THE PHYSIS
THE OFFICIAL JOURNAL OF THEJK CHAPTER OF THE IOA
JUNE-2019
SYMPOSIUMTHE KNEEVOLUME-1 | ISSUE-2
THE PHYSIS
THE OFFICIAL JOURNAL OF THE JK CHAPTER OF THE
INDIAN ORTHOPAEDIC ASSOCIATION
PUBLISHED BY
THE JAMMU AND KASHMIR ORTHOPAEDIC ASSOCIATION
VOLUME-1 | ISSUE-2
THE PHYSIS
OFFICIAL JOURNAL OF THE JKOA
FIRST PUBLISHED BY THE JKOA IN 2019
Science and technology are constantly changing fields. New research and
experience broaden the scope of information and knowledge. The authors have
tried their best in giving information available to them while preparing the
material for this journal. Although all efforts have been made to ensure optimum
accuracy of the material, yet it is quite possible some errors might have been left
uncorrected. The publisher, the printer and the editors, will not be held
responsible for any inadvertent errors, omissions or inaccuracies.
Cover Credit: Master Hamza Hamid
JAMMU AND KASHMIR ORTHOPAEDIC ASSOCIATION
THE EDITORIAL
MESSAGE
EDITORIAL BOARD
THE JKOA EXECUTIVE BODY
PERSPECTIVE. GROWTH OF JKOA 01
PERSONALITY. GAVRIL ABRAMOVICH ILIZAROV 02
A SHORT REVIEW OF OSGOOD SCHLATTERS DISEASE 05
THE HIGH TIBIAL OSTEOTOMY. A REVIEW 11
MENISCAL INJURIES 17
THE PATELLAR FRACTURE 26
OSTEOCHONDRAL INJURIES 36
TECHNICAL TIP 44
CASE REPORT 46
NEWSLETTER SECTION. A LOOK AT THE PAST YEAR 49
INFORMATION FOR AUTHORS 58
C O N T E N T S
The Jammu Kashmir Chapter of the Indian Orthopaedic Association has had an eventful first year of its
existence. In pursuit of making the association well rounded, the association conducted its first two
conferences in Jammu and Kashmir over the last year. Both conferences elicited a warm response from the
delegates. Faculty from all over India participated in the conferences and the educational and teaching standard
was quite fulfilling.
The first issue of The Physis Journal also came out during this period. The journal is directly aimed at the young
and budding orthopaedic surgeons. The journal was put together by the editorial board and was very well
received. The JKOA decided to expand the editorial board to improve the vitality and quality of the ideas going
into the formulation of the journal. The result is the 2nd issue of the journal currently in your hands. The new
members of the board come from various institutes of India and will surely add to the value of the journal.
The process of constructing the first issue of the journal was interesting and educational. As we went back and
forth on ideas, the journal began to grow and take shape. Everything that we could discuss was pored over and
dissected. The second issue has also been the handiwork of the editorial board mainly. However, in the future
the JKOA members are expected to participate wholeheartedly in submitting review articles, case reports and
technical tips for enriching the future issues of this journal. A journal is only as good as its base of authors. The
address for submission is once again reproduced below.
This inaugural issue focused mainly on the foot and the ankle. In pursuit of the same methodology, this issue
has a small symposim on disorders around the knee. The thought process is that if one area is properly read
about, it would encourage the development of good all-round orthopaedic surgeons ultimately. In the future
issues we hope to continue the 'symposium' methodology.
We would definitely want to have some feedback from the readers about this. All of us are open to suggestions.
The journal includes a section which is a newsletter on the activities of the JKOA. We hope that you enjoy that
section too. Future contributions for this section are welcome too.
Our thanks to Sheen Graphics for the wonderful work they have put in.
We are thankful that we have been offered help by Systopic Labs in getting the Journal published.
We must take this opportunity to extend thanks to Mr. Shafiq Ahmad for the immense help he rendered in the
publication process.
The e-mail address for communication is [email protected].
We would love to hear from you.
The Editorial Board
EDITORIAL
It is indeed heartening to note that the J & K Chapter is publishing the 2nd Issue of it’s Official Journal. I
believe that the Journal is the face of any Academic Association and I congratulate all members for the same.
The year 2018/19 has been an year of achievements for the J & K Chapter
1. 1st year of its official affiliation with the IOA
2. 1st J & K Chapter conference at Srinagar was successfully organised and I was fortunate to attend
3. 1st time participation in the Jhunjhunwala trophy for Best State Chapter with less than 400
members and Winning the 2nd prize.
4. 1st Official issue of the Journal
This speaks volumes of the commitment of Dr. Rajesh K Gupta as Secretary and Dr. Naseer Mir as
President and the contribution of all members at large.
Keep up the good work.
Enroll maximum members from your State into the mainstream IOA
Wishing you all the best and a Very Happy Healthy Prosperous and Joyous Year.
Warm Regards
Dr. Atul Srivastava
Hon. Secretary IOA
MESSAGE
Dr. Atul SrivastavaHon. Secretary IOA
MessageFROM THE SECRETARY IOA
EDITORIAL BOARD
CHIEF EDITORS
DR LOVI PADHA DR ALTAF KAWOOSA DR ABDUL GHANI
EXECUTIVE EDITOR
DR SHABIR A DHAR
ASSOCIATE EDITORS
DR SIDDHARTH SHARMA DR ASIF NAZIR BABA DR AGNIVESH TIKOO DR KHALID MUZAFFAR
JKOA EXECUTIVE BODY
PRESIDENT Prof N. A. Mir
VICE PRESIDENT Dr. Lovi Padha
Dr. AR Badoo Dr. Sanjeev Gupta
HON. SECRETARYProf Rajesh K Gupta
TREASURERDr. Manish Singh
Dr. I. K Wangnoo
EXECUTIVE MEMBERS
– 1 –
PERSPECTIVE
Dr. Rajesh Gupta
In the last couple of years our chapter has grown
exponentially with the efforts of all the worthy
members. From Nov. 2019 till date the number of
life members has increased from 135 to 150. We are
also having 25 associate members. I am very happy that academic activities now are
going on all over the state. Because of these activities
& growth of our chapter & also activities of our
members at the national & international level our
chapter has been awarded 2nd best chapter by Indian
Orthopaedic Association in the category of small
states ( Jhunjhunwala award). We will be getting the
award at IOACON at Kolkata in November 2019. It
is indeed a proud movement for all of us as we got
the award in the first year of our affiliation with the
IOA. We have to keep up this momentum & even
work harder so that we can bag first place this year.
Our 2nd annual conference was held in Jammu from
8th to 10th Feb 2019. It was a combined meeting
with the 38 th NZIOACON. Dr Anil Gupta was the
organising secretary. About 200 delegates attended
the conference. There were 5 preconference
workshops on clubfoot, pelvic acetabular fractures,
osteotomies in relation to hip, basic spine & total hip
replacement. The conference was inaugurated by Sh
Vijay Kumar, the health & medical education advisor
to the hon'ble governor of J&K. Dr Atul Srivastva
IOA secretary & Dr Manish Dhawan treasurer IOA
were our IOA representatives. There were two
orations. Dr Ashai Memorial oration was delivered
by Dr Ram Prabhu & Dr Pachnanda Memorial
oration was delivered by Dr SS Yadav.
During the conference website of JKOA was
launched ( http://www.jkoa.in).
The first issue of the official journal of JKOA
(PHYSIS) was also released during the conference.
Here I must acknowledge the great efforts of the
whole of the editorial team especially Dr Shabir
Dhar.
We also expanded our editorial board by including
Dr Agnivesh Tickoo, Dr Sidharath Sharma, Dr
Khalid Muzzafar & Dr Asif Nazir Baba.
We also constituted our medico legal & ethical teams
so that issues related to medicolegal & ethical aspects
of our members are taken care of.
Our next annual conference will be held in
Government Bone & Joint Hospital Barzulla
Srinagar in June 2020.
At last my sincere request to all the worth members
to contribute more for the growth of our chapter.
Thanks
Dr Rajesh Gupta
Growth of JKOA over the last year
[Dr Rajesh Gupta Works at the The Acharya Shri Chander Hospital Jammu]
– 2 –
PERSONALITY
Dr Shabir A Dhar, Dr Tarsem Lal
Gavriil Abramovich IlizarovThe Magician from Kurgan
Gavriil Abramovich Ilizarov was born a sixth
child to a poor Jewish peasant family in Poland
in June 1921. His initial years were hard. He
worked in the fields as he did not obtain any
formal education till 11 years of age. He
attended a vocational school after that which
was primarily meant to help the peasant
children. He excelled at school and in 1939
entered the Crimea Medical School in
Simferopol. After finishing the school in
1944 Ilizarov was sent to a rural hospital in
Dolgovka, a village in Kurgan Oblast in
Siberia, 2000 km east of Moscow. This area
had a large number of people who had been
wounded in the World War. These patients
had deformity, segmental bone defects, non-
union and osteomyelitis.
Under such difficult conditions, Ilizarov, who
had no formal surgical training had to face a
difficult choice of amputation or attempting
salvage. It was under these circumstances that
he developed the concept of 'distraction
osteogenesis'. As an orthopaedician with
minimal resources, he made use of whatever
was available in Kurgan to develop ingenious
methods of treatment of complicated
orthopaedic cases. The area had a tank
factory and a bicycle factory. Ilizarov's initial
constructs used tank tread material to make
rings and bicycle spokes as wires.
Serendipity led Ilizarov to discover the
existence of 'distraction osteogenesis'. While
treating a war veteran for a shortened tibia,
ilizarov placed an external fixator and did a
corticotomy. His intention was to lengthen the
bone whilst creating a defect. He intended to
fill the defect with bone graft once the
required length had been obtained. By
chance he forgot to remove the fixator
before proceeding on a vacation. On return
he got a radiograph done. To his surprise he
found that there was no gap and bone had
formed there.
In 1950s rumours about Ilizarov's methods
spread across Russia. People flocked to his
two-story hospital and he applied the law of
tension stress to the benefit of many patients.
Gradual traction on living tissues was found to
[Dr Shabir A Dhar and Dr Tarsem Lal Work at SKIMS MC Bemina]
– 3 –
stimulate and maintain the regeneration and
active growth of certain tissues. For long
time, Ilizarov faced skepticism, resistance
and political intrigues from the medical
establishment in Moscow which tried to
defame him as a "quack". However, the
steadily increasing statistics of successful
treatments of patients led to a growing fame
of Ilizarov throughout the country. He
became known among patients as the
"magician from Kurgan".
Despite such marvelous work, it took Ilizarov
decades to be recognized for his work. His
breakthrough moment in terms of fame came
in 1968 when he treated Valery Brumel, a
world record holder and gold medalist high
jumper for stiff non-union of the tibia and
lengthened it by 3.5 cm. it is worthwhile to
remember that Brumel had spent about three
years for unsuccessful treatments in various
clinics and underwent seven invasive and 25
non-invasive surgeries. This catapulted
Ilizarov into fame in the medical circles in
USSR. However, the technique could not
reach the outside world due to the Iron
curtain.
Another chance interaction opened up this
methodology to the western world. Thor
Heyerdahl a Norwegian explorer wanted to
prove that there were contacts between the
Mesopotamian and the Indus valley
civilizations. He assembled a crew of three
people Carolo Mauri from Italy and Yuri
Senkevich from Soviet Union. Carolo Mauri
suffered from stiff non union of the tibia.
On urgings by Senkevich, Mauri travelled to
Kurgan n 1980 during the Cold War in the
Soviet Union. He was treated by Ilizarov for a
tibial fracture that healed incorrectly after a
skiing accident ten years earlier. Italian
doctors had long given up hope of any
surgical improvement to the leg. Ilizarov
distracted the stiff non-union in his tibia by 2
cm, healing the pseudarthrosis, corrected an
equinus deformity by distraction and
lengthened his leg. Mauri dubbed Ilizarov
"the Michelangelo of Orthopaedics". In the
meantime he was made the Director of the
Kurgan Research Institute for experimental
and clinical orthopaedics and trauma in 1971.
