Utem Talk 2022

DR.
PREMGANESH A/L
LT.COL (R).
DR.GANAISAN
ORTHOPAEDIC SURGEON
MBBS ( MANIPAL), MS ORTHOPAEDICS (UM)
ADVANCE TRAUMA (KKM), ACETABULAR-PELVIS FELLOWSHIP (GERMANY)
ILIZAROV FELLOWSHIP ( ITALY, BANGLADESH)
CERTIFICATION IN WOUNDCARE (MSWCP)
ACADEMIC QUALIFICATIONS
TITLE FIELD YEAR INSTITUTION
MBBS Graduate/Bachelors 2003 Melaka-Manipal
Medical College

MsOrtho Post-graduate 2012 University Malaya

MRCS 1&2 Post-graduate 2007 & 2008 Royal College of
surgeons Edinburgh

Advanced Trauma Trauma 2014 ATLS Society
Life Support ( ATLS)

Fellowship in Pelvis Sub-specialty 2016 University Hamburg-
and Acetabular Eppendorf, Hamburg,
surgery Germany

Fellowship in the Sub-speciality 2016 G.B. Mangioni
Method of Illizarov Hospital,
Italy
Fellowship in Illizarov Sub-specialty 2016 Bari Ilizarov Centre,
and reconstruction Dhanmondi, Dhaka,
surgery Bangladesh
Advanced Trauma Subspecialty 2018 Ministry of Health
Subspecialty Malaysia

BRIEFLY ON MYSELF…
 QUALIFIED AS A SPECIALIST IN 2012
 GAZETTED IN MELAKA GH TILL 2014
 SUBSPECIALITY TRAINING 2015 -2018

SERDANG, KLANG & SEREMBAN GH
GERMANY, ITALY & BANGLADESH GH
 HEAD OT TRAUMA UNIT ( & SOUTHERN REGION ) - MELAKA GH 2018 – MAY

2019
WHAT I DO…
 GENERAL ORTHOPAEDICS – LUMPS-BUMPS, FRACTURES
& JOINT PROBLEMS .. & ACHES- PAINS FROM EVERYWHERE
 TRAINED IN PAIN MANAGEMENT USING RADIOFREQUNCY & LASER

SPECIALITY: COMPLEX
FRACTURES
ACETABULAR INJURIES COMPLEX FRACTURES
TRAUMA TRAINER
KANGHUI-MEDTRONIC SMITH&NEPHEW
MUSCULOSKELETAL
A SAFE AND VERSATILE METHOD TO MANAGE BONE DEFORMITY, COMPLEX FRACTURES AND COMPLICATIONS - BONE
LOSS AND INFECTIONS
THE COMPLICATIONS WHICH CAN ARISE FOLLOWING INJURY, INFECTIONS OR BIRTH DEFECTS TO THE BONE CAN BE
TRAUMATIZING – TO THE PATIENT ANDTHE FAMILY.
THE HEALING PORCESS CAN BE ARDOUS IF NOT MANAGED PROPERLY OR PROMPTLY, WHICH CAN RESULT IN DEFORMTY
AND DISABILITY.
INFECTIONS
THE ILIZAROV AND LLRS (LIMB LENGHTENING AND RECONSTRUCTION SYSYTEMS PROVIDE A VERSATILE AND SAFE
FIXATION OPTION. THE SYSTEMS CAN PROVIDE STABILITY, ADJUSTABILITY AND FUNCATIONALITY TO BONE AND TISSUE
HEALING
BONE DEFORMITY CORRECTION
BONE LOSS MANAGEMENT
FRACTURES ASSOCIATED WITH SKIN- MUSCLE LOSS

AND …CURRENTLY
WHY??
JOINT-RELATED
PAIN
DISORDERS
ROLE OF STEROIDS, HYALURONIC ACID,
PRP & RADIOFREQUNCY ABLATION
SCOPE OF THE WEBINAR
 COMMON PROBLEMS OF:
1. SHOULDER
2. ELBOW
3. KNEE
4. ANKLE/FOOT
5. ANYWHERE APPLICABLE
 TREATMENT OPTIONS – STEROIDS vs HA vs PRP
 WHAT ELSE CAN BE OFFERED – RADIOFREQUENCY ABLATION ( RFA)

ANATOMY
PATHOLOGY
 MUSCLE INJURY
 LIGAMENT & TENDON DAMAGE
 ROTATOR CUFF INJURY – SHOULDER
 PLANTAR FASCITIS
 OSTEOARTHRITS – KNEE & SHOULDER

MUSCLE INJURY
CLASSIFICATION : (Fernandes et al 2010)
 MILD ( GRADE 1)- SLIGHT OEDEMA & BRUISE
 MODERATE ( GRADE 2) - LOSS OF FUNCTION
- ECCHYMOSIS WITHIN 2-3 DAYS

