Case study 1: Tennis Elbow

25 year old lady working in Software Company complains of pain last 2 years. Pain increases on lifting objects. She was diagnosed having tennis elbow for which she received treatment in form of analgesics, heat therapy, steroids and brace for 4 months. Twice she was given local steroid injections which resulted in temporary and incomplete relief. Pain persisted even after 10 months of therapy. Debridement of extensor tendon origin with decompression of bone was done followed by post operative physiotherapy. During debridement we remove angiofibroblastic tissue (this is abnormal tissue) {fig 1&2} and suture bck the tendon {fig 3}. Conventionally for tennis elbow release of tendon is done which results in weakness and prolonged morbidity. In comparison to release debridement has early recovery {fig 4} and very less weakness.

Case study 2: Thumb Lengthening Surgery

17 year old boy presented with injury to the right thumb resulting in the shortening. On examination interphalangeal joint of the thumb fused with 2.5 cm shortening of the thumb. Ring fixator applied to the right thumb for lengthening of right thumb. 1.9 cm increase in length achieved as there was no movement at the IP joint therefore full correction was not desired.

Case study 3: Proximal Humeral Fracture Fixation

54 year old businessman had road traffic accident. After clinical examination, Radiographs and CT Scan patient was diagnosed as a case of fracture dislocation proximal humerus left shoulder. Open Reduction and screw fixation was done for the fracture. Stability of fixation was checked intraoperatively on image-intensifier (click here for video). Patient was mobilized with in first week on pendulum exercises and in 2nd week passive abduction and in 3rd week active abduction was started. Patient had good movements after 4 months of rehabilitation.

Case study 4: Endoscopic Carpal Tunnel Release

28 year old male having pain, numbness and loss of sensations in right hand for last 6 months. Numbness was in thumb, 2nd and 3rd fingers of right hand. Patient used to wake up in night many times. EMG and NCV were suggestive of carpal tunnel syndrome right hand. Endoscopic carpal tunnel release was done with 7 mm incision. Post operative no immobilization was given. Patient was able to do light work from third postoperative day. He was able to join active duties in merchant navy within a month. Patient did not have any scar tenderness and after nine months follow-up no complaints in the same hand.

Case study 5: Endoscopic Cubital Tunnel Release

There was 24 year old male complaing of paraesthesias and pain in ulnar side of palm and 4th and 5th fingers. Provocative test i.e elbow flexion test was positive. Tinnel’s sign was also suggestive of cubital tunnel syndrome. Electrodiagnostic studies were supporting the diagnosis. Patient was initially treated conservative in form of avoiding activities aggravating pain, night splints and anti inflammatory drugs. There was no response to conservative management, patient was taken up for Endoscopic Cubital Tunnel release. Patient positioned supine tourniquet inflated after Esmarch bandage. Two cm incision transversely (some people like longitudinal incision). Find the plane of ulner nerve and introduce special self retaining retractors. (see the video 1) insert a scope with special sleeve with retractor. Deroof the cubital tunnel (see the video 2). decompress the nerve and inspect it (see the video 3) if required open the sheath of ulnar nerve if required (see the video 4). Finally before closing inspect the nerve again. (see the video 5) patient is given bandage (bulky) for two days. 3rd day patient is given smaller bandage and allowed movements (see the video 6). Within 3 weeks all the symptoms of patient disappeared.

Case study 6: Fracture clavicle

19 year old male had fall resulting in injury to left clavicle. Patient had fracture lateral third clavicle with communition (many pieces of bone fragment) {fig 5.1}. Fracture was fixed with LCP Reconstruction plate{fig 5.2}. At 6 weeks fracture united {fig 5.3}and patient had full movements{video 5.4}.

Case study 7: Nonunion Fracture Right Scaphoid

Patient had history of fall on outstretched hand which resulted in injury to right wrist. Patient was treated conservatively in cast for fracture scaphoid. There was nonunion fracture right scaphoid on radiographs (fig 1). MRI showed nonunion fracture scaphoid with avascular necrosis proximal fragment (fig 1). Patient was treated by screw fixation (Herbert-Whipple, Zimmer) and 1,2 ICRSA vascularised bone grafting was done (fig 2). Fracture united within 6 weeks post operatively. After rehabilitation wrist was fully functional (fig 3).