Italian surgeons were so impressed with this
that they invited Ilizarov to speak at the Italian
AO conference in Bellagio. It was the first time
that the outside world heard about Ilizarov. At
the end of the lectures, Ilizarov earned a ten-
minute standing ovation. After this the
Ilizarov methodology spread rapidly to the
rest of the world. While Codivilla, Putti and
Wagner were already working on limb
lengthening, it was Ilizarov who made it an
absolute science. He discovered the law of
tension stress, the principle of distraction
osteogenesis and taught us the rate and
rhythm of distraction.
Bibliography
1. Gavriil A. Ilizarov. Transosseous Osteosynthesis.
Theoretical and Clinical Aspects of the Regeneration
and Growth of Tissue. Translated by Stuart A. Green.
Springer, Berlin, Heidelberg, New York, 1992, ISBN 3-
540-53534-9. New edition 2011, ISBN 978-3642843907.
2. "Small Bone Innovations, Inc. Extends its Exclusive
– 4 –
Training Agreement with Russian Ilizarov Scientific
Center for an Additional 5 Years". China Weekly News.
17 August 2010. Archived from the original on 28 March
2015.
3. Svetlana Ilizarov (2006). "The Ilizarov Method: History
and Scope". In S. Robert Rozbruch and Svetlana Ilizarov
(eds.). Limb Lengthening and Reconstruction Surgery.
CRC Press. pp. 3–6
4. Christian Jürgens, Hergo Schmidt, U. Schümann, B.
Fink: Der Ilisarow-Ringfixateur und seine technische
Anwendung. Der Unfallchirurg 95 (1992), p. 529–533.
5. Klaus Seide, Dietmar Wolter : Universe l l e
dreidimensionale Korrektur und Reposition mit dem
Ringfixateur unter Anwendung der Hexapod-
Anordnung. Der Unfallchirurg 99(1996), p. 422–424.
– 5 –
BACKGROUND
In 1903, Robert Osgood (1873-1956), a US
orthopedic surgeon, and Carl Schlatter
(1864-1934), a Swiss surgeon, concurrently
described the disease that now bears their
names. Osgood-Schlatter disease (OSD) is a
common causes of knee pain in active
adolescents.
INTRODUCTION
OSD is a traction phenomenon resulting
from repetitive quadriceps contraction
through the patellar tendon at its insertion
upon the skeletally immature tibial tubercle
[1]. This occurs in preadolescence during a
time when the tibial tubercle is susceptible to
strain. A similar process can occur at the
patella-patellar tendon junction, which is
referred to as Sinding-Larsen-Johansson
syndrome (the adolescent equivalent of
jumper's knee). The primary cause of this
condition is the stress from the patellar
tendon at its point of insertion [2, 3]. In a
recent study, the shortening of the rectus
femoris muscle was also reported to be one
of the main factors associated with the
presence of OSD in adolescents.
The injury mechanism in adults is usually
related to the direct impact on the tubercle,
rather than contraction of the quadriceps as
seen in adolescents [4].
ETIOLOGY
Because of a lack of a precise etiology and
therefore definition, some practitioners may
find differentiating OSD from avulsion
fractures of the tibial tubercle to be difficult.
In general if the patient is unable to
ambulate, an acute avulsion fracture of the
tibial tubercle is more likely. OSD patients
typically can ambulate, albeit with pain.
There is a partial loss of continuity of the
patellar tendon-cartilage-bone junction of
the tibial tuberosity. An inflammatory
process starts in the region and ends with
patellar tendinitis, multiple subacute
fractures, ir regular ossification with
underlying bone. When an individual with an
injured t ibial tubercle continues to
participate in sports, more and more
REVIEW ARTICLE
Prof NA Mir, Prof Rajesh Gupta, Dr Lovi Padha
A Short Review of Osgood Schlatters Disease
[Prof. NA Mir Works at the SKIMS Medical College Bemina, Prof. Gupta Works at the Acharya Shri Chander Hospital Jammu and Dr. Lovi Padha works at the JK Medcity Jammu]
– 6 –
microavulsions develop, and the reparative
process may result in a markedly pronounced
prominence of the tubercle, with longer-
term cosmetic and functional implications. A
separated fragment may develop at the
patellar tendon insertion and may lead to
chronic, nonunion-type pain.
In a magnetic resonance imaging (MRI)
study of 20 patients with OSD, the patellar
tendon was noted to attach more proximally
and in a broader area to the tibia in patients
with OSD [5]. Approximately 50% of
patients with OSD relate a history of
precipitating trauma.
EPIDEMIOLOGY
OSD is the most common apophysitide
disorder among children and its incidence
has been reported at 21% among adolescent
athletes compared to only 4.5% among non-
athletes. One Finnish study found that OSD
affected 13% of athletes. [6,7].
OSD occurs more frequently in boys, with a
male-to-female ratio of 3:1.
OSD usually is seen in the adolescent years,
after a patient has undergone a rapid growth
spurt the previous year. Girls who are
affected are typically aged 10-11 years but
can range from age 8-12 years. Boys who are
affected are typically aged 13-14 years but
can range from age 12-15 years [8].
It is bilateral in 30-40% cases [4].
CLINICAL FEATURES
Osg ood-Sch la t te r d i sease i s eas i l y
recognized in the adolescent with complaints
of pain which is localized to the area of the
tibial tubercle. Discomfort is usually
generated with running, kneeling, ascending
or descending stair [9,10].
Weakness of the quadriceps and pain on
resisted knee extension are common signs, as
is an enlarged tubercle. D'Ambrosia and
MacDonald report reproduction of pain
with passive knee flexion, which Jakob et a1.
attribute to a hypertrophied quadriceps
group exhibiting decreased flexibility
[11,12,13, 14,15, 16]. Tenderness, swelling,
thickening of the patellar tendon and
enlargement of the tibial tuberosity are often
observed during physical examination.
Patients may walk with an antalgic gait.
During palpation, a firm mass (bone
irregularities) is often observed in chronic
conditions. Acute cases may present with an
extensor lag. There is no sign of effusion or
instability, and passive range of motion in the
knee is full. The frequency of quadriceps and
hamstring muscle tightness is common
[17,18].
The differential diagnosis of OSD includes
osteochondri t is dissecans, S inding-
Larsen–Johansson syndrome, patella-
femoral syndrome, patellar dislocation or
subluxation, chondromalacia patellae,
avulsion fracture of the tibial tuberosity, pes
anserinus bursitis, tumor and infection. If
the pain is worse at night or during rest, a
differential diagnosis should be considered.
They should be accreted with a detailed
– 7 –
history, focused physical examination and
radiography of the patient [19,20].
RADIOLOGY
The lateral radiograph is most helpful in
evaluating the extensor mechanism.
Radiological evaluation may indicate
superficial ossicle in the patellar tendon, soft
tissue swelling anterior to the tibial tuberosity
and thickening of ligamentum patellae.
Ultrasound (US), magnetic resonance
imag ing (MRI ) and compu te r i z ed
tomography (CT) are other imaging
modalities used for the diagnosis of OSD.
US may show the thickened patellar tendon
better than plain radiography. It can also
d e m o n s t r a t e p r e t i b i a l s w e l l i n g ,
fragmentation of the ossification center and
excessive fluid collection in the infrapatellar
bursa [3].
In MRI, T2-weighted imaging, increased
hyperintense irregular signal intensity
superior to epiphyseal line in the proximal
part of the tibia can be viewed. It may play a
role in the future in the staging of the disease
and prognosticating the clinical course, as the
role of MRI in diagnosis, prognostication
and management is currently limited [2].
TREATMENT
Numerous inter ventions have been
proposed in the literature for the treatment
of OSD. Unfortunately, scarce evidence is
available from randomised clinical trials and
systematic reviews to support physical
therapy interventions while lesser quality
studies and expert opinions abound [21].The treatment of OSD is guided by the
severity of the symptoms. OSD is a self-
limited disease and generally ceases with
skeletal maturity. Improvement can be
gradual.
The condition may recur for 12–18 months
before complete resolution at skeletal
maturity. This correlates with the closure of
the apophysis.
1. Stretching. With a systematic
review and mult iple exper t
opinions, there is strong evidence
to support the use of stretches for
tight musculature secondary to
OSD in the literature. To address
both the anterior and posterior
knee musculature, several experts
also recommend stretching both
the hamstrings and quadriceps or
stretching in general [22,23]. 2. Quadriceps strengthening is
recommended in Antich and
Brewster's systematic review of
the literature in which they state
t h a t i s o m e t r i c q u a d r i c e p s
exercises, straight leg raises, and
short arc quadriceps sets should be
considered standards of care. It is
noted again that exercises should
be performed only if they are pain
free to decrease the risk of an
avulsion fracture during treatment
[24,25].
3. Knee orthosis. In a case series of
– 8 –
17 patients and 24 knees, Levine
and Kashyap, reported successful
management of OSD using an
infra-patella strap worn during
active periods of the day after 6–8
weeks of use [7]. Two knee
orthoses, the patellofemoral knee
orthoses with an H buttress and
the infra-patel la half-moon
buttress, are also recommended
and specially designed for relief of
symptoms associated with OSD
[26].
4. Iontophoresis. The literature
p rov ides s t rong bu t da ted
evidence for iontophoresis. Antich
and Brewster's (1985) systematic
review noted that iontophoresis
aides pain relief in the tibial
tubercle area. Antich and Brewster
(1985) recommended initiating a
maximum trial period of three
treatments with a 20 minute
duration up to 5.0 milliamps (mA)
e v e r y o t h e r d a y w i t h
d e x a m e t h a s o n e - s o d i u m -
phosphate and 1 cc HCl injected
over the positive electrode to
determine the effectiveness of
treatment before proceeding [24].
5. Patient education. These include:
rest; activity modification; heat
modalities for warm-up; cold
modalities after aggravating
a c t iv i t i e s f o r o e d e m a a n d
inflammation and proper shock-
absorbent footwear. As such, the
therapist should educate their
clients on these topics to improve
both prognosis and function [24].
6. A l t h o u g h c o n s e r v a t i v e
m a n a g e m e n t h a s b e e n
conventional ly favored, for
patients who have intolerable
symptoms, surgical intervention
can be successful [27,28].
7. No prospective, interventional
studies evaluate the treatment of
Osgood-Schlatter disease. One
case series followed the natural
course of the disease in 261
patients (365 symptomatic knees)
for 12 to 24 months; 237 (90.8%)
pat ients responded wel l to
restriction of sports activity and
nonsteroidal anti-inflammatory
agents. The 24 patients who did
not improve with conservative
measures underwent surgical
excision of ossicles, and all
returned to normal activities
(mean time, 4.5 weeks) [5].
8. Refractory cases have been treated
w i th a va r i e t y o f su rg i c a l
interventions. In 1 case series, 67
patients (70 knees) (mean age 19.6,
77% male) with at least 18 months
of symptoms despite conservative
treatment underwent resection of
an ossicle (62 cases) or excision of
– 9 –
prominent tibial tubercle (8 cases).
These patients were followed for
2.2 years, with 56 (90%) patients
with ossicle-resection able to
return to maximal sports activity
without pain, tenderness, loss of
motion, or atrophy [29].
9. Another case series compared 22
patients who1 underwent drilling
of the tibial tubercle (with or
without the removal of the tibial
tubercle) with 22 patients who had
excision of loose ossicles or
cartilage. Seventeen of the 22
(77%) patients with ossicle
excision had complete resolution
of symptoms compared with 8 of
the 22 (36%) in the patients who
underwent tibial tubercle drilling
[30].
