May issue health care times

Healthcare Times Palliative care Talk to Your Doctor and Make Your Voice Heard

Special Focus: Orthopedics Can Orthopaedic Innovation Be Learnt Nano-coated Orthopedic Implants Sports Medicine : Sports Knee Injury

+MORE INSIDE Issue 02 / May 2017

FROM THE DESK

C

urrent issue of Health Care Times focuses on the issue of Palliative care and Orthopedics. Palliative care is an approach that improves the quality of life of patients and

their families facing the problem associated with life-threatening

illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of

pain and other problems, physical, psychosocial and spiritual. Palli-

ative care intends neither to hasten or postpone death, but to provides relief from pain and other distressing symptoms and to affirms life and regards dying as a normal process.

Here Dr. Helen Senderovich, Assistant Professor of the University of Toronto, Division of Palliative Care, talks about the importance of communicating with your doctor.

In the orthopedics section Dr. Hemendra Agrawal talks about importance of sports medicine, Dr. Suman Singh from CSIR-CSRO

gives insights on the development of Nano-coated orthopedic im-

plants. Dr. Debrupa Lahiri, assistant prof. IIT Roorkee analyses the importance of Multifunctional Surface Treatment for Orthopedic Implant. Dr. Mohamed Mediouni from Université de Sherbrooke, Québec, Canada talks about innovation in orthopedic medicine.

Regards!

Abhishek Prasad

The Team Managing Editor: Abhishek Pr asad abhishek@healthcaretimes.org Senior Editor: Chandan Singh editorial@healthcaretimes.org Senior Editor: Sagar Rawat Head Office: Health Care Times E/218 B, Sector 63, Noida, U.P. PIN Code – 201301

For Editorials, Advertising and Media Partnereship: editorial@healthcaretimes.org

Contents

Healthcare Times

Cardiology Humanization In Emergency Care— Is It Possible?

Issue 02/ May 2017

Palliative Care Talk to Your Doctor and Make Your Voice Heard

Orthopedic

Our Contributors: Dr. Danielli O. C. Lino Dr. Helen Senderovich

Emergence of nano-coated orthopedic implants

Shaira Wignarajah

Can Orthopedic Innovation be Learnt?

V. K. Meena

Sports Medicine—Knee Injuries Multifunctional Surface Treatment for Orthopedic Implant

Dr. Suman Singh

Dr. Hemendra Kumar Agrawal Dr. Mohamed Mediouni Dr. Debrupa Lahiri Manoj Kumar R.

NEWS Biocon Ltd announced its consolidated financial results for the fourth quarter and full year FY17

opment for the treatment and prevention of RSV infections.

Synpromics Raises £5.2m Of New Investment

connectors. The site provides information for medical staff and raises awareness about the therapeutic benefits and risks associated with the new connection standCommenting on the perfoards for enteral feeding devices. mance, Chairperson and ManagThe site has a special focus on ing Director Kiran Mazumdarpremature neonates and newShaw stated: “We have closed the borns; considered to be high-risk year FY 17 with a strong revenue populations.

Synpromics Ltd, the leading syngrowth of 18% led by a sturdy perthetic promoter and gene control formance of our Biologics as well company, is pleased to anas Small Molecules businesses. nounce that it has completed a ReViral Announces Good On a full year basis, our EBITDA Safety and Pharmacokinetics financing round of £5.2M. Particirose 34%, while Net Profit before pants included existing investors exceptional item reported a robust From Phase 1 Programme for Calculus Capital, the Scottish InRSV Antiviral RV521 in growth of 54 %. Our revenue vestment Bank, the investment Healthy Volunteers growth was muted in Q4 FY 17. arm of Scottish Enterprise and priOur EBITDA margin at 24 % in Q4 vate shareholders. reflects a healthy operational performance. Our Net Profit for Q4 at Rs 135 Cr, represents a growth of Glenmark Gets USFDA Nod 75%, after adjusting for an excepFor Anti-Cholesterol Drug tional item in Q4FY16.”

Enteral feeding: Vygon Group launches safeenteral.com

ReViral, a UK based biotechnology company focused on the discovery and development of antivirals for respiratory syncytial virus Vygon, the single-use medical de- (RSV), announced today top-line vices group, today announces the safety and pharmacokinetic (PK) launch of safe-enteral.com, a web- data from the Phase 1 single and site dedicated to the therapeutic multiple ascending dose (SAD and implications of enteral tubing and MAD) trial of RV521. RV521 is a novel oral fusion inhibitor in develHEALTHCARE TIMES

4

Drug firm Glenmark Pharmaceuticals today said it has received final approval from the USFDA for Fenofibrate Capsules USP, 67 mg, 134 mg and 200 mg used for lowering cholesterol.

MAY 2017

NEWS Bharat Biotech’s Zika Vaccine month. “We have already got the Domain Therapeutics and 100% Efficient In Animal Tri- approval from DCGI [Drug Control- Pfizer Inc. enter into collaboler General of India] in March to als ration agreement on bioSencarry out the Phase I clinical trial,” sAll™ says Dr. Krishna Ella, Chairman and Managing Director of Bharat Biotech.

