A detailed presentation on tuberculosis of the joints, clinical features, investigations and management

1. FELLOWSHIP OF ORTHOPAEDIC RHEUMATOLOGY
(FEIORA)
Under the Aegis of
“SYNOPSIS WORK”
BY
DR. M.PRAVEEN
UNDER GUIDANCE OF
PROF. DR. MANISH KHANNA,
NATIONAL COURSE CHIEF, FEIORA
AND
DR. RAM MANOHAR LOHIA NATIONAL LAW UNIVERSITY
LUCKNOW, UTTAR PRADESH.
2022-2023

2. PUBLICATION

3. PRESENTATION

4. TUBERCULOSIS OF THE
SKELETAL SYSTEM –
SURGICAL NEEDS
Dr. M.PRAVEEN
FEIORA FELLOW 2022 – 2023
GUIDE – PROF. DR. MANISH KHANNA

5. Content
 General Considerations
 Extra-Spinal regional Tuberculosis
 Tuberculosis of the spine
 Tuberculosis of the Hip joint
 Tuberculosis of the Knee joint
 Tuberculosis of the Shoulder joint
 Miscellaneous bone tuberculosis

6. Tuberculosis: Epidemiology and Prevalence
 It is a chronic granulomatous disease caused by “Mycobacterium
Tuberculosis” complex.
 Lichtor and Lichtor (1957) reported the evidence of TB in Bones, Joints
and Spine.
 Percival Pott in 1779 described TB of the Spinal Column.
 Laennec discovered the basic microscopic lesion ‘tubercle’.
 Robert Koch in 1882 isolated “ Mycobacterium Tuberculosis”

7. Regional Distribution of Osteoarticular Tuberculosis
 Spine - 44%
 Hip - 8.1%
 Knee - 8.9%
 Sacroiliac Joint - 6.9%
 Elbow
 Ankle
 Shoulder
-
-
-
5.1%
4.3%
1.7%
Other bones -11%

8. Pathology and Pathogenesis
 Osteoarticular Tuberculous lesion is a result of hematogenous
dissemination from primarily infected visceral focus.
 The Primary focus may be active or quiescent. Can be either in the lungs /
lymph nodes of the mediastinum/ Kidney or other viscera.
 The infection reaches skeletal system through vascular channels generally
the arteries or in axial skeleton through Batson’s plexus of veins.
 Tubercular bacilli reach the joint space via the blood stream through sub-
synovial vessels, or indirectly from the lesions in the epiphyseal bone.

9. Cold Abscess
 A cold abscess is formed by a collection of products of liquefaction and the
reactive exudates.
 Composed of Serum, leucocytes, caseous materials, bone debris, and the
tubercle bacilli.
 The cold abscess feels warm, though the temperature is not raised as high
as in acute pyogenic infections.

10. Type of the disease
Caseous Exudative type
 More destruction, more
exudation and abscess
formation.
 Onset is less insidious,
constitutional symptoms and local
signs of inflammation are marked.
 Sinus and abscess formation are
common.
Granular Type
 Less destruction, abscess formation
is rare.
 Insidious onset.

11. Diagnosis of skeletal Tuberculosis
 X-rays:Localized osteoporosis, articular margins and bony cortices become
hazy -“washed out” appearance.
 Blood Investigations: Lymphocytosis, low hemoglobin and raised ESR.
 Biopsy
 Synovial fluid examination and Synovial biopsy
 RT PCR : Also useful in differential diagnosis with Brucellosis, Typhoid
infection and Syphilitic infection.
 Xpert MTB/RIF
 Radio-isotope scan
 Imaging Techniques:USG, CT, MRI and PET CT

12. Anti Tubercular Drugs

13. DOTS REGIMEN
Treatment group Type of patient REGIMEN
IP CP
New (category I) New sputum smear positive
New sputum smear negative
New extrapulmonary
New others
2H3R3Z3E3 4H3R3
Previously treated(Category II ) Smear positive relapse
Smear positive failure
Smear positive treatment after
default
Others
2H3R3Z3E3S3
1H3R3Z3E3
5H3R3E3

14. TUBERCULOSIS OF THE HIP
 The initial focus of Tuberculous lesion may start in the acetabular roof,
epiphysis,metaphyseal region or in greater trochanter region.
 As the upper end of the femur is intra-articular the joint gets involved
rapidly.
 Clinical features : Pain, Limping, deformity, and fullness around the hip.

