Prof (Dr) M Sudhakar Shetty ’s Memorial XXIX Mangalore Orthopaedic Course lecture Notes

 

Index 02/07/11 10:14 AM

 

Sl No

Title Author Section

1 Lower Limb Prosthetics Prof. A. Srinivasa Rao 1 2 Rigid versus elastic fixation &

concept of MIPO technique Dr. B. Seetharama Rao 2

3 Traction in Orthopaedics Dr B Jayaprakash Shetty 3 4 Charcot’s joint Prof. A. Srinivasa Rao 4 5 Distal humerus fracture Dr. Purushotham J 5 6 Aetiopathogenesis and the

current concepts of knee arthritis

Dr Deepak K Rai

6

7 Pelvic Injuries-Evaluation & Management Strategies

Dr Naresh Shetty 7

8 Periprosthetic Fractures Of Femur - A Challenge

Prof. M. Shantharam Shetty

8

9 Flaps in Upper Limb Dr B.Jagannath Kamath 9 10 Chest Injury for Orthopedic

Surgeons Dr. Ashok B. Shetty 10

11 Evaluation of the lower limb in cerebral palsy and management strategy

Dr. Benjamin Joseph

11

12 Juvenile idiopathic arthritis Dr Nuthan Kamath 12 13 Hyperparathyroidism Dr. Sridhar Shetty 13 14 Posterior cruciate ligament

and posterolateral corner injury

Dr Vivek 14

15 Pott’s Disease Of Spine DR. S.P. Mohanty 15 16 Bio Degradable Implants in

Orthopaedics Dr Ronald Menezes 16

17 Congenital Clubfoot Pathoanatomy and management

Dr Hithesh Shah 17

18 Fracture Dislocations Of Hip DR. K. S. ARIF 18 19 Evaluation Of Knee Swelling DR Lawrence Mathias 19 20 IM nailing Dr Syed Nizamuddin 20 21 Anatomy & Biomechanics of

hip Dr. Sharath K Rao, 21

22 Patellofemoral instability Dr Sudharshan 22

 

 

Bhandary

LOWER LIMB PROSTHETICS Prof. A.Srinivasa Rao M.S.(Ortho); Fellow Ortho. Path. (USA) Emeritus Professor of Orthopedics Consultant, KIMS, Secunderabad

 

Prosthesis vs Orthosis: A prosthesis replaces a missing part of the body while an orthosis supports an existing but disabled part of the body. Characteristics of a successful prosthesis: Easy to put on and remove Comfortable to wear Light weight Durable Requires only reasonable maintenance & Cosmetically acceptable The prostheses are basically of two types: Exoskeleton type – the limb consists of a hard laminated hollow shell Endoskeleton type (modular) – central metallic frame which is covered by foam rubber to conform to the shape of the limb PARTS OF A PROSTHESIS (Artificial Limb) in General The artificial limb consists of the following parts from proximal to distal end – Suspension system, Socket, Knee joint set up, Shank and Foot piece. Suspension system: The socket of the artificial limb is attached to the body by this component. They are of four types :- a) Self suspension socket – makes use of the anatomical shape of the stump eg: Syme’s , knee disarticulation etc. b) Suction suspension, also called suction socket, consists of a total contact, form fitting , rigid socket with a one way air valve. The stump is pulled into the socket by means of stockinet, which comes out through a small hole in the lower part of the socket. Once this hole is closed the one-way air valve pushes out the remaining air and develops a negative pressure inside. Though the proprioception is good, there is heat build up and skin problems may arise. c) Suspension device or harness: Cuffs, belts, corset etc. d) Combination of above

 

 

2. Socket: This is the bucket-like part of the prosthesis, which accommodates the amputation stump. It transmits weight from the body to the prosthesis. The socket is made after taking a plaster mold of the stump. A soft liner lines the socket. It is the socket, which decides the contact of the stump and is of three types – end bearing, side bearing and total contact. End bearing and total contact sockets are preferable which simplify socket fitting considerations and minimize the stump-socket interface issues (Symes, knee disarticulation) 3. Knee joint setup: This part is there only in above knee prostheses. In the recent times several sophisticated designs of the knee joint have been developed. Some of the knee joints in vogue are Manual locking knee, simple hinge knee, polycentric knee, Hydraulic, pneumatic and microprocessor controlled knees. The Hinge type dangles during swing phase without control. This is minimized in the constant or variable friction types of knee joints. Extension stop prevents hyperextension. 4. Shank or Shin piece or Pylon: This part connects the socket (or the knee joint as the case may be) to the foot piece Foot piece: The artificial foot on which the patient walks. It is also called the foot-ankle assembly since it includes the ankle joint, if there is one. Otherwise simulated action of the ankle joint is built into the foot piece. The foot piece absorbs shock and very little is transmitted to the stump-socket interface. This can be compared to the suspension system of a car, which absorbs the shocks of a bumpy road and does not transmit to the passenger sitting inside. For this purpose, it is ideal if the foot can move in two directions – dorsi-plantar flexion & inversion-eversion. The latter is essential while walking on an uneven ground. Conventional Foot piece is a unit with a single axis ankle movement SACH foot (Solid Ankle Cushion Heel) is a modern foot piece and is the lightest of all foot pieces, inexpensive and durable. It has a central wooden keel which prevents all movements around ankle. The heel consists of alternating layers of hard and soft rubber. During heel strike this rubber is compressed and it simulates plantar flexion movement. It is best used on a flat surface. The SACH foot goes into regular shoe and one cannot walk without a shoe. Modifications of SACH foot: Madras Foot: To enable the patient walk bare footed, Madras Foot was developed. SACH foot was covered on all sides to maintain alignment.and

 

 

make it a plantigrade foot. Shaped toes are provided and skin colour given.. This foot is not suitable for an irregular terrain. Failure rates are high with this foot. Jaipur Foot: Developed by Prof. P. K. Sethi. Natural appearance of foot is reproduced and the patient can walk bare footed. The central wooden keel of SACH foot is replaced by layers of microcellular rubber, divided into blocks. This enables movements at different levels during dorsi-plantar flexion and also permits inversion-eversion. This foot is best suited for rural Indian population as this can be used on uneven terrain and can be washed. Chappals or shoe wear is optional. Seattle Foot: Developed by Ernst Burgess. It has a cantilever spring keel. This permits initially softer deflection for walking but becomes progressively firmer as force increases during faster gaits. This foot piece also has a natural appearance and permits multidirectional movements. SAFE (Stationary Ankle Flexible Endoskeleton) /has an elastic keel permitting multidirectional movement. Prosthesis is fitted when a part of the lower limb is amputated due to any one of several causes. The classical amputations in the lower limb are: 1. Hemipelvectomy (Hind quarter amputation) 2. Hip Disarticulation 3. Above Knee amputation 4. Knee Disarticulation 5. Below knee amputation 6. Syme’s amputation 7. Chopart’s amputation (mid tarsal) 8. Lisfranc’s amputation (tarso-metatarsal) 9. Disarticulation of toes. We shall consider prostheses for the first six important amputations only in this article. The first and second amputations share the same prosthesis. Hemipelvectomy / Hip disarticulation prosthesis: They share the same prosthesis but after hemipelvectomy there is no ischial tuberosity to bear weight.

 

 

There is an opening in the socket on the inner side to enable donning. The socket is so shaped that when it is laced up, it holds the iliac crests. The socket helps as a suspension system also – self suspension socket There are three types of prosthesis – Saucer type, Tilting Table Type and the Canadian type. In the first and second, the prostheses are locked at hip and knee. Canadian type is most commonly used, more functional and cosmetically better. The hip and knee joints are not locked but are stabilized by keeping the hip in front and knee behind the body gravity line Above knee prosthesis: The socket is total contact and quadrilateral – there is room for adductor longus tendon anteromedially; there is space for greater trochanter laterally. The stump is pressed backwards by a smooth projection in the Scarpa’s triangle area so that the ischial tuberosity sits on the ischial platform of the prosthesis and weight bearing is facilitated. Suspension is by means of a auxiliary hip joint & pelvic band. Modern limb is suspended by suction socket or Silesian Band. Prosthesis for knee disarticulation: Advantages are the stump is end bearing and has a broader weight bearing area and so proprioception is good.. The lever arm is long to power and control the prosthesis. This is a good stump in a child since the growing lower end of the femur is preserved. The disadvantage is that there is no place for a modern knee joint and once fitted the knees will be asymmetrical. Otherwise one has to go for an external hinge knee. The socket is harnessed to the thigh by laces. Since the end is bulbous this is a self suspension Below Knee prosthesis: Conventional: The suspension system is a laced thigh corset attached to the socket by external hip joints. PTB (Patellar Tendon Bearing): is modern type for amputees with a minimum stump length of 5”. The suspension system is a supracondylar cuff. The socket is so shaped that 60% of weight is borne by the patellar tendon and 40% by the tibial flares. The height of the posterior wall is very critical and is up to the popliteal crease. It should be long enough to push the stump forward so that the patellar tendon bears weight; it should be short enough to enable the knee to flex to 90°. PTS (Patellar Tendon Supracondylar): is used where the stump length is too short, even up to 2”. The medial, lateral and anterior walls of the socket are shaped and raised above the femoral condyles whom2 they

 

 

hold – self suspension. The stump is introduced into the socket by rotating through 90° and once in, derotated so that the femoral condyles are held by the extensions of the socket. This exercise is like inserting an electric bulb into the holder and rotating it. Syme’s prosthesis: The problems are the bulbous end of stump and too long a stump. Bulbous end makes it difficult to insert the stump into the socket but once in, it holds the socket –self suspension. The long stump limits the prosthetic foot options. To facilitate insertion of the stump, a window is cut in the lower part of the prosthesis anteriorly, medially or posteriorly. It is a cosmetically unacceptable prosthesis but still Symes is popular in developing countries because proprioception is good and the person can walk without prosthesis in an emergency. EXTENSION PROSTHESIS is used where the limb is very short, common cause being a congenital anomaly. A platform is provided for the natural foot from which the prosthesis extends proximally to ischial tuberosity or patellar tendon and distally to the ground where a foot piece is fixed. The prosthesis can be caliper type or limb type. IPPF (Immediate Postsurgical Prosthetic Fitting) has proprioceptive and psychological advantages. Stump edema is minimized. The author has developed an indigenous jig made of aluminum tubes and other locally available materials.

 

 

RIGID VERSUS ELASTIC FIXATION & CONCEPT OF MIPO TECHNIQUE DR.B.SEETHARAMA RAO, Professor of Orthopaedics, KMC, Mangalore

 

Internal fixation is a valuable aid to rehabilitation but can only be justified and satisfactory when the fracture is entirely controlled in a way, which allows early pursuit of active function after surgery. Such control follows rigid fixation of the components to re-establish a cohesive skeletal support, and is supplemented by fastidious reduction even of small fragments, especially in fractures near to or directly involving joints. Lettin (1965) concluded from an experimental series that rigid internal fixation results in increasing the strength and stability of fractures much more rapidly than in similar fractures treated in plaster. Therefore, primary healing can be achieved from good internal fixation on mechanical grounds. It has been observed that in rigidly plated fractures there is a reduction in the amount of fibrous tissue and cartilage between the bone ends during healing and that the basic process of bone repair may be modified so that fibrous tissue is ossified without the intermediate formation of cartilage. Rigid fixation prevents micro motion across lines of fracture to enable healing and prevent infection, which happens when implants such as plates (e.g. DCP) are used. Type of Fracture Healing with Treatment Technique Cast treatment Secondary: enchondral ossification External fixation Secondary: enchondral ossification IM nailing Secondary: enchondral ossification &

intramembranous Compression plate Primary: Haversian remodeling Preservation of hard and soft tissue integrity along with utilization of stable implants are the keys for reduction of patient morbidity and return to function. Danis in 1949 recognized the need for compression between the fracture fragments. He achieved this goal using a plate he called the coapteur, which suppressed interfragmentary motion and increased the stability of the fixation. It led to a mode of healing he called soudure autogène (autogenous welding), a process now known as primary bone healing. His revolutionary concept influenced all subsequent plate designs. In 1958 Bagby and Janes6 described a plate with specially

 

 

designed oval holes to provide interfragmentary compression during screw tightening. Müller et al. in 1965 presented another design that permitted interfragmentary compression by tightening a tensioner that was temporarily anchored to the bone and the plate. The plate was heavier and thicker (4.5mm) than those designed by Eggers and Danis. With this design, Müller and his group set the stage for the rigid plating of fractures that resulted in a mode of bone healing characterized by the absence of periosteal callus formation. The appearance of any periosteal callus was interpreted as a sign of instability. “The appearance of callus after plate fixation may be an indicator for an unknown degree of instability.” The use of the tensioner was eventually abandoned in favor of oval holes with a design similar to that of the Bagby plate. This new design, known as a dynamic compression plate (DCP), was claimed to have been developed without the knowledge of Bagby and Jane’s invention. Although this plate was called a dynamic compression plate (DCP) only one-time static compression could be obtained. Despite the obvious advantages, the developers of the DCP still looked for improvement in the design. This was probably because of certain disadvantages with the DCP that included delayed union as well as persistence of a microscopically detectable fracture gap that acted as a stress riser after plate removal. Cortical bone loss under the plate and difficulty to assess the state of healing of the fracture radiologically was other disadvantages. During physiological healing, disappearance of the fracture gap and development of an external bridging callus are criteria for assessing the state of healing of the fracture; they are not present after rigid internal fixation. Rigid plates carry a great percentage of loads relieving the plated bony segment of stimuli needed to maintain bone mass and for posttraumatic osteogenesis (i.e., formation of new bone for bridging the fracture gap). Endosteal bone buildup at both ends of the fracture plate where load is shunted from bone to plate proximally and from plate to bone distally is proof that rigid plates carry a higher percentage of load than bone. ASIF has developed a variety of plates, most of which can be used for both rigid and flexible fracture fixation. With flexible fixation, the fracture fragments displace in relation to each other when the load is applied across the fracture site. Fracture fixation is considered flexible if it allows appreciable interfragmentary movement under functional load. All fracture fixation methods, with the exception of compression techniques,

 

 

may be described as flexible or biologic fixation. Fracture healing under flexible fixation typically occurs by means of callus formation. However, despite wide use of flexible fracture fixation, rigid fracture fixation with plates and screws still has an important place and is desirable for fractures that involve an articular surface. Bridging of the fracture with a stiff splint reduces mobility of the fracture fragments, which allows minimal displacement under functional load. Although rigidity of the fracture fixation contributes to reducing fracture mobility, the only technique that can effectively abolish motion at the fracture site is interfragmentary compression. With a plate and screws, complete stability diminishes the strain at the fracture site to such extent that it allows for direct healing without formation of visible callus. Articular fractures require exact anatomic reduction and stable fixation to avoid development of abundant callus. This is important because unevenness of the joint surface and presence of callus formation at the articular surface lead to patient discomfort and often development of early and progressive osteoarthritis. Percutaneous plating was developed in an effort to combine the advantages of intramedullary nailing with the more stable fracture fixation available with plating. In percutaneous plating, a smaller incision is used to place the plate and the screws are then placed percutaneously. Preliminary reports about the results of percutaneous plating are promising. However, these methods are technically challenging, and long-term results from prospective studies will be needed for definite assessment of their advantages and disadvantages. Principle of "Elastic Stability”: The flexible rod is initially bent or curved (plastically deformed). During intramedullary insertion, which is typically retrograde in the femur, the relatively straight medullary canal (compared with the contoured nail) forces the curved rod to straighten within the bone. This elastic deformation creates a bending moment within the long bone which will tend to angulate the fracture in the direction and the plane of the concavity of the curved rod, as the rod wants to return to its initial curved state. This moment is counteracted by a second rod of matched diameter and curve, which balances the first rod with an equal but opposite moment. The two intramedullary nails act complimentarily to stabilize the fracture. This biologic fixation is not rigid but sufficiently stable against angular, translational and torsional deforming forces and is associated

 

 

with early formation of exuberant callus. Typically, no additional external immobilization is required. However, any significant imbalance in the magnitude or the direction of the moment created by the two nails will result in angulation of the fracture in the direction of the stronger nail. General principle of elastic nailing: General principle of 3-point fixation of the elastic nail: Nailing of the forearm will achieve the different types of stability through fixation of both bones or with one of the bones intact. The rotational stability should be complemented with cast fixation. Biomechanical features of elastic stable intramedullary fixation: It is agreed that the type of bone reparation is determined by the extent to which particles can move after fixation. Fixation with plates and screws prevents movement therefore callus cannot form properly. The bone heals with direct bridging with ingrowth of the Haversian canals. This form of bone reparation is known as primary healing. Second form of healing involves micro movement between particles and consequently the formation of periosteal and endosteal callus. This so-called secondary healing is the result of conservative treatment of long bone fractures or of elastic stable intramedullary fixation. The principle of ESIF is to combine elastic and non-elastic fixation, which were long considered contradictory methods. In ESIF, certain movement is allowed in the area of the fracture. Pre-curved intramedullary wires change the rotational forces into longitudinal dynamic compression and stretching, and this movement accelerates the formation of callus and the healing process. Stability is provided through the proper position of the pre-curved wires that fixate the bone in three places. The contact between the fragments and the surrounding soft tissues (musculature) adds to this stability. Because of some biological and mechanical features titanium wires of different dimensions are more and more replacing steel wires. The main advantage of ESIF in cases of femoral fractures is the fact that it is cheap, safe and easy to perform. The surgical wound and the blood loss during the operation are minimal. The rehabilitation process starts early, and the hospitalization period is short. Numerous studies indicate no special complications therefore ESIF can undoubtedly be considered as one of the possible methods of femoral fractures fixation.

