Intra-articular and Allied Injections Sureshwar Pandey, Anil Kumar Pandey
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1Intra-articular and Allied Injections2
3Intra-articular and Allied Injections
SECOND EDITION
Sureshwar Pandey MBBS (Hons) MS (Gen) FICS FIAMS MS (Ortho) FACFAC FACS FNAMS Professor Emeritus University of Ranchi Founder and Founder Director GNH Handicapped Children Hospital and RJS Artificial Limb Centre Founder and Consultant Ram Janam Sulakshana Institute of Orthopaedics and Research, Ranchi. Founder and Founder President and Sec. General Indian Foot Society (Affiliated to International Federation of Foot and Ankle Societies IFFAS). Founder and Emeritus Editor: The Journal of Foot Surgery Visiting Professor: Universities of Tokyo, Osaka, Teikyo, Adelaide, Flienders, Vjung Pandang, Singapore ex-Chairman ASIA-CIP (IFFAS) Founder and Chairman Ram Janam Sulakshana Pandey Cancer Hospital and Research and Rehabilitation Centre, Ranchi Anil Kumar Pandey MBBS, CORM, Ph.D Orth, MAMS Director and Consultant Ram Janam Sulakshana Institute of Orthopaedics and Research (RJSIOR), Ranchi Asst. Director and Consultant GNH Handicapped Children Hospital and RJS Artificial Limb Centre, Ranchi Consultant Ram Janam Sulakshana Pandey Cancer Hospital and Research and Rehabilitation Centre, Ranchi
4Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Intra-articular and Allied Injections
© 2005, Sureshwar Pandey, Anil Kumar Pandey
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors and the publisher.
First Edition: 1982
First Japanese Edition: 1987
Second Edition: 2005
9788180615375
Typeset at JPBMP typesetting unit
Printed at Paras Offset
5
to
the fond memory of my beloved parents
Sulakshana Pandey
and
Ramjanam Pandey
who were, are, and will be
always with me to love, teach and guide
who taught me to persue my
dreams—because nothing is impossible
6
7
“DHANVANTARI”
The Hindu God of Medicine
Commonly worshipped as the Hindu God of Medicine, DHANVANTARI is regarded as the original exponent of Indian medicine. DHANVANTARI has many myths and legends woven around him. He emerged with the pot of ambrosia (symbolic of medicine) in his hand from the ocean when it was churned by the contesting gods and demons. He is viewed as the very incarnation of God VISHNU. He is said to have recovered ambrosia which had been lost, and thus obtained a share in sacrifices.
Legends make him reappear as “DIVODASA”, the prince of Benaras (Kasiraja), in the family of Ayus. Dhanvantari, Divodasa and Kasiraja are names of the same person who is “the first god and who freed the other gods from old age, disease and death”, and who in his Himalayan retreat taught surgery to Susruta and other sages.8
DHANVANTARI appeared on earth in Benaras in the princely family of Bahuja and became known as Divodasa; he wandered about as a mendicant even during his early years.
DHANVANTARI also appears to have been an actual historical person, although his precise identity is hard to be ascertained. He taught surgery and other divisions of Ayurveda (Indian system of medicine) at the instance of Susruta, to a group of sages among whom Susruta was the foremost. DHANVANTARI is regarded as the patron-God of all branches of medicine. While DHANVANTARI is not credited with any medical treatise of his own, in the early accounts, there is a voluminous glossary and materia medica in the nine sections known as Dhanvantari-Nighantu; it is a compilation which is probably contemporaneous with the famous Amara-kosha (A.D. 100). There are a few other works which are also ascribed to Dhanvantari.
There are numerous preparations which are ascribed to him, and many of them quite ancient.
Dhanvantari-Nighantu is considered the most ancient of the medical glossaries that are available. The original work is said to have been in three recensions; the present version which may have been based on one of them, is in six sections and deals with 373 medicinal substances; their names, synonyms, and brief description of properties being given. The work which claims to be ‘like the third eye’ for the practising physician, is extensively relied upon, despite several more comprehensive glossaries that have been compiled subsquently. Since there is no authentic source of information, this text can be considered more as indicative.