Domain Therapeutics, a Franceand Quebec-based biopharmaceutical company specializing in the It will be a randomised, placeboresearch and development of new controlled, double-blind trial involvdrug candidates that target G proing 48 adults, both men and womtein-coupled receptors (GPCRs), en (who are not pregnant). Each today announces a collaboration volunteer will receive two zika vacagreement with Pfizer Inc. (Pfizer; The Hyderabad-based Bharat Bio- cine doses on days 0 [the starting NYSE:PFE) aimed at assessing day] and 30 and will be followedtech’s ‘killed Zika virus vaccine’ the impact of mutations on differusing an African strain has shown up for a year for both safety and ent signaling pathways engaged immune response. Three different 100% efficacy against mortality

by GPCRs. Pfizer is interested in dose ranges will be tested. and disease in animal studies, a GPCRs with potential therapeutic study has shown. A ‘killed virus relevance; Domain Therapeutics vaccine’ or ‘inactivated vaccine’ will use its proprietary bioSencontains virus that has been grown sAll™ technology to define signalin culture and then killed using ATUM Launches Cell-Line De- ing signatures for each of the wildphysical or chemical processes. velopment Service type and mutant receptors.

The vaccine was found to confer 100% protection against infection caused by an Asian Zika virus strain as well as by the African Zika virus strain.

ATUM (formerly DNA2.0) has announced an expansion of its services to include cell line development, which has been enabled by the company’s proprietary Leap-In Transposase genome engineering All the animals that were not vac- tools. ATUM has also begun concinated died eight days after infec- struction of a new, 7,000 SF mamtion by the African strain and 12 malian cell engineering laboratory days after infection by the Asian at its Newark, CA headquarters. strain.

The new facility, due to be fully operational by September 2017, will Phase I Clinical Trial Of Zika double ATUM’s lab space dedicatVaccine To Begin Next Month ed to mammalian work, and will include a cGMP cell bank manuBharat Biotech International Ltd in facturing facility that is expected to Hyderabad will start the Phase I be fully validated by the end of the year. clinical trial of Zika vaccine (MR 766) in two centres in India next HEALTHCARE TIMES

5

BioWin reports record investment in 2016, with €24.3 million ($25.8M) 2016 was a record year for investment in R&D projects, with €24.3 million ($25.8M) in funding, including €7 million ($7.4M) in private investment 2016 saw sustained growth in jobs in member SMEs with a yearly average of +17.9% since 2005. A sharp rise in private capital investment in member SMEs: over €1 billion ($1.1bn) in total over the last 11 years

MAY 2017

Humanization In Emergency Care - Is It Possible?

DR. DANIELLI O. C. LINO, Clinical Cardiologist, Brazil Public Health Graduate Program, University of Fortaleza, Brazil.

T

he word

United States with the creation

extended their role in health

“humanization� de-

of the National Foundation on

area, represented by a signifi-

rives from the Latin

the Arts and the Humanities,

cant increase in the production

word humanus; a

which defended humanities as

of knowledge and practices.

humanist is someone who has

necessary for the human de-

Emergency care must be con-

a worldview primarily focused

velopment of society.

textualized in the health care

on human values and life. The

Humanization is a reflexive

model, mainly based on the

term "humanities" had been

process, presupposing in addi-

profile of the disease that leads

used since the nineteenth cen-

tion to treatment, dignified, soli-

the user to seek this type of

tury, but it was related to mat-

dary and friendly care on the

service. There is a struggle

ters of "general culture". Until

part of health professionals; it

against time, aiming at the sta-

the 1960s, humanities were

is necessary to promote care

bilization of the patient and life,

embedded into the field of cul-

aiming to prolonging life or pre-

which is seen as the goal of

ture and entertainment, apart

venting greater complications

the performed work.

from scientific knowledge, a

in the patient’s life. The human

However, the aim of the health

fact that changed course in the

sciences and humanities have

team work that provides urgen

HEALTHCARE TIMES

6

MAY 2017

-cy

and

emergency

The

tension

experi-

ile, and often react aggressive-

care reflects the true social

enced by these professionals

ly

misery in which the user lives.

in this work environment, the

about care are not met. The

Accidents caused by firearms,

demands of achieving positive

situation of "imminent risk of

traffic accidents, illicit drug in-

outcomes and the exposure to

death" directly affects the phys-

toxications, urban and home

violence are aspects that per-

ical and emotional balance of

violence, as well as the aggra-

meate the professional's activi-

patients and their families, gen-

vation

diseases

ty and their direct relationship

erating constant conflicts and a

comprise the daily lives of the

with the user. On the other

tense environment in the team-

teams that are confronted daily

hand, patients fear the un-

patient relationship.

with this cruel reality.

known - environment and pro-

How is it possible, then,

fessionals - and they feel frag-

after disclosing the emergency,

of

chronic

HEALTHCARE TIMES

7

when

their

expectations

MAY 2017

Unfortunately, the topic of humanization is still poorly discussed among physicians.

The inter-professional relationship must occur in a full, healthy, and integrative manner, so that the obtained results can be satisfactory

physicians’ duties dur-

verse working conditions, facili-

field of action, such subjects

ing their activities, to include

tates communication among

would show numerical preva-

humanization

professionals, accelerates the

lence, but basically there is a

processes

im-

shortage of subjects referring

proves the service provided to

to the social sciences, with em-

the user.

phasis on humanization.

during

patient

care?