 

 

Principle of "Elastic Stability”: The flexible rod is initially bent or curved (plastically deformed). During intramedullary insertion, which is typically retrograde in the femur, the relatively straight medullary canal (compared with the contoured nail) forces the curved rod to straighten within the bone. This elastic deformation creates a bending moment within the long bone which will tend to angulate the fracture in the direction and the plane of the concavity of the curved rod, as the rod wants to return to its initial curved state. This moment is counteracted by a second rod of matched diameter and curve, which balances the first rod with an equal but opposite moment. The two intramedullary nails act complimentarily to stabilize the fracture. This biologic fixation is not rigid but sufficiently stable against angular, translational and torsional deforming forces and is associated with early formation of exuberant callus. Typically, no additional external immobilization is required. However, any significant imbalance in the magnitude or the direction of the moment created by the two nails will result in angulation of the fracture in the direction of the stronger nail. The titanium nails have been distinguished from other flexible nail systems such as Ender nails, made of stainless steel. The latter are believed to be insufficiently elastic for children’s fractures. MIPPO technique of fracture fixation: L’ostéosynthèse par plaques par voie mini-invasive (technique MIPPO): Conventional ORIF is associated with extreme operative dissection through poorly vascularised and traumatized soft tissue envelope of bones. Minimal invasive percutaneous plate osteosynthesis avoid extensive dissection and periosteal stripping. Smaller wound heals faster. This causes less wound complications. Biological fixation without disturbing fracture hematoma also aids in achieving early union. It is advocated to use longer plates (for improved mechanical leverage) and fewer screws (to avoid unnecessary bore and soft tissue damage). In fact filling each and every hole can weaken the bone and it may refracture on implant removal. Lag screws are preferably inserted through the plate to avoid excess soft tissue stripping. By this technique plate becomes a load bearing implant till callus appears. These plates require only 2 to 3 bicortical holds in each main fragment to achieve stability. It helps in achieving faster fracture healing. In AO-L.C.P. plate, plate mainly acts as an internal fixator, where micromotion is possible between the fragments

 

 

making lag screw fixation through plate impossible as L.C.P. always has gap between bone and plate, and in case lag screw is used to fix the two fragments the screw will break. AO group in 2005 had come up with new plate system called Locking Compression Plate (L.C.P.) especially for minimally invasive plating of periarticular fractures with or without osteoporotic bone. The plate has an advantage of two plate systems i.e. conventional D.C.P. along with fixed angle locking compression plating. The plate definitely has an advantage over other plates for periarticular fractures in form of not requiring accurate contouring of the plate for fixation, and prevention of loss of primary and secondary reduction, good fracture healing and less stress shielding as there is no plate bone contact resulting in less subperiosteal damage to cortex. The technique of MIPPO is relatively safe and efficacious modality of the treatment for fractures with following advantages: (1) Biological reduction with least disruption of soft tissue and fracture hematoma. (2) Early joint mobilization leading to complete restoration of joint motion. (3) Reduced surgical time and tourniquet time along with smaller incision. (4) Reduced incidence of wound complications. (5) Early union of fracture. (6) Cosmetic effect (7) Rapid callus formation The main point of fracture management with MIPO is to protect the blood supply of the fragments and the biological environment at the fracture site from destruction, thus to guarantee the callus formation and fracture healing. The operative procedure should follow the principles that denudating the fragment of soft tissue attachment must be avoided as much as possible, the fracture be indirectly reduced and the implant be inserted subcutaneously or beneath the muscle layer. When practiced, the implant should be well selected according to the concrete situation of the fracture, and the tool and technique to be used as well. By this technique, only the normal bone cortexes, both proximal and distal to the fracture site, are exposed for positioning the plate and inserting the screws, while the fracture site is not explored so that osteogenetic tissues surrounding the fracture are well protected and their blood supply preserved. Indirect reduction of the fracture is performed with intensified supervision. The plate is extraperiosteally inserted beneath the muscle, crossing over the fracture site distally onto the bone cortex, and fixed in place by the ordinary technique through both the proximal and distal incisions. It has

 

 

been confirmed that with MIPO the plate-induced damage to the perforating vessels and the nutrient vessels of the fragments is much less serious than that in ordinary plating.7 Besides, with MIPO, the fixation of the fracture requires a longer plate and less screws, thus reducing the stress per unit area on the plate. Stress shearing is therefore avoided to some extent. As more clinical experiences have been collected, MIPO has technically evolved into minimally invasive percutaneous plate osteosynthesis (MIPPO).8 By the MIPPO technique, following close reduction of the fracture, the plate is introduced through a small skin incision and crosses over the fracture site to reach the cortex distal to it. The operative procedure is thus simplified, the damage to the fragments minimized, and the fracture healing accelerated. . Mast et al first reported the importance of reduced surgical dissection of the fracture site and utilised the surrounding soft tissues for fracture reduction. He termed this indirect reduction of the fracture. This helps to maintain blood supply to the bone ends and reduces non union rates. The LISS plate was developed to complement the concept of the MIPPO technique. It consists of a precontoured plate to the bone block utilising multiple fixed angle screws. Utilising the cantilever principle, the bone – plate interface closely resembles an external fixator. It is not surprising that it has been called an Internal Fixator. Its other main advantage is preservation of bone biology, eliminating the need for bone grafting in most cases. The PERI-LOC plate incorporates all the advantages and principles of the LISS plate with better contouring. REFERENCES: www.ncbi.nlm.nih.gov/pubmed www.medicinski-mesecnik.com www.aofoundation.org/AOFileServer www.jurnalulpediatrului.ro/pages www.sciencedirect.com/science www.lww.com/static/docs www.rcsed.ac.uk www.mch-orth.com/pdf

 

 

Traction in Orthopaedics Dr B Jayaprakash Shetty HOD, Orthopaedics, K. S. Hegde Medical Academy. Mangalore

 

Traction: application of a force to stretch certain parts of the body in a specific direction Controls pain. Reduces fracture Prevents & corrects deformity. Maintain reduction. It is a safe & dependable way of treating fractures for >100 years. The bone reduced and held by soft tissue. Allows more joint mobility than plaster with less risk infection at fracture site and with no devascularization. History: Skin traction was used extensively in Civil War for fractured femurs (known as the “American Method”). Steinmann and Kirschner introduced skeletal traction by a pin through bone Disadvantages: Costly in terms of hospital stay Hazards of prolonged bed rest Thromboembolism Decubitus ulcers Pneumonia Requires meticulous nursing care Can develop contractures Classification: 1. Based on duration Continuous traction Intermittent traction 2. Based on principle Fixed traction (Traction is applied to the leg against a fixed point of counter pressure. Eg. fixed traction in Thomas’s splint) Sliding traction (When the weight (of all or part of the body) acting under the influence of gravity is utilized to provide counter-traction. Eg. Buck’s traction or Extension, 90 /90 traction. 10% of body weight is used as weights for example in femoral shaft fracture and the foot end is

 

 

elevated so that body slides in opposite direction. The general guideline is to elevate 1inch for each 1 lb of traction weight) 3. Based on application Manual traction Skeletal traction Skin traction Adhesive. Max wt 15 lb or 6.7 kg. Not used in thin, atrophic skin and in skin sensitive to adhesive strapping Non – adhesive. Max wt < 10 lb or 4.5 kg Skin traction rarely reduces a fracture, but reduces pain & maintains length in fractures. Buck's skin traction is widely used in lower limb esp in lower backache, femoral fractures, acetabular and hip fractures. Skin is prepared & shaved. Must be dry. Tincture benzoin improves adhesion. Bandage should not extend above level of fracture. Dangers include distal oedema, vascular obstruction, peroneal nerve palsy, skin necrosis over bony prominence’s and allergic reactions to adhesives. Skeletal traction: Its put with either a pin or wire, commonly in lower limb fractures. Its reserved when skin traction is contraindicated or insufficient. Common sites include olecranon, metacarpal, upper end femur, lower end of femur, upper end of tibia, lower end of tibia and calcaneum. Complications include infection, cut out, application of splint difficult, distraction at fracture site, ligament damage, physeal damage and depressed scars. Head Halter traction: Simple type cervical traction for management of neck pain. It can be used a few hour at a time with a weight <5 lbs initially. Cervical skeletal traction: Used to treat unstable spine which gives a pull along axis of spine It preserves alignment & volume of canal Types: Gardner-Wells: Easy to apply. Its placed directly cephalad to external auditory meatus in line with mastoid process just clear top of ears avoiding excessive manipulation. Screws applied with 30 lbs pressure. Pin site care is important. Poor placement

 

 

cause flexion/extension force. Disadvantages includes occipital pressure sore Crutchfield Tongs: Risks similar to Gardner tongs. Incise skin & drill cortex to place tongs. Rotate metal traction loop so that it touches skull in midsagittal plane and place above ext auditory meatus Extremity Traction : reserved for comatose, multiply injured patient and in settings where surgery can not be done Dunlop’s Traction: Forearm skin traction with weight on upper arm with elbow flexed to 45 ° is applied in supracondylar fractures in children when closed reduction difficult or traumatic. Olecranon Pin Traction: Used for difficult supracondylar/distal humerus fractures. Greater traction forces allowed. Place pin 1.25 inches distal to tip of olecranon. Avoid ulnar nerve. Can make angular/ rotational corrections. Metacarpal Pin Traction: Used in obtaining reduction in difficult forearm and distal radius fractures. Once reduced, pins can be incorporated in cast. Pin placed radial to ulnar through base 2nd/3rd metacarpal. Intrinsic stiffness common. Bucks traction: Often used preoperatively for femoral fractures. Not used to obtain or hold reduction. Can use tape or pre-made boot. No more than 10 lbs of weight is used. Split Russell’s Traction: Buck’s traction with sling which is used in more distal femur fractures in children. It’s modified to exercise hip and knee. 90-90 Traction: Used in subtrochanteric & proximal 3rd femur fracture esp in young. Traction is given through lower femoral pin, which is more efficient, or

 

 

by upper Tibial pin. Allows for easier management of fracture with posterior wound. It matches flexion of proximal fragment. The main disadvantage is flexion contracture in adult. Femoral traction Pin: Place just proximal to adductor tubercle in midcoronal plane with proximal pole patella in extended position. Avoid growth plate in children, suprapatellar pouch & NV structures. Used for femoral shaft fracture when strong force needed or knee pathology present Proximal tibial traction: Used for distal 2/3rd femoral shaft fracture. Easy to avoid joint & growth plate. Placement is 1inch distal & posterior to tibial tubercle Charnley’s traction unit: Steinmann / Denham pin is incorporated in BK POP cast. Ext rotation of foot & distal fragments can be controlled. Care should be taken to prevent common peroneal nerve & tendo achilles is protected. Distal Tibial Traction: Useful in certain tibial plateau fractures. Its placed 1.25 proximal to tip medial malleolus avoiding saphenous vein. Place through fibula to avoid peroneal nerve. Gallows traction: Indication: femoral fractures in infants / children Danger: Vascular compromise . Check the circulation twice daily. Prerequisite: Child must weigh <12 kg with intact skin. Both the fractured & normal femur are placed in skin traction and the infant is suspended by these from a special frame. The buttocks should be just off the bed.

CHARCOT’S JOINT (Neurogenic arthropathy) Prof. A.Srinivasa Rao M.S.(Ortho); Fellow Ortho. Path. (USA) Emeritus Professor of Orthopedics Consultant, KIMS, Secunderabad

 

In 1868 Jean Martin Charcot described a chronic destructive arthropathy associated with decreased sensory innervation of the involved joint. In this condition there is massive destruction of the stress bearing portion of the joint and dramatic hypertrophic changes in the periphery. In effect, this is an exaggerated form of osteoarthritis precipitated by repeated trauma to the joint not protected by proprioceptive and nociceptive reflexes. The joint is referred to as “painless bag of bones” Etiology: A few decades ago syphilis (tabes dorsalis) was most common cause but now Diabetes Mellitus takes its place. Other causes are Leprosy, Syringomyelia, Chronic alcoholism, myelomeningocele, spinal cord injury, spinal tumours, congenital indifference to pain, cortisone arthropathy and other sensory neuropathies. Sites: Usually lower limb joints are involved: knee, hip, ankle and lower spine in that order. In diabetes foot is most commonly involved. Shoulder is most commonly involved in syringomyelia. Pathological Events and Natural History: One of the early features seem to be insidious onset of loss of stability of joint probably due to decrease in tendon and ligament tone. Soon the stress bearing portions of joint cartilage undergoes fibrillation and eventual fragmentation that aggravates instability. If the patient remains active, the progress is much more rapid. As a compensation, there is remarkable growth of cartilage at periphery, which eventually ossifies. Destruction of normal weight bearing surfaces leads to subluxation and dislocation. The synovium hypertrophies and injury causes effusion. Ultimately there is loss of architectural normalcy. Pathogenesis: The exact cause for all these changes is uncertain – it seems to lie in the nervous system. Two theories have been proposed – neurotraumatic and neurovascular theories. A) Neurotraumatic theory – sensory neuropathy renders the patient unaware of osseous destruction that progress. B) Neurovascular theory – the underlying condition produces autonomic neuropathy due to which the extremity receives

 

 

increased blood flow and abnormal bone formation. It is possible that a combination of both sensory and autonomic neuropathies may be responsible for the changes. In Diabetes mellitus and Leprosy, foot and ankle are commonly involved. Several patterns have been described depending on the anatomic site of involvement – the simplest is that of Saunders and Mrdjencovich.: 1. Forefoot 2.Tarso-metatarsal joints 3.Naviculo-cuneiform, Talo-navicular & Calcaneo-cuboid joints 4.Ankle joint 5. Posterior Calcaneum. 2nd and 3rd patterns together account for nearly 80% of cases. Presentation: The clinical presentation depends on the stage at which patient is seen – the picture may vary from mild swelling & no deformity to significant deformity and swelling. The natural history of the disease is divided into four stages for convenience – Stage ‘0’: Joint edema, x-ray is normal, isotope scan is positive. Stage ‘1’: Acute Charcot, osseous fragmentation with subluxation, skin ulcers. Stage ‘2’: Less of local edema, coalescence of fragments, absorption of fine debris, surrounding sclerosis. Stage ‘3’: No edema, consolidation and rounding of fragments, hypertrophy of bone, foot is stable. There is an acquired flat foot or varus foot deformity. Clinical presentation may be in the acute or chronic stage. In the acute stage there are signs of inflammation – swelling, warmth, erythema and joint effusion – the picture is one of osteomylitis, but there is no fever, counts and ESR are normal. In the chronic stage there is bone resorption in an insensate foot which is relatively painless, 40% of patients may present with skin ulcers. Work Up: In spite of all theory, in a good number of cases we may not be able to ascertain the cause. History must be elicited for Syphilis, Diabetes mellitus, injuries to spine and peripheral nerves etc.