15. Stages Clinical findings Radiologic features
Synovitis Apparent lengthening, Flexion,
Abduction, ER
Soft tissue swelling, Osteopenia in
sub chondral region
Early Arthritis Apparent shortening, Flexion,
Adduction , IR
Osteopenia, marginal bony
erosions on both surface
(Acetabular and femoral head)
Advanced Arthritis Flexion, Adduction, IR, True
shortening
Above + Reduction in joint space
Advanced arthritis with subluxation/
dislocation
Flexion, Adduction, IR, with gross
shortening
Gross destruction
“ Mortar and pestle appearance”
STAGES

16. SHANMUGASUNDARAM CLASSIFICATION

17. Management of TB Hip
 Anti Tubercular therapy (ATT).
 Traction to be applied ( To relieve Muscle spasm, prevents/corrects
deformity, prevents subluxation/dislocation,maintains joint
space,prevents migrating acetabulum).
 Hip mobilization exercises to be done with gradual increase in
duration and frequency.
 Non weight bearing for 12 weeks followed by partial weight bearing for
next 12 weeks.

18. Surgical Management
 In Synovial stage : Arthrotomy and synovectomy
 In Early arthritis : Synovectomy + removal of loose bodies, pannus covering
articular cartilage.
 In advanced arthritis :
• Arthrolysis
• Ankylosis
• Debridement along with arthrodesis/ Girdlestone’s Excisional arthroplasty
of the joint(unstable joint)-pelvic support osteotomy.

19. Contd.
Healed status of disease:
• Upper femoral corrective osteotomy
• Upper femoral displacement cum corrective osteotomy
• Conversion of painful ankylosis to a sound arthrodesis(not preferred now)
• Conversion of anklyosed hip to mobile state by Excision or Total Hip
Replacement

20. TUBERCULOSIS OF THE SPINE

21. Regional distribution of Spine TB
 Cervical – 12%
 Cervicodorsal –5%
 Dorsal –42%
 Dorsolumbar –12%
 Lumbar – 26%
 Lumbosacral –3%

22. Types of vertebral lesions
 5 types:
 Paradiscal- Arterial spread
 Central – Venous spread
 Anterior- Subperiosteal spread
 Appendicular
 Articular

23. Clinical features of spinal TB
 Back Pain/Night cries
 Stiffness
 Deformity
(Gibbus/Knuckle/Kyphosis)
 Restricted movements of spine
 Malaise
 Loss of weight/appetite
 Night sweats
 Evening rise of temperature
 Neurological deficit

24. Pathogenesis of TB Spine
 Secondary infection.
 Primary site in the lung, viscera or lymph
nodes.
 Hematogenous Spread / Batson plexus of
veins
 Delayed hypersensitivity immune
reaction.
Inflammatory reaction with Langhan’giant cells,
Epitheliod cells and inflammatory cells .
 The granulation tissue
proliferates producing thrombosis of
vessels.

25.  Granulomatous inflammation leads to
erosion of vertebrae.
 Associated disc degeneration due to end
arteritis, finally complete destruction.
 Weakening of trabeculae leads to compression
collapse and Deformity.

