- An open randomized study evaluating the thrombo prophylactic efficacy of low molecular weight heparin (Fragmin) v/s no thrombo prophylaxis in total hip and knee replacement surgeries and fracture femur intervention. The first study of its kind being carried out on the Asian population.
- The prevalence and incidence of DVT and its control.
- Study on EPREX which is a Erythropoietin factor capable of enhancing the haemoglobin in patients to allow them to tide over surgical procedures which may result in blood loss without the need for blood transfusions in the peri-operative period.
- The use of Calcium Hydroxy Appetite in the enhancement of bone unions at fracture sites.
- Ongoing research on Bone graft substitutes
- Ongoing research on Alendronate and its use to prevent AVN (alongwith Dr. V.R. Joshi).
- Round the year teaching activities of DNB Orthopedic programme
- Prevention and Prevalence of DVT in Indian patients
- Ongoing research on Stem Cell Research in the treatment of Avascular Necrosis of the Hip.
- Bisphosphonate therapy which was pioneered by Dr. Sanjay Agarwala has certainly changed the treatment scenario. Dr. Sanjay Agarwala had started the research regarding management of AVN with bisphosphonate therapy and reported on it in 2001,probably one of the only surgeons reporting in medical journal. His index case was of a patient who refused any surgical intervention. Dr Agarwala analysed the cause of pain as collapse of bone due to weakness of the weakened bone.
Avascular Necrosis or Osteonecrosis of the femoral head is a pathological process that results from interruption of blood supply to the bone which leads to the death of marrow and osteocytes resulting in collapse of the necrotic segment of the femoral head. In the early stages of the disease there is severe pain from the dying bone. Later this leads to arthritis of the hip, causing stiffness, limitation of movement and adds to the disability of the patient in day to day routine life.
– Citations for Bisphosphonates management of the crippling conditions of Avascular Necrosis (AVN) of the hip.
– On-going research on Stem Cell Research in the treatment of Avascular Necrosis of the Hip.
– Research Publications Prevention and Prevalence of DVT in Indian patients.
– Use of Calcium Hydroxy Appetite in the enhancement of bone unions at fracture sites.
– This is the most common cause of total hip replacement in young patients in India
– Though Avascular Necrosis of the bone was published in 1794, Ficat and Arlet had described the pathology of this condition in 1960. It is caused by injury or due to other causes
– There is no reliable data on the incidence and prevalence of this disease. Approximately 15,000 to 30,000 new cases occur annually in the USA. In India as there is no statistical data available, considering the population of over a billion approximately 70 to 90,000 patients get affected with AVN. The disease occurrence is more in men than in women.
– AVN is often seen in association with a number of different conditions.
– Trauma with fracture of the femoral neck, especially in the sub-capital region, interrupts the major part of the blood supply to the head and may lead to AVN. The risk has been reported to be as high as 10-43% after a displaced femoral neck fracture.
– Excess alcohol consumption, with an allergy to the chemical
– Corticosteroid therapy, the risk of AVN with corticosteroid therapy is dose related.
– Sickle cell disease, where the clumps of sickle cell physically block the end arteries
– Caisson’s disease , (decompression syndrome)where escaping gas bubbles from blood block the blood vessels
– Gaucher’s disease
– Systemic Lupus Erythematosus
– Rheumatoid arthritis
– Immuno-deficiency syndrome
– Pathogenesis :
– The hematopoietic cells are most sensitive to Anoxia (due to interruption of blood supply causing inadequate oxygenation).
– Ischaemia causes death of marrow cells, death of bone cells causing necrosis of the affected segment which leads to weakness and collapse of the femoral head. This in turn causes incongruity leading to arthritis of the hip joint. Body tries to heal this condition by removal of dead cells by oseoclasts and layering of new bone cells by osteoblasts. This natural process of healing takes upto three years , the life cycle of the disease
– There are four stages (Ficat & Arlet) of AVN of the femoral head based on the clinical and radiological presentation. Stage 1 the normal congruity of the femoral head is maintained with minimal symptoms and Stage IV is the end stage with collapse of the hip with arthritis.