10. T h e t w o m o s t c o m m o n
procedures performed are ossicle
excision and tibial tubercle
prominence resection [31]. Ossicle
removal is supposed to be the best
method in the surgical treatment
o f O S D [ 3 2 ] . T u b e r c l e
prominence resection has also
shown good results in recalcitrant
cases [33] . Procedures that
promote early fusion of the
apophysis of the tuberosity to the
diaphysis, such as pegging the
tubercle to the tibial metaphysis
with autogenous bone graft or
drilling the tuberosity, have not
been recommended.
11. DeBerardino et al. recommended
an arthroscopic technique with
recalcitrant OSD lesions. They
revea led two pat ients wi th
excellent short-term results [34].
CONCLUSION
OSD is a self-limiting condition which
occurs commonly in adolescence. Patients
who have a history of a rapid spurt of
growth and participate in intense sports in
their early age present with anterior knee pain
during activities. Conservative treatment IS
efficient in the acute stage. However
symptoms may continue in severe cases. It
may affect patients' daily activity and reduce
performance in sports. There has been a
reported successful experience about
surgical treatment of unresolved OSD
patients.
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13(6):379–382
3. Hirano A, Fukubayashi T, Ishii T, Ochiai N (2002)
Magnetic resonance imaging of Osgood–Schlatter
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31(6):334–342
4. de Lucena GL, dos Santos Gomes C, Guerra RO
(2011) Prevalence and associated factors of
Osgood–Schlatter syndrome in a population-based
sample of Brazilian adolescents. Am J Sports Med
39(2):415–420.
– 10 –
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injuries in adolescents. Prim Care: Clin Office Prac 25(1):
211–23.
7. Levine J, Kashyap S (1981) A new conservative
treatment of Osgood-Schlatter disease. Clin Orthop
Relat Res (158): 126–8
8. Kujala UM, Kvist M, Heinonen O (1985) Osgood-
Schlatter's disease in adolescent athletes. Retrospective
study of incidence and duration. Am J Sports Med 74(4):
431-436.
9. Katz JF: Nonarticular osteochondroses. Clin Orthop
158:70-76. 1981
10. Mital MA, Matza RA: Osgood-Schlatter disease: The
painful puzzler. Phys Sportsmed 560-73, 1977.
11. Mital MA, Matza RA, Cohen J: The so-called
unresolved Osgood- Schlatter lesion. J Bone Joint Surg
(Am) 62:732-739, 1980.
12. Grass AL: Treatment of Osgood-Schlatter injury. JAMA
240:212- 213. 1978
13. Smillie IS: Injuries to the Knee Joint, Ed. 5. Edinburgh:
Churchill Livingstone. 1978
14. D'Ambrosia RD, MacDonald GL: Pitfalls in the
diagnosis of Osgood-Schlatter disease. Clin Orthop 11
0:206-209, 1975
16. Jakob RP. Von Gumppenberg S. Engelhardt P: Does
Osgood-Schlatter disease influence the position of the
patella? J Bone Joint Surg (Br) 63579-582, 1981
17. Gholve PA, Scher DM, Khakharia S, Widmann RF,
Green DW (2007) Osgood Schlatter syndrome. Curr
Opin Pediatr 19(1):44–50
18. Cakmak S, Tekin L, Akarsu S (2014) Long-term
outcome of Osgood–Schlatter disease: not always
favorable. Rheumatol Int 34(1):135–136.
19. Morgan B, Mullick S, Harper WM, Finlay DB (1997)
An audit of knee radiographs performed for general
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20. Yen YM (2014) Assessment and treatment of knee pain
in the child and adolescent athlete. Pediatr Clin North
Am 61(6):1155–1173
21. Laura Kabiri, Howell Tapley, Stasia Tapley.
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23(10):1127 e1121–1127 e1123
– 11 –
REVIEW ARTICLE
Dr Tahir A Dar, Prof Naseer A Mir, Prof Saheel Maajid, Prof JA Bhat
The High Tibial Osteotomy.
A Brief Review
[All Authors Work at the SKIMS MC Bemina Srinagar Kashmir]
INTRODUCTION
The high tibial osteotomy [HTO] is a
p r o c e d u r e t o a d d r e s s t h e m e d i a l
compartment osteoarthritis of the knee.
High tibia osteotomy (HTO) is intended to
transfer the mechanical axis from medial to
slightly lateral to the midline of the knee to
decrease the load and subsequently delay the
progress of osteoarthritis (OA). The
procedure was introduced by Jackson and
Waugh in 1961 [1]. However, the procedure
became popular after Coventry described it
in 1965 [2]. Many techniques have been
developed (i.e. closing wedge, opening
wedge, dome and 'en chevron' osteotomies),
but opening (medial) and closing (lateral)
wedge osteotomies are the most commonly
used [3,4]. In all methods a partial unloading
of the medial compartment with a slight
overcorrection of the mechanical axis (from
6 to 10° of valgus) is aimed for. Shaw and
Moulton [5], in their biomechanical cadaver
study, showed that to obtain a complete
medial compartment unload the valgus
correction should be at least 25°. Even
though the efficacy of HTO is accepted
worldwide, there are still some debated issues
about osteotomies. These include the choice
between opening or closing wedge tibial
osteotomy, the graft selection in opening
wedge osteotomies, the type of fixation, the
comparison with unicompartmental knee
arthroplasty (UKA) and whether HTO
affects a subsequent total joint replacement
(TKR) [6].
INDICATIONS
There are some evidences that stretch the
indications to ankle problems in patients
who have pain and instability because of a
varus ankle malalignment [7]. Other
indications in the presence of varus knee are
meniscal transplantation after total medial
meniscectomy, isolated chondral defect in
the medial compartment of a varus knee,
secondary degenerative arthritis in a varus
knee with medial joint line pain, and
ligamentous instability with varus thrust in
– 12 –
which correction of the varus deformity
unloads the reconstructed ligament while it
heals [8,9,10,11,12]. It, however goes without
saying that the main indication for HTO is
medial compartment osteoarthritis.
The review of the literature shows that some
conditions are correlated with a poorer
prognosis and these include:
(1) severe articular destruction (III
or more according to the
Ahlbäck classification)
(2) advanced age
(3) patellofemoral arthrosis
(4) markedly decreased range of
motion [13, 14]
(5) p r e v i o u s a r t h r o s c o p i c
débridements
(6) joint instability [15,16]
(7) lateral tibial thrust [15,16]
Most authors agree that HTO is more
appropriate than unicompartmental knee
arthroplasty for overweight patients, but the
influence of body mass index on the results
of HTO remains controversial [15].
The ideal candidate for HTO is an individual
who is between 60 to 65 years of age with
isolated medial osteoarthritis with a varus
deformity and good range of motion (ROM)
and without ligamentous instability [17].
TYPES OF OSTEOTOMIES
Jackson and Waugh in 1961 involved division
and removal of the head of the fibula, with a
subsequent dome osteotomy below the level
of the tuberosity, and immobilization in a
full-length plaster cast [1].
Coventry presented on a new stepped staple,
to overcome the previous issues with
conventional staples being unable to fully
engage the distal end of the osteotomy site
[2].
Different techniques later developed include
the development of a special blade plate,
leaving the anterior cortex of the distal
fragment and the posterior cortex of the
proximal fragment intact to create an
interlocking effect at the osteotomy site,
elevation of the tibial tuberosity, and oblique
osteotomies for oblique plain corrections.
Leaving a hinge of bone intact increases
stability of the osteotomy site but can also
have effects on the tibial slope after bony
union. However, the lateral closing wedge
procedure requires a fibular osteotomy or a
release of the proximal tibiofibular joint,
which can resu l t in neurovascu la r
complications. Lateral bone resection can
cause shortening of the lower limb. In
addition, stem impingement or metal
augmentation is unavoidable in a subsequent
total knee replacement due to the proximal
tibial deformity and bone loss of the lateral
condyle. [18,19,20,21,22,23]
The lateral closing wedge osteotomy has
gradually given way to the Medial open
wedge HTO technique. This technique has
been claimed as being technically easier, with
reproducible and predictable correction of
– 13 –
malalignment, good maintenance of bone
stock, and lower risk of injury to the peroneal
nerve. However, the technique has been
associated with high nonunion rates, long
period of weight-bearing restriction, and leg
lengthening. [24,25,26,27]
Chevron osteotomy is a procedure in which
an inverse V-shaped bone cut is made, a
lateral wedge is inserted medially, and rigid
metal plate fixation is performed. Although
this technique does not cause bone loss or
require bone grafting, it has not been
frequently employed due to its technical
difficulty and invasiveness. The progressive
callus distraction is performed through an
opening wedge osteotomy and external
fixation using an axial or ring fixator.
PLANNING
Patient factors. Patient's age, career, level of
activity, previous history of surgery on the
knee, and expectation should be taken into
consideration before deciding upon surgery.
Closing wedge HTO may be more effective
in heavy smokers.
Radiographic assessment. Bilateral weight-
bearing anterior-posterior views in full
extension, tunnel views with the knee in 30
degrees of flexion, Rosenberg views with the
knee in 45 degrees of flexion, lateral views,
and skyline views. The severity of medial
osteoarthritis and bone loss can be evaluated
from the anterior-posterior views and
patellar height can be measured from the
lateral views using InsallSalvati, Blackburne-
Peel, or Caton-Deschamps index [28].
Correction assessment. Fujisawa et al
reported that the postoperative mechanical
axis should pass through the lateral one third
of the tibial plateau [14]. Jakob and Jacobi
suggested that correction of the mechanical
axis depends on the thickness of the cartilage
in the medial compartment: if one third of
the medial cartilage is lost, the mechanical
axis should pass 10-15% lateral from the
center of the tibial plateau; if two thirds of
the cartilage is lost, the axis should pass 20-
25% lateral; and if all is lost, the axis should
pass 30-35% lateral [30].
CARTILAGE REGENERATION
Studies indicate that a correction of
malalignment of the knee is beneficial for the
recovery and maintenance of articular
cartilage, even without additional cartilage
restoration procedures. As such, it has been
thought that correction of malalignment of
the knee is closely related to the success of
cartilage restoration procedures of the knee.
It is with this concept that various studies
have been conducted to investigate the
functional outcomes and success of cartilage
restoration techniques when intrinsic
malalignment of the knee has been corrected
in the same setting. The wide-ranging types
of cartilage restoration procedures set the
premise for interesting studies based on
various permutations of such techniques
along with an HTO [31,32,33].
– 14 –
POSTERIOR TIBIAL SLOPE AND
PATELLAR HEIGHT
Lateral closing wedge osteotomy causes an
elevation of the tibial tuberosity due to
shortening of the proximal tibia during the
procedure, which increases patellar height
and is useful for patella baja [34]. Medial
opening wedge osteotomy causes a decrease
in patellar height because the tibial tuberosity
is lowered due to opening of the proximal
tibia during the procedure [35]. Lateral
closing wedge osteotomy can result in a
decrease in posterior tibial slope that causes
hyperextension and overload on the
posterior cruciate ligament (PCL), which
contributes to reduction in anterior
instability. Medial opening wedge osteotomy
heightens the likelihood of increased
posterior slope that restricts extension and
causes overload on the ACL. Accordingly,
this procedure is recommended in knees
with chronic PCL injuries and posterolateral
instability that has been inversely correlated
with posterior tibial slope.
COMPLICATIONS
The following complications are known to
occur in high tibial osteotomy.
1. Fracture of the medial or lateral
hinge
2. Intraarticular fracture
3. Non union in open wedge
osteotomy is reported to be 0.7-
4.4%
4. Patella infera secondary to
contracture
5. The incidence of common
peroneal nerve palsy caused by
nerve damage during HTO is 2-
16% and fibular shaft osteotomy
(at 15 cm distal to the fibular
head) can be useful for reduction
of such damage. The reported
rate of infection following
external fixation is 2.3-54.5%,
whereas that of infection
following internal fixation is
≤ 4 % . O t h e r p o s s i b l e
complications include fixation
failure, loss of correction,
pseudoarthrosis, deep venous
t h r o m b o s i s , p u l m o n a r y
embolism, and compartment
syndrome [34].
