DECEMBER 2018 ISSUE 32 - Nanavati hospitalwrist or hip. Old bones get continually replaced with new bones as bones are living tissues. Around 85 to 90 per cent of the grown-up bone

BACK IN THE

P6GAME

THE SCIENCE OF FIXING A BIRTH DEFECT P4

ELIMINATING THE ODD P9

BLK Super Speciality HospitalAccredited by JCI

BLK Super Speciality HospitalPusa Road, New Delhi-110005 (India)

24-Hour Helpline: 011- 3040 3040Email: [email protected]

[email protected]

Nanavati Super Speciality HospitalSwami Vivekanand Road, Vile Parle WestMumbai, Maharashtra-400056 (India)24-Hour Helpline: +91-22-26267500marketing@nanavatihospital.orgwww.nanavatihospital.org

Radiant

PULSEDECEMBER 2018 | ISSUE 32

BACK IN THE GAME by Dr. Yajuvendra Gawai

6 - 7

THE SCIENCE OF FIXING A BIRTH DEFECT

by Dr. (Maj Gen) Avtar Singh Bath

4

THE SECRET BEHIND STRONG BONESby Prof.(Dr.) Pradeep B. Bhosale

5

ARE YOU IN PAIN TODAYby Dr. Bhushan Nariani

8

A LASTING FIXby Dr. Subhash Chandra, Dr. Satbir Singh & Dr. Dheeraj Gandotra

10

ELIMINATING THE ODD by Dr. Suruchi Desai

& Dr. Uddhavraj Dudheria

9

EXPANDING THE HORIZON

by Dr. Rajiv G. Bhagwat

11

BLK & NANAVATI IN NEWS

14 - 15

EVENTS ANDACTIVITIES

12 - 13

FROM THE DIRECTOR’S DESK

02 Radiant Life Care | Newsletter | December 2018 03BLK, New Delhi | Nanavati, Mumbai

CONTENT SHIKHA GIRGLA MAMTA SINGH

Nanavati Super Speciality HospitalMumbai, Editorial Team

PRAJAKTI SHIRSEKARSHYAM SHIRSEKAR

EDITOR-IN-CHIEF PARUL CHHABRA

CREATIVE CONCEPT PARUL CHHABRA SHIKHA GIRGLA

SUNIL KUMAR

DESIGN & VISUALISATION

SUNIL KUMAR

CONTENTS

Dear Reader,

In the last edition of this year’s Pulse, we bring you some of the most complex and challenging cases that were performed at our hospitals in Mumbai and Delhi.

For the cover story we have featured the case of an upcoming star of the Indian Women's Cricket team.She was admitted to Nanavati Super Speciality Hospital, our group hospital in Mumbai, after sustaining an ACL tear and medial meniscus posterior horn tear. The specialist team at the hospital after careful examination and assessment of her specific condition decided to perform a double-bundle ACL reconstruction using dual hamstring graft and all-inside meniscus to treat her. The surgery went uneventfully. She is currently undergoing a rehabilitation program under the close supervision of the experts at Nanavati and will soon return to her normal form and start playing again. Another interesting story is that of a 24-year-old female patient with multiloculated cyst which was removed successfully by the experts at Nanavati. You will also find an interesting piece on Osteoporosis and weakening of bones as well as tips on how to maintain healthy bones after crossing the age of 50. There is also an article by Dr. Rajiv Bhagwat on his recent participation in the prestigious European Bifurcation Club at Brussels.

From BLK, we bring you an interesting article on use of Computer Navigation Technology for Total Knee Replacement Surgery by our Joint Replacement Specialist - Dr. Bhushan Nariani. There's also a story on how PFO intervention gave a 49-year-old female patient, who suffered Cryptogenic Stroke, a lasting cure. You will also find the story of a 16-year-old male patient with severe depression of the chest wall since birth and how his deformity got corrected all thanks to the experts at the BLK Centre for Plastic & Cosmetic Surgery.

Before I conclude, I want to thank you all for your continued support and contributions. If you have more such inspiring pieces fit for this newsletter, do share it with us at: [email protected].

Stay Healthy, Stay Happy!