27. •Formation of cold abscess
•Collect under ant-long-ligament
•Vertebral collapse
•Expression of collection of tuberculous debris
Slides along VB and invade the
vertebral canal through
intervertebral foramen.
Pathology of Abscess Formation
Diverted forward along
different anatomical sites

28. Neurological deficit
 10-30% cases – Neurological
deficit.
 Age: First 3 decades.
 Disease below L1 vertebrae
rarely causes Paraplegia.
 Highest Incidence of paraplegia
seen in TB of lower thoracic
vertebrae

29. Classification of TB Paraplegia
Early onset paraplegia
 Appears within 2 years of onset.
 Underlying pathology
Inflammatory edema
TB Granulation tissue
Abscess
Caseous tissue
 Ischaemic lesion of cord (Rare)
 Good prognosis
Late onset paraplegia
 Appears more than 2 years of
disease in vertebral column
 Underlying pathology –due to
mechanical pressure on cord TB
Debris
 TB Sequestra from body and disc
Internal gibbus
 Canal stenosis / Severe deformity
 Poor prognosis

30. Staging of Neurological Deficit
Stage Severity Clinical Features
I Negligible Patient unaware of neurodeficit, physician detects plantar
extensors or ankle clonus
II Mild Patient aware of deficit but walks with support
III Moderate Non ambulatory due to spastic paralysis (in extension),
sensory deficit less than 50 %
IV Severe III + Flexor spasm / Paralysis in flexion / Flaccid/ Sensory
deficit more than 50 % / Sphincter Involved

31. Pathology of TB Paraplegia
 Extradural mass:
• The Commonest mechanism affecting spinal
cord function
• Material compressing
may be
 Fluid pus
 Granulation tissue
 Caseous material
Bony Disorders:
• Internal Sequestrum from
disc or body
• Gibbus
• Pathological Dislocation

32. Clinical features of Pott’s Paraplegia
o Paraplegia itself – Rare
o Spontaneous muscle twitching in lower limbs
o Clumsiness while walking
o Extensor plantar response
o Exagerrated reflexes – Sustained clonus of patella and ankle
o Motor affected first – then Sensory
o Sense of position and vibration – last to disappear

33. Investigations
o CBC:
Hb% ↓
Lymphocytosis
o ESR:
Raised in active stage of disease
Normal ESR over period of 3 months suggests patient is in stage of
repair.
o Biopsy

34. Radiological Investigations
 Xray:
o Reduced disc space
o Blurred paradiscal margins
o Destruction of bodies
o Loss of trabecular pattern
o Increased prevertebral soft tissue
shadow
o Subluxation /dislocation
o Decreased lordosis/Kyphosis
• Skipped lesions: More than one TB Lesion in
vertebral column with one or more healthy vertebrae
in between lesion.

38. BONE SCAN (Technitium (Tc) – 99 m )
Increased uptake (60% patients)
with active tuberculosis
> 5mm lesion size can be
detected.
Avascular segments and abscesses
show a cold spot due to decreased uptake
Highly sensitive but nonspecific.
Aid to localize the site of active
disease and to detect multilevel
involvement

39. Biopsy :For definitive diagnosis
CT or ultrasound guided or open
biopsy during a surgical procedure.
Z-N staining: a quick and
inexpensive method.
Culture :
 results are available only after
a few weeks
 positive only in 60% of cases;
most specific.
Histology: demonstration of
tubercle, 80%
cases.

40. Xpert MTB / RIF
• Xpert MTB / RIF has been endorsed by WHO since 2010 as a rapid diagnostic
tool for diagnosis of pulmonary and extrapulmonary tuberculosis.
• Although this does not replace the need for AFB microscopy, culture and growth
based drug susceptibility results it is an addition for genotyping and early
detection of cases.

41. DIFFERENTIAL DIAGNOSIS
 SPINALINFECTIONS
o pyogenic
o brucellosis
o fungi / syphilis
 NEOPLASTIC
o Extradural – Lymphoma / Metastasis etc.
o Intradural extramedullary – Meningioma
/neurofibroma
 DEGENERATIVE / OSTEOPOROTIC
 TRAUMA
 CONGENITAL DEFECTS
 SPINAL OSTEOCHONDROSIS

43. MIDDLE PATH REGIME

44. INDICATIONS- SURGICALTREATMENT
 Failure to respond to conservative Rx
after 3-6 months therapy.
 Symptomatic abscess.
 Neurological indications.
 Mechanical instability.
 Deformity.
 Recurrence of disease.