OUTCOMES
G ood long-term results are closely related
to correct patient selection, surgical
technique, rigid fixation, and postop
protocol. Ten-year survival rates for closed
wedge osteotomy were reported from 51%
by Naudie et al to 93.2% by Koshino et al
(15,32,36,37). The best results by Koshino
was related to some post operation factors
including no flexion contracture, valgus
anatomical angle of 10°, and concomitant
patellofemoral decompression procedure if
indicated.
– 15 –
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18. Koshino T, Morii T, Wada J, Saito H, Ozawa N,
Noyori K. High tibial osteotomy with fixation by a blade
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Orthop Clin North Am 1989;20:227-43.
19. Ogata K. Interlocking wedge osteotomy of the proximal
tibia for gonarthrosis. Clin Orthop Relat Res
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20. Putnam MD, Mears DC, Fu FH. Combined maquet
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21. Williams AT. Tibial realignment by oblique wedge
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24. Chae DJ, Shetty GM, Wang KH, Montalban AS Jr.,
Kim JI, Nha KW. Early complications of medial
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Staubli AE, Wymenga AB, van Heerwaarden RJ.
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Windsor RE. High tibial osteotomy. J Am Acad Orthop
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tibial osteotomy on osteoarthritis of the knee. An
arthroscopic study of 54 knee joints. Orthop Clin North
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30. Jakob RP, Jacobi M. Closing wedge osteotomy of the
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Orthopade. 2004;33:143-52.
31. Kanamiya T, Naito M, Hara M, Yoshimura I. The
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32. Koshino T, Wada S, Ara Y, Saito T. Regeneration of
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Südkamp NP, Köstler W. Open-wedge osteotomy
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34. Hohmann E, Bryant A, Imhoff AB. The effect of
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Windsor RE. High tibial osteotomy. J Am Acad Orthop
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37. Billings A, Scott DF, Camargo MP, Hofmann AA.
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– 17 –
REVIEW ARTICLE
Dr. Khalid Muzzafar, Dr. Muhammad Haseeb
Meniscal Injuries: A Review
Dr Khalid Muzaffar Works as Assistant Professor and Head, Department of Orthopaedics, GMC Doda. Dr Muhammad Haseeb Works as Speciality Registrar, Department of Orthopaedics Royal London Hospital, London.
INTRODUCTION:
Meniscal injuries are a common cause for
pain and functional impairment of the knee
joint. Initially it was thought that meniscus
was a unnecessary appendage and could be
sacrificed.[1] it was only after Fairbank
described radiographic changes in the knees
following menisectomy and poor results of
total meniscectomy that conservative
approach towards meniscal injuries was
considered.[2] This meniscal preservation
lately has led to development of new surgical
techniques to restore the native structure of
the meniscus so as to restore function and
biomechanics of the knee. Meniscal tear
surgeries are among most common surgical
procedures performed in orthopaedics.
ANATOMY:
On gross examination menisci are smooth,
lubricated tissue. They are crescent-shaped
wedges of fibrocartilage located on the
medial and lateral aspects of the knee joint.
The wedges are flat on the tibial side and
concave on the femoral side to accommodate
the femoral articular surface. The peripheral
one third of the wedge is thick and vascular
often called as Red zone, the wedge tappers
on inner border and is avascular in inner two
thirds, also referred to as white zone (Figure
1).[3] Both menisci differ from one another
in shape.
Medial meniscus: The medial meniscus is
C shaped and occupies about 50% of the
area of the medial compartment. The
anterior horn of medial meniscus is attached
firmly to the tibia anterior to the anterior
cruciate ligament (ACL). The posterior horn
is attached in front of the attachment of the
posterior cruciate ligament (PCL). The outer
border of the medial meniscus merges with
the knee joint capsule making it less mobile
and prone to injuries. The coronary ligament
attaches the meniscus to the upper tibia.
Fig. 1
– 18 –
Lateral meniscus: The lateral meniscus
covers 70% of the lateral tibial plateau. The
transverse (intermeniscal) ligament attaches
the anterior horns of the lateral and medial
menisci. The posterior horn of the lateral
meniscus is attached to the PCL and medial
f e m o r a l c o n d y l e t h r o u g h t h e
meniscofemoral ligaments of Wrisberg (the
posterior meniscalfemoral ligament) and
Humphrey (the anterior meniscal-femoral
ligament). It is also attached to the popliteus
tendon.[4] The lateral meniscus is more
mobile and is not anchored to the lateral
collateral ligament. The anchor of the lateral
meniscus to the femur and the popliteal
tendon couples its motion with that of the
femoral condyle during rotation. It is
therefore less likely to be injured. Discoid
lateral meniscus is a variant of lateral
meniscus. It was thought to be due to
developmental arrest, however Clark and
Ogden proved otherwise.[5] Discoid
meniscus have been classified into complete,
incomplete and the Wrisberg type. Complete
and incomplete have good posterior
anchorage, while Wrisberg lacks posterior
anchorage. Discoid meniscus causes a
snapping or popping knee.
The main function of the menisci is
tibiofemoral load transmission, shock
absorption, and lubrication of the joint.[6]
The menisci compensate for significant
incongruity between the femoral and tibial
articulating surfaces. The human menisci
transmit 30–55% of the load in a standing
position.6 After meniscectomy, tibiofemoral
contact area decreases leading to contact
stresses these changes ultimately cause joint
degeneration. They also help to distribute
synovial fluid throughout the joint and aid in
the nutrition of the articular cartilage. The
menisci also contribute to the stability of the
knee, largely as secondary soft tissue
restraints which prevent anterior tibial
displacement.
CLINICAL PRESENTATION:
The meniscal injuries have a bimodal age
distribution in young active sports person
and in elderly people. In young people most
common reason is a non contact sports
injury which occurs while decelerating,
rotating on knee, or landing and jumping on
the knee. However in old age tear is mostly
degenerative with patient unaware of it until
mechanical symptoms occur. Locking,
buckling, catching are suggestive symptoms
of a meniscal injury. Some patients may even
claim to have heard popping sensations
during injury. Swelling often occurs a day or
two later, immediate swelling usually is a sign
of bleeding into the knee. The swelling
associate with the meniscal injury may be
recurrent. Most of the symptoms are non
specific.
Clinical evaluation starts with the gait
examination, a painful limp is usually present
more so in acute injuries. Care should be
taken to access thigh muscle wasting, knee
joint effusion and joint line tenderness.
Proper examination for ligamentous and
– 19 –
other soft tissue injuries should be done to
rule out injury to these structures. The
stability of the knee should be assessed for
concurrent ligamentous injury.
Following specific tests for meniscal injuries
have been described.
McMurray test: with patient supine, hip and
knee is flexed, medial meniscus is accessed by
external rotation of foot and extension of
knee, while lateral meniscus is accessed by
internal rotation of foot and extension of
knee. Feeling of a clunk is considered a
positive test. A specificity of 100% is
reported with this test.[7]
Apley's Grind test: This test is used to
d i s t ingu i sh be tween men i sca l and
ligamentous involvement. With the patient in
a prone position, the knee flexed at 90°, and
the leg stabilized by the examiner's knee,
distract the knee while rotating the tibia
internally and externally. Pain during this
m a n e u v e r i n d i c a t e s l i g a m e n t o u s
involvement. Then, compress the knee while
internally and externally rotating the tibia
again. Pain during this maneuver indicates a
meniscal tear. This test is currently
discouraged.[7]
Bounce home test: The patient is supine
with heel held in the examiner's hand. The
examiner fully flexes the knee and then
passively extends the knee. If the knee does
not reach complete extension or has a
rubbery end feel, test is considered positive.
The knee movement may be blocked by a
torn meniscus.
O'Donoghue test: With the patient prone,
the examiner flexes the knee 90°. The
examiner rotates the tibia internally and
externally twice, then fully extends the knee
and repeats the rotations. Increased pain
during rotation in either or both knee
positions indicates a meniscal tear or joint
capsule irritation. With a valgus force to a
flexed and laterally rotated knee, the medial
meniscus, medial collateral ligament (MCL),
and the ACL all may be injured, representing
the O'Donoghue triad.
Thesally test: The examiner supports the
patient by holding his or her outstretched
hands while the patient stands flat footed on
the floor. The patient then rotates knee and
body, internally and externally, three times,
keeping the knee in slight flexion 5°. The
same procedure is then carried out with the
knee flexed at 20°. The test is always
performed first on the normal knee first.
Discomfort or sense of catching or locking is
considered positive.[8]
The reliability of the different tests and signs
for meniscal lesion has been studied by
several authors.
Fowler et al evaluated the predictive value of
common clinical tests for the diagnosis of
meniscal tears in 161 patients. They
evaluated joint line tenderness, pain on
forced flexion, the presence of a positive
McMurray test, positive Apley grind, and
distraction tests, and the presence of a block
– 20 –
to extension. They compared clinical
findings with arthroscopic findings. The
authors have found that no one test was
predictive for the diagnosis of a meniscal
tear.[9] A combination of several positive
tests is highly indicative of a meniscal tear.
RADIOLOGICAL EVALUATION:
Plain Xrays of the knee should always be
asked. These help to rule out any bony injury,
arthritic changes, loose body and joint
malalignment.
MRI is the benchmark for the non invasive
investigation for the meniscal injuries.
Meniscal signals shown by MRI have four
grades:
• uniformly low signal intensity (normal
meniscus) : Grade 0
• irregular increases in intrameniscal
signal: Grade 1
• linear increased signal patterns not
extending to meniscal surface: Grade2
• abnormal signal extends to the
articular surface: Grade 3
While g rades 0–2 have no surgica l
significance, grade 3 represents a meniscal
tear.[10,11] One of the reasons for many
fa l se pos i t ive MRI repor ts i s over
interpretation of grade 2 signals.
Several studies have shown equal accuracy
for clinical examination and MRI in
diagnosing meniscal tear, however MRI helps
to access the extent, location and type of tear,
besides any associated cruciate ligament or
chondral injury [12,13,14]
CLASSIFICATION:
Meniscal tears have been classified in various
ways depending on aetiology, location,
pattern and MRI findings. However the most
reliable and valid classification is the
International Society of Arthroscopy, Knee
Surgery and Orthopaedic Sports Medicine
classification.[15] which is a elaborate
classification taking into account Tear depth,
Rim Width, Radial Location, Tear pattern,
Quality of the tissue, Length of tear
percentage of meniscus (surface area) that
was excised.
TREATMENT:
With the reports of osteoarthritis in knees
after menisectomy and keeping in view the
functions of the meniscus, preservation,
repair or reconstruction of meniscus is now
the standard form of care. The choice of
treatment usually should take into account
age, activity level, aetiology, patients
expectations and lesion morphology.
Conservative treatment: is often considered
for stable small peripheral vertical tears.
Conservative treatment is also first line
treatment in degenerative tears in elderly
unless locking is present. Non operative
treatment is also the first treatment in acute
knee trauma in form of protection, rest, ice,
compressions and elevation PRICE regimen.
A conservative trail of at least 3 to 6 months
is warranted if mechanical symptoms don't
exist.[16] physiotherapy in form of
– 21 –
quadriceps strengthening exercises, activity
modification and off load bracing has shown
to be of help in patients with degenerative
tears. A recent RCT showed that patients
who underwent surgical debridement and
physiotherapy showed equally good results
as patients who received physiotherapy
only.[17]
Surgical procedure might be necessary if
there is locking or if symptoms persist for
more than 6 months after injury.
Surgical treatment: Diagnostic arthoscopy
is often necessary to determine the optimal
treatment for the meniscal lesion. The main
surgical procedures for the meniscal lesions
can be braoadly divided into menisectomy,
meniscal repair and meniscal reconstruction.