Dr. Mradul KaushikDirector - Operations & Planning BLK Super Speciality Hospital New Delhi

The patient was discharged on the seventh post-operative day in stable condition with fully corrected deformity. The patient and his parents were satisfied with the outcome of the procedure. Earlier, he was advised by multiple surgeons across countries that his deformity cannot be fully corrected at this age, and that he will need multistaged surgery. The patient's concern regarding the deformity was resolved finally after the correction procedure at BLK.

Pectus Excavatum is one of the very rare deformities in coloured races and quite uncommon in India. There is hardly any publication in literature from India. There are a variety of operative techniques described for the correction of Pectus Excavatum. The most popular being open Ravitch repair and its modifications. These are 2 stage procedures with associated complications of bar migration. For this particular patient, another modification (single staged) of Open Ravitch procedure was used which is not associated with the afore-mentioned serious complications.

THE SCIENCE OF FIXING A BIRTH DEFECTTotal Single Stage Repair of Pectus Excavatum Deformity

Dr. (Maj Gen) Avtar Singh BathSr. Consultant & Head BLK Centre for Plastic & Cosmetic SurgeryBLK Super Speciality Hospital, New Delhi

A 16-year-old male patient was brought to the BLK Centre for Plastic & Cosmetic Surgery with severe depression of the chest wall since birth, associated with difficulty in breathing during strenuous activities. The patient was diagnosed to have severe Pectus Excavatum with the Haller's Index of 3.8.

The patient underwent Single Stage Total Pectus Excavatum repair, a modification of the open Ravitch procedure. Bilateral inframammary incision was used and skin flaps were raised superiorly till clavicle and inferiorly upto costal margins followed by elevation of the pectoralis major muscle and rectus abdominis muscle flaps on both sides. After resection of the deformed cartilages on both the sides, substernal space was dissected. Wedge Osteotomy was performed in the superior part of sternum and deformity was fully corrected. Rigid fixation of the Osteotomy site of the sternum was performed using two titanium plates. Additional stability was provided to the corrected sternum by placing reconstruction plate anterior to the sternum and fixing it to rib and sternum using SS wires.


THE SECRET BEHIND STRONG BONESUnderstanding Osteoporosis and tips on maintaining healthy bones after 50

Prof.(Dr.) Pradeep B. BhosaleDirector Arthritis & Joint Replacement Surgeries Nanavati Super Speciality Hospital Mumbai

Osteoporosis occurs when the bones start weakening leading to easy breakage of bones and fracture. It affects men and women both, but the risk is higher in women due to menopause which results in a sudden reduction in oestrogen level. Risk factors for osteoporosis include ageing, high body weight, poor activity level, low sex hormones or menopause, smoking and few drugs.

Osteoporosis is a disease that arrives silently and one gets to know about it only after experiencing a crack or fracture. The side effects of Osteoporosis include backache, slow loss of height and formation of a stoop and easy micro-fractures at multiple levels of spine, wrist or hip. Old bones get continually replaced with new bones as bones are living tissues. Around 85 to 90 per cent of the grown-up bone mass is gained by the age of 18 in women and 20 in young men, so forming solid bones during youth can help avoid Osteoporosis at a later age. Brain governs hormonal activities, and our daily activities

provide feedback to the brain. The brain makes necessary changes to improve bone structure in order to perform those activities. Hence for a person who is bedridden, his brain understands his activity need is poor, and the bones tend to become weaker. While a person who works out every day, the brain will stimulate stronger bone formation.

There are some lifestyle choices one can adopt to prevent oneself from Osteoporosis which include:

Performing weight-bearing exercise: Physical exercises that power you to neutralise gravity, for example, strolling and climbing, reinforce your bones and muscle.

Following a healthy diet: Eating nutritious food that is rich in calcium and vitamin D is basic to bone well being.

Abstaining from drinking alcohol in excess: People who drink a great deal of liquor at a young age are more inclined to bone misfortune and broken bones as the critical bone building is damaged due to heavy intake of alcohol.

Quit smoking: Notwithstanding being injurious to the heart and lungs, smoking is additionally harmful to bones, since individuals who smoke may assimilate less calcium from the nourishment they eat.

Early diagnosis: Bone Density Test is the most precise diagnostic tool to pre-empt the onset of Osteoporosis. If you hit early menopause, it is recommended to do a Bone-density test.Pre-operative image Post-operative image

UNDERSTAND YOUR BONES

Osteoporosis happens when bone density decreases and the body stops producing as much bone as it did before.