It is worth emphasizing, before evaluating the profes-

and,

lastly,

sional-patient relationship, the

Unfortunately, the topic

In a practical manner,

emergency/cardiologist physi-

of humanization is still poorly

and considering the peculiari-

cian as the leader in the multi-

discussed among physicians.

ties of the emergency physi-

professional team. The inter-

When evaluating the syllabi of

cian’s / cardiologist’s activities,

professional relationship must

the Medical Residency Pro-

how can humanization be in-

occur in a full, healthy, and in-

gram in Cardiology and Emer-

cluded and what is its power to

tegrative manner, so that the

gency Medicine, the quantita-

modify the cruel reality of Ur-

obtained results can be satis-

tive

gency and Emergency ser-

factory. A human attitude in

‘technicist’ approach is well

this relationship undoubtedly

known. It is obvious that be-

leads to the mitigation of ad-

cause of these professionals’

HEALTHCARE TIMES

superiority

8

of

the

vices?

MAY 2017

Within the context of

attention not only to the purely

lated, offering them encourage-

the emergency physician hav-

technicist aspects of their ac-

ment for commitment with

ing a fundamental role in the

tions. Both the relationships

quality of care and by involving

decision-making and behaviors

with the multidisciplinary team,

them in a new attitude when

to be defined and performed by

and with the patients and their

facing the demands of every-

the care team, a human rela-

families, especially in the pres-

day life. As said by the Ameri-

tionship with the multiprofes-

ence of negative outcomes,

can physician, Francis W. Pea-

sional team tends to have posi-

are issues wherein the physi-

body, “the treatment of a dis-

tive impacts on the dynamics

cian-humanization interface is

ease may be entirely imper-

of the patient care delivery.

crucial. The inclusion of hu-

sonal; the care of a patient

Tensions intrinsic to the work

manization into the practices of

must be completely personal�.

environment can be minimized,

advanced life support, per-

in an environment of relaxed

formed in the emergency unit,

dialogue, mutual cooperation

becomes possible if humanistic

and respect.

competence is developed at the same level as the technical

Finally, the emergency physi-

-scientific competence of the

cians / cardiologists must pay

health professionals is stimu-

HEALTHCARE TIMES

9

MAY 2017

Palliative Care

Dr. Helen Senderovich, MD MCFP COE PC Geriatrics &Palliative Care &Pain Medicine Baycrest Health Sciences Assistant Professor of the University of Toronto Department of Family and Community Medicine Division of Palliative Care, Toronto, Ontario, Canada

Talk to Your Doctor and Make Your Voice Heard - By Dr. Helen Senderovich and Shaira Wignarajah Dr. Senderovich is a physician with practice focused on Geariatrics,Palliative Care, and Pain Medicine. She is an author of multiple manuscripts focused on geriatrics, pain management, patientcentered care, ethical and legal aspect of doctor -patient relationship, palliative and end-of-life care’ Shaira Wignarajah presently studying for Bachelors of Science in Kinesiology at York University

There may come a time where

avoid a situation where we feel

these wishes and values would

you are no longer able to make

helpless or disengaged from a

be communicated to your phy-

decisions on your own. You

medical treatment plan. ACP

sician, who would follow your

may find yourself unable to

allows your voice to be heard

directive if and when you are

communicate the type of medi-

by speaking to your physician

not able to communicate any-

cal care you would like to re-

about the type of care that you

more. In the event you lose the

ceive. This type of situation

would like to receive in the fu-

ability to make decisions due to

can leave you feeling helpless

ture. Through this process, one

cognitive and/or physical de-

dependent on your loved one

would typically express their

cline, your POA or SDM can

to make a decision for you –

wishes and values first to a

direct the care. As such, the

one that may not be the one

family member or someone we

ACP process is critical to en-

you would choose.

have appointed as our Power

suring that our wishes are met

Advanced Care Planning

of Attorney (POA) or Substitute

during our last days. In fact,

(ACP) is a solution to help you

Decision Maker (SDM). Next,

research has shown that peo-

HEALTHCARE TIMES

10

MAY 2017

Palliative Care

people without advanced direc-

help address the nature of any



tives are more likely to report

illness, disease trajectory, and

But communication should also

concerns around a physician’s

what to expect down the road.

be a two-way street. Your phy-

communication, and about being informed about the course

Blood transfusion

sician and health care team ACP can address your con-

members must also speak to

of an illness. Having an ad-

cerns about:

you, the patient, about ACP

vanced directive in place helps



Resuscitation

during routine annual exams.

families and health care staff



Comfort care with or with-

Making this discussion a rou-

out life prolongation

tine occurrence will help com-

Benefits of quality vs quan-

municate your changing wish-

tity of the remaining life

es to both your family and

1

know the goals of care and how to proceed in case of an



acute emergency, especially when the prognosis and quality



Use of antibiotics

heath care team. Revisit your

of the remaining life is poor.



Artificial nutrition and hy-

goals of care whenever there

dration

is a decline in your functional

Use of a feeding tube vs

status, or if you experience fre-

comfort feeding

quent hospitalizations.