 

 

Clinical examination: of local part – synovial thickening, bony irregularities, crepitus on movement, abnormal mobility and pain (relatively painless) Status of joint (subluxed or dislocated), vascularity (peripheral pulses), examination of spine and peripheral nerve status, Neurology of limb, all modalities of sensation; Foot examination Plain Radiographs: two types of changes are seen – atrophic and hypertrohic The changes are described as 6Ds by Yocham & Rowe.- Distended joint, Density increased, Debris production, Dislocation, destruction and Disorganisation. Doppler study Other Investigations: TLC, DLC, ESR, Blood Sugar, S. Creatinine, Blood Urea (for CKD), S. Ca, P, ALP, PTH (for Met.Bone Disease),LFT (for Chr. Alcoholism), S. B12 Procedures: Joint aspiration – C & S Synovial Biopsy TREATMENT Acute Stage: Immobilise by total contact casts for 12 – 18 weeks. This reduces the stress and prevents plantar ulcers. The knee can be immobilsed by a brace. Serial radiographs are taken to evaluate progress. AFO or PTB are used depending on the situation. Ambulation is by using crutches or walker. Bisphosphonates are used to reduce resorption. Post-acute Stage: Life long foot protection – PTB braces or pneumatic walking braces., Calipers are used for the knees to reduce stress. Surgery: contraindicated in the acute inflammatory stage Even in the chronic stage, bony union rarely occurs. When there is a risk of ulceration due to the deformity and abnormal weight bearing, the goal is to create a plantigrade foot which can be protected with appropriate foot wear. Arthrodesis is a salvage procedure to correct the deformity, even if the arthrodesis fails. Skin healing is not a problem. Arthrodesis can be tried using Ilizarov technique. TKR is generally not tried for fear of failure rate. In one study (CORR 1986) out of the nine TKRs, surprisingly, eight were doing well at 3 yrs. However, constrained prosthesis and bone grafting were used.

 

 

Distal humerus fracture Dr. Purushotham J Professor BMC, Bangalore

 

Though fractures of distal humerus are not very common they remain challenging injuries to treat. Most fractures involve articular surface & may occur in older patients. Much earlier these fractures were treated non operatively, which resulted in malunion, non union & joint stiffness. With the advent of modern techniques & implants, these fractures are almost always treated operatively. This has resulted in better end results allowing the patients to return to useful employment. With more & more advances in the designs of the implants, the earlier non operative treatment of ‘bag of bones’ for complex fractures is rarely advocated these days. The incidence of these fractures is 3% of all fractures and 30% of humerus fractures. The incidence is on the rise worldwide, especially in the developing countries owing to increased incidence of osteoporotic fractures. There is a bimodal distribution with respect to age, at 2nd decade & 7th/8th decade. Males appear to be younger to females when they sustain fractures. Majority of these fracture are due to domestic falls, though RTA also contributes significantly. Classification: Quite a few classifications of these fractures have been attempted to identify these complex fractures & mange them. Earliest classification was based on anatomical regions terming them as codylar, epicondylar & supracondylar with or without displacement. Riseborough & Radin (1963) classified the intercondylar fractures. Type 1: undisplaced fracture. Type2: T shaped fractures with trochlear & capitellar fragments separated without rotation. Type 3: Fractures with separated fragments with rotation of fragments. Type 4: Fractures with severe communition of articular surface with wide separation. With the need of managing these fractures more accurately, AO classification, which is a modification of original OTA classification, was produced. Essentially they are classified as a) extra articular, b) partially

 

 

articular, c) complete articular. They are further sub classified into 61 types. Though this classification is in vogue, the complexity of this classification limits its usage. A simpler classification described by Jupiter& Mehne describes only 25 types. It is classified according to 2 column & “tie –arch concepts of elbow stability (refer the table below). This classification has been widely accepted as it helps in preoperative planning & acts as a guide to better reconstruction. Jupiter & Mehne classification:

Treatment: Although the surgical treatment of these fractures has significantly improved the complication rates still remains quite high. The goal of treatment is to restore anatomy, with stable internal fixation that allows early movement of the joint. Non operative treatment: With the advent of improvised anaesthesia and modern implants such as pre contoured locking plates, non operative treatment is rarely advocated in the distal humeral fractures these days. However in situations where the patient is very elderly, frail, with limited functional expectations, non-operative treatment can be considered. Associated significant co-morbidities can also be considered for conservative management. In

 

 

totally un-displaced single columnar fractures non operative treatment is worth considering. In these circumstances plaster slab or cast, & splints are recommended. Operative treatment: The operative treatment of distal elbow fractures is complex, labor intensive with high risk of complications. Ideal treatment consists of early open reduction, anatomical reconstructions of joint surface & adjacent metaphyseal bone, replacement of lost bone, and rigid internal fixation. This should be followed by early aggressive physiotherapy to regain the range of movement. As with any complex fractures, it requires surgical expertise & experience with the availability of wide range of reconstructive implants. Single columnar fractures (AO/OTA type B1/B2) Lateral columnar fractures are much more common than the medial columnar fractures. Both occur in relatively younger patients. Lateral kochers approach is recommended for lateral columnar fractures. Medial approach is recommended for medial columnar fractures. Though high type fractures are more unstable, they are relatively easier for reconstruction owing to their large fragment. Varieties of options are available for these fractures. In simpler cases multiple interfragmentary screws are sufficient. In more complex fractures reconstruction, DCP, or locking reconstruction plates are recommended. In cases where they are not reconstructable, like in low fractures excision of the fragment or even total elbow arthroplasty is rarely advocated. Bi columnar fractures (AO/OTA type C fractures) Over the last 2 decades there is a significant paradigm shift in the management of these fractures from relative non-operative treatment to almost total operative management. Although, there are some instances especially in older individuals, where it is un reconstructable along with osteoporosis, total elbow arthroplasty (TER) has been the choice. With the availability of verities of implants the debate is always on the choice of approach in these fractures. Proper preop planning is of paramount importance, which is made easier by applying the recent

 

 

classification system of Jupiter. Access to the distal humerus, especially visualization of the articular surface is the key to successful fixation of these fractures. All approaches that have been described have both advantages & disadvantages. The approaches most used are: Posterior triceps splitting approach of campbells Posterior approach with olecranon osteotomy Triceps reflecting approach of Brian & Morrey Triceps reflecting anconeus pedicle of Brian, Morrey 7 O’driscoll Of the above approaches olecranon osteotomy is the most preferred one though, there are disadvantages of non union of the osteotomy. The choice of the implant depends on the type of fracture patterns. The recent advances in the plates, like pre contoured locking plates are preferred in complex fracture in osteoporotic fractures. Both the columns need to be fixed to get absolute stability of the fracture. The placement of plates is again a matter of debate, the choice being of parallel plate fixation or of orthogonal (90/90) plate fixation. Though there are no significant differences in the recent plates, orthogonal plate fixation is preferred in older generation plates. In these cases posterolateral & medial orientation of plates are undertaken. In the recent types of locking reconstruction plates parallel plating is preferred. Where necessary augmentation with bone cement or bone graft are contemplated. Double column tension band wiring for osteoportic fractures in elderly patients have been in tried earlier, but with the introduction of pre contoured locking plates it is rarely indicated these days. Usages of hinged external fixators especially in open fractures have been reported, although they are considered as temporary fixations. The success of the surgery depends on the following points: Anatomic stable reconstruction of articular surface Stable reconstruction of two columns of humerus using two plates Early post operative joint movement.

 

 

Review of literatures show that inspite of using modern fixation methods the functional outcome in these fracture is short of complete recovery, though it can be considered reasonably good. Complications: Loss of fixation Mal union Non union Residual stiffness of elbow Heterotrophic ossification Post traumatic osteoarthrosis Generalized functional disability. References: 1)Aron nauth, Michael MckeeJBJS am, vol 93, 2011 2)Chapmans orthopaedic surgery 3rd edition 3)Edward Riseborough, JBJS, vol 51a, 1965 4)Jesse B Jupiter; instructional course lecture; AOAS volume 44, march 1995 5) Rockwood& Greens fracture in adults , 6th edition 6) Surya Bhan IJO, vol 47, 2007 7) srinivasan,Mathews j, CORR may 2005

AETIOPATHOGENESIS AND THE CURRENT CONCEPTS OF KNEE ARTHRITIS Dr Deepak K Rai Professor Dept of Orthopaedics Yenepoya Medical College, Mangalore

 

Knee osteoarthritis is a degenerative disease of the knee joint. It is more common in people older than 40 years. Women have greater chance to be affected than men . Despite pharmacological advances and surgical innovations, the ideal strategy for the patient with knee arthritis at an early age still remains a challenge. Furthermore the demands of the younger patients generally exceed those undergoing a surgical procedure at an elderly age . Arthritis by and large affects approximately 70million of our adult population eclipsing heart disease as the leading cause of disability in India . Moreover as the retirement age approaches, these number dramatically increase in number . Symptoms: Some of the signs and symptoms associated with knee osteoarthritis include, Pain Stiffness Decreasing range of motion Muscle weakness and atrophy due to inactivity or stiffness Crepitus Joint Effusion Deformity Swellings around the knee due to bursa, osteophytes and bakers cysts Osteoarthritis of the knee is predominately considered a "wear and tear" process, where there is gradual degradation of the hyaline cartilage that covers the articulating surfaces of the bones in the knee joint. In most people, the disease is either post-traumatic or hereditary. Other causes or contributing factors may include: Trauma Intra articular injuries of the knee joint Tear of meniscus Partial menisectomy via arthroscopy ACL injuries

 

 

Recurrent patellar dislocation and patella fracture Interarticular fractures of the knee and knee dislocations Arthritis (such as rheumatoid arthritis, infectious arthritis, etc) Deformities of the knee joint viz Genu varum Genu valgum Genu recurvatum (Knee hyperextension) Flexion deformities Ligamentous instability Anterior cruciate ligament Posterior cruciate ligament Medial collateral ligament Lateral collateral ligament Obesity Genetics factors Osteochondritis dissecans disease Meniscal cyst Discoid meniscus PATHOPHYSIOLOGY The most important characteristic of knee osteoarthritis is degeneration of the articular cartilage in the knee joint. Osteoarthritis of the knee can involve one, two, or all three compartments of the knee: Medial or lateral compartments of the tibiofemoral joint (between femur & tibia) Patellofemoral joint (between the femur and patella) RADIOLOGY It is important to take adequate X-rays of the patients before coming to an exact diagnosis Standing weight bearing AP view of the knee Lateral view Merchants view of the patellofemoral joint . DIAGNOSIS Joint space narrowing Osteophyte formation at the joint margins Subchondral Sclerosis (new subchondral bone formation in response to stress on the bone)

 

 

Subchondral Cyst formation (joint fluid under pressure gets into cracks in the cartilage) TREATMENT Over the years there have been a number of advances in the management of arthritis. It has all the more become relevant as more and more patients are being diagnosed with arthritis at an early age and also the demand and physical activities increasing over the past decade. Conservative modalities Pharmacologic therapy (paracetamol; NSAIDS such as ibuprofen, naprosyn, etc.; glucosamine/chondroitin) Intra-articular injection (steroid or hyaluronic acid preparations such as Synvisc or Hyalgan) Weight loss (if obesity or overweight) Physical therapy Low Impact Aerobic Exercise (walking, treadmill, elliptical, bike or stationary bike, swimming or water aerobics) Aims of physical therapy include: Pain and spasm relief Reducing stiffness Muscles strengthening Increasing range of motion Increasing flexibility Gait training Balance improvement Assistive devices (cane, walker) Unloader brace which can dynamically alter the weight bearing from the unicompartmental arthritic knee to the less involved side SURGICAL OPTIONS Surgical treatment is opted for when all non surgical modalities have failed. Surgical operations can include the following: Arthroscopic debridement and lavage OATS (osteochondral autograft transplantation) Total or partial knee replacement (Arthroplasty of the knee) Tibial osteotomy Femoral osteotomy ARTHROSCOPIC DEBRIDEMENT AND LAVAGE

 

 

Arthroscopic debridement (so-called "clean out"). Debridement may be done for these knee problems: Damaged cartilage Damaged meniscus The presence of loose bodies in knee joint Osteophytes of the joint Synovial hypertrophy (by synovectmy) Criteria for Knee Arthroscopic debridement 1.Normal limb alignment 2. History of mechanical symptoms 3. Minimal radiographic degenerative finding 4. Short duration of symptoms Contraindications for Arthroscopic procedures: Varus /valgus malalignment, loading symptoms , severe radiographic degenerative findings , previous surgeries , chronic symptoms . OATS This is a wellestablished technique for the treatment of chondral and osteochondral defects. Also known as mosiacplasty , it was first described by Yamashita of Japan who used it first for osteochondritis dessicans . Cylindrical osteochondral plugs are harvested from areas of articular surface with a lesser weight bearing role and transferred to areas of osteochondral damage. Using apressfit technique these plugs are inserted to replace damaged or missing articular cartilage . The presence of focal unipolar cartilage defects in the knee measuring 1 to 4 cm2 is the current indication for oats. OATS is well documented in isolated femoral condylar lesions (degenerative or traumatic). OSTEOTOMIES AROUND THE KNEE One of the most common presentation in the Indian setup is the presence of deformities around the knee in arthritis One of the standard options available at present is the resurgence of osteotomies with the advent of early arthritis in younger individuals. A thorough understanding of the normal knee alignment is needed before knee malalignment can be addressed.

 

 

The classical High Tibial Osteotomy (HTO) for varus arthrosis was first mentioned by Jackson in 1958 and later described by Jackson and Waugh. HTO was later popularized by Coventry during the 1960s and 1970s, when little options were available for the treatment of arthritis. The procedure is also known as the Coventry osteotomy. The key to HTO is not the correction, but the overcorrection of the deformity. When standing, the standard knee bears 60% of the load through the medial aspect of the joint, and 40% through the lateral aspect. A line drawn from the centre of the femoral head to the centre of the ankle should pass just medial to the centre of the knee in normal alignment known as the Mechanical axis of the knee. Because of the femur is offset by the femoral neck, an angle is created by the centre of the shaft of femur & that of the tibia. This angle or also known as Anatomical axis, is generally 6°to 8° of anatomical valgus. As deformity occurs about the knee, the manner in which the joint surfaces bear the load is altered, leading to overload. This may cause pain and progressive deformity. By correcting the deformity, the surgeon hopes to reverse the arthritic process and the progression of the disease, achieving an ideal mechanical solution to the problem. Procedure

Indications Technique Anatomy Pitfalls

Hto Varus deformity Adequate motion Medial pain

Closing wedge tibial metaphysis

Tibiofibular joint Peroneal nerve Petellar tendon

Undercorrection or overcorrection Articular fracture Nerve palsy Delayed union or non-union

Distal femoral osteotomy

Valgus deformity Adequate motion

Closing wedge femoral metaphysis

Distal femur approach

Fixation failure Delayed union or nonunion

 

 

Lateral pain High tibial valgus osteotomy

Valgus deformity Lateral pain

Closing wedge medially

Tibial metaphysis Patellar tendon

Joint line angulation Undercorrection or overorrection Articular fracture Nerve palsy Delayed union or non union

UNICOMPARTMENTAL KNEE ARTHROPLASTY RADIOLOGIC STUDIES Surgery(new york) consists of a standing ap view, a flexed-knee lateral view, a notch view ,and a the standard four- view series developed by the knee service at the hospital for special merchant view. The standing ap radiograph is an excellent initial screen for alignment problems. INDICATIONS FOR SURGERY The diagnosis of isolated unicompartmental knee disease is a synthesis of the patient’s clinical symptoms, a supportive clinical examination, and rediographic confirmation. The treatment options for unicompartmental disease include conservative treatment with physical therapy and NSAIDS, arthroscopic debridement, realignment osteotomy of the fEmur or tibia, unicompartmental resurfacing, and total knee arthroplasty. contraindications for unicompartmental knee replacement excessive deformity infalmmatory arthropathies ligamentous incompetence patellofemoral symptoms patient expectation TOTAL KNEE REPLACEMENT

 

 

The final frontier in giving a painless mobile stable and functionally near anatomic knee to an arthritic individual. Prosthetic implants have now a near normal anatomic conformation than before . The present generation implants have been divided as Fixed bearing : cruciate retaining / cruciate substituting. Mobile bearing Trumatch knee.