“

”

Pectus Excavatum is a congenital deformity of the chest wall that causes several ribs and the breastbone (sternum) to grow in an inward direction.

“

”

numerous mid to long-term studies in the western medical literature, failure rates are higher with cadaveric tissue grafts. Hence, the experts at Nanavati Super Speciality Hospital decided to go ahead with autograft.

There are a variety of options in autografts as well. Most commonly used grafts are Hamstring and Bone-Patellar tendon-bone graft (called BTB for short, it has bone plugs at either end). There are other less commonly used options like Peroneal Longus Tendon and Quad Tendon. These are generally reserved for revision purpose. Between Hamstring and BTB grafts, failure rates are marginally higher in Hamstring tendon grafts as per the studies. However, there is a slightly higher risk of developing anterior knee pain, especially while kneeling or squatting in the BTB group. These movements are important and sometimes inevitable in professional sports hence it was decided to use the dual Hamstring graft.

Single-bundle versus double-bundle reconstruction:

ACL Reconstruction can be performed in either of the above techniques. In a single-bundle reconstruction, only one cylindrical graft is used to replace

BACK IN THE GAMEExperts perform double-bundle ACL Reconstruction to treat an upcoming star of the Indian Women's Cricket team

ACL Reconstruction is one of the most common surgeries in Sports Orthopaedics today. In the USA alone around 60,000 to 100,000 ACL Reconstruction surgeries are performed every year as per the NHDS database. However, ACL Reconstruction is not like a “one size fits all” kind of surgery. There are at least 10-12 widely accepted variations of this procedure. The ideal approach has to consider patient factors and injury pattern to achieve good outcomes. Also, post-operative rehabilitation plays a pivotal role especially in the case when the player is trying to return back to the sport.

Ms. Keerthi James, one of the upcoming stars of the Indian Women's Cricket team, had an ACL tear and medial

meniscus posterior horn tear and was brought to Nanavati Super Speciality Hospital, Mumbai. The specialist's team at the hospital decided to perform a double-bundle ACL reconstruction using dual hamstring graft and all-inside meniscus to treat her.

One factor to consider in ACL Reconstruction is graft choice. There are classically two choices- Allograft, which is cadaveric tissue and Autograft, which is the patient's own tissue. Due to lack of cadaveric tissue processing and storage facilities, allograft tissue is not freely available in India. It can be imported if requested.

However, importing increases the cost of the procedure significantly. Also, as per

Dr. Yajuvendra GawaiConsultant – Shoulder & Knee specialistArthroscopy surgery & Sports MedicineNanavati Super Speciality Hospital Mumbai

the native ACL. In a double-bundle reconstruction, two smaller bundles are used which are more anatomical.

In numerous clinical studies, there have not been any statistically different outcomes as regards to single and double-bundle reconstructions. However, biomechanical studies have established that double-bundle reconstruction more closely mimics a normal ACL. Also, the failure rates are slightly lower for double-bundle reconstructions. And, because of all these reasons, the team decided to go ahead with the double-bundle technique.

Modes of fixation:There are plethora of fixation devices to fix the grafted tissue. Most commonly used ones are cortical buttons and interference screws. Studies have shown that fixation methods do not significantly alter the outcomes. Hence, we decided to use cortical buttons on the femoral side and biocomposite screws on the tibial side.

After the surgery, structured rehabilitation is equally important in achieving a good outcome. It may last for anywhere between 6-8 months for return to play. Sometimes even upto a year or more in a professional athlete. The challenge here is to hold back the sportspersons who are quite eager to get back into the thick of action- especially, when it means representing one's country, there is a degree of pride and responsibility attached to it as well.

Currently, Keerthi is having her rehabilitation at the Kerala Cricket Association facility under the close supervision of our doctors. The Nanavati Super Speciality Hospital family wishes her a speedy recovery and hopes she gets back into her normal form soon and makes us all proud.