- HEALING OVER 2-3 WEEKS
 SEVERE ( GRADE 3) - COMPLETE LOSS OF MUSCLE FUNCTION
- FAILURE OF MUSCLE STRUCTURE

- HEALING OVER 4- 6 WEEKS
 REPARATIVE PHASES:
1. DESTRUCTION
2. REPAIR
3. REMODELING
 STARTS BY 1 ST DAY
 BY 10 DAYS NO MORE FRAGILE
 VASCULARIZATION – VITAL PROCESS
TENDON INJURIES (FU ET AL EFORT 2017)
 DENSE CONNECTIVE TISSUE

 COMPLEX STRUCTURE
 HEAL SLOWLY
 RARELY RETAIN THE STRUCTURAL INTREGRITY & MECHANICAL STRENGTH
 TENDINOPATHIES :
1. OVERUSE
2. VASCULARISATION
3. AGING
 TENDON HEALING:
1. INFLAMMATION
2. CELL PROLIFERATION
3. EXTRACELLULAR MATRIX REMODELLING
OSTEOARTHITIS
EXTRINSIC INTRINSIC
Osteophytes MATRIX DISRUPTION
Synovitis CHONDROCYTE APOPTOSIS
Hypertrophy of Joint Capsule INCREASED VASCULARITY TO MENISCUS
Thickening of Subchondral bone
Changes in Periarticular fat, muscles, nerves INCREASED INFAMMATORY MARKERS
LIPID PEROXIDATION
Meniscal & ligament damage OXYGEN RADICALS PRODUCTION
REVIEW OF TREATMENTS
 STEROIDS
 HYALURONIC ACID
 PLATLET- RICH PLASMA
STEROIDS
 COMMONLY USED:
1. TRIAMCINOLONE ACETONIDE
2. METHYLPREDINISOLONE ACETATE
3. TRIAMCINOLONE ACETATE
 MECHANISM:
1. REDUCES SYNOVIAL BLOOD FLOW

2. REDUCES LOCAL LEUCOCYTE & INFLAMMATORY RESPONSE
3. ALTERS COLLAGEN SYNTHESIS
 LASTS 1-2 WEEKS
 NOT MORE THAN 3 /YEAR

HYALURONIC ACID
 GLYCOAMINOGYLCAN IN SYNOVIAL FLUID AND CARTILAGE
 NORMAL KNEE: 4-6 MILLION DALTON ; OA KNEE : LESS THAN 2 MILLION
 TYPES BASED ON MOLECULAR WEIGHT

 COMBINATIONS :
1. SORBITOL, MANNITOL - ANTI OXIDATIVE

2. STEROID (TRIAMCINOLONE) – ANTI INFLAMMATORY
 ACTS WITHIN 3 WEEKS & OPTIMIZED BY 8 WEEKS (CUBURKE

ET AL)
RECOMMENDATIONS:
 MODERTAE OA
 NOT TOO OLD
 SYMPTOMATIC
 COMBINE WITH GLUCOSAMINE
 NO INDICATION AS PREVENTIVE PROTECTION- NO

CHONDROPROCTECTIVE EFFECT
 YEARLY INJECTIONS – IF SYMPTOMATIC

- ALTMANN et al (2018)
PLATLET-RICH PLASMA
 4 TYPES: BASED ON FIBRIN & LEUCOCYTE CONTENT
 BEEN USED FOR DECADES
 CURRENTLY MORE TOWARDS: Leucocyte-&-Fibrin poor

1. LEUCOCYTE RICH: Pro-Inflammatory factors
2. LEUCOCYTE POOR: Anti-inflammatory factors
MECHANISM OF ACTION:
 ANGIOGENESIS
 CELL PROLIFERATION
 CHEMOTAXIS OF HEALING FACTORS
 STIMULATION OF GROWTH FACTORS
 CHONDROSCENENCES
 COLLAGEN-DEGRADING ENZYME INHIBITED
USES:
GOOD OUTCOME
OSTEOARTHRTIS
MY USES:
 MUSCLE DEFECTS:
1. NOT SO COMMON, DEPENDING ON INJURY
 TENDINOPATHIES:
1. SHOULDER, ELBOW, KNEE, ANKLE,
2. WRIST- deQuervain’s ….as it can be intratendinous
 JOINTS: POST-TRAUMATIC OSTEOARTHRITIS

SUMMARY OF INJECTIONS:
STEROIDS HYALURONIC ACID PRP
Acute injury Ideal for OA Role in OA, Tendon & Muscle
injury
Pain relief Opt for SINGLE , HIGH Acute or Chronic injuries

MOLECULAR WEIGHT
PERITENDINOUS Combine with analgesics / Steroid Acute- allow acute phase to

resolve
Not for Chronic injuries Aspirate Effusion prior SOMETIMES REQUIRES
IMAGING AIDS
NOT Multiple injections NOT DURING ACUTE FLARE
UP
RFA
RADIOFREQUENCY ABLATION
 BASIS: THERMAL DESTUCTION TO NERVES THAT CARRY PAIN FIBRES
 High frequency electrical current in about 500kHz
 TYPES:
1. THERMAL: Gross Thermal ablation…….JOINTS

- continuous waveform
- tissue temperatures 50-60’C
2. PULSED: Neural Modification of pain fibers….. NERVES