Pelvic Injuries-Evaluation & Management Strategies Dr Naresh Shetty Senior Professor Department Of Orthopaedics MSR Medical College Bangalore

 

Anatomy Pelvic ring consists of Two Innominate Bones & Sacrum Innominate bones are Ilium,Ischium & pubis The Structural quality of bone in Ilium:Bone is strongest & thickest in one column that runs from ischial tuberosity to SI joint(sitting force Transfer) ,second column from dome of acetabulum to SI Joint(standing force transfer). Posteriorly SI Joints inherently unstable due to Geometry of Sacral Ala & medial surface of Ilium Major Trunks of of Iliac system& Neurovascular structures pass thru greater & lesser sciatic notches hence prone for injury

Ligamentous Support: Anterior SI ligament: 15 % stability Posterior SI Ligament Interosseus Ligament Sacrotuberous Ligament Sacrospinous Ligament Superior Pubic & Arcuate Ligaments Primary Survey: Airway maintenance with cervical spine protection Breathing and ventilation Circulation with hemorrhage control

 

 

Disability: Neurologic status Exposure/environment control: undress patient but prevent hypothermia Physical examination: Neurologic Deficit Degloving injuries Pelvic,Flank,perineal Ecchymosis,Contusions Limb shortening,Limb rotation Open wounds in groin ,Buttocks,\perineum Swelling & hematoma Positive Pelvic Compression/Distraction Special Signs: Destot s sign: Roux’s Sign Earle’s Sign Major Pelvic Injuries Classification: TILE CLASSIFICATION Classification of Burgess-Young

� Type  A  Stable  

A1-­‐Fractures  of  the  pelvis  not  involving  the  ring  

A2-­‐Stable,  minimally  displaced  fractures  of  the  ring    

Type  B    

Rotationally  unstable,  vertically  stable  B1-­‐Open  book  

B2-­‐Lateral  compression:  ipsilateral  B3-­‐Lateral  compression:  contralateral  (bucket-­‐

handle)  

 

 

3 distinct mechanisms of injury 2 combined mechanisms. Each : Anterior ring signature key Clue to the mechanism and to the important posterior ring injury

Anterior-Posterior Compression: APC Large force applied to the anterior pelvis MVA, pedestrian vs auto, fall from a height Anterior ring key: Vertical rami fractures or diastasis of symphysis pubis

APC Type I Stretching of Anterior SI Ligament <2 cm widening of Pubic Symphysis APC Type II Tearing of SI and pelvic Floor Intact Posterior SI ligament Vertical sacrum fractures Hemodynamic instability: high

 

 

Treatment: ORIF

APC Type III Disruption of anterior and posterior sacroiliac ligaments: SI joint dissociation. Hemodynamic instability: Very High Treatment: ORIF

Lateral Compression Types I, II, III Force applied to side of pelvis MVA, fall from a height, pedestrian vs motor vehicle All types have horizontal or oblique fracture of a ramus: Anterior key Lateral Compression: posterior injuries Type I: Sacrum arcade fracture(s), Ipsilateral Type II: Crescent fracture of ilium, Ipislateral Type III: Anterior disruption of contralateral sacroiliac joint

 

 

Anterior ring key, common to all LC’s: Horizontal or oblique ramus fracture.

LC Type I Most common major force pelvis fracture: 70% of total Sacral arcade fracture Hemodynamic instability: Low Treatment: Nonoperative, bed rest

Arcade fractures can be subtle Look forAsymmetry,Irregularity,Overlap,Discontinuity,Angulation. LC Type II Crescent fracture of ipsilateral ilium Hemodynamic instability: moderate Treatment: ORIF

 

 

LC TYPE III Contralateral disruption of anterior sacroiliac joint Hemodynamic instability: high Treatment: ORIF

Vertical Shear: VS Posterior injury is vertical sacrum/iliac fracture or diastasis of sacroiliac joint Hemodynamic instability: variable Treatment: ORIF

ILIAC FRACTURE Isolated iliac wing fractures occur with direct force A major force fracture, but not part of previous classification High incidence of intra-abdominal injuries, so always get CT Abdomen

 

 

Rami Fractures Osteoporosis is the most common predisposing condition. Stable, if isolated. Treatment is symptomatic

Sacrum Fractures Fall directly on the buttocks or repetitive microtrauma Common in osteoporosis Acute and stress types Can be subtle on plain films Treatment is symptomatic. May occasionally damage sacral plexus nerve roots. Denis Classification Type 1: Lateral to neural foramina thru Sacral Ala Type 2: Transforaminal #’s Type 3: Transverse sacral #,Medial to foramina

 

 

Coccyx Fracrures Fall on buttocks. Radiologic diagnosis is difficult due to marked normal variation. Clinical diagnosis is more accurate: local tenderness. Stable. ,Symptomatic treatment.

Avulsion fractures Apophyseal avulsions from abnormal tension by tendons: physis injuries. Anterior-superior and anterior-inferior iliac spines, and ischial tuberosity are most common sites. Athletic older adolescents and young adults. Nonoperative injuries. Miscellaneous Fractures Malgaigne : # of Both Pubic Rami + SI joint Straddle : Bilateral Pubic rami # Unusual # of Childhood: Ilium Dislocation

 

 

Jumpers Pattern:Dislocation of central portion of upper sacrum from pelvic ring Management Goals Resuscitation Restore bony Anatomy Prevent Deformity Maximize function Investigations Blood Group Hb,PCV X ray : Pelvis AP,Pelvic Inlet,Pelvic Outlet CT Pelvis: 3-D Reconstruction(2-3mm cuts) USG Abdomen: FAST Peritoneal Lavage Arteriography Contrast Urethrography/Retrograde Cystogram

Defining Pelvic Stability Radiographic

Pelvic  Inlet  View      Pelvic  outlet  View  

 

 

Hemodynamic Biomechanical (Tile & Hearn) Mechanical “Able to withstand normal physiological forces without abnormal deformation” Stability Classification

AO-OTA Stability Classification

� Type  A:  Stable  fractures  Mechanical  ring  structure  of  the  pelvic  ring  remaining  intact  (incidence  50–70%  of  the  

patients).

� Type  B:  Partially  unstable  injuries  Partial  posterior,  rotational  instability  after  anteroposterior  or  lateral  compression  (incidence  20–30%  

of  the  patients).

 

 

Radiographic Signs of Instability Sacroiliac displacement of 5 mm in any plane 1 cm cephalad displacement of hemipelvis Posterior fracture gap (rather than impaction) Avulsion of fifth lumbar transverse process,Lateral border of sacrum (sacrotuberous ligament),Ischial spine (sacrospinous ligament) Open Pelvic Injuries Mortality upto 50 % Open wounds extending to the colon, rectum, or perineum Strongly consider early diverting colostomy Soft-tissue wounds should be aggressively debrided Early repair of vaginal lacerations to minimize subsequent pelvic abscess Urologic Injuries 15% - 20 % incidence 22 -34 % Mortality Gross Hematuria Most Common :Extraperitoneal Bladder Ruptures Blood at meatus or high riding prostate Retrograde urethrogram indicated in pelvic injured patients ANY Definitive surgery Should not contaminate Orthopaedic Field Pelvic Fractures & Hemorrhage Fracture pattern associated with risk of vascular injury (Young & Burgess) ER & VS > IR APC & VS at increased risk Injury patterns that are tensile to N-V structures

 

 

Iliac wing fractures with Greater Sciatic Notch extension Sources Of Haemorraghe External (open wounds) Internal Chest Long bones Abdominal Retroperitoneal Vascular Injuries Arterial vs Venous vs Cancellous Unstable posterior ring association Associated fracture extension into notch Role of angiography Arterial only 5-15% Timing &Institution dependent

Protocol for Management Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. JOT, 2001 5 Elements Immediate trauma surgeon availability Early simultaneous blood and coagulation products Prompt diagnosis & treatment of life threatening injuries Stabilization of the pelvic girdle Timely pelvic angiography and embolisation

 

 

O’Brien et al AAOS,2005

 

 

Parkland Memorial Protocol

 

 

Pelvic damage Control

 

 

Sheet Application Autotransfusion Close “open book “ injuries- Tamponade Stabilise Pelvis Ring : Clot Formation

 

 

Pelvic Binder

External Fixation Location Purpose AIIS Resuscitative ASIS Augumentative C Clamp Definitive Slatis Frame : Used for Rotationally unstable injuries Ganz Frame :Hemodynamically unstable patients until definitve ORIF

 

 

Ganz Fixator Application Indications for External Fixation: Resuscitative (hemorrhage control, stability) To decrease pain in polytraumatized patients As an adjunct to ORIF Definitive treatment (Rare!) Distraction frame Can’t ORIF the pelvis Resuscitative

 

 

Adjunct To ORIF

Technical Details: ASIS Frame Fluoro dependent 3 to 5 cm posterior to the ASIS Incisions directed toward the anticipated final location 1/3 from the medial aspect (lateral overhang) Aim:30 to 45 degrees (from lateral to medial)Toward the hip joint

Anti-shock Clamp (C-clamp) Better posterior pelvis stabilization Allows abdominal access Apply under C –arm /OR

 

 

Combined with packing

Basic Principles Of Definitve Pelvic # Fixation Complete instability of Posterior Ring Anterior Fixation – Inadequate Complete Instability of Posterior Ring Anterior + Posterior Fixation Definitive Treatment Indications Stable, nondisplaced pelvic fractures Tile type A, Young and Burgess types LC I and AP I Conservative:Early mobilization and analgesics Rotationally unstable but vertically stable Tile type B, Young and Burgess type AP II Fractures with a pubic symphysis diastasis of more than 2.5 cm Pubic rami fractures with more than 2 cm displacement, Rotationally unstable pelvic injuries with significant limb-length discrepancy of more than 1.5 cm Unacceptable pelvic rotational deformity Tile type B (Young and Burgess type AP II) injuries External fixation --Definitive treatment Tile type C (Young and Burgess types AP III, LC III, vertical shear Posterior fixation to regain vertical stability Anterior Pelvic Injuries Indications for ORIF:

 

 

Symphyseal Dislocations demonstrating > 2.5 cms diastasis on either static/dynamic imaging To Augument posterior fixation in vertically displaced instable pelvic ring fractures. Locked symphysis Pain & inability to mobilize Symphyseal Dislocations: No significant difference in Internal /External Fixation Technique for Anterior External Fixation: Multipin Iliac Crest Frames:To Iliac Wing Two Supra pin Acetabular Frames:directed towards PIIS Technique for ORIF:Weber et al,Plate fixation Posterior Pelvic Injuries: Indications of ORIF: Displaced Iliac wing Fractures that enter & exit both Greater sciatic notch & Crest,SI joint. Disruption of Posterior SI Ligaments resulting in multiplanar instabilty of SI Joint Non Impacted communited displaced sacral fractures Any posterior ring injury with propensity for cephalad displacement U shaped sacral fractures with spino pelvic dissociation Technique for Iliac Wing Fractures & fracture dislocations(Crescent) Iliac Wing Fractures:Pelvic Reconstruction plate/Lag screw ( anterior approach) or Sciatic Buttress. Crescent Fractures: Iliac wing fracture – partial dislocation of SI joint Depends on size of crescent fragment Sacroiliac joint Dislocations: Anterior or posterior Approach Percutaneous Screw Fixation:IlioSacral Screws Sacral Fractures: Indications for Reduction & stabilisation

 

 

Anterior & posterior Pelvic Injuries with vertical or cephalad instability forvertical sacral fractures Non impacted or communited sacral ala fractures with ER deformity U shaped sacral fractures with spino pelvic dissociation,cauda equina syndrome or sacral kyphosis Impacted sacral fractures Percutaneous screw fixation Anterior Approach to SI Joint

Approach to Pubic Symphysis Pfannerstiel incision

 

 

Posterior Approach to Ilium,SI joint & Sacrum

Percutaneous Pelvic # Fixation Indications: Severe Soft tissue injury/Contamination/Bad open #’s Contraindications:Sacral Dimorphism Percutaneous fixation of the pelvic ring:Best Results in Experienced Hands

 

 

The risk of neurological injury after positioning of sacroiliac screws have been reported to between 0.5% and 7.7%. Post Op Management: Bladder,Bowel Care Drain Care DVT Prophylaxis, Pulmonary embolism Complications Infection Erectile Dysfunction: upto 45 % ThromboEmbolism Malunion,Non union Mortality upto 10 %

 

 

PERIPROSTHETIC FRACTURES OF FEMUR - A CHALLENGE Prof. M. Shantharam Shetty Vice Chancellor, Nitte University Chairman, Tejasvini Hospital Mangalore

 

There is a sudden Upsurge of Periprosthetic Fractures in the last 2 Decades which includes both the Primary and Revision Arthroplasties, mainly because of Increased life expectancy all round the world. Not only majority of those hip & knee replacements we had done have become 20 years older, it is also the wrong techniques of different types of prosthesis which has added on to the number. Keeping pace with the type of prosthesis has become like models keeping pace with latest fashion in Paris Femur is the most common bone 80% to be involved in Periprosthetic Fractures. According to Springer, Berry, Lewallen, JBJS(A) Nov 03;85/11:2156-216, out of 30000 cases studied, 1.1% were Primary; 4% revision surgeries resulted in these fractures and average time to fracture is 8 years Periprosthetic fractures are different from other fractures because they are associated with Osteopenia / Osteoporosis Wear debris - Osteolysis Interference of prosthesis for fixation In our country, Financial constraints is an added factor and also lack of Bone bank facility Proper instrumentation Periprosthetic fractures related to THR can be in Femur or in Acetabulum and TKR can be in Femur or Tibia or in Patella. Periprosthetic Femur Fractures Vancouver Classification (post-op) is the most commonly followed and complete classification . Trochanteric - 4% Greater Lesser

 

 

About Tip of Stem - 87% 1 Stable prosthesis 18% 2 Loose prosthesis 45% 3 Inadequate bone stock 37% Distal to tip - 9 % Duncan, Masri: Fractures after hip replacement. Instr Course Lect 44, 1995 Vancouver classification:

Type Location and nature

AG Greater trochanter

AL Lesser trochanter

B1 Around or just distal to the prosthesis, implant stable

B2 Around or just distal to the prosthesis implant unstable

B3 Around or just distal to the prosthesis implant unstable, bone stock inadequate

C Well below prosthesis

Definitive protocol for management of these fractures. Classification based on site , stability & bone stock Duncan et al- Instr course 44.1995 Vancouver Classification (intra-op) Type A: proximal metaphysis Type B: diaphyseal Type C: distal metaphysis (beyond the longest revision stem). Each further classsifed into 3 subtypes: Subtype 1: simple cortical perforation Subtype 2: undisplaced linear crack Subtype 3: displaced / unstable Periprosthetic Femur Fractures TEND to occur At tip with stable prosthesis

 

 

More Proximally with loose stem distal is usually due to a fall with a rotational strain or direct impact. Lewis & Rorabeck Classification for Supra condylar fractures based on the status of the prosthesis (intact or failing) & the displacement of the fracture Type I - undisplaced / Intact prosthesis Type II - displaced / intact prosthesis Type III- displaced-undisplaced / prosthesis loose or failing Periprosthetic Femur Fractures Treatment Objectives to be aimed at Healing of fracture Maintain prosthesis function Maintain alignment Avoid complications Periprosthetic Fractures – Principles PROSTHESIS INTACT LOOSE Fix Fracture Revise and fix if necessary Special challenges to be kept in mind are: Constrained prosthesis/IM nails in TKA Long stem in THR Bone graft/substitutes/reconstruct in case of defect Systemic Factors can also be a challenge Age Function Co-morbidities Smoking Osteopenia

 

 

Immuno-compromise Steroids Biological Factors can be a problem like Osteolysis Polyethelyne debris Cellular compromise Immunologic Cytokine Osteoblast dysfunction Local Factors which is to be considered are Osteolysis Local biology Infection Altered bed Radiation. Mechanical Considerations to be looked into are Loosening Stress riser Multiple implants Varus Status host bone stock Cement Surgical Treatment Options- Plate Fixation Always Overlap stem with +/- Cerclage Proximal unicortical screws beneficial Dennis et al, J Arthrop 2000 Use Long plates and Cable systems Min. 3 points fixation proximal and distal Plate Fixation Circlage Techniques At least 3 points fixation proximal and distal Provisional clamping options Sequential and retightening

 

 

Cable fixation options Locking Plates TKA Locked plates combined with minimally invasive insertion technique for the treatment of Peri- prosthetic supracondylar femur fractures above a total knee arthroplasty is an ideal solution. William Richey,Joseph Barilly, et al Journal of Trauma, March 2006 However if the bone stock is poor an Intramedullary device is preferred. Technique: With the knee placed in 90 degrees of flexion, a medial parapatellar approach is done to reach the femoral component. The cruciate substituting device has a hole in the box cut which can be used as entry point for a nail Internal fixation alone is contraindicated if the component is loose or there is severe Osteopenia surrounding the implants. Revision with a long stemmed implant is the procedure of choice in such a situation. However, distal femoral allograft , internal fixation devices also may be used to augment the stability of the implant. Summary Locking Plates provide added stability in osteoporotic periprosthetic fractures of the femur Most stable fixation Lower is Locking Screws + cables proximally Bicortical Locking screws distally When ever the prosthesis is loose it has to be replaced with a longer stem or a modular prosthesis as indicated. Periprosthetic femoral fractures: Distal of tight hip prosthesis: Use Plate - LCP Distal of loosened hip prosthesis: Revision (prosthesis with prolonged stem)

 

 