Menisectomy: Menisectomy can either be a
open or arthroscopic procedure. Nearly all
of the procedures now a days are performed
arthroscopically. The procedure can be total
menisectomy in which whole of the
meniscus is removed or partial menisectomy
in which part of meniscus which is deemed
to be irreparable is removed, preserving as
much meniscus as possible. Due to evidence
of knee joint degeneration and altered bio
mechanics of knee joint after total
menisectomy, total menisectomy is rarely
done these days. Partial menisectomy is
usually done in radial tears in avascular zone
or degenerative tears with mechanical
symptoms as they are believed to cause
os teoar thr i t i s in long r un . Par t i a l
menisectomy i s the most common
procedure for treatment of meniscal tears.
Though it has good short term results, the
long term results of procedure have shown a
high progression to osteoarthritis.[18] In
another study it proved to be of no benefit in
degenerative root tears.[19] Current view is
that partial menisectomy should be a very
limited procedure and avoided as far as
possible even in degenerative meniscal
lesions. It can be done in a small subset of
patients with irreparable degenerative tears
causing mechanical block.[16]
Meniscal repair: The first open repair of
meniscus was reported by Annandale.[20,21]
Era of arthroscopic repair started when first
arthroscopic meniscal repair was done by
I k e u c h i . [ 2 2 ] a r t h o s c o p i c r e p a i r
predominates the open repair now a days.
Open repair is occasionally used particularly
if posterior meniscal tears in a very tight
m e d i a l c o m p a r t m e n t n e e d t o b e
repaired.[23] the long term success of
meniscal repair is between 70 to 92%.[24]
Eggli et al reported successful outcome in
73% after follow up of 7 and a half years.
Favourable factors for outcome were injury
duration less than 8 weeks, peripheral tears, a
small tear of less than 2.5cm, age less than 30
years. Lateral meniscus had better outcome
than medial meniscus.[25] the most
important condition for good recovery is a
stable knee, unstable knee often leads to
failures. Suturing techniques for repair of
tear can be inside out, outside in or all inside.
– 22 –
Fig. 2
Inside out suturing: It is strongest out of
the three[26]. It is suitable for anterior and
middle 1/3 section of the meniscus. Tear is
fixed by placement of sutures from intra-
articular region with help of special cannulae
to extracapsular area.
Outside in technique: In this technique
sutures are passed through two spinal
needles from the meniscal body to meniscal
rim, the two ends of the passed suture are
then tied over the capsule.
All inside technique: This is done with the
help of special implants called fixators.
These can be arrow head, hook devices,
staples or anchors (Figure 2). These impants
are made of polylactic acid and cause implant
induced synovitis, which limitis their use.
Flexible, suture based implants are more
commonly used now.[27] advantages of
these all inside implants is that they are
technically less demanding and quick, but
they have less strength than the sutures.
Besides these repairing techniques, certain
procedures have been described in literature
to augment healing in meniscal tears
particularly in avascular areas.
Trephination technique: it involves
making radial holes in meniscus to aid
ingrowth of vascular tissue. Combined with
suturing it shows improved results.[28]
Synovial abrasion: abrading synovial tissue
around meniscal repair area will increase
vasculature and improve healing.[29]
Fibrin clot technique: Patients venous
blood is mixed with a glass baguette, this
paste is then kept in between torn edges, this
has a positive effect on healing due to
chemotactic and mitogenic factors.[30]
Meniscal reconstruction: These are the
procedure which are used to replace a
partially or totally resected meniscus.
Though preservation is currently the main
aim of treatment, sometimes due to
irrepairable injury or previous surgery
reconstruction remains the only option. The
two procedures for reconstruction are
m e n i s c a l s c a f f o l d s o r m e n i s c u s
transplantation.
Meniscal scaffolds: These are used to fill
the defects in resected meniscus by allowing
growth of vasculature and cell migration to
form meniscal tissue. Two main types of
scaffolds are the collagen meniscus implant
and urethane scaffold.[31,32] These are cell
free and biodegradable scaffolds. Favourable
reports regarding their clinical efficacy and
long term results have been reported.[33]
lately cell scaffolds have been introduced.
– 23 –
Meniscal transplantation: To prevent
arthritis is young patients with a deficient
meniscus, transplantation remains an option.
Experimentally autografts, allografts, xeno
grafts and synthetic implants have been used.
The benefit of these in preventing
osteoar thr i t i s in long ter m is s t i l l
questionable.[34] Allograft transplantation
has shown good to excellent results in 84%
cases in a meta analysis in athletes. These
procedures have favourable outcome only if
articular cartilage is smooth and body mass
index in less than 30. Discussions on
transplantation still continue with good
short term and medium term results.[35]
Long term studies are needed.
R E H A B I L I T A T I O N A F T E R
MENISCAL REPAIR
Two protocols have been followed in the
rehabilitation of patient with meniscal
repair: The conservative protocol and the
aggressive protocol. In conservative
protocol 6 weeks of partial loading , slow
increase in knee movements in controlled
brace and avoiding sports for 6 months is
followed, while as aggressive protocol allows
immediate loading and unlimited knee
movements and return to sports as long as
patient can tolerate. In a comparative study
there was no difference in failure rates of the
two methods.[36] However result vary on lot
of factors besides the rehabilitation
protocol, it becomes impossible to compare
results of various series. Most surgeons
follow the conservative protocol.
CONCLUSION
Meniscal injuries are one of the common
reasons for knee pain and disability. Proper
clinical evaluation is needed to decide best
possible treatment for a particular patient.
Conservative treatment usually suffices in
degenerative tears without mechanical
symptoms. Treatment should be aggressive
in young athletic patients who have a fresh
injury. Current treatment focuses more on
preservation of the meniscal tissue. Focus
should be on repair rather than removal.
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Veth RPH, Jansen HWB. Use of porous polyurethanes
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– 26 –
INTRODUCTION:
Patella is the largest sesamoid bone in the
body. It functions to increase the moment
arm of the extensor mechanism of the
quadriceps by 30%[1]. The cartilage on the
articular surface of patella is very thick,
measuring up to 5.5mm[2,3]. Fractures of
patella may result from direct, indirect or
combined injury patterns and account for
approximately 1% of all skeletal fractures[2,
4]. Direct injuries may occur after a fall from
height or from dashboard impact in a motor
vehicle collision. Indirect injuries result from
force full contraction of the quadriceps with
the knee in a flexed position. Majority of the
fractures have a transverse pattern. Fracture
may occur through the body, apex or distal
pole of patella.
Open injuries are quite common due to
anterior location of patella and thin
overlying soft tissue envelope. Saline load
test5 is advised in occult open fractures.
Early intervention gives satisfactory
outcome in these cases[6].
Concomitant injuries occur commonly in
association with patella fractures and more
so in high energy injuries[7]. More often the
associated injuries occur in ipsilateral lower
limb esp distal femur or proximal tibia
fractures[6].
Patients typically present with the history of
particular mechanism of injury. Complaints
of anterior knee pain, swelling and difficult
wa lk ing are common. On phys ica l
examination, there is usually an acute
hemarthrosis and tenderness. A palpable
defect may be felt between the fracture
fragments. Patient will be unable to do a
straight leg raise or extend a partially flexed
knee against gravity if extensor mechanism is
disrupted.
DIAGNOSIS:
Radiography: Plain radiography is typically
sufficient to confirm the diagnosis of patellar
fracture or extensor mechanism injury.
Anteroposterior, Lateral and Axial views of
the kneel joint should be obtained (Fig.1).
REVIEW ARTICLE
Dr. Shakeel Ahmad, Dr. Rouf Ibrahim, Dr. Pervaiz Ahmad.
Treatment Strategies for Patella Fracture- A Review
[All Authors Work at the SKIMS Medical College Bemina]
– 27 –
Patellar height should be assessed using
Insall-Salwati ratio[8] and Blumensaat's
line[9].
Fig.1
CT scan: CT is rarely done in the evaluation
and management of isolated patellar
fractures. CT scan allows for improved
assessment of articular congruity and
fracture comminution. CT scan provides a
more important role in the evaluation of
stress fracture[10], non-union and malunion.
Routine use of CT scan may result in
increased surgical indications[11]. MRI: MRI plays an important role in
evaluation of suspected extensor mechanism
injuries[12] as well as chondral injuries
associated with patellar dislocations[13].
However, MRI in acute patellar fractures is
also not routinely used.
CLASSIFICATION:
Patellar fracture classification is typically
descriptive and based on fracture pattern,
degree of displacement or mechanism of
injury. Currently, OTA classification is used
for standardizing classification of patella
fractures for clinical research[14, 15, 16].
Patella fracture is usually clinically classified
as displaced and undisplaced. Displaced
fractures are defined by separation of
fracture fragments by more than 3 mm or
articular incongruity of more than 2 mm.
The injury can further be sub-categorized on
the basis of geometric configuration of the
fracture lines into following types (Fig.2);
Transverse
Stellate
Vertical or longitudinal
Apical or marginal
Osteochondral
Patellar sleeve fractures
Fig.2
– 28 –
TREATMENT:
The goals of surgical intervention are:
• Maximal preservation of the bone
• Restoration of the articular congruity
• Preservation of the functional integrity
and strength of the extensor mechanism
Currently, the main treatment options for
patellar fractures are:
• Nonoperative management
• Open reduction and internal fixation
• Partial patellectomy
• Complete patellectomy
NON-OPERATIVE TREATMENT
Nonoperative treatment may be indicated
for patellar fractures with <3 mm of
fragment displacement, <2 mm of articular
incongruity, intact extensor mechanism and
severe osteopenia.
Non-operative treatment should also be
considered when significant patient
comorbidities make operative intervention
dangerous[2].
Non-operative management consisting of
immobilization for 4 weeks results in good to
excellent results in 99% of patients with an
intact extensor mechanism, less than 3 mm
displacement and less than 2 mm of articular
step-off [2, 4].
Prolonged immobilization can result in knee
joint stiffness, quadriceps wasting and joint
adhesions[17]
Melvin and Mehta[2], recommended weight
bearing as tolerated in a knee immobilizer
locked in extension with straight leg raises as
tolerated followed by active and active
assisted range of motion at 2 weeks.
OPERATIVE TREATMENT
There are numerous operative treatment
methods including tension band, modified
tension band, osteosynthesis with plates and
screws, suture repair, circlage wiring,
percutaneous reduction and internal
fixation, arthroscopy assisted reduction and
internal fixation, external fixation, partial
patellectomy and total patellectomy for
patella fracture[2,18 - 22].
Operative treatment is indicated for patellar
fractures with >3 mm of fragment
d i sp lacement , >2 mm of ar t icu lar
incongruity, osteochondral fractures with
associated intra-articular loose bodies, a
compromised extensor mechanism with loss
of active extension.
Tension band fixation: It is the most
commonly used technique for simple
transverse fractures. Tension band fixation is
usually performed through an anterior
longitudinal incision. The classic technique
consists of two parallel vertical kirschner
wires with a tension band passing anteriorly
over the patella and posterior to the kirschner
wires. This technique has been found to be
associated with prominent hardware
requiring removal, implant migration, wire
breakage, loss of reduction and muscle
– 29 –
atrophy.
Various methods of tension band technique
have evolved since the start of operative
fixation of patellar fractures. Important to
mention among these include (Fig.3)
A: Standard tension band. B: Modified
anterior tension band (MATB). C: MATB
with vertical figure-of-8 wire. D: Magnusson
wiring. E: Cerclage wiring. F: Parallel lag
screws. G: Lotke longitudinal anterior band.
H: MATB with horizontal figure-of-8 wire. I:
Cannulated screws with figure-of-8 wire. J:
Pyrford technique. K: Separate vertical
wiring (lateral view). L: Basket plate.