Initiating the conversation yourself and discussing your goals for care during routine



visits to your doctor will also HEALTHCARE TIMES

11

MAY 2017

Palliative Care they will be abandoned

Emphasizing the importance of ACP, benefits you, and may also ease the potential burden



Dispel any myths that they may have

on your loved ones. By making these difficult

heard about any life prolonging method

decisions beforehand, you and your family are

used in end-of-life care when prolong-

no under pressure to make them during an emergency, when you may no longer be able to communicate.

ing life is not desired 

If your loved one states that he/she is not interested in thinking about end-of-

End-of-life talks are by nature difficult to have,

life, and thus ACP, ask them about

and one that many of us and our families

what they are most afraid of (financial

“But communication should also be a

concerns, pain, etc.) 

two-way street. Your physician and health care team members must also

Ask your loved one about what’s most important to them



Let your loved one know that unexpected things can happen and knowing their wishes in advance may help you

speak to you”

to respect these wishes while managing their health, especially in a time of criti-

may refrain from having. But you and your health care team must be open and frank about the discussion of death, End-of-Life

cal illness 

You may ask your loved one: “If I needed to make decisions about your care

care, and ACP, since these discussions are

and you were unable to speak for your-

essential to ensure that you or a loved one is cared for according to his/her wishes. In the

self, whom would you want me to speak

same way that we have stimulated discussion

to about your care?”

around mental health, and organ and tissue



Let your loved one know that ACP

donation, various communities and organiza-

gives him/her control of the instructions

tions must help to create conversations and

they wish the physicians to follow

spread the importance of ACP. 1. Teno, JM., Gruneir, A., Schwartz, Z., Nada, A.,

Tips on having the discussion with your

Wetle, T. (2007). Association between advance

loved one:

directives and quality of end-of-life care: a na-



Reassure your loved one that discussing the topic of ACP does not mean that

HEALTHCARE TIMES

tional study. Journal of the American Geriatrics Society, 55 (2), 189-94.

12

MAY 2017

Palliative Care

Advanced Care Planning can address your concerns about: 

Resuscitation



Comfort care with or without life prolongation



Benefits of quality vs quantity of the remaining life



Use of antibiotics



Artificial nutrition and hydration



Use of a feeding tube vs comfort feeding



HEALTHCARE TIMES

Blood transfusion 13

MAY 2017

Orthopedics Emergence of nano-coated orthopedic implants - By Dr. Suman Singh and V. K. Meena

DR. SUMAN SINGH Senior Scientist at CSIRCSIO, Chandigarh, India

A

Dr. Suman Singh is a Senior Scientist at CSIR-Central Scientific Instruments Organisation (CSIR-CSIO). Her area of research is designing of composites consisting of functional bulk and nanomaterials.

ccording to availa-

be due to many reasons like in-

surface functionalized orthope-

ble data, the Indian

appropriate mechanical

dic implants can rectify these

orthopedic devices

strength between bone and

problems. The coating industry

market is around

implant, biocompatibility issue,

is again bound to increase with

Rs 2,400 crores and is ex-

infection and corrosion, to

rise in medical devices market,

pected to grow at around 20 %

name few. Failed implants re-

which is expected to grow at a

every year. And in the world,

quire revision surgeries, which

CAGR of 7.3 % between 2014-

India is one of the top 20 medi-

is again associated with cost,

19.

cal device marked and fourth

additional pain and recovery.

Among various materials that

largest marked in Asia. Chang-

Bacterial infection associated

can be used for functionaliza-

es in the market composition,

with implants has become a

tion of implant surface, nano-

policy and regulatory environ-

growing threat to human

dimension materials are at-

ments will alter the landscape

health. It is rather a challenging

tracting the attention of scien-

further in the near future. How-

task to treat an infection of or-

tific community as well as im-

ever, from medical point of

thopaedic implant. It may

plant coating manufacturers

view, orthopedic implants do

cause various complications

due to their size resemblance

not completely allow patients

like prolonged morbidity, ex-

with natural tissues, bones,

lead their normal life and their

tended rehabilitation, repeated

related proteins, etc. The phys-

average lifetime is also only 10

debridement and surgery. Re-

iochemical properties of nano-

-15 years. Implant failure can

searchers have studied that

HEALTHCARE TIMES

14

MAY 2017

Orthopedics materials play im-

composed of collagen, ar-

unreachable for most of the

portant role in cell growth

ranged into nanofibers of size

middle class strata. Indian or-

stimulation and tissue regener-

ranging in 50 – 500 nm.

thopedic manufacturers face

ation due to their high surface roughness and high surface area. Many studies have shown

the mimicking ability of nano rough surfaces for natural tissue processes, and they showed better tissue growth compared to flat or nano-smooth implants.

Our research group at Central Scientific Instruments Organisation (CSIR-CSIO),

Chandigarh, India, is working on synthesis of nanoceramic biomaterials like hydroxyapatite and its conjugate with biocompatible metal nanoparticles like silver nanoparticles, zinc oxide nanoparticles etc. Diverse structured like nanospheres, nanoslabs, etc nanohydroxyapatite is fabricated using different synthetic methods. Hydroxyapatite is a wellknown bone like material. The natural bone is a nanostructured composite consisting of organic and inorganic phases.

The organic phase is mainly

HEALTHCARE TIMES

the constraint of support infra-

“The natural bone is a nanostructured composite consisting of organic and inorganic phases. “ The in-organic phase consists of nanometer-sized carbonated hydroxyapatite, embedded between nanofibers.

Hydroxyapatite has mechanical strength and morphology identical to natural bone and its composite with silver nanoparticles provide resistance again bacterial colonization. We are also working on coating of these biomaterials on implant

structure such as common testing laboratories and coating

facilities which can help them to improve validation of their products and bring down costs.