– Patients with AVN have a varied presentation based on their involvement of the femoral head (Stage of AVN). In early stages, patients present with groin, buttock, thigh pain or even with the knee pain with normal x-rays and an abnormal MRI. In later stages, patient present there is a limp, limitation or decreased movements of the hip joint and restriction of activities of daily living.
– Investigations :
– Standard plain x-rays of pelvis with both hips (PBH view) and MRI helps in making a diagnosis as well as prognosis of the conditions. In certain cases radio-nuclide bone scan also helps.
Methods of treatment :
– Surgical management
– There are various surgical procedures which have been described such as core decompression, vascular fibular bone grafting, osteotomies around the femoral head and vascular pedicle graft, with varied success rate. All these surgical procedures help in early stages of AVN with poor success and adds morbidity to the patient.
– The only consistent good results are seen in total joint replacements.
– Directly implanted stem cells are the latest in this long road to salvation and are showing promise in controlled trials.
– Medical Management involves :
i. Aspirin has a role with very poor results.
ii. Vaso-active drugs may play a role in early AVN but never proven.
iii. Chinese herbal products -very suspect !
iv. Pulse Electro magnetic therapy with no proven results.
v. Bisphosphonate therapy , the only currently available peer reviewed and consistently proven in world literature.
The results of the initial study was published in December 2001 in the Journal of the Association of Physicians in India and was honored with the Best Paper Award and subsequently extended studies were published in Rheumatology Journal by 2005.
Dr. Sanjay Agarwala has recently published his 8 year follow-up in the JBJS, (British Journal of Bone and Joint Surgery)2009 and in 2011 the 10 ye results were confirmed in JOA (Journal of Arthroplasty). These studies have shown 98% success rate in Stage I, 92% with Stage II and 70% with Stage III which is far better than various studies done in the past which had a success rate if only around 30%.
The cost involved for this treatment is a bare minimum of Rs. 150/- per month, which is affordable to the common man, and this avoids or postpones the requirement of total hip replacement surgery the cost of which is very high.
This path breaking research on Bisphosphonate therapy in the management of AVN has paved the way for an economic mode of treatment while at the same time postponing or even avoiding the need for a hip replacement surgery.
This amazing discovery from an Indian surgeon, done with dogged persistence over 15 years, is now internationally acclaimed and cited in all legendary textbooks of Rheumatology and Orthopaedics. It has spawned new research in the previously difficult disease and is even used in pediatric conditions like Perthe’s disease.
- The next frontier would be when Dr Agarwala presents his findings in stem cells, which is his current research arena and regenerates bone!
Stem cells are cells that regenerate. The body uses these cells for growth and repair on a daily basis. Clearly these cells become less prolific as age advances.
The technique that Dr. Agarwala follows is where he harvests these cells from the bone marrow of the patient himself. These are then isolated, cultivated and grown in an approved centre. When the requisite numbers of these actively growing cells have been collected, they are surgically introduced into the dead avascular bone in the head of the femur.The dead bone matrix now gets transformed to living new bone cells over a period of time ! This is the miracle of stem cells and this extraordinary surgical procedure augmenting and repairing nature with a helping hand. Tweaking to help the natural processes get a head start turning despair to hope in these AVN cases. Similar techniques have been used by him in repairing isolated islands of destroyed cartilage. The miracle of modern science for the common man is now available for the cure of patients.
Some patients who have advanced disease and who cannot or do not benefit from these methods can still have outstanding results by total hip replacements – THR. Patients can hope to be restored to their former functions within the ambit of norms for these artificial joints.
Continuing in the traditions of the surgical masters of legend like Sushruta, Indian surgical care is writing a new chapter in world literature