considered for pain management especially during the first four weeks. Shoulder rehabilitation protocol The shoulder is perhaps the most challenging joint to rehabilitate both postoperatively and after conservative treatment. Early passive motion according to pain tolerance can usually be started after the first postoperative day. The program of rehabilitation has to be adjusted to the ability and expectations of the patient and the quality and stability of the repair. The full exercise program progresses to protected active and then self-assisted exercises. The stretching and strengthening phases follow. The ultimate goal is to regain strength and full function. Activities of daily living (ADL) can generally be resumed while avoiding certain stresses on the shoulder. Mild pain and some restriction of movement should not interfere with this. The more severe the initial displacement of a fracture, and the older the patient, the greater will be the likelihood of some residual loss of motion. Generally, shoulder rehabilitation protocols can be divided into three phases. Gentle range of motion can often begin early without stressing fixation or soft-tissue repair. Gentle assisted motion can frequently begin within a few weeks, the exact time and restriction depends on the injury and the patient. Resistance exercises to build strength and endurance should be delayed until bone and soft-tissue healing is secure. The schedule may need to be adjusted for each patient. Phase 1 (approximately first 6 weeks) Bandage • Immobilization on a shoulder abduction pillow in neutral position of rotation Range of motion • Passive motion within the pain free interval for abduction, adduction and flexion • No internal or external rotation • Shoulder joint motion up to 90° • ADL for eating and writing allowed Physiotherapy • Passive motion up to 90° • Relaxation/stretching of neck muscles • Training of elbow and hand functions • Specific stabilization therapy for the shoulder joint • Isometric exercises in all directions • CPM up to 90° of abduction Massage • Neck • Shoulder girdle • Thoracic spine Training therapy • Training of the contralateral arm (overflow cardiovascular training) Phase 2 (approximately week 7-11) Bandage • No longer required Range of motion • Assisted/active motion within the pain free interval, also beyond 90° • Careful rotation Physiotherapy • Free motion of shoulder girdle (scapula, clavicle, cervicothoracic junction, cervical and thoracic spine) with specific mobilization • Strengthening exercises especially for ADL • Eccentric muscle activity Massage • As required Ice/warmth • As required Training therapy • Mobilization bath, wound permitting • Training of hand and forearm muscles • Set for shoulder therapy Phase 3 (after week 11) Range of motion • No restrictions on Shoulder movement • Muscle growth for shoulder girdle and all arm muscles Physiotherapy • All physiotherapeutic techniques allowed, active and against resistance • Increasing eccentric muscle activity Training therapy • Handcycling • Training for specific ADL and sports • Machine training • Free weight training

OVERVIEW Fractures (Broken Bones) of the Shoulder, Elbow and Wrist are common from both minor and major accidents. These are incapacitating in the short term as they commonly require the use of a cast or brace and restrict the use of the affected limb. DESCRIPTION Upper limb fractures occur from either direct trauma or indirectly from forces applied to the limb (eg twisting injuries). The type of fracture depends on the size and direction of the injury to the limb. Low energy injuries (such as falls from a standing height), usually result in less complex fracture patterns and less soft tissue injury. Typical symptoms of a fracture include: • Pain • Swelling • Deformity • Difficulty lifting things Lower energy injuries can be missed and may be passed off as ‘sprains’ or ‘strains’. If you have had an injury that is not responding to treatment, it is advisable to see your doctor and obtain X-Rays to rule out a fracture. Higher energy injuries (such as motorcycle and car crashes) typically fracture bones in multiple places, into smaller pieces, and commonly disrupt the soft tissues resulting in large amounts of bruising and swelling. These can be challenging to treat and frequently require surgery to restore the bones to their anatomical position to make healing quicker and your function better in the long term. TREATMENT The treatment of lower limb fractures requires careful tailoring to the individual patients demands and the type of fracture sustained. Non-operative treatment of upper limb fractures may involve: • Braces or Slings • Plaster Casts • Activity Restriction • Physiotherapy Dr. Jain always encourages non-operative treatment whenever possible, however, many fractures do much better with surgical intervention as surgery can speed up recovery and improve the short and long term outcome. As there many different types of upper limb fractures, there are a large range of surgical options that can be used, these can include: • Plates + screws • Wires • Rods/Nails • External Fixators Sometimes a combination of these is used, and Dr. Jain will discuss the surgical plan with you pre-operatively. He uses the latest technology in orthopedic trauma implants to give you the best outcome possible. After surgery, Dr. Jain will discuss your operation as well as plan your rehab in line with your goals and expectations. He uses a highly qualified team of physiotherapists and rehabilitation specialists to get you back to your activities as quickly as possible. Dr. Jain has extensive experience treating fractures, he has completed Training at Cascais Hospital in Lisbon (Portugal, Europe) with world recognized leaders in Orthopedic Trauma Surgery, and has worked as an Orthopedic Joint Replacement & Trauma Consultant at Tata Hospitals. He routinely attends conferences and visits trauma centers worldwide to refine his skills and stay on top of the most recent advances in trauma surgery.