Lack of such facilities makes them uncompetitive as they have to access international service providers for such needs. However, the policies being undertaken by present

government in terms of regulatory and domestic innovations, under the umbrella of ‘Make in India’ and ‘Saksham Bharat’, campaign is expected to support the Indian orthopedic manufacturers.

material surface and are study-

ing the effect of these coating on bacterial resistance and corrosion resistance.

At present, functionalized/ coated implants are either being imported or implants are sent to foreign manufacturers for coating, which make them

15

MAY 2017

Orthopedics Sports Medicine Sports Knee Injury - By

Dr.Hemendra Kumar Agrawal is a Sports & Joints Orthopedic surgeon and a Sports Arthroscopy & Arthroplasty Fellow

Dr.HEMENDRA AGRAWAL Sports & Joints Orthopedic surgeon

T

Dr. Hemendra Kumar Agrawal

he knees can

the knee, the anterior cruci-

take a lot of pun-

ate ligament (ACL) and the

ishment while

posterior

cruci-



Stopping suddenly when running.



playing sports or running,

ate ligament (PCL),

often resulting in knee liga-

nect the thigh bone with

ment injuries. Around a fifth

the bones of the lower leg.

of knee injuries from play-

But too much stress on

These injuries are common

ing sport affect the anterior

these ligaments can cause

in footballers, basketball

cruciate ligament or ACL.

them to stretch too far - or

players, skiers, gymnasts

A torn ACL can be painful

even snap.

and other sports people.

ACL and oth-

There are four ligaments in

er ligament injuries can

the knee that are prone

be caused by:

to injury.

and debilitating, but can often be treated successfully.

Anatomy of a knee injury Ligaments are tough bands of

tissue

the bones in

that your



connect body.

Two important ligaments in HEALTHCARE TIMES



con-

Suddenly shifting

Twisting your knee or

weight from one leg to the other.



Mentioned above,

Getting hit on the knee.

the anterior cruci-

Extending the knee too

ate ligament (ACL) is

far. 

Jumping and landing on a flexed (bent) knee.

16

MAY 2017

Orthopedics one of the two ma-



looseness in the joint.

Keep your thigh muscles

jor ligaments in the knee. It

strong with regular

connects the thigh bone to

stretching and strength-

the shin bone.

ening.

If they're not treated at the

Warm up before physical

time, ACL and other types

activity.

of ligament injuries may con-

Stretch after physical ac-

tinue to give trouble months

tivity.

or years later, causing the

Never abruptly increase

knee to give out when you

ate ligament (PCL) is the

the intensity of your

twist or pivot.

second major ligament in

workout. Make changes

If you have an

the knee connecting the

slowly

acute injury severe enough to

ACL injuries are a common



cause of disability in the knee

and are more common in



women than men. 

The posterior cruci-



thigh bone to the shin 

Inability to put weight on the joint without pain.

rupture your ACL, you will

bone.

What does a

probably be taken straight to

The lateral collat-

knee ligament injury feel

an emergency department. If

eral ligament (LCL) conne

like?

the symptoms are not so severe and you go to your doc-

cts the thigh bone to the fibula; the smaller bone on the outside of the lower leg. 



The medial collateral ligament (MCL) conn ects the thigh bone to the inside of the shin bone.

How can I prevent a knee ligament injury?

An ACL injury - or other ligament injury - is occasionally hard to diagnose clinically. However, sometimes the person will know immediately that something is severely wrong, because of

the pain, limitation of movement and rapid swelling that follow a ruptured internal ligament. Symptoms of a

Knee ligament injuries are

knee ligament injury are:

hard to prevent, since they're



usually the result of an accident. But taking some pre-

severe. 

cautions might lower your risks. You should: HEALTHCARE TIMES

Pain, often sudden and

tor, you will quickly be referred to an orthopaedic surgeon if an ACL injury is suspected. To diagnose an ACL or other ligament injury, you will need a thorough examination. You may also need Xrays, and an MRI (Magnetic Resonance Imaging) scan, as this can identify the structures inside the knee and clearly show the extent of the damage. Other tests may also be necessary.

A loud pop or snap during the injury.



Swelling & a feeling of 17

MAY 2017

Orthopedics Four ligaments in the knee that are prone to injury

What's the treatment for a knee ligament injury?

to the other part of the ligament if it was torn in the middle.

Unfortunately, the cruci Wear a knee brace to A mild-to-moderate ate ligaments - the ACL and stabilise the knee and knee ligament injury may PCL - cannot be repaired. protect it from furheal on its own given time.

Once they are completely ther injury.

You will be referred to the torn or stretched beyond their sports orthopaedic surgeon limit, the damage is irreparafor supervised management,  Take antible. The only option is a reinflammatoand to speed the healing you construction. In the UK, ry painkillers. Noncan take measures of your about 17,000 ACL ruptures steroidal antiown. For example, you can: occur each year, according inflammatory drugs to the NHS; and due to the (NSAIDs),  Rest the knee. Avoid like etoricoxib or ibuprofe extensive work carried out on putting excess weight on n, will help with pain and them, techniques have imit. You may need to use swelling. However, these proved over the past 15 crutches for a time. years. To reconstruct the drugs can have sideACL, tendons are taken from effects and should only  Ice your knee to reduce be used with doctors pre- other parts of your leg to repain and swelling. Do it place the torn ligament. The scription/ for 20-30 minutes every most usual sites used to supthree to four hours for two ply the new tendon are the to three days, or until the  Practise stretching and stre patellar tendon (this goes pain and swelling is gone. from below the knee-cap to ngthening exercises if they are recommended. the top of the tibia) or the  Compress your hamstrings, powerful tendons knee. Use an elastic at the back of your thigh.