45. SURGERIES FOR POTT’S SPINE
 Antero-lateral decompression (MC)-Spine is opened from its
lateral side & access is made to the front and side of the cord.
The cord is laid free from granulation tissue, caseous material,
bony spur or sequestrum
 Costo-transversectomy-Removal of 2 inches of rib &
transverse process and pus comes out.
 Radical debridement and arthrodesis(Hongkong
operation).
 Posterior spinal fusion followed by an anterior
spinal fusion (> 3 levels)
 Laminectomy-Indicated in spinal tumor syndrome and
paraplegia resulted from post spinal disease.
 Prophylactic stabilisation in radiologically “at risk” factors.

46. TUBERCULOSIS OF
KNEE JOINT

47.  Knee Joint is the largest joint in the
body having the largest intra articular
space.
 It is the 3rd most common site
for osteoarticular tuberculosis.
 Accounts for nearly 10% of all
skeletal tuberculous lesion.

48. Pathology
 The initial focus occurring by hematogenous
dissemination may start in the synovium, or in
the subchondral bone (Distal femur, proximal
Tibia, Patella).
 The synovium lesion may for
many months remain purely as
tubercular synovitis.
 The synovial membrane gets
congested, edematous and studded
with tubercles.
 The synovial lining which is normally a single
cell layer in thickness becomes hypertrophied
and thickened with granulation tissue.

49.  The joint fluid in the initial stages is
increased (Serous, Opaque, turbid,
yellowish and may contain fibrinous
flakes).
 In advanced stage of the disease
tuberculous process becomes
osteoarticular.
 The Tuberculous granulation tissue
like the pannus erodes the articular
margins, destroys the bone and
involves the cruciate ligament,
periarticular tissues, capsule and
ligaments.

50.  The Pannus may erode the margins of the
articular cartilage, grow between the articular
cartilage and the subchondral bone, thus
detaching the cartilage from the bone.
 Nutrition of the articular cartilage is thus
interfered.
 It looses its smooth glistening appearance,
there may be fibrillation of its surface, it
becomes roughened, pitted and erosion of
the cartilage exposes the subchondral
bone.

51.  As the disease advances large areas at
pressure points show osseous destruction
and the whole joint is obliterated with
granulation/fibrous tissue, capsular
apparatus and ligaments are disrupted and
joint gets a triple deformity.
 Triple deformity
I. Flexion deformity
II. Posterior subluxation
III.Lateral rotation

52. Clinical Features
• The onset and course is insidious
• The knee shows
• Warmth
• Swelling
• Patellar tap is present due to synovial effusion
• Thickened synovium
– filling up all parapatellar fossa appreciated earliest in medial parapatellar fossa.
• When the arthritis has set
– movements are grossly restricted,
– painful
– accompanied by muscle atrophy.
• Regional lymphadenopathy.

53. • Quadricep muscle shows gross wasting
• In the neglected case
– triple deformity
• Once the flexion deformity established
– tensor fasciae latae further increases
the deformity.
• In long case
– Posterior capsule of the knee joint gets
contracted

54. Differential Diagnosis
• Monoarticular affections
– rheumatic arthritis (in children)
– chronic traumatic synovitis due to chronic internal
derangement of knee (e.g.
• meniscal tears
• loose bodies
• osteochondritis dissecans
• Chondromalacia patellae
• Rheumatoid arthritis (in adults)
• Subacute pyogenic arthritis/synovitis

55. • Hemarthrosis
• Villonodular synovitis
• Synovial chondromatosis

56. Staging of the tuberculosis of the joints
Stages Clinical Radiology Treatment
Synovitis ROM >75% Soft tissue swelling,
Osteoporosis
Chemotherapy
Early Arthritis ROM 50-75% Above + moderate
diminution of joint space
+ marginal erosion
Chemotherapy +
Movements
Advanced arthritis Movements restricted
>75%
Above + marked
diminution of J.Space
+destruction of J.
surface
Chemotherapy +surgery
(Generally arthrodesis in
lower limb)
Advanced arthritis +
subluxation/dislocation
Ankylosis Joint is disorganized with
sub/dislocation
Chemotherapy +surgery
(Corrective Osteotomy/
Arthrodesis)

57. Treatment
• Non operative treatment with
antitubercular drugs is
employed in
– tubercular synovitis
• Traction is applied to
– prevent (or correct) flexion and
subluxation deformity
– keep the joint surfaces
distracted.
• In addition to the systemic drugs,
the joint may be aspirated and
Streptomycin and Isoniazid
injected intra articularly.