Proximal of knee prosthesis DFP Proximal of tight knee prosthesis Connection with intramedullary stem: with nail Proximal of loosened knee prosthesis: Revision (prosthesis with prolonged stem) Conclusion Fracture union rates have improved compared to historical controls Periprosthetic fractures of the femur still remain technically challenging and still associated with an increased morbidity and mortality With better understanding of the fracture and its healing and with the advent of newer implants/long stem prosthesis. Challenges are better faced today. When there is a Periprosthetic Fracture… Study the fracture – site & type Study the prosthesis – stable / unstable Study the bone stock. IF YOU FAIL TO PLAN, YOU PLAN TO FAIL Have the full armamentarium of alternatives like LCPs Cables Different types of prostheses, which can salvage Bone graft & Bone Substitutes

Flaps in Upper Limb Dr B.Jagannath Kamath Head of the Department of Orthopaedics Kasturba Medical College, Mangalore

 

Loss of skin and soft tissue in hand and upper limb more often needs flaps than just graft as loss of skin exposes vital structures like bone, joints, tendon and neurovascular structures. These vital structures when exposed in traumatic or non traumatic lesions form a poorly vascular bed which fails to accept a simple graft. Under these circumstances flaps which have their own blood supply are ideal for replacing the lost skin and soft tissue. A flap is skin with a varying amount of underlying tissue that is used to cover a defect and that receives its blood supply from a source other than the tissue on which it is laid. A graft is a piece of tissue that does not have an intrinsic blood supply and must be revascularized by the underlying tissue bed. Flaps are classified based on: 1. Blood Supply: Random Pattern flaps Axial Pattern flaps 2. Area: Local (Within Hand) Regional (Forearm) Distal (Abdomen, Groin) Micro 3. Component: Skin Adipo-Fascial Fascio- Cutaneous Fascio-Myo-Cutaneous Osteo- Fascio-Myo-Cutaneous (COMPOSITE FLAPS) Indications: Wound exposing tissues with poor vascularity. Permit secondary recon surgery. Provide padding and bulk. Provide sensation. Control infection. Single stage reconstruction (COMPOSITE FLAPS) Timing of the flaps: Success of the flaps depends on the timing when it is done. Ideally they should be performed primarily or delayed primarily with in

 

 

three to five days. The failure rates of the flaps increases proportionately with time and could be as high as fifty percent. Depending on the need the surgeon may prefer a flap to cover the entire raw area or atleast a critical raw area exposing vital structure. The proper technique and the choice of the flap depends on the expertise of the surgeon and the facility available, as there may be multiple options to cover a specific raw area. Loco regional flaps: Loco regional flaps are most commonly used flaps in the reconstruction of small to moderate areas in the hand & forearm. Distant flaps from the abdomen and free flaps from the trunk & thigh (LD, ALT) are generally reserved for larger raw areas. Finger tip injuries are most common clinical scenarios in orthopaedic practice. From the management point of you it can be classified into dorsal oblique, volar oblique & transverse amputations (with equal loss of dorsal & volar tissues. Transverse amputation & dorsal oblique amputation can most often be covered with volar advancement flaps which can be advanced in a V Y fashion, based on both N Y bundles (Klinert’s or Atosoy flaps in fingers and Moberg’s & Obrien’s in the thumb) & or single N Y bundle (Venkatsami flap). Volar oblique amputations up to 30 to 35 degrees can still be managed with modified V Y plasty where in volar tissue of the finger and the thumb can be mobilized on one or both pedicles with considerable proximal dissection into the palm in the fingers and thenar eminence in the thumb. If there is a total loss off pulp over the distal phalanx, they need to be replenished with either reversed digital artery flap or a standard conventional cross finger flap. The basis for homodigital reverse digital artery flap is the communication between two digital arteries at the level of neck and the base of each of the phalanges. Hence the volar skin from the proximal phalangeal area could be mobilized on the neurovascular bundle distally to cover entire pulp over the distal phalanx. However care must be taken to preserve the pivotal point at or proximal to the neck of the middle phalanx so as to ensure vascularity of the flaps. Advantage of this flap over the CFF is that it is a single staged procedure.

 

 

Major loss of pulp tissue over the distal phalanx of the thumb needs a neuro sensory flap either in the form of Littler’s flap or a FDMA flap. Littler’s N V island flap is a flap raised from the ulnar side of the middle finger (supplied by the Median nerve) up to the middle of the palm with a lengthy pedicle. The flap thus raised could be shifted to the recipient area over the tip of the thumb either by opening at the thenar eminence or by tunneling. Excellent sensory recovery is a rule especially in young individuals. The FDMA flap is based on FDM artery which is given just on the ulnar border of the EPL by the radial artery just before piercing between the two heads of the first dorsal interosseous muscle to enter into the palm. This FDM artery lying radial to the extensors of the index finger supplies the proximal half of the dorsum of the index finger. This FDMA flap is a neurosensory flap supplied by distal branch of the superficial radial nerve. This neurosensory FDMA flap is second best flap to resurface the tip of the thumb after the Littler’s because of its sensory input coming from radial nerve instead from median nerve. Conventionally distal margin of the FDMA flap should stop at the dorsum of the PIP joint allowing it to be used for resurfacing tips of slightly shortened thumb. However FDMA flaps when are used in their extended form ( flap tip going up to the DIP joint) can not only reach the tips of thumb with normal length also be used as wrap around flap for circumferential thumb tip injuries. Filleted flap: when more than 3/4 of the five elements of the digit ( skin, artery& vein, bone, flexor & extensor tendons) are irreparably damaged, the viable skin of the digit could be harvested after discarding the tendons and the bone to cover adjacent area with skin loss. These flaps are when used properly could be handy in injuries involving multiple digit. Transpositional flaps on the dorsum of the hand can be used to cover small skin defect in the first web space in both traumatic and non traumatic situation Cross Finger Flap (CFF) It’s a Random pattern flap from the dorsum of middle and proximal phalanx. It can be either proximally based, distally based or laterally based. It is most commonly used as laterally based-(Radial,ulnar) to cover significant skin loss on the volar aspect of the fingers. Generally the

 

 

radial uninjured digit is used as the donor for the CFF with the exception of index finger where middle finger is used. The plane of dissection is just superficial to the paratenon of the extensor mechanism, the integrity of which should be preserved for the proper take of the graft used to cover the donor defect. The advantages are that it is a very versatile flap, technically easier to do and can cover the entire volar aspect of the digit. The disadvantages are1. Colour mismatch, 2. insensate flap unless innervated and 3. 2 stage procedure, needs 2-3 weeks of immobilisation. Wherever there is a need for sensation, CFF can be raised as a innervated CFF by incorporating the dorsal branch of the digital nerve from the donor finger which could be anastomosed to the volar digital nerve of the recipient digit, either in the first or second stage of the procedure. The other modification of CFF is the C Ring flap wherein considerable skin on the volar and dorsal aspect of the donor digit could be raised on one of the digital artery,based proximally or distally ,to cover circumferential raw areas of the tip of the recipient digit. Reverse Cross Finger Flap (CFF) For dorsal defects the CFF can be used following the de epithelialisation.The only difference in this modification of CFF is that both the donor site and the flapped recipient site needs SSG.As in CFF the flap needs devision at the end of 2-3 weeks. These are versatile flaps for covering moderate to large size defects on the dorsum of the digit. However care must be taken to completely de epithelialise the flap before the inset of the flap as any remnant of hair follicles may lead to the growth of tuft of hair follicle under the flap. Radial Artey flap Radial Artey flap is a very versatile flap wherin the entire volar aspect of the forearm skin could be harvested ,based either proximally or distally.It used to be a commonly used free flap before the advent of Anteriolateral thigh flap.Clinically radial artery flap is most useful when it is used as a distally based flap wherin large amount of skin and soft tissue can be resurfaced over the palm and dorsum of the hand,even the fingers.Preoperative Allen’s test is a prerequisite for this flap as it is based on the communication between the radial and ulnar artery in the palm.Technically this flap is easier because of the superficial nature of the

 

 

artery and the constant anatomical features particularly the septum between the FCR and Brachioradialis which has to be raised with the flap as it a septocutaneous flap.Donor deficit is minimal from the functional point of view but may be cosmetically unacceptable in young females. Distally based radial artery flap can also be used as a composite flap (Osteo-fascio-cutaneous flap) to reconstruct a part or whole of the thumb lost either in traumatic/non traumatic conditions. Such a flap incorporates radial half or 1/3rd of the radial bone between the insertion of prona tor teres and pronator Quadratus, as this part of the radial bone is constantly supplied by a perforator from the radial artery,amenable for harvesting along with the radial artery flap. Posterior Interosseous Artery Flap A fasciocutaneous flap based on the PIA can be raised from the dorsum of the forearm, based either proximally or distally to cover the raw areas around the elbow and hand respectively. Like the radial artery forearm flap,PIA flap is a septo cutaneous flap based on the perforators present in the septum between EDU and EDM (5th Compartment).A moderate sized flap can be raised from the middle third of the forearm on the dorsal aspect to cover the dorsum of the hand and the first web space with a pivotal point about 2 cm proximal to the DRUJ where AIA communicates with the PIA through a rent in the interosseous membrane. However because of the technical difficulties, vascular anomalies and iatrogenic posterior interosseous nerve injury this flap is not as popular as radial artery flap. Becker’s Flap Just like the radial artery flap, ulnar artery flap can be raised though it is more dominant artery but because of the increased incidence of cold intolerance people avoid it. Advantage of course is concealed secondary defect (can be closed primarily) and hair less donor area. But the most commonly used flap based on ulnar side of the forearm is based on the dorsal cutaneous branch of the ulnar artery ( Becker’s flap).The dorsal cutaneous branch of the ulnar artery (DCBU) which arises 5 cm above the wrist joint divides into a ascending and descending branch. The latter anastomoses with the proximal carpal plexus of vessels. So based on the descending and ascending branch of the DCBU one can easily raise a

 

 

distally based flap on the dorsoulnar aspect of the distal half of the forearm to cover the palmar and dorsal aspect of the hand. Distant flaps : For major soft tissue defects in the hand and thumb flaps from the abdomen are common option. Abdomen flaps are work horse in the management of major soft tissue defect in hand. Flaps raised may be random pattern based or axial pattern. For defects in the radial and ulnar borders of the forearm, large superiorly based or inferiorly based abdominal flap may be used respectively. Axial pattern flap based on superficial inferior epigastric artery ( Shaw’s flap ) and superficial circumflex iliac artery ( groin flap ) are the two most commonly used flaps in hand and forearm soft tissue defect. In rare occasions both the flaps may be raised as bi lobed flaps to cover volar and dorsal defect of the hand. Disadvantages of these flaps are they are bulky, insensate and need staged procedure. Never the less they are quite useful in salvaging hands involving major skin loss especially in places where microsurgical procedures are not available. Free flaps: With advent of microsurgical free flaps varied degree of soft tissue replenishment can be obtained as one stage procedure. These flaps can not only be cosmetically more acceptable but also when used as composite flap can bring about one stage reconstruction in replenishing multiple tissue loss (Eg; muscle, bone, tendon, joint). Some of the commonly used free flaps in upper limb are lateral arm flap, antero lateral thigh flap, LD flap, Gracillis flap.

 

 

Chest Injury for Orthopedic Surgeons Dr.Ashok B. Shetty Professor CTVS KMC, Mangalore 02/07/11 10:14 AM

 

Chest injury is the common cause for significant morbidity and mortality following major trauma and the third leading cause of death after head and spinal injuries. Blunt chest injury is the primary cause for 25% of trauma related deaths and it is the contributing factor in another 50% of trauma related deaths. The prognosis of thoracic injuries can be improved if the casualty can be quickly evacuated, assessed and managed effectively. Awareness of chest injury is very important for an orthopedic surgeon for several reasons: -as an associated injury, it can lead to hypoxia, hypovolemia and shock which requires early recognition & intervention. -to plan timing of orthopedic intervention in patients with compromised cardio-respiratory function -consider the possibility of associated hemodynamic and pulmonary vascular changes secondary to orthopedic procedures - FES, ARDS etc. -as a prognostic factor, in the ultimate outcome Mechanism of chest injury could be: Blunt injuries Penetrating injuries Explosive injuries Acceleration and deceleration injuries Traumatic asphyxia In road traffic accidents, seat belts have significantly reduced the morbidity and mortality, even at low speeds, within city limits. Chest injuries can be classified into:. 1.Chest wall injuries 2.Pulmonary injuries 3.Cardiac injuries 4.Aortic injuries 5.Diaphragmatic injuries 6.Others – esophagus, thoracic duct etc. Chest wall injuries:

 

 

Soft tissue injuries – bruising, contusion & lacerations Managed with wound care, debridement and suturing. Bony injuries – ribs & sternum Rib fractures: Number of ribs fractured suggests the severity of the impact and injury. Signs: Chest pain & tenderness, bony crepitus Chest x-ray: Shows the fracture and associated injuries to the lung Treatment: Analgesics, treatment of associated injuries and ?Mechanical stabilisation Flail chest: When more than two ribs are fractured at more than one site in each rib, this segment of the chest wall moves independently, giving an appearance of ‘paradoxical movement’, i.e. appears to move inwards during inspiration, and bulge out during expiration. This paradoxical movement does not contribute to any respiratory impairment. But a flail segment indicates a very severe impact and severe lung injury which is responsible for the higher mortality associated with flail chest. Hence the flail segment itself does not require any treatment but these patients needs to be closely monitored for development of respiratory distress and managed accordingly, which may require mechanical ventilation. Sternal fractures: Usually secondary to major impact and associated with internal injuries. Signs: Chest pain, tenderness, bony irregularities X-ray / CT scan: Shows the fractures and associated injuries Treatment: Analgesics, treatment of associated injuries ?mechanical fixation Pulmonary injuries: Contusion: This is due to the impact on the chest wall leading to compression of the lung. The visceral pleura is not breached. May be associated with intra – pulmonary hematoma or a pneumatocoele. Signs: Shortness of breath, hemoptysis X-ray / CT chest: Non homogenous densities & infiltrates Treatment: Supportive measures ?mechanical ventilation Laceration: Usually due to the penetration of the broken rib ends but also could be secondary to injury from other penetrating objects. This leads to air leak and bleeding from the injured site producing pneumothorax, hemothorax or a combination of hemo-pneumothorax. Signs: Chest pain, shortness of breath, hypovolemia and hemoptysis

 

 

Chest X-ray / CT chest: Shows hemo/pneumothorax & lung injury Treatment: Intercostal drainage. If the air leak or bleeding persists, thoracotomy with suturing of lacerated lung. Lobectomy or pneumonectomy may be required if the damage is deep or more extensive. Bronchial & major vascular injuries: These major injuries are significantly symptomatic with cardio-respiratory compromise and need immediate attention, involving ventilatory care, rapid resuscitation, initial intercostals drainage followed by thoracotomy with repair or most often, resection of the involved lobe or lung. Cardiac injuries: Myocardial contusion: Usually associated with sternal fractures. Patients may be asymptomatic initially and as the myocardial edema sets in, they develop arrhythmias and deteriorating myocardial function. ECG and Echocardiogram should be done in suspected patients and treatment is supportive with inotropes and antiarrhythmic drugs. Coronary artery injuries: These injuries can lead to myocardial ischemia, infarction or bleeding with cardiac tamponade. They require urgent attention with ECG and Echocardiographic evaluation, followed by pericardiocentesis and Coronary angiogram to decide percutaneous intervention or surgery to repair the damage. Myocardial lacerations: These patients will present with low cardiac output and cardiac tamponade which requires urgent surgical intervention with relief of tamponade followed by repair of cardiac injury directly or using cardio-pulmonary bypass. Valvular injuries: Depending on the severity of the valvular insufficiency, these patients may be managed conservatively in the begining or require urgent surgical intervention requiring repair or replacement of the valve. Aortic injuries: Ascending aorta and arch are injured more due to direct impact where as the commonest injury involving the junction between the arch of aorta and the Descending thoracic aorta is secondary to deceleration injury leading to partial or complete aortic transection. These patients manifest with severe chest pain, hypotension and mediastinal hematoma. When the hematoma leaks through, they can manifest with significant cardiac tamponade or massive hemothorax. An echocardiogram and immediate contrast CT or a CT angiogram can tell us

 

 

the severity of the injury to plan further management. Ascending aortic and arch injuries require immediate repair using cardiopulmonary bypass and have a very high morbidity and mortality. The injury at the origin of Descending Thoracic Aorta is usually managed by percutaneous stent-graft placement or surgical repair using direct suturing or graft replacement. Diaphragmatic injuries: Left dome of the diaphragm is injured 5 times more commonly than the right, more often in patients following fall from height and these patients may be having associated vertebral fractures with or without paraplegia. Chest x-ray and CT scans are useful in diagnosing these injuries. They require early attention, particularly if the herniation is substantial. Repair involves endoscopic or direct surgical access via thorax or abdomen, reduction of hernia and repair of the defect. Traumatic asphyxia: This is due to sudden progressive compression on the chest by an heavy object or being trapped between two rigid objects, which prevents the patient from expanding the chest wall leading to sustained increase in intrathoracic pressure, venous hypertension in the upper chest, neck, both upper limbs and head. Patients present with severe upper body edema, petichae, subconjunctival hemorrhage and multiple intracerebral hemorrhages. Once the patient is released from the compression, treatment is supportive and the prognosis is usually good.