For severe collatbandage, straps or eral ligament tears, you may sleeves on your knee to need surgery to attach control swelling. the ligament back to the  Elevate your knee on a bone if it was pulled away, or

HEALTHCARE TIMES

pillow when you're sitting or lying down.

18

MAY 2017

Orthopedics File Photo: Knee injury

A ligament reconstruction for an ACL or PCL injury is nowdays done arthroscopically with minimal incisons. Arthroscopic ligament reconstruction help in better recovery and painless physiotherapy to patient. People who have pain or instability in their knees may choose to have it.

So might professional sports people or devoted amateurs who really want to return to their previous level of activity will need to discuss the options with your consultant sports orthopaedic surgeon.

Recovery time depends on how severe your knee ligament injury is. People also heal at different rates. You will need intensive input from a physiotherapist under the supervision of your sports surgeon who can supervise the various stages of your recovery. It will take at least six months before you are able to return to sport, and often longer. While you recover - if your doctor agrees you could take up a new activity that won't hurt your knee. For instance, runners could try swimming.

Whatever you do, don't rush When will I feel better af- things.

ter a knee ligament injury?

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

You feel no pain when you bend or straighten your knee.



You feel no pain in your knee when you walk, jog, sprint or jump.



Your knee is no longer swollen.



Your knee feels as strong as your uninjured knee.

If you start using your knee before it's healed, you could cause permanent damage and disabilities.

So prevention of knee injuries is always better, however early diagnosis & treatment by sports orthopaedic surDon't try to return to your old geon will help in better and level of physical activity until: speedy recovery.

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MAY 2017

Orthopedics Can Orthopedic Innovation be learnt?

- By Dr. Mohamed Mediouni MOHAMED MEDIOUNI UniversitĂŠ de Sherbrooke, QuĂŠbec, Canada

G

Mohamed Mediouni is a prominent figure in orthopaedics surgery.

He is the Editorial Board Members of a number of reputed International Journals. He has been awarded with Antoni-Trias-Biomet in the year 2013-2014.

etting sci-

lenging experience for all the

must be corrected: being inno-

ence poli-

authors who contributed to this

vative does not mean invent-

cy right is

publication. The degree to

ing.

a core ob-

which innovation can be man-

Until recently, many scientists

jective of

aged, directed and predicted

think that innovation is innate

all governments around the

are critically. Innovation is

ability and our aim as scientific

world in many field such as

viewed as a ''change that cre-

community is to support it by

economic growth, health, and

ates a new dimension of per-

providing a great environment

longevity. As science advanc-

formance'' [1]. According to

as well as funding, time and

es, innovators seeks to over-

Michael Porter [2], ''innovation

infrastructure. Face with this

come the trend and challenges

includes both improvements in

reality, the leadership must

that faced us. In light of these

technology and better methods

play such a catalytic role. Elias

substantial shifts in the scien-

or ways of doing things'' . Rein-

Zerhouni [3, 6], the former di-

tific process, how might ortho-

forcing recent views from the

rector of National Institutes of

pedic innovation policy evolve?

literature on research of defini-

Health (NHI) is an example of

Orthopedic innovation cannot

tion, researchers must under-

scientist that we need, he con-

be relegated to a second-class

stand that innovation can be

vened a series of whirlwind

status by the urgency of day-to

stepwise, or it can be trans-

meetings with top clinicians

-day operations. Writing about

formative in medicine. In addi-

and scientists.

medical innovation was a chal-

tion, a common misconception

HEALTHCARE TIMES

20

MAY 2017

Orthopedics The NIH, under him has also

covery. The graduate course

that are fundamental to your

been trying to encourage re-

''innovative thinking'' devel-

thinking. She thinks that

searchers to be creative. He

oped by Dr. Ness and Dr. Jack

''creativity gap'' due to the ab-

think that innovation is specific

Smith provides new ideas to

sence of strategies to educate

to humans, and it exists in eve-

find an innovative solution for

student to be innovative. Train-

ry country and every society,

some problems in practice. Ac-

ing of thinking led researchers

but it can only flourish where it

cording to Ness, innovation is

to demonstrate a greater atti-

is nurtured. For that to happen,

creativity with a use, proves to

tude for solving complicated

people must work together,

be problematic. Teach stu-

problems.

share their knowledge and

dents to be more innovative,

In the last decade a global

pool their expertise. The great

how increase the generation of

movement emerged to in-

revelation given the innova-

new idea? The strategies

crease the impact of innova-

tions was, "why not?'', Zer-

would actually be useful to an-

tions successfully tested in pi-

houni said that his residence

yone struggling to find new ide-

lot or experimental projects.

completed as soon arrived at

as, better approaches, and

the department of radiology at

more effective strategies. She

The question of sustainable

Johns Hopkins, he developed

mentioned that the key of suc-

innovation is the implemen-

some preliminary research ide-

cessful innovation generation

tation on the large scale.