58. • With the quiescence of acute local signs, gently
active and assisted knee bending should be.
• Usually after 12 weeks of treatment the patient
may be permitted ambulation with suitable
orthosis and crutches.
• After 6 to 12 months of treatment, in cases with
favorable response, the crutches or orthosis may
be discarded.
• Unprotected weight bearing is usually permitted 9
to 12 months after the start of treatment.

59.  Arthrodesis of the grossly destroyed knee in children should be deferred till the
completion of growth potential of the distal femur and proximal tibia.

60. Operative Treatment
• In the synovial stage
– arthrotomy and synovectomy should be carried out.
• In early arthritis,
– synovectomy,
– removal of loose bodies, debris, pannus, loose articular cartilage and
– careful curettage of osseous juxta-articular foci
• Postoperatively triple drug therapy,
– traction,
– intermittent active and assisted exercises,
– suitable brace ambulation should be continued

61. • In adults with advanced arthritis or in cases which resulted in painful fibrous
ankylosis during the process of healing, the knee joint may be treated by
arthrodesis.
• This option provides
painless stable knee
prevents recrudescence
corrects deformity
patients can do long hours of standing and walking.
• However it imposes a lot of restrictions in sitting, using public transport and
many other social activities.
• Corrective reposition osteotomy should be considered to those joints which
are ankylosed in a sub optimal position.

62. Arthroplasty
• Optimally Total Knee Arthroplasty should be delayed until pateints show no
evidence of recurrent disease after completion of therapy
• Recent days though controversial arthroplasty is considered under cover of ATT
within 6-12 weeks

63. TUBERCULOSIS OF
SHOULDER JOINT

64.  The incidence of tuberculosis of
shoulder joint is rare and accounts
for only 1–2.8% of cases of skeletal
TB
 Tuberculous disease of the
shoulder is rare constituting nearly
1-2% of skeletal tuberculosis.
 The disease originates in the head
of the humerus, glenoid of the
scapula or rarely from the
synovium.

65.  It is extremely uncommon for the disease to
present at the stage of synovitis.
 Painful limitations of abduction and external
rotation occurs early and there is marked
wasting of the deltoid, supraspinatus and other
muscles.
 As the disease progresses there is marked
destruction and atrophy of upper end of the
humerus and glenoid and the shoulder
undergoes fibrous ankylosis.

66.  The common variety is a dry atrophic
form (Caries
sicca).
 Very rarely there may be swelling and
cold abscess or sinus formation
presenting in the deltoid region along
with biceps tendon, in the axilla or in
the supraspinatous fossa.
 In the unattended cases the scapula-
humeral muscles contract. Pull the
humeral head against the glenoid and
fix the shoulder in adduction.

67. Three types of TB shoulder
Type I: “caries sicca” Marked wasting of the shoulder. Painful restriction
of all movements.
Type II: “caries exudata” Swelling of the joint, cold abscess. Sometimes a
sinus.
Type III: “caries mobile” Restriction of active movements of the shoulder.
Nearly full passive abduction.

68. Differential Diagnosis
 Adhesive capsulitis / frozen shoulder/
periarthritis
 Rheumatoid arthritis of the
shoulder joint.

69. Radiological findings
 Generalized rarefaction of bones is
present with varying degree of erosion
of articular margins or actual
destruction of upper end of humerus or
the glenoid.
 In the absence of sinus formation little
periosteal reaction is seen.
 In advanced cases inferior subluxation
of the humeral head.