EVALUATION OF THE LOWER LIMB IN CEREBRAL PALSY AND MANAGEMENT STRATEGY Dr. Benjamin Joseph Prof of Orthpaedics, KMC, Manipal

 

While evaluating the lower limb in a child with cerebral palsy several assessments need to be made in order to plan a strategy of treatment; these assessments include the following: Assessment of the severity of involvement The neurological pattern of involvement The nature and extent of gait abnormality Assessment by observational gait analysis Assessment by instrumented gait analysis Motor system assessment Assessment of spasticity Assessment of muscle power Assessment of selective motor control Assessment of the degree of muscle imbalance Assessment of the severity of contractures Assessment of the hip, knee, ankle and foot Assessment of the severity of involvement Currently the classification system used universally is the GMFCS (Gross Motor Function Classification) which grades the child’s mobility from Level I (walks independently in the community, can run and jump, negotiate stairs without support but speed, co-ordination and balance are limited) to V (Totally wheelchair dependent). Children in Levels I to III are ambulators while children in Levels IV and V are non-ambulators. The need to make this distinction is because the approach to management varies in both these groups of children. The questions we need to answer regarding ambulant children are: Can the pattern of walking be improved? Can the child be made to walk more efficiently (i.e. by reducing the energy consumption)? Can the child be enabled to walk more? While the questions we need to answer regarding non-ambulant children are: Can the quality of life be improved? Can we make it easier for the care giver to look after the needs of the child?

 

 

Consequently, the aims of treatment in the ambulant child with cerebral palsy is to enable the child to walk more normally, more efficiently and walk longer while in the non-ambulant child is to improve the quality of life and facilitate the care giver. In addition to these aims a concerted effort must be made to prevent hip dislocation and treat it if it has occurred irrespective of whether the child is ambulant or not. Assessment of the neurological pattern of involvement A distinction needs to be made between spastic cerebral palsy and other forms of cerebral palsy (athetoid, dytonic, ataxic and atonic) as the outcome of treatment varies a great deal between these groups. For example, outcome of treatment is far more unpredictable in children with an ataxic or athetoid component. Assessment of the gait aberration Assessment of the abnormality in gait may be done by observational gait analysis or instrumented gait analysis if this facility is available. Observational gait analysis entails careful and meticulous documentation of the movement of the pelvis, hips, knees, ankles and feet while the child is walking. Though it may be done by simply observing the child walking, it can be facilitated by recording the gait with a video camera, playing the clip repeatedly and pausing at critical points to ascertain subtle abnormalities during the gait cycle. It needs to be emphasised that however well documented, observational gait analysis only records some kinematic variables of gait. Instrumented gait analysis has different components that include kinematic analysis, kinetic analysis, dynamic electromyography and energy consumption analysis. Advocates of gait analysis recommend that all children who need to undergo surgery for improvement of gait should undergo instrumented gait analysis prior to surgery. However, this is far from practical in most countries. Some abnormal gait patterns can be identified by observation and they include the following. Careful assessment of individual joints can to a large extent explain the underlying pathomechanics of the abnormal gait pattern in each of these situations (See Table).

 

 

Gait pattern Pathomechanics Scissor gait Spasticity or contracture of the hip adductors

(adductor longus and gracilis particularly) Internal rotation gait

Excessive femoral anteversion Spasticity of the internal rotators of the hip

Crouch gait Spasticity or contracture of the hamstrings Weakness of quadriceps Stretching of the patellar tendon resulting in patella alta (in long-standing cases)

Stiff knee gait Co-spasticity of the hamstrings and the rectus femoris muscle

Equinus gait Spasticity or contracture of the gastroc-soleus Assessment of the motor system Motor system dysfunction in cerebral palsy is due to a combination of the following factors and hence it is necessary to test each of these at the hip, knee, ankle and foot: Spasticity Paresis Muscle imbalance Lack of selective control Inco-ordination Contractures Apart from assessing the extent of these abnormalities there are specific problems that may develop at each joint. Assessment of the hip The common problems seen at the hip include adduction of the hip with a scissor gait, flexion deformity, internal rotation gait and hips instability. The underlying pathological findings in each of these situations are listed below in the Table. Problem Clinical assessment Investigation Adduction with scissoring

Spasticity or contracture of the adductors to be tested with the knees extended

Nil

 

 

Flexion Spasticity or contracture of the iliopsoas tested by the Thomas’ test or Staheli’s test

Nil

Internal rotation gait

Test for femoral anteversion by assessing the way the child sits (‘W’ position) and the passive range of hip rotation (internal rotation far exceeds external rotation).

May be confirmed by ultrasonography or CT scans

Hip subluxation or dislocation

Limitation of passive abduction of the hips < 30o when tested with the knees extended

Reimer’s migration index > 20% Break in Shenton’s line and an increased medial joint space all of which are seen on a plain AP radiograph of the pelvis

Hip dislocation in the diplegic can lead to loss of walking ability and pain in the hip while in a child with total body involvement who is bed-ridden hip dislocation can preclude sitting, interfere with perineal hygiene and cause pain which in turn will result in marked increase in spasticity. Hip dysplasia should be diagnosed early so that subluxated hip can be prevented from progressing to a frank dislocation. In order to achieve this aim, all children with cerebral palsy need to be screened for impending hip subluxation on a regular periodic basis as recommended by the team at the Melbourne Children’s Hospital (JBJS Br 2002; 84:720-6). Since we know that the frequency of hip dysplasia is infrequent in hemiplegics, more frequent in diplegics and most common in total body involvement special care needs to be taken to screen he more severely affected. Assessment of the knee The common problems at the knee include flexion deformity with a crouch gait, a stiff-knee gait and genu recurvatum. The underlying pathological findings in each of these situations are shown in the Table below. Problem Clinical assessment Investigation Crouch gait Spasticity or contracture of the

hamstrings

 

 

Stress fracture of the patella and fragmentation of the tibial tuberosity, patella alta Weak quadriceps muscle

Lateral radiograph of the knee Manual muscle testing or dynamometry

Stiff-knee gait

Spasticity or contracture of the hamstrings and rectus femoris (i.e. co-spasticity of the flexor and extensor of the knee). The politeal angle will be abnormal and the prone rectus test will be positive

Dynamic electromyography

Recurvatum Contracture of the gastroc-soleus

Assessment of the foot and ankle The ankle and foot should be assessed with the child recumbent, then while the child is standing and finally when the child walks. The common abnormalities that may be encountered include equinus (dynamic and static), equinovarus, valgus and calcaneus deformities. Equinus deformity may be dynamic (appears only when the child is walking but is absent when the child is recumbent; the gastroc-soleus is not contracted in these children but is spastic. If the equinus deformity is present even when the child is recumbent there will be contracture of the gastroc-soleus. Clinical examination can distinguish between gastrocnemius contracture and contracture of the soleus by testing for equinus with the knee flexed and extended. Problem Clinical assessment Investigation Equinus Distinguish between dynamic and

static deformity If the deformity is static, distinguish between gastrocnemius contracture and soleus contracture

Equino-varus

Distinguish between spasticity of the tibiais anterior and the tibialis posterior

May be facilitated with fine needle dynamic EMG

 

 

Valgus Check for contracture of the gasrtoc-soleus (valgus ex-equino) Check for spasticity or contracture of the peronei

Calcaneus Determine if the Achilles tendon has been over-lengthened in the past

MANAGEMENT STRATEGY The aims should be to: Reduce spasticity Restore muscle balance Release contractures The ways in which each of these aims can be achieved are shown in the Table below Aim Method Reduce spasticity Physiotherapy – slow repeated stretching

Tone inhibition casting Splintage e.g. AFO Myo-neural block Surgery

Restore muscle balance

Weaken overactive muscle e.g. tendon lengthening, muscle slide, myo-neural block Strengthen weak muscle e.g. plication of over-lengthened muscle tendon unit or tendon transfer Improve mechanic of weak muscle by restoring the normal lever arm e.g. De-rotation osteotomy of the tibia or femur if there is a torsional abnormality

Release contractures

Tendon lengthening Aponeurotic release Muscle slide Bone shortening

General principles of decision-making

 

 

Select the simplest and least invasive option and then proceed to more complex and invasive options only if the simpler options fail. Procedures that have the least chance of overcorrection and potential complications should be preferred

JUVENILE IDIOPATHIC ARTHRITIS Dr Nuthan Kamath Prof of Paediatics, KMC, Mangalore

 

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children and is a group of diseases characterized by chronic synovitis with number of extra articular manifestations. JIA is defined as arthritis involving at least one joint that begins before the age of 16 years, persists for more than six weeks and other known causes have been excluded. Many children with JIA have active disease that can persist into adulthood and may result in short or long term morbidity. Since JIA can mimic other causes of arthritis in children, the treating physician should be cautious in the diagnosis of this condition. Classification The different classification criteria are juvenile rheumatoid arthritis (JRA) proposed by American College of Rheumatology (ACR); developed by European League Against Rheumatism (EULAR) and new term juvenile idiopathic arthritis (JIA) by International League of Association of Rheumatologists (ILAR) (Table 1). The JIA classification criteria was described first time in 1995, later revised at Durban in 1997 and again in 2007 at Edmonton. The details of ILAR classification is given in (Table 2). Epidemiology The incidence and overall prevalence vary among ethnic and geographically different population. The overall prevalence of JIA is estimated to be from 0.07 to 4.1 per 1000 children, with an incidence of 0.008- 0.226 cases of JIA /1000 children. Table 1 ACR Juvenile Rheumatoid Arthritis JRA

EULAR Juvenile chronic arthritis JCA

ILAR Juvenile idiopathic arthritis(JIA)

Duration of disease 6 weeks or longer Systemic : characteristic fever with arthritis Polyarthritis : 5 and above joints

Duration of disease 3 months or longer Systemic : characteristic fever with arthritis Polyarticular : 5 and above joints – RF negative Juvenile Rheumatoid Arthritis : 5 and above joints – RF positive

Duration of disease 6 weeks or longer Systemic Polyarthritis-RF negative Polyarthritis-RF positive

 

 

Oligoarthritis : 4 and less joints

Pauciarticular: 4 and less joints Juvenile psoriatic arthritis Juvenile ankylosing spondylitis.

Oligoarthritis Persistent Extended Psoriatic arthritis Enthesitis related arthritis Undifferentiated arthritis

Pathogenesis The pathogenesis of JIA is not fully understood. There are evidences to show that JIA is an auto immune disease. The Human Leucocyte Antigen (HLA) class-1, HLA-B27 is associated with enthesitis related arthritis and HLA class-II, DR1 and DR4 are seen in polyarticular RF positive type. Abnormal autoimmune activity is present in JIA. Tumor Necrosis Factor Alpha (TNF Alpha) plays a significant role in polyarticular type and Interleukin-6 (IL-6) level is increased in systemic type. There are studies to support that JIA is an antigen driven T cell mediated disease. Theories show that immune complex activate inflammatory cascade in JIA. The immune-pathogenesis of JIA is complex and multifactorial involving T and B cells. Clinical features JIA is classified into eight categories based on clinical and investigational evidence in the first six months of the disease. These types differ in their clinical presentation, outcome and immunogenic background, supporting the concept that JIA is a heterogenous group of arthritides with different pathogenic mechanismsa Table 2. Categories Systemic onset

Definitions Arthritis in one or more joints with or precede by fever of at least two weeks duration that is documented to be daily (quotidian) for at least 3 days and accompanied by one or more of the

Exclusions A,B,C,D

 

 

Oligoarthritis Polyarthritis (RF Negative) Polyarthritis (RF Positive) Psoriatic arthritis Enthesitis related arthritis (ERA) Undifferentiated

following : Evanescent (non fixed) erythematous rash Generalized lymph node enlargement Hepatomegaly and/or splenomegaly Serositis Arthritis affecting 1 to 4 joints during the first 6 months of disease. Two subcategories are recognized: 1. Persistent oligoarthritis: affecting not more than 4 joints throughout the disease course. 2. Extended oligoarthritis affecting a total of more than 4 joints after the first 6 months of disease. Arthritis affecting 5 or more joints, during the first 6 months of disease; a test for RF is negative. Arthritis affecting 5 or more joints, during the first 6 months of disease; two or more tests for RF at least three months apart, during the first 6 months of disease is positive. Arthritis and psoriasis or arthritis and at least two of the following: 1. Dactylitis 2. Nail pitting or onycholysis 3. Psoriasis in a first degree relative Arthritis and enthesitis , or arthritis or enthesitis with at least 2 of the following: 1. Presence of or a history of sacroiliac joint tenderness and/or inflammatory lumbosacral pain

A,B,C,D,E A,B,C,D,E A,B,C,E B,C,D,E A,D,E

 

 

arthritis 2. Presence of HLA-B27 antigen 3. Onset of arthritis in a male over 6years of age. 4. Acute (symptomatic) anterior uveitis 5. History of ankylosing spondylitis , enthesitis Realted arthritis, sacroilitis with inflammatory bowel disease, Reiter’s syndrome or acute anterior uveitis in a first degree relative. Arthritis that fulfils criteria in no category or in two or more of the above categories.

Exclusions Psoriasis or history of psoriasis in the patient of first degree relative. Arthritis in a HLA-B27 positive male beginning after the sixth birthday Ankylosing spondylitis, sacroilitis with inflammatory bowel disease, Reiter’s syndrome, Acute anterior uveitis or a history of one of those disorders in a first degree relative Presence of IgM rheumatoid factor on two occasions at least three months apart. Presence of systemic JIA in the patient. Details Quotidian fever is defined as a fever that rises to 39°C once a day and returns to 37 °C between fever peaks. Serositis denotes pericarditis or pleuritis or peritonitis Dactylitis is swelling of digits, which extends beyond the joint margin. Enthesitis is defined as inflammation at the site of insertion of a tendon, ligament, joint capsule or fascia to bone Inflammatory lumbosacral pain refers to lumbosacral pain at rest and morning stiffness that improves on movement.