(By courtesy Pfizer Limited)
9Preface
There has been significant progress in orthopaedics and rheumatology, especially with the advent of robotics and computer-navigated systems even though they are fairly costly.
The patient expects his/her doctor to be the best healer one can possibly be. However, one should choose the mode and technique according to the need of the patient and must not try to fit his/her technique to every patient. More you grow, the knowledge and technique improve with the amalgamation of theory and practice.
The advent of corticoids placed in the hands of the clinician the panacea to treat many unexplained and chronically resistant condition—and so in the musculo-skeletal system as well. But what has been powerful for good is potent for evil too, and this is agonisingly evident in cases of well meant but injudicious use, misuse or even overuse of corticoids. The overenthusiastic use of corticoids have definitely led to irreversible legacies. However judicious uses have been definitely effective without any obvious complication.
Injection of corticoids or allied chemicals into the joints, periarticular area and other tissues is an accepted method of treatment for a variety of conditions. Even though its exact mode of working has not been fully understood, its effective use in many conditions has been proved beyond question. In certain cases these injections may avert surgery as well. However the result of treatment by these injections depends largely on the exact location of the injection.
This monograph was produced as the first attempt in this direction in 1982, detailing the methodology for properly and exactly injecting into the joint and other tissues. The first edition, though poorly produced, was well received by young orthopaedic and general surgeons, rheumatologists and even general practitioners. Further, no less than Emeritus Professor N. Tsuyama, the then Chairman cum Director of the Division of Orthopaedics of the University of Tokyo, Japan chose to translate this book into Japanese language for the benefit of Japanese orthopaedic surgeons and patients. So the first Japanese Edition was produced in the year 1987. Thus the practical utility of this book has been proved beyond doubt.
In the first edition emphasis was on injecting hydrocortisone acetate, however, gradually methyl-prednisolone acetate replaced it to a greater extent. For few years there has been inclination to treat osteoarthritis, especially of knee joint, by injecting hyaluronic acid into the joint.10
This aspect has also been dealt with in this edition including the result of comparative evaluatioin between corticoids and hyaluronic acid.
In the methodology of injection technique, while the basics remaining the same, stress has been given on the ‘no-touch technique’ of injection.
Acupuncture and allied treatments have not proved their sustained effectivity (rather appeared even as placebo in several cases), hence nothing more has been dealt in those aspects.
Certain definite inferences have been drawn after practicing the out-lined procedures in more than eleven thousand injections. It is almost certain that if one strictly adheres to the methodology detailed in this book, there will not be any infection after the injection. Further, in most of the cases the injection, if properly given at the exact site, proves useful. The appreciable result is reflected only after the first injection.
Sureshwar Pandey
Anil Kumar Pandey
11Acknowledgements
It is always difficult to organise and sustain academic activity especially in print format, but for the doggedness and sustained enthusiasm, which only gets augmented by the observations over the subjects—the patients. We are obliged to them for providing experiences to us to the extent which stimulated us to bring out the Second Edition.
Unless the users—the young orthopaedic and general surgeons, rheumatologists and even general practitioners—would have accepted the First Edition willingly, the stimulus to bring out the Second Edition would not have been sustained. We are indebted to them.
Arranging the manuscript and putting them in proper order and further printing it out are really great annoying jobs. These all have been very gladly and patiently done by my dear grand-daughter Pallavi and dear Secretary Sheeja. I (SP) cannot return their debt.
My (SP's) grandchildren—Pallavi, Shivam, Vaishnavi, Shruti, Soumya and Satyam have been real source of easing tension of my life with pleasant moments with them—God bless them always.
I bow my head to the feet of my Revd. illustrious fatherly teacher Padma Bhushan Emeritus Professor B. Mukhopadhaya, who remained the perennial source of inspiration for me.
How can I forget the immense help of Shri JP Vij, the CMD of Jaypee Brothers Medical Publishers (P) Ltd, and all persons involved in producing such a nice monograph. We are really thankful to one and all of Jaypee Brothers.