70. Management
 ATT
 Shoulder spica in 70-90 degrees of abduction,
30 degrees forward flexion and 30 degrees of
internal rotation to encourage ankylosis of
gleno-humeral joint in functioning position.
 Following 3 months of spica is replaced by
abduction brace.
 Scapulo-thoracic and elbow joint movements
are encouraged after spica removal.

71. Arthrodesis of Shoulder-Extra articular arthrodesis
 Before the availability of effective
antitubercular drugs bony fusion of the joint
was obtained by an extra articular operation
carried out by inserting an autologous tibial
strut graft (12-15cm) between the scapula and
humerus through a posterior approach.

72. Intra articular arthrodesis
With the availability of effective anti
tubercular drugs intra-articular arthrodesis
is preferred.
Synovectomy, joint debridement, removal
of loose sequestra , destroyed tissue,
freshening of the joint surfaces and
insertion of bone grafts at the site of
desired fusion.

73. TUBERCULOSIS OF ELBOW JOINT

74.  TB Elbow constitutes nearly 2-5 % of all cases
 Starts from the olecranon or lower end of humerus
 Sometimes the onset is synovial or upper end of radius.

75. Management
 ATT
 Rest in the best functional position – 90 degress of flexion and mid prone
position of forearm
 Active disease – With elbow extended or any other position – Serial casting to
bring to neutral position
 Excision Arthroplasty
 Arthrodesis
 Total Elbow Arthroplasty

76. Tuberculosis of the short tubular bones
 Tuberculosis of the metacarpal,
metatarsal and phalanges is
uncommon after the age of 5 years.
 In children the disease may occur in
more than one short tubular bone at a
time.
 Tuberculous infection of
metacarpals, metatarsals and
phalanges is known as
tuberculous dactylitis.

77.  The hand is more frequently
involved than the feet.
 During childhood these short tubular
bones have a lavish blood supply
through a large nutrient artery.
 The interior of the short tubular bone
is converted virtually into a
tuberculous granuloma.
 This leads to a spindle shaped
expansion of the bone aka “ Spina
Ventosa"

78.  With the occlusion of the nutrient artery of the
involved bone and the destruction of internal
lamellae, there is endosteal destruction and
concomitant subperiosteal new bone formation.
 Abscess and sinus formation is quite common.
Management :
 ATT
 Bracing
 Excision Arthroplasty
 Corrective osteotomy
 Amputation

79. Miscellaneous Bone TB
 Tuberculosis of Sacroiliac joints and Sacrum
 Tuberculosis of rare sites , Girdle and Flat bones
 Tuberculous Osteomyelitis
 Tuberculosis of tendon sheaths and bursae

80. Take home points
 No surgical resection is a substitute for a prolonged course of
antitubercular drugs and supportive therapy.
 With the passage of time indications for surgery have become
universally more selective ,less for the biological control of
disease,but more for prevention and correction of
deformities/complications and for improving the quality of function
of diseased joints.