 

 

Systemic onset JIA (SoJIA) This type of onset is also known as Still’s disease, who made earliest formal description of Juvenile Arthritis in 1897. SoJIA constitute 10-20% of all JIA but highest morbidity occurs in this type. There is equal sex incidence and can occur at any age during childhood. The characteristic of fever will be one or two spikes a day in the evening or early morning lasting for a few hours, comes back to normal and subsides on its own whether treatment is given or not. During the peak of fever evanescing maculopapular rash occurs predominantly in the covered portion of the body. The other manifestations are lymphadenopathy, hepatosplenomegaly, pericarditis and rarely myocarditis . The clinical course is variable . Systemic features like fever may precede arthritis by weeks or months. In 50% of cases, the extra articular features subside during initial years of the disease. The polyarticular course of the disease involving larger and smaller joints will be progressive in nature. Many patients who have persistent active disease develop cervical spine involvement that will lead on to ankylosis. Because of the prolonged disease activity, physical inactivity and glucocorticoid treatment severe osteoporosis can occur that can lead on to fractures. To prevent this complication adequate prophylaxis and treatment with calcium, vitamin D and bisphosphonates is required. Due to this same reasons growth abnormalities can occur. Rarely secondary amyloidosis may occur due to persisting disease activity for many years. Macrophage activation syndrome ( Hemophagocytosis) is a rare life threatening complication of SoJIA. There will aggressive proliferation of macrophages and histiocytes which phagocytose other blood cells. The irregular fever in SoJIA will become continuous along with hepatosplenomegaly, lymphadenopathy, coagulapathy with hemorrhagic manifestations and neurologic symptoms. The laboratory abnormalities include abnormal liver function, pancytopenia, hypofibrinogenemia, normal ESR, increased triglyceride and ferritin levels. Hemophagopcytosis by macrophages will be seen in bone marrow aspiration study. The treatment includes steroids and cyclosporine. Oligoarthritis JIA In this type, girls are more commonly affected and it usually occurs under the age of 6 years. It involves mainly knees, ankles and joints will be swollen but pain may not be severe. A limp may be the only sign of the disease. ANA positivity can occur in this type with the risk of developing

 

 

asymptomatic chronic anterior uveitis (inflammation of iris and ciliary body). If early diagnosis has not been made it can lead on to complications like cataract, glaucoma, posterior synechiae, band keratopathy and loss of vision and so it requires glucocorticoid and mydriatrics eye drops, systemic steroids or subtenon injection, (injection through the tenon, the thin membrane which envelopes the eyeball from the optic nerve to the limbus) immunosuppressives and sometimes biological agents. The subtype extended oligo arthritis will behave like polyarthritis type and can lead on to erosions and deformities. Polyarthritis JIA Rheumatoid factor positive type usually affects girls in late childhood. Because of the development of severe arthritis with bony erosion and extraarticular manifestation including rheumatoid nodules, it is called adult type of JIA. The manifestations will be symmetrical polyarthritis involving larger and smaller joints including metacarpophalangeal, interphalangeal, temporomandibular joints and cervical spine. Rheumatoid factor negative type occurs throughout childhood and the disease severity will be less than the RF positive variant. ANA positivity can be associated with chronic anterior uveitis. Enthesitis related arthritis This type is characterized by enthesitis at the site of insertion of tendo achilles, plantar fascia and also in tarsal area. Asymmetrical arthritis predominantly affecting the lower limbs. Hip joint involvement is not uncommon and erosion at the site of enthesitis can be found. Eye involvement as symptomatic recurrent acute anterior uveitis is a frequent extra articular manifestation. Boys above the age of 6 years are affected and are often HLA B27 positive. Many children in this type may develop sacroiliac and spinal joint involvement. Ultimately some develop one of the spondyloarthropathies like Juvenile onset ankylosing spondylitis and undifferentiated spondyloarthropathy. Psoriatic arthritis PsA is rare in children. Arthritis can precede skin lesions by many years. Apart from oligoarticular and polyarticular manifestations, axial joint

 

 

involvement can occur. The arthritis can be chronic and destructive, requiring immunosuppressive treatment used for children who have polyarthritis JIA. Differential diagnosis A detailed history and clinical examination with laboratory support will be useful, not only in making the diagnosis of JIA but also to find out the type of onset. The differential diagnosis is given in (Table-3) Since 15% of leukemic (usually acute lymphoblastic leukemia) patients can present initially with musculoskeletal manifestations, it has become an important differential diagnosis for SoJIA and the features are as follows . 1) Fever may not be quotidian but can be continuous 2) Pain in the joint is not proportionate to the degree of involvement 3) Night pain and bone pain can be predominant 4) Anemia will be disproportionate to the duration of the disease 5) Elevated lactate dehydrogenase level 6) Leucopenia and thrombocytosis in contrast to polymorpho leucocytosis and thrombocytosis in SoJIA. Table-3 Systemic onset JIA Oligoarthritis JIA Polyarthritis JIA Rheumatic fever Leukemia Systemic lupus erythematosus Juvenile dermatomyositis Vasculitis Infective endocarditis

Septic arthritis Reactive arthritis Hemophilia Tuberculosis Villonodular synovitis

SLE Dermatomyositis Spondyloarthropathies Serum sickness Leukemia Immune deficient states

Investigations

 

 

Laboratory tests should not be solely relied upon to make the diagnosis of JIA. Children with JIA usually have normochromic normocytic anemia, polymorphonuclear leucocytosis, thrombocytosis and elevation of erythrocyte sedimentation rate and C-reactive protein. RF will be positive in less number of patients with JIA (polyarticular RF positive). Anti Cyclic Citrullinated peptide (Anti CCP) is positive mostly in patients with RF positivity. ANA can be positive mostly in oligoarticular type and less frequently in polyarticular type. HLA-B27 can be positive in Enthesitis Related Arthritis (ERA). False positive Anti Streptolysin-O, can occur due to inflammation and polyclonal B cell activation-anamnestic reaction. X-rays show soft tissue swelling, subchondral osteoporosis, periosteal elevation and rarely bone erosion. Cervical spine x-ray is useful in diagnosing fusion and atlanto axial subluxation. Ultrasound with high power Doppler and Magnetic Resonance Imaging are useful in the early detection of synovitis and erosion. Treatment Being a chronic disease that can cause significant morbidity, JIA requires an early and aggressive treatment. For good results a multidisciplinary approach is necessary with Rheumatologist, physiotherapist, occupational therapist, orthopedic surgeon, paediatrician, psychologist and social worker. Non Steroidal anti inflammatory drugs NSAIDs are the first line of treatment for symptomatic relief from joint symptoms and fever but it will not change the course of the disease. Commonly used NSAIDs are given in Table 4. Table-4

DRUG DOSE

 

 

Ibuprofen Naproxen Indomethacin Diclofenac Meloxicam Celecoxib Etodolac (after 6 years)

35-40 mg/kg/day TID 15-20 mg/kg/day BD 1-3 mg/kg/day TID 2-3 mg/kg/day TID 0.25 mg/kg/day OD 6-12 mg/kg/day BD 20 mg/kg/day OD

To decide about the efficacy of particular NSAID, it should have been tried at least for two weeks. The side effects are many which includes gastritis, gastric ulcer, liver enzyme elevation and central nervous system symptoms like head ache, mood changes and tinnitus. Pseudoporphyria is a rare side effect of commonly used Naproxen characterized by a blister formation, healing with hypopigmentation in sun exposed areas in fair skinned children. Glucocorticoids Glucocorticoids play an important role in the management of JIA. Oral prednisolone (0.5 to 1mg/kg/day in tapering dose) is used in systemic type as a bridge therapy i.e. till disease modifying anti rheumatic drugs (DMARDs) start acting. A course of low dose prednisolone could be considered for reduction of pain and stiffness in children with severe polyarthritis. The severe manifestations like pericarditis and myocarditis require intravenous pulse therapy with methylprednisolone (30mg/kg/day for three days). Intra articular (IA) steroid injections with Triamcinolone Hexacetonide (0.5mg/kg/joint) are frequently needed especially in oligoarticular type. Moreover children with pauci articular JRA who received IA steroids within first 2 months of diagnosis demonstrated no leg length discrepancy as compared to a group of children who had been treated primarily with NSAIDs for several years. Apart from the known common side effects of steroids growth arrest or retardation should not be forgotten.

 

 

Disease modifying anti rheumatic agent Methotrexate is the commonly used DMARD in JIA. This can be given orally, subcutaneously or intra muscularly. This drug starts acting after eight to twelve weeks. It is safe, effective and well tolerated in patients with JIA. Folic acid is administered to reduce the frequency and severity of side effects. Liver function tests and blood counts should be done every three months to monitor the side effects. Tapering the dose of methotrexate can be attempted twelve months after complete remission. Sulfasalazine is primarily used in ERA and also in combination with methotrexate in polyarthritis. It is better to avoid in SoJIA when systemic manifestations are present. Blood counts and liver function tests should be done periodically. Hydroxychloroquinee(HCQ) is usually given in combination with Methotrexate but ophthalmic examination should be done every six months. Leflunomide, Cyclosporine and Thalidomide are rarely used. The doses and side effects of DMARDs are given in Table 5. Table-5 DRUG DOSE SIDE EFFECTS Methotrexate Sulfasalazine Hydroxychloroquine Cyclosporine Leflunomide

0.5-1 mg/kg/once a week 12.5-50 mg/kg/day BD 6 mg/kg/day 3-5 m/day BD 3-10 mg/day

Mucosal ulceration, nausea, vomiting, loss of appetite, hepato toxicity, bone marrow toxicity Rash, gastrointestinal toxicity, bone marrow toxicity Nausea, vomiting, ocular toxicity Hypertension, renal toxicity, hypertrichosis Teratogenicity, hepatotoxicity, mucosal ulceration, diarrhea

Biological agents These drugs are usually used when non-biological DMARDs do not give good results. Tumor necrosis factor alpha inhibitors are commonly used biological agents. Screening for tuberculosis with Mantoux and x-ray chest should be done before the initiation of therapy with biological agents and steroids as it can cause reactivation of the disease. Patients should be monitored for other infections also.

 

 

Etanercept is the more commonly used TNF alpha inhibitor in JIA. It is a chimeric molecule of a soluble TNF receptor coupled to Fc fragment of IgG1. This binds to the circulating TNF alpha, which is a major cytokine in causing inflammatory synovitis and reduce the quantity of TNF alpha. The dose of Etanercept is 0.4mg/kg (Maximum 25mg), to be given as subcutaneous injection 2 times a week. The common side effects are local injection site reaction, fever and rash. Infliximab is a chimeric human/mouse IgG1 Anti TNF alpha antibody. It binds both soluble and membrane bound TNF alpha. It is administered by intravenous infusion 0,2,6 and thereafter every 8 weeks. The dose is 3 – 5 mg/kg. Adalimumab is a recombinant fully humanized monoclonal antibody that binds to TNF alpha. It is administered by subcutaneous injection on a weekly to alternate week schedule. Anakinra is a recombinant IL-1 receptor antagonist and it is given daily by subcutaneous injection in a dose of 0.1mg/kg/day. In SoJIA administration of Anakinra was associated with marked improvement. Tocilizumab (TCZ) is a humanized monoclonal IL-6 receptor antibody which is a useful drug in SoJIA given at a dose of 8mg/kg every 2 weeks for 3 months. The side effects are infections and mild liver enzyme elevation. Abatacept is a fusion protein linking the extracellular domain of human cytotoxic T-lymphocyte associated antigen-4(CTLA-4) to the Fc portion of human IgG1. It acts by competing for the binding of CD28 on T cell and CD80/86 on the antigen presenting cell. This costimulatory signal, which is necessary for T cell activation is blocked. This is the recently approved biological agent for JIA. Abatacept has been studied in children with polyarticular JIA including those who have failed other biological therapies, showed good improvement. Rituximab is an anti CD20 monoclonal antibody that causes B cell depletion. Other therapy Autologous stem cell transplantation has been tried in SoJIA who have been resistant to treatment. This procedure is associated with significant morbidity and mortality. Physical therapy Physiotherapy and occupational therapy are important components in the management of JIA. They are helpful to maintain the strength of the muscles and the mobility of the joints. Depending upon the joints

 

 

involved, severity of arthritis and degree of deformity, mobilization and strengthening exercises should be given. Different kinds of splints may be used for the prevention and correction of deformities. Swimming and cycling, which do not put weight on joints should be encouraged. Pyschosocial development Psychological assessment can be done periodically by counselor or psychologist. The children with JIA should be encouraged to attend school regularly and participate in recreational activities in whatever possible way. Surgery Surgery should be considered in children with JIA whose cartilage is destroyed. Total joint replacements are being performed with great success for young people who have JIA. The longevity of the replaced joint must be considered when planning on such surgery. Outcome Severe arthritis at the onset of the disease, persistently active disease, early development of bony erosion, early involvement of hip joint are markers for poor prognosis. Even though there is no cure in spite of advances in therapy like methotrexate and biological agents, long remission of the disease activity can be achieved. The prognosis of polyarticular and systemic onset types is unpredictable. Bony erosions and deformities can occur in polyarticular rheumatoid factor positive type. Asymptomatic uveitis in oligoarticular type can produce long term morbidity. Further Reading 1. Ravelli A, Martini A. Juvenile idiopathic arthritis. The Lancet 2007; 369 : 767-779. 2. Cassidy JT, Petty RE, Southwood TR. Chronic arthritis in childhood.In: Textbook of Pediatric Rheumatology,5th Edn, Cassidy JT, Petty RE Eds, Elsevier Saunders, Philadelphia 2005; pp206-260. 3. Cassidy JT, Levinson JE, Bass JC, Baum J, Brewer EJ Jr, Fink CW, et al. A study of classification criteria for a diagnosis of juvenile rheumatoid arthritis. Arthritis Rheum 1986; 29 : 274-281. 4. Wood PH. Nomenclature and classification of arthritis in children. In: Munthe E Ed, The care of rheumatic children. Bassel: European League against Rheumatism 1978; pp 47-50.

 

 

5. Fink CW. Proposal for the development of classification criteria for idiopathic arthritides of childhood. J Rheumatol 1995;22:1566-1569. 6.Petty RE, Southwood TR, Baum J, Bhettay E, Glass DN, Manners P, et al. Revision of the proposed criteria juvenile idiopathic arthritis: Durban 1997. J Rheumatol 1998; 25: 1991-1994. 7. Petty RE, Southwood TR, Manners P, Baum J, Glass DN, Goldenberg J, et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol 2004; 31:390-392. 8.Yakota S, Imagava T, Mori M, Miyamae T, Aihara Y, Takei S, et al. A multicentre randomized double blind, placebo controlled study of tocilizimumab, an anti il-6 monoclonal antibody, in children with systemic juvenile idiopathic arthritis. Ann Rheum Dis 2006; 65(suppl.11):59-60. 10.Ravelli A, Martini A. Early predictors of outcome in juvenile idiopathic arthritis. Clin exp Rheumatol2003;21(sup31):S89-S93

 

 

HYPERPARATHYROIDISM. DR. SHRIDHAR SHETTY AJIMS, MANGALORE.

 

PARATHYROID GLANDS: ---Ivar Sandstrom, Sweedish medical student discovered parathyroid glands in 1880.They are ductless endocrine glands. Anatomy.-They are small yellowish brown, ovoid bodies, lie on the posterior border of Thyroid gland. Size: 6mm in length, 3-4 mm width, &1-2 mm thick. Each weighs about 50 mg.Are four in number, two superior and two inferior. Superior is more constant in position behind thyroid glands. Inferior parathyroids are variable in position. Superiorly may be upto bifurcation of carotids and below up to mediastinum.Sometimes parathyroid may be 3 in number or may lie as scattered tissues. Embryology: Development from the entoderm of the pharyngeal pouches. Totally there are 5 pouches. Inferior develops from the third and so it is called parathyroid three. Superior develops from 4th pouch and so called as parathyroid fourth. FUNCTOINAL ANATOMY & PHYSIOLOGY: Parathyroid chief cells have calcium-sensory receptors on their surface. These cells directly respond to changes in the calcium concentrations via these receptors. Paratharmone (PTH) is secreted in response to low serum level of calcium. PTH has two effects-----DIRECT-1) promotes reabsorption of calcium from renal tubules. 2) Promotes reabsorption of calcium from bone. 3) Promotes excretion of phosphates INDIRECT EFFECT: Increses the renal conversion of 25-Dihydroxycholecalciferol to the more potent 1-25-Dihydroxy cholecalciferol. This results in more absorption of calcium from food. 99% of total body calcium is in the bone.PTH plays a central role in regulating calcium homeostasis. INITIAL EFFECT of PTH is------To stimulate osteolysis –returning calcium from bone to the extracellular fluid. PROLONGED EFFECT OF PTH --- is associated with increased ostioclastic activity, extreme bone remodelling & osteoblastic repair. CALCIUM IN SERUM:-exists 50% as ionised form Ca2+, ----10% as non ionised or complexed with organic ions like citrates & phosphates.—40% as protein bound(albumin) .Ionised calcium regulates pth production.