A study by Benjamin et al.[23] compared the
strength of four different fixation strategies
(tension band wiring, modified tension band
wiring over Kirschner wires, and Ecker
long i tud ina l anter ior banding , and
circumferential circlage wiring) in a
transverse patellar fracture and retinacular
disruption model. The modified anterior
tension band technique of transosseus K-
wire fixation with anterior banding
demonstrated superior strength to all other
constructs
Tian et al[24] performed a retrospective
review comparing a modified tension band
technique using Kirschner wires with a
modified tension band technique using
cannulated screws. They found improved
fracture reduction, a reduced healing score,
and better Iowa knee scores with the
cannulated screw modification. Additionally,
the implant migration rate and the second
operation rate were 15.4% and 5.7%,
respectively, for the Kirschner wire, with no
complications in the cannulated screw
cohort. In a cadaveric study, Carpenter et
al[25] found that a modified tension band
with cannulated screws had a higher load to
failure than cannulated screws alone or a
modified tension band with Kirschner wires.
Plating: Small plates can be applied to the
anterior surface of the patella in the setting
of comminution to provide additional
stability. Taylor et al[26] reported techniques
and outcomes of plate fixation for patella
fractures. They presented 8 patients with
patella fractures or nonunion treated with a
combination of plate and interfragmentary
screw fixation. All of their patients went on
to union at a mean of 3.2 months with an
average total arc of knee motion of 129°.
There were no cases of hardware removal for
symptomatic implants.
Thelen et al[27] used a 2.7-mm, fixed-angle
plating construct for transverse patella
fractures in cadavers and compared with
Kirschner wire tension band fixation and
– 30 –
cannulated screw tension band fixation.
After 100 cycles of full extension to 90° of
flexion, the fixed-angle plating group
averaged less than 1 mm of displacement,
compared with 7.1 and 3.7 mm in the
Kirschner wire and cannulated screw tension
band groups, respectively. Banks et al[28]
compared the tension band construct with
cannulated screws with a tension band
construct with a locking plate in a cadaveric
transverse patella fracture model. The locked
plate tension band models had similar load to
failure, significantly higher ultimate fixation
strength, and slightly lower stiffness at final
loading compared with the cannulated screw
tension band construct. In a foam patella
model, Wurm et al[29] found that the tension
band construct had a 33% lower load to
failure and 5 times larger fracture gap
displacement than the locking plate
construct.
Screw Fixation: There is not much
literature on isolated screw fixation for
patella fractures. Wang et al[30] published a
retrospective review of transverse patella
fractures treated with modified tension
bands compared with those treated with
parallel interfragmentary screws in a lag
design fashion. They found parallel titanium
screw fixation to have a shorter operative
time, a lower loss of fixation, and lower rates
of symptomatic hardware and second
surgery.
Tandogan et al[31] reported on 5 patients
with displaced patella fractures without
extensor mechanism disruption treated with
ar throscopic assisted reduction and
percutaneous screw fixat ion. Their
technique returned all but 1 patient to full
range of motion with no implant failure or
i n f e c t i on . Cadave r i c s t ud i e s have
demonstrated that cannulated screws have a
lower load to failure than cannulated screws
with a modified tension band technique[25].
Minimally Invasive and Percutaneous
Techniques: Percutaneous treatment of
patella fractures has been proposed as a
means to preserve vascular supply and to
decrease insult to the soft tissue envelope. In
a randomized, controlled trial of 53 patients,
Luna-Pizarro et al[32] compared the
percutaneous patellar osteosynthesis system
technique with open surgery for operative
patella fractures. They found that the
percutaneous patellar osteosynthesis system
resulted in shorter surgical time, less pain,
better range of motion, fewer complications,
and similar functional scores at 2 years
postoperatively.
A minimally invasive technique for tension
band fixation of transverse patella fractures
using the cable pin system (Cable-Ready,
Zimmer, Warsaw, Indiana) was evaluated by
Mao et al[33]. A total of 31 patients were
followed for an average of 21 months.
Fracture union occurred at a mean of 7.2
weeks with an average of 91° of active
flexion at that time. Full range of motion was
achieved in 93.5% of the patients at final
follow-up and excellent results in 30 of 31
– 31 –
patients.
External Fixation: Wardak et al[20] used a
compressive external fixation system for the
treatment of 84 displaced primarily
transverse patella fractures, of which 31%
were open fractures. The device was left in
place for a total of 6 weeks on average, at
which time all fractures had attained union.
Pin tract infection and/or wire site irritation
occurred in 12% but resolved after device
removal without further surgical procedures.
Articular surface incongruity of 2 mm or
greater was seen in 11% of patients, all of
whom had radiographic evidence of arthritis
at 18 months postoperatively. No secondary
surgical procedures were required. The
authors concluded that their compression
external fixation system was a safe and
effective method for treating patella
fractures, especially in cases with a poor soft
tissue envelope, in salvage situations, and in
locations with limited resources.
Partial patellectomy: Partial patellectomy
may be indicated when comminution of the
distal pole or a fragment of the patella is
extensive and cannot be stabilized with
internal fixation. In addition, fragments that
are dysvascular or free with limited soft tissue
attachments and likely to become loose
bodies within the knee joint should be
removed. Partial patellectomy should be
avoided when the entire patella is salvageable
or a tendon repair can be performed without
removal of bony fragments. Par tial
Patellectomy performed by first excising
comminuted bone fragments and then
passing nonabsorbable braided suture from
the patellar tendon through drill holes in the
patella, similar to a traditional patellar tendon
repair. Bone fragments can often be
incorporated into the repair. Partial
patellectomy has been described as a means
to preserve the moment arm of the patella
resulting in less loss of strength, ligament
instability, and quadriceps atrophy when
compared with total patellectomy34.
Bonnaig et al[35] compared 26 patients who
underwent patella open reduction and
internal fixation with 26 patients who
underwent partial patellectomy and found no
difference in outcomes between the two
groups.
Total patellectomy: Total patellectomy is
occasionally performed for highly displaced,
comminuted fractures in which stable
fixation cannot be achieved and when no
large fragments can be retained, failed
internal fixation and patellar osteomyelitis.
When total patellectomy is performed,
extensor lag is one of the most common
complications. Total patellectomy is
primarily of historical interest and is rarely
performed, being reserved for instances of
substantial bone loss or as a salvage
procedure[2,4]. Complete patellectomy
eliminates the mechanical advantage
provided by the patella to the extensor
mechanism and results in a 49% reduction in
knee extension strength[34,36]. A modified
technique described by Günal et al[37] using
– 32 –
a vastus medialis advancement resulted in
less pain, less activity limitation, better
quadriceps strength, improved cosmesis, and
better functional performance than
patellectomy alone. However, the authors
stated that the patella should be preserved if
possible.
OPEN FRACTURES
The pa te l l a rema ins subcutaneous
throughout its length, and patella fractures
are open 6% to 13% of the time[2,7]. Open
patella fractures tend to result from higher
energy mechanisms than closed patella
fractures, with motor vehicle accidents
causing 94% of open patella fractures and
falls causing 62% of closed patella fractures
in the same study. Additionally, associated
injuries occur in 81% of open fractures
compared with 31% of closed patella
fractures[7]. Treatment of open patella
fractures should follow the same principles
as treatment of all open fractures: timely,
appropriate antibiotics followed by urgent
irrigation and thorough debridement with
definitive fixation and wound closure as soon
as possible[2,7]. Outcomes following open
patella fractures are typically inferior to those
following closed patella fractures. Secondary
procedures are more common in open
patella fractures (up to 65%), and delayed
wound coverage/closure is associated with
increased risk of deep infection[7,38,39].
COMPLICATIONS
Patient factors have a direct effect on
outcomes after surgical treatment of patella
fractures; history of a cerebrovascular
accident has been found to induce a 6-fold
increased risk of infection and a nearly 15-fold
increased risk of nonunion[40]. Diabetic
patients have more than 8 times increased
likelihood of reoperation for all causes[40].
Symptomatic hardware, especially in patients
treated with a tension band, is common and
may occur in up to 60% of patients, often
result ing in the need for hardware
removal[2,41]. Hardware failure occurs in 8%
to 22% of patients, most commonly when
Kirschner wires are used, and both local and
distant hardware migration has been
described[42-44]. Higher fixation failure rates
have been found with increasing patient age
and use of Kirschner wires with or without
tension band fixation. Increasing duration of
follow-up is associated with reoperation and
hardware removal, indicating that patellar
fixation implants may become more
noticeable and symptomatic as time increases
after surgery[45].After operative treatment,
nonunion and delayed union occurs in 2% to
12.5% of patients and the infection rate ranges
from 0 to 5%; both are increased in open
fractures. Knee stiffness can best be mitigated
by solid fixation and early range of motion.
Postoperative radiographic and clinical
osteoarthritis are both more common
following displaced patella fractures than in
the general population and are best minimized
by anatomic reduction, solid fixation, and early
range of motion[2, 46].
– 33 –
REHABILITATION
Although numerous clinical protocols have
been described, there has been minimal
research about the outcomes of specific
clinical protocols[2, 47]. Most surgeons
recommend gentle early knee range of
motion and full weight bearing in a knee
brace locked in extension. Flexion is typically
allowed to 30° within 2 weeks following
su rg i c a l fixa t ion w i th p rog re s s ive
advancement. This may be delayed in cases
of extensive comminution or tenuous
fixation[2, 47].
CONCLUSION
Patella fractures represent a broad spectrum
of injuries ranging from subtle non-
displaced fractures to open comminuted
fractures with significant bone loss.
Treatment should be directed to obtaining an
anatomic reduction and using a fixation
method that maximizes stability while
minimizing hardware prominence. Surgeons
should select fixation techniques that best
address the fracture pattern being treated, as
there is l i tt le high-quality evidence
comparing treatment methods. Despite all
of the advances in surgical treatment
options, functional impairment, pain, and
decreased quadr iceps s t rength and
e n d u r a n c e p e r s i s t t o 1 2 m o n t h s
postoperatively and beyond48. Knee joint
mobilization and range of motion as early as
fixation stability permits will help to
minimize posttraumatic arthritis and allow
optimal postoperative recovery.
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– 36 –
INTRODUCTION:
The knee joint is composed of three
compar tments - med ia l and l a t e ra l
tibiofemoral, and the patellofemoral
compartments. The articular surface is
covered by hyaline cartilage[1]. Articular
cartilage consists of a sparse population of
chondrocytes embedded within a highly
hydrated extracellular matrix composed of
collagen, mainly type II collagen, and
proteoglycans (PGs)[2]. Grossly, the
articular cartilage appears as a smooth,
homogeneous tissue approximately 2 to 5
mm thick. The structure of the cartilage
creates a low-friction surface allows it to
withstand multiple forces generated during
different movements of the knee.
For adequate functioning of the joint,
preservation of anatomical and physiological
properties of the cartilage is of utmost
importance. Because the cartilage lacks
blood vessels, lymphocytes and the
chondrocytes lack capability to multiply and
differentiate the chondral and osteochondral
lesions of the knee remain one of the biggest
challenges for the orthopaedic surgeon [3].
Due to the lack of access to the vascular
system, visible damage to the cartilage
surface that does not extend into the
subchondral bone does not initiate a
reparative response. Transient proliferation
of chondrocytes near the edges of the defect
has been observed, but the cells do not
proliferate into the defect or produce a
significant amount of matrix. The cells
briefly increase synthesis of type II collagen
and PGs, but the in jur y resul ts in
chondrocyte apoptosis and cessation of
matrix synthesis. Damage to the superficial
zone disrupts the collagen network and
increases the permeability of the matrix,
thereby decreasing the ability of the matrix
to resist tensile and compressive loads. This
results in increased stress in the matrix and
subchondral bone with eventual progression
to osteoarthritis.