Case study 8: Wrist Arthroscopy

R S Sirohi, a civil engineer, had been suffering from wrist pain for more than a year making his right hand completely immobile. His wrist pain was finally cured with the help of wrist arthroscopy surgery, following which a diagnosis was made.
“It all started one evening, when my cell phone rang and I turned around to pick it up from the bed-side table. I felt a sharp pain in my wrist. At first I thought it was a sprain, because of the sudden movement, and waited for it to subside. Even after several weeks, when the pain still persisted; I decided to see a doctor. I am an engineer with the Northern Railways, and responsible for the maintenance of the tracks. The wrist pain made it increasingly difficult to concentrate on any work. I first went to the Railway hospital and despite being given medicines, did not get relief. Thereafter began a long journey: I went to every possible doctor, and every conceivable medical test was done to get some clue about the wrist pain. Even a CT scan of my brain and spine did not reveal the cause of the pain in my wrist! Unable to diagnose the mysterious problem, a doctor gave me steroid injections as a last option, to relieve me of the chronic pain. Unfortunately, even that didn’t work”.
“One doctor told me that my diabetic condition was the reason, and I was put on medications to control diabetes along with pain killers. When the pain persisted, I was put on heavy medication. With each passing day it became more and more difficult for me to move my hand, to the extent that I couldn’t even lift a piece of paper. The pain was terrible and more than a year went by with my right hand almost paralysed. By this time my family was very worried. There were speculations about my condition. Some even said it might be a rare case of cancer which is why diagnosis was proving difficult. This thought scared me”.
“Finally, I went to AIIMS, where I was suggested synovial biopsy in my wrist, because the doctor suspected an infection. Because of the rush at AIIMS, I went to see another specialist, Dr Vikas Gupta (a hand specialist) at Fortis hospital. Dr Gupta suggested a synovial biopsy after seeing my reports. After the biopsy procedure, when I came to my senses, the mysterious pain had gone. I was later told that I had been suffering from tuberculosis for the past one year, and it was the cause of the chronic wrist pain. During the biopsy, Dr Gupta had simultaneously cleaned up the infected tissues through a 15- minute surgery, called wrist arthroscopy”.
“However, it came as a total surprise that I had TB in the wrist. I only thought TB affects the lungs. Apparently, TB can affect the bones or spine as well. While TB of lungs is infectious, other forms aren’t. I learn’t that when TB bacteria enters a patient’s body, the natural immunity fights off the bacteria, indicated by pus formation. In my case the bacteria persisted, causing me pain. But soon after the surgery, which detected and cleaned up the bacteria infected tissue, followed by medication to cure the remaining TB infection, my pain gradually subsided”.
“I am very grateful to Dr Gupta who was the first to be able to diagnose my problem, and relieve me from the agony I was in.Two months after the surgery, I am almost normal and after months, I am back to work. Looking back, these 15 months have been the most difficult. It was for the first time I was so dependent on my family for everything. As I continue taking two tablets daily, as part of my TB treatment, I already feel fitter and better”.
Dr. Vikas Gupta on the condition and its treatment
“When Sirohi came to me his hand was swollen and he was in severe pain. After going through the various reports, I recommended a synovial biopsy, which helped make a conclusive diagnosis. For the biopsy, we made two incisions in the wrist of his right hand and with the help of a camera, we found tuberculosis infection in his wrist”.
“Then on the operation table itself with the patient under anaesthesia, I cleaned up the infected issues with a procedure called wrist arthroscopy. It is a simple minimally invasive technique. In this procedure, a small camera fixed to the end of a narrow tube is inserted through a small incision in the skin directly into the back of the wrist joint. The camera lens magnifies and projects the small structures in the wrist onto a television monitor, allowing for a more accurate diagnosis. Several small incisions are used to allow the surgeon to place the camera in different positions to see different structures inside the joint as well as to place various small instruments into the wrist joint to help diagnose and treat various problems”.
“This surgery is particularly helpful for patients suffering from chronic wrist pain for a long period of time, or for those suffering from fracture, arthritis and physical trauma. Traditionally, such conditions were being treated through an open procedure which doesn’t guarantee 100 per cent mobility in the wrist, and a greater risk of infection. Sirohi’s pain is almost gone. After the surgery, physiotherapy was required to avoid stiffness in the hand”.

Case study 9: Ulnar collateral injury right thumb


23 year old athlete had injury to right thumb while playing cricket 3 months back. Initially patient was treated elsewhere conservatively. But patient complaint of difficulty in bowling and pain on fielding. On examination it was found that there was tenderness on ulnar aspect of Metacarpophalangeal joint thumb. On stress there was pain and instability.
Patient was advised ulnar collateral ligament reconstruction.before surgery instability was demonstrated on fluoroscopy (video 1). During surgery MCP joint was opened from medial aspect and ulnar collateral reconstructed using a tendon graft and fixed to bone using anchor sutures (fig 1 &2). Intraoperatively stability of joint was again cheked clinically as well as under image intensifier (videos 2 &3). Three months after surgery patient had stable painless joint (video 4 &5) and returned to active sports.
Ulnar Collateral Injury Condition Video

Case study 10: Percutaneous Scaphoid fixation

I am practicising as a neurosurgeon in south Delhi for last 18 years. I sustained a fracture scaphoid right wrist. I got scared as far as my knowledge of scaphoid fracture was that it is notorious for nonunion (not uniting) and avascular necrosis (bone becoming dead). These thought are like nightmare for neurosurgeon. It was then a came to know about Dr Vikas Gupta who was fixing these fractures percutaneously (without opening fracture) with screws. When I approached him he was confident that he would be able to fix my scaphoid with this minimally invasive technique and scheduled the surgery next day. Later I came to know that he was first person to fix scaphoid percutaneously in India. . I was able to start operating within 3 weeks of surgery. Presently I don’t have any complaints in my right wrist. I wish Dr Vikas Gupta all the best for all his future endeavors.
Percutaneous Scaphoid fixation