"Unlike professional sportspersons, most recre-ational athletes do not have access to good quality sports medicine infrastructure and expertise in India. To solve this problem, we have started a comprehensive sports med-icine facility here at Nana-vati Hospital. It includes services of Sports Orthopedic surgeon, a team of sports Physiotherapists, Sports Nutritionists and Sports Physicians. It is this team approach that sets us apart from the average Sports Or-thopedic setups." – Dr. Yajuvendra Gawai

“IN THE USA ALONE AROUND 60,000 TO 100,000 ACL RECONSTRUC-TION SURGER-IES are performed every year as per the NHDS data-base. We, in India, are getting there slowly but surely. However, ACL Reconstruction is not like a “one size fits all” kind of surgery.

There are at least 10-12 widely accepted variations of this procedure. The ideal approach has to consider patient factors and injury pattern to achieve good outcomes.

“

”

ARE YOU IN PAIN TODAY?Bank on Computer Navigated Total Knee Replacement Surgery

Joint pain has become a common ailment in India and a major health concern for the people. Earlier, this Orthopaedic problem was prevalent in elderly people. Now, even the younger generation, both men and women are being affected by joint problems due to several reasons including injuries. Orthopaedic surgeons recommend Hip or Knee Transplant to overcome the joint pain. However, challenges are many. Right from identifying the exact need of the patient, selection of right implants to performing high-end surgeries with precision-skill sets, each aspect needs focused attention to make Orthopaedic surgeries successful. Implant selection and adoption of global best practices, quality and skills of a surgeon play a key role in making an Orthopaedic surgery effective.

Patient safety remains a major concern. Patients, in need of Joint Replacement Implants, trust surgeons blindly. Hence, it is paramount that the experts should never fail them. Use of advanced technology has come as a boon for the patient. Obviously, surgeons were expected to know not only about the implants and its exact surgical procedures but also inform the patients about its efficacy and risks. It is roughly estimated that over one lakh Joint Replacement surgeries are carried out in the country every year. Of these, an estimated 70,000 to 80,000 are Knee Replacements, and 20,000 to 30,000 are Hip Replacement Surgeries. However, the joint registry established by the Indian Society of Hip and Knee Surgeons (ISHKS) has recorded only 1.71 lakh Knee and 14,000 Hip Replacement surgeries since it began collecting data in 2007.

Total Knee Replacement SurgeryTotal Knee Replacement surgery is performed on patients with extreme

destruction of the knee joints, associated with progressive pain and impaired function. It is a surgical procedure in which the diseased knee joint is replaced with artificial material. Total Knee Replacement surgery has become a commonly used and very successful procedure to treat damaged knees. With the advancement of medical technology and latest innovations almost every day, the success rates and post-operative satisfaction of the patients are only increasing.

Minimally Invasive Total Knee Replacement SurgerySpeaking of the latest technology in the medical world, Total Knee Replacement surgery technique has crossed another milestone with the inclusion of computer navigation. The evolution of the surgical procedures with the involvement of minimally invasive techniques has made it possible for surgeons to perform more accurately and with better control. The computer navigation enables the surgeon to locate the problem area more precisely than ever before. Patients also take lesser time post-operatively for rehabilitation after the surgery. The pain is lesser, hospital stay gets shorter, and the scars are smaller under this surgical technique.

Use of technology especially in the medical field has come after prolonged Research and Development. Nearly 10 years of clinical trials are recommended should this be a norm in case of such implant. However, the patients should also be educated about a critical fact that implants cannot replace the original knee or hip, hence, they also need to follow certain protocols to make the best use of it and for the safety purpose.


ELIMINATING THE ODDDiligent intervention by experts removes multiloculated cyst in a 24-year-old patient

Dr. Suruchi DesaiConsultant Gynaecologist & Obstetrician Nanavati Super Speciality Hospital Mumbai

A 24-year-old unmarried girl came to Nanavati Super Speciality Hospital with complaints of pain in the abdomen and gradual distension of abdomen with discomfort. Upon investigation, the abdomen was found to have distended in the past 32 weeks. On further examination, a tense mass was felt in the abdomen area. The patient was sexually not active as well. MRI showed multiloculated cyst arising from the left ovary with cystic components. No ascites and lymph nodes were seen.

After careful examination and arrangement, the patient was prepared for surgery. Laproscope was inserted just below xiphisternum while suction was inserted through another port via the umbilicus. Suction was inserted into the cyst and it was decompressed taking great care to avoid any spillage. After that, Laparoscopic Cystectomy was done, and the cyst was removed through minilap incision using Coviedon Sleeve. The cyst was removed in Toto and send for Holoprosencephaly (HPE). Since the right ovary showed

a small cyst of about 3 cms, the same was removed and sent for HPE. The HPE results showed Bilateral Borderline Mucinous Tumour of endocervical type. An omental biopsy was taken. The minilap incision was closed, and the patient's post operative recovery was uneventful.