81. POSTER
PRESENTATION ICOR-
IORACON 2022
KOLKATA

82. INTRODUCTION :
The purpose of the study to show the functional outcome of non-surgical treatment in
undisplaced fractures and surgical treatment in Mason type II and III fracture.
MATERIALS & METHODS :
This is a prospective study of Radial head and neck fractures admitted between
December 2018 to June 2020 in IOT,RGGH and MMC.
Inclusion Criteria: Radial head fractures ,Radial neck fractures ,Age >18 years ,
Patients without any coexisting major comorbid conditions.
Exclusion Criteria: Age <18 years ,Concomitant neurovascular injuries, Patients not
willing for the surgery , Patients not fit for the surgery.
MANAGEMENT OPTIONS:
1.Conservative
2.Surgical
a. Fixation.
b. Replacement.
c. Excision.
DISCUSSION:
As the degree of severity of injury increases management option shifts from
conservative to surgery. Out of 24 patients 4 cases Type I Mason were managed
conservatively shows good result at 6 months . 8 cases (MASON Type I-2, II-6)were
managed with fixation & their MAYO ELBOW SCORE found to be Good at 6 months. 12
cases were MASON TYPE III ,6 cases underwent excision and 6 cases underwent
replacement. Replacement showed better stability and excellent results at 6 months.
CONCLUSION:
From our study we came to a conclusion the management option is based on the
severity of injury with Replacement shows Good result in Type III Mason, Fixation in
Type II Mason & Conservative in Type I Mason.
REFERENCES:
Ikeda M, Sugiyama K, Kang C, Takagaki T, Oka Y. Comminuted fractures of the radial head. Comparison of
resection and internal fixation. J Bone Joint Surg Am 2006;88(Suppl 1 Pt 1):11-23.
David E. Ruchelsman, MD, Dimitrios Christoforou, MD, and Jesse B. Jupiter, MD Current Concepts Review
Fractures of the Radial Head and Neck-THE JOURNAL OF BONE & JOINT SURGERY d JBJ S .ORG VOLUME
95-A d NUMBER 5 d MARCH 6, 2013.
ANALYSIS OF FUNCTIONAL OUTCOME IN THE MANAGEMENT OF RADIAL
HEAD AND NECK FRACTURES
PRESENTOR : DR.M.PRAVEEN, MS ORTHO.,
FEIORA FELLOW 2022-2023
LM/P/145T

83. Scope of Orthopaedic rheumatology fellowship-
Being an Orthopaedic Surgeon I was interested in OrthopaedicRheumatology from my trainee
days. I am always interestedin learning more about the subject.Even if we have a lot of patients
Suffering from Rheumaticand other associated disease, many are not diagnosedat an early age
due to lack of awareness. Many patientsare misdiagnosed and undertreatedor treated only with
Steroids up to an advanced stage of the disease due to lack of proper training and lack of
knowledge on the latest treatmentmodalities on the part of the treating Physician/Surgeon. In our
part of the country Rheumatologyis in very rudimentarystage. There are only a few
Rheumatologistsand No SpeciallytrainedOrthopaedic Rheumatologist. Most of the Medical
Rheumatologists do not refer the patient to an Orthopaedic Surgeon at the correct time to prevent
deformities. Ultimately, it’s the patientswho have to suffer.
Regenerative Medicine holds promise in the treatment of many OrthopaedicDiseases. Regenerative
medicine as a subject has evolved a lot, but most of the advances are still unknownto a large
number of Orthopaedic surgeons and hence not applied in clinical practice especiallyin Northeast.
Neither, do we have the proper training and expertise to apply the same. Our work in
orthobiologics is stilllimited to PRP and that also is being used by very few orthopaedic Surgeons. I
want to learn and train myself in the use of other orthobiologics which have shown promising
results in many diseases. Also, what better way to learn more about these exciting specialities of
Orthopaedics,other than to get enrolled in a fellowship program curettedand guided by the
Stalwarts in the field. If I get the opportunity to participatein this prestigious fellowship, I would
strive to learn and apply the teachings for the benefit of patientsin my region to best of my
Capabilities.
What I intend to gain from the fellowship-
I encounter a large number of patients in my clinical practice who have Rheumaticand
rheumatoid diseases.Though I am able to treat them with my current knowledge, I want to be
groomed further and learn more about the subject and newer modalities of treatment in this field.
I also want to train myself in regenerative medicine and its latest applications. This knowledge will
not only help me treat my patients in a betterway but also help my professionaladvancement. As I
am working in a GovernmentMedical college, the knowledge gained by this fellowship will let me
help the economically weaker patients also in a great way in regards to specialized
Rhematologicalcare. A specialized setup for research and clinical activities in regenerative
medicine is lacking in my region. Acquaintance in the field of regenerative medicine will also help
me in future to set up a well-equippedfacility for performing the various proceduresand research
activities in this less exploredsub speciality of Orthopaedics. As there are no FIORA fellows from
North-east, there is lot of opportunity of growth of this Speciality here, which will also have a good
effect on my professional growth. In future I want to establish myself as an Orthopaedic
rheumatologistand for that this prestigious fellowship will be crucial.