as to extract biological infor-

is based on: learn to observe,

mation of the human body us-

ask the right question, use

''Scaling up'' has been used to

ing scanned images. His pro-

analogy to see the challenge in

describe an increase in the

fessor Stanley Siegelman said:

new ways, juggle induction and

coverage of orthopedic inter-

" I'm not sure of the value of it,

deduction, change your point

ventions that have been tested

but why not? For that purpose,

of view, broaden your perspec-

in pilot and experimental pro-

it is essential to adopt an open

tive, dissect the problem, re-

jects in order to benefit more

attitude and encourage the

verse your thinking, recombine

people and support policy and

student to go further in their

and rearrange, rely on the

programme development at a

dreams.

power of groups, shift the

large or national scale. With

Roberta Ness [4] thinks that

frame, and move away from

increasing interest in scaling

we can teach innovation to

the limits.

up, the outcomes will be multi-

challenge the biggest prob-

Among the objective of Ness is

plied. What we present is not a

lems. She thinks that innova-

to remove the feel of the fear

theory, scaling up may

tion represents a way to move

of failure and to raises your

from a normal science to a dis-

ability to identify the frames

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MAY 2017

Orthopedics File photo: orthopedic innovation succeed or fail which depend on many factors includes the strategies employed for having broader impact, the environment, and the resource organization or resource team. Success in achieving improvements in orthopaedic will also depend on efforts undertaken Mediouni [5], is among the rare scientists who are interested in the success of scaling up which depends on the following conditions: 

Orthopaedic community must perceive a need and motivate to implement it. Does the innovation respond to a priority and who are exactly the advocates of this innovation?



We must make sure that timing and circumstances are right.



Maximize the opportunities and minimize the constraints for better implementation.



Build a strong team, network of supporters include individuals and institutions and find an appropriate collaboration. It is important to ensure that managerial expertise and

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skills in advocacy are well integrated.

References [1] Goldsmith M, Baldoni J, McArthur S (2010) The AMA Handbook of Leadership. New York, NY: American Management Association.

[2] Porter ME. The Competitive Advantage of Nations. New York, NY: Free Press; 1990 [3] Elias Zerhouni. Nature Biotechnology 29, 188 (2011) [4] https://sph.uth.edu/research/centers/ ingen/ [5] Mediouni M, Vaughan N, Shetty SH, Arora M, Volosnikov A, et al. (2016) How Challenging is the ‘Scaling Up’ of Orthopaedic Simulation?. Peertechz Journal of Orthopedics and Rheumatology 1: 12-14.

[6] Stanley S. Siegelman. Elias A. Zerhouni, MD, Radiologist: New Director of the National Institutes of Health. Radiology.

309-312, 2002.

22

MAY 2017

Orthopedics Multifunctional Surface Treatment for Orthopedic Implant - By Dr. Debrupa Lahiri and Manoj Kumar R DR. DEBRUPA LAHIRI

Department of Metallurgical and Materials Engineering, IIT Roorkee

Dr. Debrupa Lahiri is an assistant professor in the Department of Metallurgical and Materials Engineering, Indian Institute of Technology, Roorkee, India Manoj Kumar R is a Ph.D. candidate working under the supervision of Prof. Debrupa Lahiri.

D

uring last five

rent size of the Indian orthope-

globally, include joint diseases,

decades, bio-

dic devices market is ~$375

such as, osteoarthritis, osteo-

materials have

million US Dollars (Rs. 2,400

porosis, fragility fractures, back

seen a rapid

crores) and it will grow ~ 20%

and neck pain, soft tissue rheu-

growth, due to its direct relation

every year for the next decade

matism, injuries due to sports,

and impact on healthcare and

to reach $2.5 billion US Dol-

workplace and road traffic acci-

advancements in the fabrica-

lars (Rs. 16,000 crores) by

dents [4]. In India, 12-15% of

tion of synthetic biomaterials.

2030 [3].

the population seems to suffer

The biomaterials market, in-

from MSK [5]. Sharp increase

cluding medical device and im-

Owing to an increase in the

in the number of primary total

plants, is estimated to be

aging population and active

hip orthroplasties (THA) and

greater than $130.17 billion US

sedentary lifestyle, musculo-

primary total knee orthroplas-

Dollars by the end of 2021 and

skeletal (MSK) disorders are

ties (TKA) are noticed in last

is expected to increase by 13.2

the second most cause of disa-

two decades, due to increasing

% every year [1, 2]. The largest

bility worldwide, according to a

cases of osteoarthritis [6]. Os-

market size amongst all bio-

report by international experts,

teoarthritis is degenerative joint

material products belongs to

published in The Lancet on

syndrome, resulting from sick-

orthopedic devices and it is

15th December 2012. Muscu-

ness, generic factors and obe-

expected to reach $41.2 billion

loskeletal conditions, which

sity. It makes cartilage to worn

US Dollars by 2019. The cur-

affect over 1.7 billion people

out and creats severe pain

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23

MAY 2017

Orthopedics

Multifunctional surface properties required in total hip arthroplasty

during movement, due to bone to bone contact [7]. Implants are suggested medically as an option only when all non-surgical treatments have failed. The advantages of orthopedic implants should offer enhanced mobility of patient, reduced pain, restored function of the joint and higher quality of life. According to 2007 estimation, ~1.5 million joint replacements are performed around the world [6]. In India, over 70,000 hip and knee replacements are being performed every year [5]. However, even after decades of successful track record, ~10% of

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these implant fail prematurely, within the first 10 to 20 years, thereby affecting many tens of thousands of patients annually. The two primary causes of prostheses failure are aseptic loosening and peri-prosthetic joint infection. Strategies to tone down these two failure modes is most necessary.