Focal chondral defects need to be
differentiated from osteoarthritis of the knee
REVIEW ARTICLE
Dr. Asif Nazir Baba
Osteochondral Injuries of Knee- A Review
[Asif Nazir Baba Works at the Bone & Joint Surgery Hospital, Barzulla]
– 37 –
as the latter is characterized by progressive
loss of articular cartilage, osteophytes,
subchondral cysts, joint space narrowing,
and intermittent inflammation of the joint
tissues.
Incidence: Since majority of osteochondral
lesions are asymptomatic, it is difficult to
assess the actual incidence of these injuries.
Curl et al reviewed 31,516 knee arthroscopies
and detected chondral lesions in 63% of
cases, with 19.2% of these patients having
lesions extending into subchondral bone [4].
Widuchowski et al had observed chondral
lesions in 60% of patients, mostly on patella
and medial femoral condyles [5].
Classification: Cartilaginous lesions of
knee can broadly be classified depending
upon the depth of lesion into mild (partial
thickness), moderate (full thickness) and
severe (extension into the subchondral bone)
[6]. Based on the macroscopic findings,
Outerbridge classified the lesions into four
grades [7]. However, nowadays the defects
are graded macroscopically using the
International cartilage Repair Society (ICRS)
classification which is a simplified form of
scoring system as given by (Table 1) [8,9].
Table 1: Classification of chondral
lesions according to the ICRS system
Etiology: Focal chondral lesions are caused
by trauma, osteochondritis dessicans (OCD)
or ostenecrosis. Trauma is the most common
cause, usually due to accidents or sports
injuries. Patellar dislocation is responsible for
40-50% of ostechondral lesions around
femoral condyle [10]. Osteochondritis
dessicans, first described by Konning in
1888, is usually the result of recurrent
microtrauma to femoral condyle and is
classically located on the lateral aspect of
medial femoral condyle [11]. Osteonecrois
can be primary or secondary to steroid
therapy, alcoholism or meniscal injury [12].
Degenerative defect are the result of
ligamentous instability, meniscal injuries or
malalignment [13].
Clinical features: The most common
symptoms are pain and swelling. Pain is
sudden onset in case of trauma, and vague
and poor ly loca l i zed in OCD and
osteonecrosis. Features of associated
conditions like catching and instability may
be present. In case of a full thickness tear, the
most common symptom is a loose body and
its associated features. Examination
– 38 –
commonly reveals knee effusion. Point
tenderness within joint or above the joint
line, crepitation and wasting of muscles
(quadriceps and vastus medialis) are seen.
Wilson test is positive in case of OCD [14].
Clinical features of associated conditions like
meniscal tear (McMurray, Apley Grinding
test) and ACL injuries (Anterior drawer test,
Lachman test) may be present.
Radiology: Routine radiological evaluation
includes a weightbearing anteroposterior
(AP) and lateral view as well as an axial view
of the patella such as a sunrise or Merchant
view. Rosenberg view, a PA view of the knee
in flexion allows better assessment of the
lateral and posterior aspects of the joint
space. A full length AP view of the entire
extremity from hip to ankle demonstrates
any varus or valgus malalignment. CT
arthrogram is helpful to evaluate the cartilage
integrity and diagnose subtle patellar femoral
maltracking. However, the disadvantage of
CT is the exposure to ionizing radiation.
Magnetic resonance imaging is commonly
used to confirm the presence of chondral
defects, look for associated pathology such
as meniscal and cruciate ligament tears,
visualize cartilage surfaces and detect bone
marrow edema beneath the defect [15].
Magnetic resonance ar thrography is
repor ted to be more accurate than
conventional MRI in the evaluation of
articular cartilage, the assessment of stability
of OCL and the detection of intra-articular
bodies [16]. Diagnostic arthroscopy remains
the “gold standard” for evaluating the joint
surfaces and provides the most accurate
means of diagnosis [17]. Although a surgical
procedure, it can be readily utilized to
diagnose as well as treat cartilaginous injuries
of the knee at the same setting or as a staged
procedure.
MANAGEMENT: The management of
chondral defects of the knee is a challenge
for the orthopaedic surgeon. The fact that
the articular cartilage has limited potential
for repair and healing, make the management
of defects all the more important. The most
important factors to consider are the size of
lesion (measured at least in two planes
perpendicular to each other), depth of
defect, location ( weight-bearing area or not)
and number of defects as all cartilage defects
do not produce the same degree of clinical
symptoms [18]. Other important factors to
be considered are the age of patient, body
mass, act iv i ty demands, assoc ia ted
ligamentous and meniscal injuries, alignment
of knee and the condition of the remaining
cartilage all play a role in determining the
treatment course [19]. The defects need to be
treated as natural history studies show that
FCD may progress to degenerative arthritis
[20]. Although the risk of progression is
multifactorial, the defect size is the most
important factor [21].
Conservative management: Conservative
management is the initial management for
majority of chondral lesions, especially in the
patel lofemoral region. The goal of
– 39 –
conservative treatment is to reduce the
symptoms, not heal the lesion [22].
Conservative management is effective in
patients with mild symptoms, with small
lesions (especially in non-weight bearing
regions) and in patients at high risk for
surgery. There is a wide variation in the
minimum size of lesion that is treated
s u r g i c a l l y, va r y i n g f r o m 0 . 7 5 c m 2 2(Lorentzon) to 1.6 cm (Brittberg) [23, 24, 25,
26]. Since most of the surgical modalities
involve a vigorous rehabilitation protocol
with 6-12 weeks of protected weight bearing,
the patients not willing for same can also be
managed conservatively. Similarly, the
patients with limb mal-alignment will need a
corrective procedure prior to or along with
the cartilage surgery. Ligamentous laxity like
ACL tear or significant meniscal damage in
the form of previous subtotal or total
meniscectomy is a contraindication for
isolated cartilage resurfacing.
The mainstay of conservative management
is activity modification and maintenance of
ideal body weight. High impact activities like
jogging and jumping need to be avoided.
Oral NSAIDs and tramadol are useful for the
temporary swelling and discomfort. Use of
cane, physical therapy, glucosamine, MSM,
Omega -3, intra-articular steroids and
viscosupplementation can also be tried.
However, there is no evidence of structural
improvement with these modalities [27].
Platelet rich plasma (PRP), which is rich in
growth factors like PDGF, TGF-β, bFCF,
ICF, VEGF, is emerging as an attractive
treatment for these lesions.
Surgical management: The ideal aim of
surgical intervention is regeneration of
chondral defect to ultrastructural and
biomechanical competence of hyaline
cartilage. The method chosen depends upon
the size of lesion, location of lesion, age and
a c t i v i t y l e v e l o f p a t i e n t . T h e
c o n t r a i n d i c a t i o n s o f s u r g e r y a r e
inflammatory arthropathy, unstable or
malaligned joint (as isolated procedure),
kissing lesions, infection and obesity.
The surgical options are broadly divided into
three types:
1. Marrow stimulation techniques.
2. Osteochondral transfer- autograft
or allograft
3. A u t o l o g o u s c h o n d r o c y t e
implantation (ACI).
1. Marrow stimulation is based on the
premise that stimulation of the subchondral
bone may release mesenchymal cells from
the bone marrow, thus promoting formation
of new tissue [28]. It is usually done
arthroscopically in grade 3-4 lesions. Marrow
stimulation can be performed by different
techniques. Chondroplasty involves conversion of
uneven cartilage surfaces to a smooth
surface, especially in partial thickness lesions.
This can be achieved by use of motorised
shavers or by radiofrequency. The latter may
– 40 –
lead to high intra-articular temperatures and
potential of damage to the joint cartilage[29].
Microfracture is the most common method
of car t i lage restorat ion by mar row
stimulation [30]. Arthroscopically small
multiple holes, 3-4 mm apart, are made with
awls in the defect to allow egress of marrow
element and formation of superclot which
remodels into fibrocartilage. It is indicated in
small full-thickness defects (< 2-3 cms), less
than one year post-injury and occasionally in
large lesions in older, less-demanding
patients. Contraindications include age > 50
years, concomitant knee pathology, inability
to follow rehabilitation protocol, underlying
AVN and diffuse joint degeneration. The
advantages of the method are its simplicity,
can be done arthroscopically and have less
morbidity. However, the fibrocartilage
formed in this method is inferior to native
hyaline cartilage. The long term results are
not good, as only half of the patients return
to pre-injury sports levels [31, 32].
Complications associated with the procedure
include fracture of subchondral bridge,
incomplete microfractures and hypertrophic
overgrowth.
Subchondral drilling was first described by
Smillie & Dundee [33] and popularized by
Priddie [34] After debridement of lesion the
subchondral bone is drilled with high speed
drill using 2-2.5mm K-wires. Blood perfuses
into the defect bringing with it mesenchymal
cells which proliferate to form fibrocartilage.
Thermal necrosis is the chief drawback of
the technique.
2. Osteochondral Autograft Transfer
(OATS) or mosaicplasty: It allows the
restoration of hyaline cartilage at the defect. 2It is ideally suited for defects upto 2.5cm in
medial or lateral femoroal condyles, and
trochlear groove. The method was first
described by Hangody et al [35]. The
receptor bed is prepared and cylindrical
tunnels 15 mm deep with 1mm spacing are
created. The graft is harvested from non-
weight bearing portion of the joint with a
length of 10-15mm. Finally the graft is
inserted into the defect. This method uses
patients own tissue and thus eliminates risk
of disease transmission, while providing a
superior cartilage. 90% good or excellent
results with early return to sports activity are
r e p o r t e d w i t h t h i s m e t h o d [ 3 6 ] .
Disadvantages include inability to mange
larger defects and the donor site morbidity.
Complications include overfilling of donor
site with fibrocartilage leading to mechanical
symptom and pain, DVT, infection and
hemarthrosis [37].
Osteochondral Allograft Transfer is used
to fill larger defects. Size matched cadaver
donor plugs permit immediate restoration of
joint articular surface. Fresh allograft have
high chondrocyte availability but the risk of
disease transmission is more, while
cryopreservation decreases immunogenicity
and disease transmission at the cost of lower
chondrocyte availability. Implantation is
recommended at 14 to 28 days after
– 41 –
procurement for optimal cell viability [38].
3. Autologous chondrocyte implantation
(ACI): Brittberg (1994) published the first
paper on implantation of chondrocytes for
treating osteochondral defects [39]. ACI is
indicated in young, active patients with full-
th ickness chondra l defect 2-10cm,
surrounded by healthy cartilage. The
technique has superior results compared to
other modalities [40]. The technique has
rapidly evolved over the past 3 decades. The
first generation ACI was a two step
procedure. In the first step the cartilage is
harvested arthroscopically from healthy area
and from this chondrocytes are cultured and
expanded in the laboratory. In the second
stage the defect is prepared by removing
unstable and damaged cartilage. The
prepared chondrocytes are placed in the
defect and the chondrocytes covered by
periosteal flap which is obtained from
proximal medial tibia.
Second generation ACI is similar to first
generation, but the implantation is simplified
by using a synthetic collagen for cell
placement. This obviates need for a
periosteal flap and additional incision and
morbidity associated with it. In addition, spill
over and asymmetric distribution of
chondrocytes following implantation is
avoided. In the third generation ACI the
chondrocytes are embedded in three-
dimensionally constructed scaffolds for cell
growth. They do not require a periosteal
cover and exactly fit into the defect with
fibrin glue.
The advantages of ACI are superior results,
utility in larger lesions, defects which have
failed other restorative methods and less
donor site morbidity. However, ACI is
contraindicated in inflammatory arthritis and
pat ients not co-operat ive for long
rehabilitation. The disadvantages of the
method include the need for two stage
procedure, requirement for arthrotomy (first
and second stage) and the high cost of the
procedure,
Conclusion: Chondral defects of knee are
important because cartilage lacks the
potential for repair and the untreated lesion
leads to degenerative changes in the future,
the defect needs to be evaluated properly and
the appropr ia te t rea tment dec ided
considering the size and site of lesion,
patient factor and associated injuries. Each
m e t h o d h a s i t s a d v a n t a g e s a n d
disadvantages, but when applied prudently
all have given good results.
