THE CASE

Juhi (name changed), 48 years of age, was constantly disturbed by her irregular heavy vaginal bleeding. She consulted her gynaecologist at Panipat who advised a routine USG followed by DAC. It was a real shock for her and her family when the report indicated cancer of uterine lining. She was advised an open surgery at Panipat with complete staging. Juhi was completely shattered until someone suggested her to consult the cancer team at BLK Hospital. The team counselled her to get it removed Laparoscopically along with Sentinel Lymph Node Mapping (LNM ).

THE PROCEDURE

Sentinel Lymph Node (SLN) mapping in Endometrial Cancer provides a bridge between overtreatment and understaging of patients. It targets those nodes which are most likely to harbour the disease, and are easily visible and hence amenable to removal easily.

At BLK, Radioactive tracer (Tc 99m colloid) and coloured dye (methylene blue) are used to locate “hot” nodes. We utilized a combined superficial and deep cervical injection of the tracer and dye for SLN mapping on the day of surgery. Single-photon emission computed tomography (SPECT) and gamma probe were used to locate the hot nodes along with direct visualisation of

THE CASE

Bekzod Abdulakhatov, a 35-year old former athlete had a common birth defect which could have been easily diagnosed and treated at an adolescent age. However, it went unnoticed for 33 years. And when diagnosed, it was mistaken for a tumour near the spine for which he had to undergo critical open surgery at his hometown Tashkent some years back to remove the tumour. The surgery went wrong to an extent that Bekzod was reduced to wheelchair and lost his movement completely. For all the following years, he had to suffer for something which is easily curable - Spinal Arteriovenous Malformation (AVM) - a rare, abnormal tangle of blood vessels on, in or near the spinal cord.

AVMs are defects of the circulatory system that are generally believed to arise during embryonic or foetal development, or soon after birth. It is an abnormal connection between arteries and veins bypassing the capillary system. As a result, they can cause intense pain, bleeding or lead to other serious medical problems.

In Bekzod’s case, spinal neurovascular angiogram at the neurovascular cath lab revealed too many blood vessels cluttered in one area. This AVM was stuck to his spine and spreading in between his spinal discs like parasites. Not only was Bekzod's AVM misdiagnosed, but it was also not cured from the roots.

Although, after the surgery the blood clot around his spine was absent for a few weeks, it reappeared and started to choke on his spinal cord with enough high pressure to cripple him.

THE PROCEDURE

Dr. Vikas Gupta, Director & HOD, Neuro-Surgery, Interventional & Endovascular Neuro-Surgery and the team carried out eight hour long embolisation procedure to correct the anomaly. For this, a C1 catheter was used to cannulate bilateral spinal radicular vessels from D7 to L3. A large arteriovenous malformation in nature was found fed by Radicals of D11-12 and L1. At-least four radicals were embolised with 50% glue. This cut the blood supply from the selected arteries to the affected area of the spine and prevented increased malformation. This automatically released the pressure and gave strength to his spine to conduct voluntary movement in his limbs.

THE RESULT

He was kept under observation and monitored closely in NSICU. Power in both lower limbs improved slightly (grade 3/5 at knee joint) in first few days. Bekzod stood first time after two years on his own and walked free to return home.

Total Knee Replacement (TKR) is a widely performed surgery nowadays. Over the years, the surgery has evolved quite significantly in terms of the techniques utilised and the outcome thereof. It has come a long way from the monoblock technique to the more advanced high flex TKR. In today’s digital era, computer is an integral part of TKR surgery, creating milestones of accomplishment with the success rate as high as 99 percent.

Computer was first introduced in Orthopaedics in France, 1980 for Anterior Cruciate Ligament (ACL) surgery. In the late 90s, computer technology was introduced for Joint Replacement Surgery. Many organisations have invented surgical navigation system to assist during the surgery, some major ones being - BrainLabs, Medtronics, Aesculap, Zimmer and Stryker. These are all closed systems with limited popularity as they are error prone and are not considered as userfriendly technology. The evolution of the technology in this field could be summarised as follows:

The first generation - Single way communication, closed system, pins in bones.
The second generation- Two way communication, open system, pins in bones.
The third generation - Pinless- World’s only 3rd generation surgical navigation system for Knee: ASM (Articular Surface Mounted), Stryker, produced in 2010.

BLK Super Speciality Hospital is equipped with third generation pinless ASM (Articulate Surface Mounted) Nav3 Express software technology. Previous versions involved wire and lesser sensitive trackers whereby, the surgeon had to drill a pin in the thigh and leg bone to fix the tracker, leaving accuracy in doubt and increasing risk of fracture of shaft because of the pin. If the pin is loose by any chance, not holding in osteoporotic bone, all the efforts would be wasted.

THE CASE

An 80-year-old male was admitted with a complex fracture of the right shoulder joint (proximal humerus). He had osteoporosis with severe intractable pain. He was advised Shoulder Replacement Surgery elsewhere for which he did not agree. He wanted a fully mobile, pain-free shoulder joint but not at the cost of replacing his normal shoulder with an artificial joint.

THE PROCEDURE

Dr. Prakash Doshi, Director of Trauma & Orthopaedics in Nanavati Super Speciality Hospital, along with his able trauma team, performed a surgery where the head of humerus was preserved. A minimal invasive approach was used and the fractured head of humerus was stabilised with a specialised titanium MultiLoc nail.

THE RESULT

Post-operation, the patient had no plaster cast – just a cuff and collar sling to support his operated shoulder. His pain was minimal and the rehabilitation programme was started on the 3rd day. He was already performing simple pendular movements in the first week itself. At the end of 10-12 weeks, he had a fully functional, pain-free shoulder joint.