Recently most of the study focused on bioactive coatings on orthopedic implants, either to prevent antibacterial infection, while ignoring implant osseointegration or vice versa, to promote bone mineralization ignoring the antibacterial resistance property.

24

However, all the functionalities are essential to achieve the long-term success of an implant. Therefore, these two modalities must be addressed parallelly during the development of new orthopeadic implant materials [8]. The current research and development is focusing on multifunctional surfaces for implants in total hip arthroplasty for efficient performance in various biological and mechanical tasks. The response depends on the specific abilities of the surfaces/coatings acquired during fabrication

MAY 2017

Orthopedics Our present invention has shown long term drug delivery in a controlled manner to inhibit the bacterial infection and also to promot the osseointegration. On other hand, improved mechanical and tribological properties of the implant shows great promise for future implants and potentially targeted drug delivery systems.

This will improve the success rate of hip implants and longevity of replacement surgery. It definitely has the potential to offer for a group of people for whom, at the moment, hip implants are not surviving long enough. Indian government is taking steps to strengthen the policy and regulatory framework and campaigns, such as, ‘Make in India’ to improve the R&D capability of domestic industries. This is planned to be achieved through collaboration with academic institutions to introduce innovative products that can expand the market and also emerge as an export hub for medical devices to the rest of the world.

L.C. Huber, Mechanisms of disease: molecular insights into aseptic loosening of orthopedic implants, Nat. Clin. Pract. Rheumatol. 3 (2007) 165 –171 Z. Song, L. Borgwardt, N. Høiby, H. Wu, T.S. Sørensen, A. Borgwardt, Prosthesis infec-tions after orthopedic joint replacement: the possible role of bacterial biofilms, Orthop. Rev. 5 (2013) 65-71.

Raphel, Jordan, Mark Holodniy, Stuart B. Goodman, and Sarah C. Heilshorn.

"Multifunctional coatings to simultaneously promote osseointegration and prevent infection of orthopaedic implants." Biomaterials 84 (2016): 301-314.

Kumar, R. Manoj, Pallavi Gupta, Sandan Kumar Sharma, Akshat Mittal, Manish Shekhar, Vijayesh Kumar, BV Manoj Kumar, Partha Roy, and DebrupaLahiri. "Sustained drug release from surface modified UHMWPE for acetabular cup lining in total hip implant" Materials Science and Engineering: C 77 (2017) 649-661

References Chu, Paul K., and Xuanyong Liu, eds. Biomaterials fabrication and processing handbook. CRC press, 2008. https://www.mordorintelligence.com/ industry-reports/global-biomaterialsmarket-industry http://www.sathguru.com/Publication/ download/Orthopedic-industry-inIndia.pdf M. Louise, C.G. Helmick, The impact of osteoarthritis in the United States: a population-health perspective, Am. J. Nurs. 112 (2012) 13–19. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3796925/ D. Philipp, A. Eckardt, R.E. Gay, S. Gay,

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MAY 2017

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The enhanced Taq DNA polymerase, available in standard and hotstart formats, offers a balance between performance and value.

HEALTHCARE TIMES

26

MAY 2017

Products INVIEW ONCOPANEL GATC Biotech, a leading provider of advanced genome analysis and diagnostic services, launched today INVIEW ONCOPANEL, a comprehensive multigene cancer panel for solid tumour profiling.

The next-generation sequencing (NGS)-based panel consists of 50 cancer-specific genes that could add diagnostic, prognostic and therapeutic value to personalised care.

“INVIEW ONCOPANEL was the lone missing member of our cancer research and diagnostics portfolio,” said Dr Markus Benz, COO of GATC Biotech. “The service perfectly complements our liquid biopsy-based assay GATCLIQUID ONCOPANEL. It enables researchers and clinicians to screen not only liquid biopsy samples, but also tissue biopsy samples for genomic alterations. These carefully selected genes can help characterise a patient’s tumour and identify the most suitable treatment course on a case-by-case basis.”

tumour tissue and plasma-based patient samples under diagnostic conditions, we also aim to contribute evidence to proof-of-concept studies that are needed to implement liquid biopsies in clinical settings.”

INVIEW ONCOPANEL, which is a standardised sample-to-data solution, applies proprietary protocols for low-input DNA extraction from precious formalin-fixed, paraffin-embedded (FFPE) or fresh tissue samples. Optimised workflows carried out on leading technologies consistently result in extraordinarily high sequence coverage, uniformity and sensitivity that are needed to profile solid tumours and support tailored treatment decisions with absolute confidence.

With the rising need for validation of non-invasive Please visit www.gatc-biotech.com for more inforliquid biopsies, researchers can now evaluate the mation about genomic innovation – Made in Gerconcordance in mutation profiles from tumour tis- many. sue samples with INVIEW ONCOPANEL and from liquid biopsy samples with GATCLIQUID ONCOPANEL. Both cancer sets consist of more than 200 clinically actionable regions on 50 cancer-specific genes with strong predictive and prognostic potential. The targeted cancer-related genes include well-known tumour activators, tumour suppressors and biomarkers of drug resistance.

“By providing cost-efficient detection of mutations in key cancer drivers, we hope to draw the most meaningful molecular information out of invasive, but necessary tissue biopsies,” added Dr Benz.

“With the ability to perform comparative studies on

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MAY 2017