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3. Ozório de Almeida Lira Neto, Carlos Eduardo da
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– 42 –
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Bone Joint Surg Am. 1975;57(6):802-10.
18. Minas T. The role of cartilage repair techniques,
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Orthopedics Special Edition. 2000;6:71-76.
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severe damage to weight-bearing cartilage in the knee.
Acta Orthop Scand. 1996;67:165-168.
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of articular cartilage lesions of the knee. International
Orthopaedics (SICOT) (2010) 34:621–630
23. Lorentzon R, Hildingson C, Alfredson H. Treatment
of deep cartilage defects in the knee with periosteum
transplantation [abstract] Swedish Orthopaedic
Association Meeting; September 1996; Karlstad,
Sweden.
24. Minas T. The role of cartilage repair techniques,
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chondral knee damage. Instr Course Lect. 1999; 48: 629-
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scaffolds in the treatment of early knee arthrosis: a
prospective 4-year follow-up of 37 patients. Clin Orthop.
1994;307:155-164.
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al. Perichondral grafting for cartilage lesions of the knee.
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27. Browne JE, Branch TP (2000). Surgical alternatives for
treatment of articular cartilage lesions. J Am Acad
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28. Nehrer S, Spector M, Minas T. Histologic analysis of
tissue after failed cartilage repair procedures. Clin
Orthop Relat Res. 1999; (365):149-62.
29. Caffey S, McPherson E, Moore B, Hedman T,
Vangsness CT Jr. Effects of radiofrequency energy on
human articular cartilage: an analysis of 5 systems. Am J
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30. McNickle AG, Provencher MT, Cole BJ. Overview
of existing cartilage repair technology. Sports Med
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Traumatol Arthrosc. 2005; 13:213-221.
32. Gudas R, Kalesinskas RJ, Kimtys V, et al. A
prospective randomized clinical study of mosaic
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defects in the knee joint in young athletes. Arthroscopy.
2005; 21:1066-1075.
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knee. J Bone Joint Surg [Br] 1959; 41:618–623.
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in the knee]. Magy Traumatol Ortop Kezseb Plasztikai
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Mandelbaum BR. Return to sports participation after
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Isaksson O, Peterson L. Treatment of deep cartilage
defects in the knee with autologous chondrocyte
transplantation. N Engl J Med. 1994;331(14):889-95.
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– 44 –
One of the biggest advantages of the
Ilizarov technique is the correction of
rotational deformities. The configuration of
the ring system allows for correction of
angular deformities in multiple planes and
correction of rotations over 360 degrees.
Though all other components of deformity
like correction of limb length discrepancy,
correction of angular deformities and bone
transport are achievable with uniplaner
external fixators like orthofix and rail yet for
correction of rotational components the
configuration of a ring system is mandatory.
How a ring is made to rotate
The rotational assembly consists of multiple
obliquely placed connecting rods that
connect two rings via ilizarov posts. Each set
consists of a connecting rod connecting two
post with routine movable nuts. The whole
de-rotation assembly may consist of three or
more such sets.de-rotation is achieved by
turning the nuts as shown by the arrows in
figure 1. This manoeuvre creates torque
forces that convert linear motion into a
rotational one.
Fig.1 Fig.2
Case example.
32 years old male presented with complex
deformity of the right leg post growth arrest
in the childhood and a shortening of 9 cms.
In addition to angular deformities the patient
had a 90 degree internal rotation of the
affected limb. Fig 2 shows that all other
deformities were corrected and the only
component left is that of rotation. At this
stage the de-rotation assembly was added
across the site of regeneration. After gradual
correction the deformity was fully corrected
as in Fig 3. A twist in the regenerate can be
TECHNICAL TIP
Prof. Altaf Ahmad Kawoosa
Management of Rotational Component ofComplex Deformities with Ilizarov Technique
[Dr Altaf A Kawoosa Works at the Bone & Joint Surgery Hospital, Barzulla]
– 45 –
clearly appreciated in the Fig. 4.
Fig. 3 Fig. 4
How does one know that de- rotation is
happening correctly?
The conventional ring construction should
always be done having all the ring connection
bolts lying in one line anteriorly (in case if
tibia along its anterior border). Once the de
rotation process is started the movement of
distal ring complex relative to the proximal
ones can easily be monitored for correct de
rotation.
Note.
1. De rotation must be performed
before the consol idat ion of
regenerate
2. It is mandatory to watch the distal
neurovascular status as de - rotation
may create a kink in the vessels and
nerves. Since the process is a gradual
one this complication may never
happen
– 46 –
INTRODUCTION
Penetrating injuries of the foot are a
common presenting complaint in the
emergency department. The residents of the
underdeveloped world are especially prone
to suffer such injuries as barefoot walking is
still common. An injury peculiar to shod feet
occurs when a nail penetrates through the
sole of the footwear and leaves behind a
piece of the material from the rubber sole
within the soft tissues of the foot [1,2,3].
This piece of rubber often causes a range of
manifestations as already reported [4]. We
report a case of Osteomyelitis of the
metatarsal head as a delayed manifestation of
the nail slipper injury.
CASE REPORT
A 4-year-old man presented to the OPD of
the department of orthopaedics with pain of
the left foot. The pain was increased by
movement of the toe. The patient reported
that the pain had been present on and off for
1year with varying severity. He reported
significant exacerbations also.
Clinically there was tenderness of the head
of the 3rd metatarsal of the foot. Range of
motion of the toe was painful. An x ray was
advised which showed osteomyelitic changes
in the metatarsal head. A USG showed soft
tissue swelling around the metatarsal head.
MRI was reported as Osteomyelitis. On
being specifically asked the patient reported
penetrating injury of the foot with a nail
through the rubber soled shoe that he had
been wearing at that time. He had got the nail
tract washed and dressed up at that time. It
had healed uneventfully over a 2-week period
and the tenderness had subsided over a 6-
week period. After 3 months of the injury,
the patient had started to develop symptoms
of that had brought him to the hospital.
The patient was offered curettage and
d e b r i d e m e n t w h i c h h e a c c e p t e d .
Intraoperatively the metatarsal head was
found to be surrounded by granulation
tissue. After cleaning the metatarsal head a
CASE REPORT
Prof Anil Gupta, Prof Sanjeev Gupta, Dr Manish Singh, Dr Tahir Afzal, Dr MF Butt
Osteomyelitis of The Metatarsal Head
Caused By The 'Nail Slipper' Injury
[All Authors Work at The GMC Jammu]
– 47 –
hole in the head was found which was a
remnant of the nail tract. A rubber piece 5
mm x 5 mm was retrieved from the
metatarsal head. The material was sent for
culture sensitivity and relevant antibiotics
given for 6 weeks. After 6 weeks the patient
was symptom free.
FIGURE 1; Osteomyelitis picture of the 4th metatarsal head.
FIGURE 2; The metatarsal head with the curretted nail track.
FIGURE 3; The rubber piece retrieved from the metatarsal bone head.
DISCUSSION
A special type of injury that occurs in people
sustaining penetrating injuries from a nail,
while wearing footwear is encountered with
increasing frequency these days [4]. This
injury is referred to as the ''Nail-Slipper
injury''
In the acute setting at the emergency level
management of these injuries is of a very
basic nature. The wound track is cleaned with
antiseptics and daily dressings applied. As the
wound track is small and the rubber foreign
body is usually less than 2 mm, it is ethically
debatable to use wide debridement as a
routine procedure.
The ''Nail-Slipper injury'' is different as
delayed presentation is the norm rather than
an exception. Even if the patient presents at
the time of initial injury, detection of a
rubber foreign body is not possible.
According to Peterson et al. when a history
of penetrating trauma is suggested, its
– 48 –
severity is difficult to estimate clinically. Also,
the initial contamination and damage make
for an excellent medium for microorganisms
[5].
The important thing is to ask for antecedent
history of nail penetration in a range of foot
symptoms and signs. Our case conclusively
demonstrates that the Nail Slipper injury can
present as osteomyelitis of the foot bones as
well.
Bibliography
1. Chachad S, Kamat D (2004) Management of
plantar puncture wounds in children. Clin Paediatr
43:213–216
2. Baldwin G, Golbourne M (1999) Puncture wounds.
Pediatr Rev 20:21–23.
3. Dhillon MS, Prassana HM, Goni V et al (2000)
Wooden splinter induced pseudo tumor of the
metatarsal. Foot Ankle Surg 6:45–48.
4. Dhar SA, Dar TA, Sultan A et al. Delayed
manifestations of the ''Nail-Slipper injury''.
Musculoskelet Surg (2009) 93:149–153.
5. Peterson JJ, Baneroft LW, Kransdorf MJ (2002)
Wooden foreign bodies, imaging appearance. AJR
178:557–562
– 49 –
JKOA NEWSLETTER
IMAGES
THE JKOA//NZIOA CONFERENCE
LET THERE BE MORE LIGHT
– 50 –
THE INAUGURAL MOMENTS. FOR POSTERITY.
THE AUDIENCE. KNOWLEDGEABLE.
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ORATIONS
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LAUNCHING THE JKOA WEBSITE
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FIRST SKIMS CONNECT AT SKIMS MC BEMINA
THE PHYSIS IS UP AND RUNNING
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COURSE AT SKIMS MC BEMINA
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– 58 –
Information For Authors
e next symposium is going to be about ‘THE HIP’.
erefore review articles about the pathologies of the hip are solicited.
Case reports and Technical Tips are allowed pertaining to any topic.
e article will undergo a review by the editorial board before publication.
e address for submission is [email protected]
All members of the JKOA are speci�cally requested to submit images for the Newsletter Section
2
3
4
5
6
7
e “PHYSIS” invites articles for its future issues from all interested authors.1
SIR JOHN CHARNLEY
Charnley was born into a middle class family in a northwestern suburb of Manchester, England. His father, Arthur, was a pharmacist. His mother, Lily, was a nurse. Charnley went through the usual boys' course of study at Bury Grammar School from 1919 to 1929. He was not a diligent student but did well in science. In the fall of 1929 he entered the Victoria University of Manchester School of Medicine. In 1935 he received both the Bachelor of Medicine (M.B.) and Bachelor of Surgery (Ch.B.) degrees. He became a Fellow of the Royal College of Surgeons in 1936. When World War II began in 1939, Charnley already had plenty of surgical experience in several prominent British hospitals. He volunteered for military service immediately and was commissioned a lieutenant in the Royal Army Medical Corps in May 1940. at same month he participated in the evacuation of trapped British soldiers from Dunkirk, France. From 1941 to 1944 he was an orthopedic surgeon to the British forces in North Africa. While stationed in Cairo he began inventing and improving orthopedic devices and
instruments. He arrived back in England just before D-Day and returned to civilian life in February 1946. His �rst two books, Closed Treatment of Common Fractures (1950) and Compression Arthrodesis (1953), established his reputation as an innovative and thoughtful biomechanical engineer as well as a surgeon. In 1958 the Manchester Royal In�rmary allowed Charnley to create his own hip surgery facility at Wrightington Hospital. is was the great turning point in his career, because it gave him the resources and staff to perform the kinds of experiments and operations he envisioned. At Wrightington Charnley was incredibly productive. He used polytetra�uorethylene (PTFE), better known as Te�on, and stainless steel to realize his ideas for "low friction arthroplasty," that is, manufacturing and safely implanting strong, durable, biochemically inert arti�cial joints. In 1961 he published his basic results in Lancet, an in�uential British journal of medicine. By the mid-1960s THR had become a routine surgical procedure. He is rightfully known as the father of hip arthroplasty.
JAMMU KASHMIR ORTHOPAEDIC ASSOCIATION
Prin
ted
by S
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