Dr. Bhushan NarianiDirector- Joint ReplacementBLK Institute for Bone, Joint Replacement , Orthopaedics Spine and Sports MedicineBLK Super Speciality Hospital, New Delhi

Dr. Uddhavraj DudheriaConsultant Gynaecologist & Obstetrician Nanavati Super Speciality Hospital Mumbai

MRI image of the patient

A multiloculated cyst contains several compartments formed by membranous septa.

“

”

Although, Osteoarthritis is the most common form of Arthritis, there are also other forms such as Rheumatoid Arthritis, Post-traumatic Arthritis, etc. At early stages, it can be managed by medications and walking support. But, when even these things are no longer helpful, Total Knee Replacement is the option to go for. Use of technology and surgeons’ expertise are key factors in dealing with joint problems.

“

”

Cryptogenic Stroke (CS) is defined as Cerebral Ischemia( BRAIN ATTACK) of unknown origin. The cause of Cryptogenic Stroke remains undetermined because the event is transitory or reversible or investigations could not ascertain all possible causes, or because some causes truly remain unknown. One third of the Ischemic Strokes are Cryptogenic, wherein we cannot find any cause. Upto 40% of Cryptogenic Strokes are found to have concurrent PFO (Patent Foramen Ovale) which is a hole in the heart. Patients with Cryptogenic Stroke and PFO are at low risk of having recurrent cerebrovascular events. As per the current advice from guidelines, it is suggested that transcatheter closure of PFO should only be considered for patients with recurrent Cryptogenic Stroke on optimal medical management.

A 49-year-old female patient was admitted to BLK with complaints of right sided weakness and was diagnosed having non-hemorrhagic infarct involving grey and adjoining subcortical white matter of left medial frontal lobe. There were multiple areas of Cystic Encephalomalacia with surrounding gliosis involving middle and inferior frontal gyri and left parieto-occipital

A LASTING FIXPFO Device Closure – Permanent cure for Cryptogenic Stroke

lobe medially mild ex-vacuo dilatation of left ventricle. Also few punctuate foci in the right frontal subcortical white matter s/o chronic ischemic changes. She was having past H/O CVA in a similar episode in 2008.

On evaluation of etiology of the recurrent CVA, she was found having PFO on TEE (right to left flow on valsalva). Thus, a decision was made to go ahead with PFO intervention. PFO device (25mm) closure was done through the right femoral vein under local anaesthesia using 12 F sheeth resulting in no flow across the device. Subsequently, successful closure of PFO was achieved. The patient was advised to be on dual antiplatelets for one month followed by single antiplatelet.


EXPANDING THE HORIZONDr. Rajiv Bhagwat invited to the prestigious Europe-an Bifurcation Club at Brussels

Dr. Rajiv G. BhagwatCardiologist Heart Institute Nanavati Super Speciality Hospital Mumbai

Dr. Rajiv Bhagwat recently attended the prestigious European Bifurcation Club Conference at Brussels. Only a few selected esteemed doctors from around the globe are invited to attend the prestigious European Bifurcation Club (EBC) meeting which is held every year. This year nearly 242 doctors from 49 countries attended the conference including 6 doctors from India who are all members of the Bifurcation Club of India where Dr. Bhagwat is the founding trustee.

The Bifurcation Club of India holds its annual conference at Mumbai and the faculty from the European Bifurcation Club are keen to attend the meeting each year. At the conference, Dr. Rajiv Bhagwat gave insights on the ‘Modification of pre-existing technique of Bifurcation Angioplasty’ and ‘DK Crush Technique for left main Bifurcation Stenosis’. The Crush Technique was introduced by Dr. Antonio Colombo and was further modified by a Chinese Cardiologist. As a result, the DK Crush Technique is now one of the established treatment for left main Bifurcation Stenosis. Dr. Bhagwat's talk on this technique was a part of a debate on various procedures for treating left main Bifurcation disease. A modification of the pre-existing technique

of TAP stenting in the form of balloon-assisted side branch stenting which helps in the precise deployment of the side branch stent after the main branch stent is deployed.