- short intensity bursts
- lower temperatures about 40’C
SITES:
 FACET JOINTS
 DORSAL ROOT GANGLION
 SYMPATHETIC NERVOUS SYSYTEM
 PERIPHERAL NERVES
1. Suprascapular nerve
2. Gleno-humeral joint & Rotator Cuff
3. Epicondyles
4. Hip, Knee & Ankle joint
5. Small peripheral nerves
MY USES…GOOD INDICATIONS
 ELDERLY …WITH CHRONIC DEBILITATING PAIN
SITES
 FAILED OTHER THERAPEUTIC METHODS
 MEDICALLY UNFIT
 NOT KEEN FOR SURGERY

CASE 1
 65 LADY, K/C BREAST CANCER
 SHOULDER PAIN FOR OVER 2 YEARS
 MULTIPLE STEROID INJECTIONS & ANALGESIC USE
 MRI: ROTATOR CUFF ARTHROPATHY
 PROCEDURE: under Sedation/ LA
1. Pulse RF of Suprascapular nerve

2. Thermal ablation of Capsule fibres
3. Thermal ablation of Subacromion fibres
CASE 2
 54 GENTLEMAN
 SPORTS INJURY 3 YEARS AGO
 SURGERY DONE 2 YEARS AGO
 HAD ANOTHER INJURY 1 YEAR AGO
 NOT KEEN FOR SURGERY
 PROCEDURE: under sedation/ LA
1. Thermal ablation of capsule fibers

2. Intraarticular HA injection
3. Pulse Rf of suprascapular nerve
CASE 3
 40 GENTLEMAN
 LOWER BACK PAIN
 JOB NATURE REQUIRES CARRYING HEAVY OBJECTS
 NO NEUROLOGICAL SYMPTOMS
 MRI: NO PID / NERVE IMPINGEMENT
 O/E: PAIN UPON EXTENSION & SIJ
 PROCEDURE:
1. Thermal ablation of SIJ & Facet joint

2. Triamcinolone injections
CASE 4:
PLANTAR FASCITIS
 IDEALLY SETTLES WITHIN 1-1.5 YEARS
 STEROIDS ARE A GOOD OPTION
 BUT FOR RECALCITRANT CASES :
 CASE:
1. 32, post partum. Failed steroid

2. Unable to weight bear
 PROCEDURE:
1. Pulsed RF of nerves
2. PRP of Fascia, & tender points

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DR.

 GAZETTED IN MELAKA GH TILL 2014

 SUBSPECIALITY TRAINING 2015 -2018

 HEAD OT TRAUMA UNIT ( & SOUTHERN REGION ) - MELAKA GH 2018 – MAY

 TRAINED IN PAIN MANAGEMENT USING RADIOFREQUNCY & LASER

BONE DEFORMITY CORRECTION

BONE LOSS MANAGEMENT

FRACTURES ASSOCIATED WITH SKIN- MUSCLE LOSS

 TREATMENT OPTIONS – STEROIDS vs HA vs PRP

 WHAT ELSE CAN BE OFFERED – RADIOFREQUENCY ABLATION ( RFA)

 ROTATOR CUFF INJURY – SHOULDER

 OSTEOARTHRITS – KNEE & SHOULDER

 MILD ( GRADE 1)- SLIGHT OEDEMA & BRUISE

 MODERATE ( GRADE 2) - LOSS OF FUNCTION

- ECCHYMOSIS WITHIN 2-3 DAYS

 SEVERE ( GRADE 3) - COMPLETE LOSS OF MUSCLE FUNCTION

- FAILURE OF MUSCLE STRUCTURE

 DENSE CONNECTIVE TISSUE

1. REDUCES SYNOVIAL BLOOD FLOW

 NOT MORE THAN 3 /YEAR

 TYPES BASED ON MOLECULAR WEIGHT

1. SORBITOL, MANNITOL - ANTI OXIDATIVE

 ACTS WITHIN 3 WEEKS & OPTIMIZED BY 8 WEEKS (CUBURKE

 NO INDICATION AS PREVENTIVE PROTECTION- NO

 YEARLY INJECTIONS – IF SYMPTOMATIC

 BEEN USED FOR DECADES

 CURRENTLY MORE TOWARDS: Leucocyte-&-Fibrin poor

1. NOT SO COMMON, DEPENDING ON INJURY

1. SHOULDER, ELBOW, KNEE, ANKLE,

2. WRIST- deQuervain’s ….as it can be intratendinous

 JOINTS: POST-TRAUMATIC OSTEOARTHRITIS

Pain relief Opt for SINGLE , HIGH Acute or Chronic injuries

PERITENDINOUS Combine with analgesics / Steroid Acute- allow acute phase to

1. THERMAL: Gross Thermal ablation…….JOINTS

2. PULSED: Neural Modification of pain fibers….. NERVES

 NOT KEEN FOR SURGERY

 PROCEDURE: under Sedation/ LA

1. Pulse RF of Suprascapular nerve

1. Thermal ablation of capsule fibers

1. Thermal ablation of SIJ & Facet joint

1. 32, post partum. Failed steroid

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