Dr. Rajiv Bhagwat showed several cases of this modified technique at the conference along with the advantages. The audience appreciated both the lectures. This was the third invitation Dr. Bhagwat had received to attend the conference. The meeting witnessed

participation of international experts with significant emphasis on research and data from all around the world. The European Bifurcation Club is an opinion making body whose recommendations are highly regarded all over the world. Bifurcation Angioplasty is a

complex form of Angioplasty which takes some time to learn and considerable experience to achieve perfection. Close to 30% of patients have Bifurcation disease. The procedure of Bifurcation Angioplasty needs to be done perfectly to give complete and long lasting relief to the patient.

Dr. Rajiv Bhagwat will also be attending ‘India Live’ which will be held in the month of February. India Live is the biggest meeting of Interventional Cardiologists in the country, and enjoys the keen interest of delegates from neighbouring countries as well. Dr. Bhagwat has been invited to this mega event as the course co-ordinator where he would also do live cases.

THE EUROPEAN BIFURCATION CLUB (EBC) was initiated in 2004 to support continuous overview of the field of CORONARY ARTERY BIFURCATION INTERVENTIONS and aims to facilitate a scientific discussion and an exchange of ideas on the management of Bifurcation disease.

This is the first case of PFO device closure for the treatment of cryptogenic stroke performed at BLK Super Speciality Hospital.

“

Dr. Dheeraj Gandotra ConsultantCardiologyBLK Heart CentreBLK Super Speciality Hospital, New Delhi

Dr. Subhash ChandraChairman & HODCardiologyBLK Heart CentreBLK Super Speciality Hospital, New Delhi

Dr. Satbir Singh Sr. ConsultantCardiologyBLK Heart CentreBLK Super Speciality Hospital, New Delhi


EVENTS AND ACTIVITIES

Nanavati Super Speciality Hospital, Mumbai commissions another Tele-Medicine Centre at Pune in collaboration with CREATE (NGO) and Remedi (Technology partner). The Centre has provided more than 250 tele - consultations since its launch.

LAUNCH OF TELEMEDICINE CENTRE IN PUNE

Dr. Prasad Wagle has joined Nanavati Super Speciality Hospital as Head of the Department – Hepatopancreaticobiliary. In 1998, he joined the University of Hamburg Hospital in Germany as a Clinical Fellow and worked in the Departments of Pancreatic & Liver Units including Transplant Surgery. Dr. Wagle is the founder member of the Indian Chapter of the International Hepato-Pancreato Biliary Association since 1997.

NANAVATI HOSPITAL WELCOMESDR. PRASAD WAGLE ON BOARD

WELCOME TO THE BLK FAMILY

BLK DIWALI CELEBRATION

BLK Super Speciality Hospital had organised a grand ‘Diwali Celebration’ for the entire BLK family.

Ms. Rita Choudhrie, Chairperson, BLK Super Speciality Hospital presided over the event as the Chief Guest. The event witnessed enthralling performances by the staff members, felicitation of star performers and other engaging activities.

Dr. Ajay KumarChairman & HOD

BLK Institute for Digestive & Liver Diseases

Dr. Bhushan NarianiDirector- Joint Replacement

BLK Institute for Bone, Joint Replacement Orthopaedics Spine and Sports Medicine

Dr. Manav WadhawanDirector

BLK Institute for Digestive & Liver Diseases

BLK EMPLOYEE RECOGNITION

Employee of The Month- Mr. Mahesh Kumar Sharma (Assistant Manager-Stores); Doctor of The Month- Dr. Aditi Mittal (Senior Resident- Haematology & Molecular Biology); Nurse of The Month- Ms. Juna Abraham (Staff Nurse-Nursing); GDA of The Month- Mr. Jaiveer (Evershine Services); Contractual Worker of The Month- Mr. Om Prakash (STP Operator-RB Enviro Consultant) with managment of BLK Super Speciality Hospital.


BLK AND NANAVATI IN NEWS

Documents

DECEMBER 2018 ISSUE 32 - Nanavati hospitalwrist or hip. Old bones get continually replaced with new bones as bones are living tissues. Around 85 to 90 per cent of the grown-up bone