 

 

CLASSIFICATION OF DISEASES OF PARATHYROID GLANDS-mainly into-1) primary,2) secondary. 1)-primary with excess secretion—eg; adenomas, hyperplasias (primary hyperparathyroidism.), tertiary hyperparathyroidism. 2)-primary due to hormone deficiency-post surgical, autoimmune, autosomal dominant hyperparathyroidism. 3)-hormone resistance---pseudo-hypoparathyroidism., familialhypocalciurichypercalcemia. 4)-non functioning tissue----parathyroid carcinomas. CAUSES OF HYPER CALCEMIA:1)with normal or elevated pth------1)PRIMARY OR TERTIARY HYPERPARATHYROIDISM.2)FAMILIAL HYPOCALCIURIC HYPERCALCEMIA. 2) With low PTH levels----1) MALIGNANCY---- (ca breast, renal, ovarian, colonic, thyroid, lymphoma, multiple myeloma) 2) Thyrotoxicosis. 3)-Paget’s disease with immobilisation. 3) SARCOIDOSIS. CLINICAL FEATURES OF HYPERPARATHYROIDISM. (PRIMARY) Prevalence—1:800. More in females (3:1) --------90%-above 50 years.. May be associated with multiple endocrine neoplasia (MEN)—AUTOSOMAL DOMINANT GENETIC DISORDER—ASSOCIATED WITH PITUITARY TUMORS, PANCREATIC TUMORS, PHEOCROMACYTOMAS. 50% MAY BE ASYMPTOMATIC. Polyuria, polydipsia renal colic, lethargy, nausea, peptic ulceration, depression, drowsiness impaired cognition. BONES, STONES ABDOMINAL GROANS &MOANS---terms used to describe the disease. INVESTIGATIONS: Low plasma phosphate, increased alkaline phosphate &hypocalcaemia------hyperparathyroidism. Increased plasma phosphate, increased alkaline phosphates with renal impairment diagnosis of tertiary hyperparathyroidism. Other inv-x-ray., isotope `study, myeloma profile, serum angiotensin converting enzyme( elevated in SARCOIDOSIS.) SKELETAL&RADIOLOGICAL CHANGES; OSTEITIS FIBROSA: Results from increased bone resorption by osteoclasts with fibroblast replacement in the lacunae. causes bone pain, tenderness, fractures, deformity. CHONDROCALCINOSIS:--Due to deposition of calcium pyrophosphate crystals within the articular cartilage. .This mainly affects menisci in the

 

 

knee and leads to secondary degenerative arthritis or attacks of acute pseudo gout. BROWN TUMORS: haemorrhage &giant cell reaction within the fibrous stroma may give rise to brownish tumour like masses &liquefaction leads to fluid filled cysts. PLAIN X-RAYS:1) In early stages—demineralisation with subperiosteal erosion &terminal resorption in the phalanges. Best seen in the radial border of middle phalanges of second &third fingers. 2) A “pepper-pot” appearance in lateral x-ray of skull. 3) Nephrocalcinosis-scattered opacities are visible within the renal outline. 4)-Mandible-Dental pulp white line (lamina Dura) absent. 5)-there may be soft tissue calcification in arterial walls, soft tissues of the hands and the cornea BONE MINERAL DENSITY REDUCTION is now the most common skeletal manifestation of hyperparathyroidism and requires DEXA SCANNING for this purpose. Treatment.GLUCOCORTICOIDS & biphosphonates help in reducing calcium level-Urgent neck surgery is rarely indicated. Fluid deficit correction & serum calcium level correction should be done before anaesthesia. SURGERY; Debulking of tumours done in patients less than 50 years of age. Some surgeons transfer part of the hyperplasic gland to the forearm & debulk it at a later date. First two weeks hypocalcaemia persists. After that residual parathyroid tissue recovers. During this period, brisk new bone formation occurs. This is called HUNGRY BONE SYNDROME. This stage is treated with one of the vitamin D metabolites.

Posterior cruciate ligament and posterolateral corner injury. Dr Vivek Trauma, arthroscopy and joint replacement unit Orthopaedics, Kasturba Medical College Manipal,Karnataka ,India-57610

 

Posterior cruciate ligament (PCL) is an extra synovial but intraarticular ligament of the knee. It is an important stabilizer of the knee. It is the primary restraint for posterior translation of tibia over femur. It is a guide for screw home mechanism. Isolated sectioning of PCL leads to increased posterior translation of tibia especially in increasing flexion of the knee. Sectioning of PCL leads to increased forces in patellofemoral and medial compartment of knee. Anatomically, PCL has two bundles named; anterolateral (ALB) and posteromedial (PMB). ALB is tight in flexion and PMB is tight in extension. Posterior cruciate ligament (PCL) injury is uncommon in isolation but frequent in combination with collateral or anterior cruciate ligament injury. Road traffic accident remains most common cause for PCL injury in our country. It is also seen in contact sports. Mechanism of injury is direct blow over tibia and hyperflexion injury. Isolated injury of PCL is often missed. Acute clinical features include mild swelling and difficulty to walk. There is often an abrasion or contusion over anterior aspect of tibia indicating direct blow to the tibia. Clinical examination reveals positive patellar tap, posterior sag, posterior drawer and reverse Lachman positive. Plain radiographs of knee are generally normal except if there is avulsion of PCL from tibia. Magnetic resonance imaging is quite useful in acute injury to PCL. T2 sequences can reveal injury to PCL. Associated injury to meniscus, cartilage and collateral is also ruled out. Acute PCL tear (mid substance) can be managed conservatively. Patient is kept on PCL brace for three weeks with non-weight bearing. He is advised quadriceps strengthening exercises. After three weeks, he is advised gradual mobilisation with brace on. Weight bearing is permitted gradually. PCL rehabilitation is further recommended. Isolated PCL tears may heal completely or in elongation. Bony avulsion of PCL should be fixed by open arthrotomy or arthroscopic method. Isolated chronic PCL tear can remain asymptomatic for long. Patient can also present as instability while ascending or descending stairs. They also complain of instability while lifting weight in flexed knee position. In late cases, they may also complain of pain while climbing stairs and on walking. On examination, there will be gross quadriceps wasting,

 

 

posterior sag, and posterior drawer positive. Quadriceps active test may be positive. Posterior drawer test should be graded as it helps in deciding the management. Medial joint line may be tender indicating medial compartment osteoarthritis (OA) and patellofemoral joint may be arthritic. Plain x-ray may reveal medial compartment and patellofemoral OA. In chronic cases, bone scan is a useful investigation. If there is increased uptake in medial compartment of the knee, PCL reconstruction is warranted. MRI may reveal a discontinuous PCL. Sometimes it shows elongated but continuous PCL. It gives an impression as if PCL has healed. But this healed PCL may not be of functional value. In such a dilemma, stress x-ray is a useful investigation to differentiate between a functional and non-functional PCL. If there is more than 10 mm of posterior displacement of tibia, it indicates that elongated healed PCL is no functional value and it may need PCL reconstruction. Stress x-ray is also useful when there is combination of ACL and posterior cruciate ligament injury where one is not able to differentiate between anterior drawer and posterior drawer. Management of chronic isolated PCL tear is a challenge. Chronic isolated grade 1 and 2 PCL tear should be managed conservatively by rehabilitation exercises. Patients with symptomatic grade 3 PCL tear with or without early medial compartment OA or patellofemoral OA should undergo PCL reconstruction. Asymptomatic Isolated grade 3 PCL tear should be kept under close follow up and patient should be observed for future patellofemoral OA or medial compartment OA. In case such changes are detected in future, patient should undergo PCL reconstruction. Elderly patients with PCL tear should be managed conservatively even if there is OA. If OA is very significant, joint replacement is a better option rather than PCL reconstruction. Posterolateral corner (PLC) injuries have been neglected for long because of poor understanding of anatomy and biomechanics. Recognition of PLC injury is of vital importance as neglected PLC injury can lead to failure of reconstructed ACL or PCL. Isolated injuries of PLC are rare and usually occur in combination with cruciate ligament injury. Lateral collateral ligament, popliteus and arcuate complex form integral component of PLC. Sectioning of LCL & popliteus leads to increased varus movements and external rotation respectively. PLC injuries happen due to anteromedial forces over tibia forcing tibia to go for varus and posterior subluxation.

 

 

Isolated PLC injuries may present with swelling and pain over lateral aspect of the knee with ecchymoses. Chronic grade 3 PLC injuries may present with varus thrust gait and recurvatum on standing. On examination; varus stress test, external rotation recurvatum, dial test and external rotation posterior drawer will be positive. Imaging of PLC comprises of plain x-ray and MRI. MRI may reveal injury to LCL & popliteus tendon. Grade 1 and 2 PLC injury is managed conservatively in an extension brace. Later knee is mobilized in hinged brace with gradual weight bearing and patient is kept on rehabilitation exercises. Grade 3 PLC injury should be managed surgically. Acute grade 3 PLC injury should be surgically repaired within a week. Augmentation can be done using autograft/allograft. Chronic PLC injury without varus thrust should be reconstructed. If there is varus thrust, high tibial osteotomy should be performed to correct the mal-alignment. It may be coupled with PLC reconstruction.

POTT’S DISEASE OF SPINE    Dr. S.P. Mohanty    Profesor  Spine Services Unit Kasturba Hospital, Manipal

 

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, that continuous to be a major cause of morbidity and mortality. Left untreated, a single person with active tuberculosis can infect 10-15 other each year. India is the highest tuberculosis burden country globally, accounting for one fifth of the global tuberculosis incidence. Global annual incidence estimate is 9.4 million cases out of which 1.98 million cases are from India. Each year 1.8 million people develop the disease of which 80,000 of infectious and up to 3.7 lacks die. It implies that for every 3 minutes, 2 persons die in our country. The tuberculosis situation in our country is further threatened by the emergence and spread of HIV and multi drug – resistant tuberculosis (MDR-TB). Spinal tuberculosis is the commonest form of skeletal tuberculosis and constitutes 50% of all case of osteoarticular tuberculosis. The incidence of paraplegia among patients with spinal tuberculosis has been reported between 10-30%. Spinal tuberculosis is always secondary to established forms of tuberculosis infection elsewhere in the body. The primary focus may be in the lungs, lymph nodes and abdomino- pelvic viscera. From the primary focus the infection is postulated to reach on the vertebral column through vascular channels either arterial or via the Batson’s venous plexus. The exact mode of spread is uncertain. Tuberculosis lesion more frequently occurs in the thoracic and thoraco lumbar region. The type of tuberculosis lesion can be paradiscal, central, anterior, posterior – appendicial and atlanto axial out of which paradiscal type is the most common type. Classically the lesion is thought to begin in the anteroinferior portion of the vertebral body. The high flow of equatorial circulation in the metaphysical region provides sufficient oxygen concentrations for the aerophilic mycobacteria to survive. Paradiscal, central and anterior lesions are postulated to occur via the arterial route where as the appendicial lesions and skip lesions occur by the venous route. When more than two contiguous vertebras are involved they are termed in “Multiple lesions” whereas when one or more normal vertebra present between two lesions they are termed as “skip lesions”. Four to 10% lesions are skip lesions and multiple lesions occur in 18% of cases. Kumar KA (1988) explained pathogenesis of spinal tuberculosis in 5 stages:

 

 

1) stage of implantation 2) stage of early destruction 3) stage of advanced destruction and collapse 4) stage of neurological involvement and 5) stage of residual deformity and aftermath. Pain and tenderness in the back are the most common clinical presentations. Patient may or may not have fever and constitutional symptoms. Systemic examination may reveal other focus of infection and cold abscess. The deformity of the back may accompany neurological deficit. The neurological deficit is generally classified into 4 grades. Grade I (negligible), Grade II (Mild), Grade III (moderate) and Grade IV (severe). The incidence of paraplegia has been reported as between 10-30%. Early diagnosis and treatment of spinal tuberculosis is essential to prevent complications like neurological deficits. The gold standard for diagnosis should ideally be isolation and culture of tuberculous bacilli. However culture methods are slow and insensitive especially in cases of paucibacillary skeletal lesions. The shortcomings of these methods led to search for more sensitive and rapid detection methods. There are two basic approaches for the diagnosis of tuberculosis. The direct approach involves detection of mycobacterium and its products and the indirect approach involves the measurement of humeral and cellular responses of the host against tuberculosis. Polymerase chain reaction (PCR) is a comparatively simple technique and is widely used now. The high sensitivity of the PCR has been widely acknowledged but the specifity of the test is poor. In view of this it has been recommended that the decision to initiate or to stop antitubercular treatment should not be based on the results of the PCR. Sero diagnosis (IgG and IgM) is useful in cases of extra pulmonary tuberculosis viz., bone. It has been noted that it’s not reliable in paediatric cases and with HIV coinfection. The clinical and plain radiological features remain the mainstay in the diagnosis of spinal tuberculosis. However, it has to be noted that spinal tuberculosis can missed, mistaken or misdiagnosed. In the recent past computerized axial tomography, magnetic resonance imaging and isotope bone scan have shown definitive advantages over conventional radiography. CT and MRI help in pre operative planning as they show the extent of bone destruction and precise degree and level of

 

 

cord compression responsible for neurological deficits. Multifocal involvement can also be detected easily by bone scan. Evolution of treatment of spinal tuberculosis. The choice of treatment of spinal tuberculosis has always been controversial. The evolution of treatment of Pott’s disease has occurred in the following phases. Pre- chemotherapy era. Era of inactivity Era of controversial surgeries Post chemotherapy Era. Era of limited surgeries (Drainage of cold abscess) Era of radical surgeries Current trends (Era of instrumentation ) Management of Pott’s disease in the pre chemotherapy era mainly consisted of the concept laid down by Sir Hugh Owen Thomas: “Rest total, complete and uninterrupted”. Based on this concept Sir Robert Jones and Dame Agnes Hunt placed the benefit of country hospitals and opened sanatoria for these patients. Disappointing results with conservative management led to the development of surgical procedures like costo-transversectomy, laminectomy, laminotomy and other methods. However, in the prechemotherapeutic era, those produced devastating with a high incidence of sinus formation and mortality. Schatz, Bugie and Waksman discovered streptomycin in 1944 which turned out to be the most important milestone in the treatment of tuberculosis. After the advent of the other anti tubercular drugs viz., Pyrazinamide – 1949, Isoniazid – 1951, Rifampicin – 1957 and Ethambutol - 1961 ,the prognosis of spinal tuberculosis improved dramatically and now it is considered to be curable. With introduction of effective chemotherapy all other methods of treatment are regarded as supplementary. However, no drug used in the management of spinal tuberculosis can solve the problem arising from bone destruction viz., persisting and / or residual deformity and neurological complications. Limited focal surgeries aimed at drainage of the cold abscess (costotransversectomy and lumbar transversectomy) and anterolateral decompression produced some encouraging results when combined with anti tubercular chemotherapy. With advent of antitubercular drugs, better and safe more radical surgeries could be carried out. Aggressive debridement combined with bone grafting was advocated. Hodgson et al

 

 

developed the “radical excision” of diseased vertebral bodies and their replacement by bone grafts in all cases of spinal tuberculosis. Conventionally the indications of surgery in spinal tuberculosis can be divided in to three categories viz., Absolute indications Relative indications Rare indications However, Tuli et al advocated the concept of a “middle path regimen” in which the patients are mostly treated on non operative lines with anti tubercular chemotherapy, rest and braces. The indications for surgery according to this regimen are No neurological recovery after the start of chemotherapy (minimum 4 weeks) Development of neurological deficit during course of Chemotherpy. Recurrence of neurological deficit after initial improvement. Worsening of neurological deficit while on chemotherapy. Advanced cases of neurological involvement. Current trends in the management of spinal tuberculosis: Early diagnosis and initiating optimal treatment would not only enable cure but also prevent complications. However, emergence of multidrug resistant tuberculosis continues to be a major problem. Osteoarticular tuberculosis being paucibacillary, even a rapid culture may not yield required results. Even though classical clinical and radiological features have been described in the literature, spinal tuberculosis does mimic other lesions and can be missed, mistaken or misdiagnosed. Isotope bone scan not only helps in early detection it also identifies skip lesions. CT scan supplements the amount of bone destruction and MRI helps in preoperative planning as it shows the extent of the lesion and precise level of cord compression. However it has to be noted that it is difficult to differentiate Caries spine from other conditions viz., Multiple myeloma, Lymphoma, and secondaries. Nevertheless, patients presenting with pain, fever, raised erythrocyte sedimentation rate (ESR) and classical radiological features viz., metaphysical lesion with paravertebral shadow may be empirically treated with antitubercular drugs. However, they have to be closely observed. After Hodgson and Stocks reported in 1960, radical debridement and anterior arthrodesis have been advocated as the treatment of choice. MRC after its controlled clinical trails also

 

 

recommended that when appropriate facilities and expertise are available this surgery has definite advantage. However long term follow up of radical surgeries (anterior debridement and bone grafting, anterolateral decompression/debridement with bonegrafting) did not produce very acceptance results. Considerable loss of correction with anterior fusion has been reported by Rajasekaran et al and Bailey et al. Five to ten years follow up studies showed graft failure and recurrence of kyphosis. This probably can be described by understanding the biological and biomechanical principles of kyphosis. Rajasekaran et al derived an equation based on initial vertebral loss. However, Parthasarthy et al concluded that the angle of kyphosis at the end of 10 years cannot actually be presented based on the initial vertebral loss in most patients. But if we try to understand the biomechanics of the spine keeping in mind the three column concept of Denis, involvement of the anterior two column of the spine will lead to progression of kyphosis whereas involvement of posterior column and early involvement of the only middle column may not produce any kyphosis. The kyphotic deformity in spinal tuberculosis can be analysed from five aspects: Mechanical Infection Neurological Disturbance of growth Respiratory function Infection and kyphosis: Tuberculosis preferentially affects the anterior structures of the vertebral column. The caseation material and granulation tissue formed weaken and destroy the vertebrae. The hyperemia associated with infection causes osteoporosis leading to collapse of the vertebrae. Collapse of single vertebra or of two adjacent vertebrae produces a “KNUCKLE” deformity. Collapse of 2 to 3 vertebral bodies anteriorly produces a “GIBBUS” deformity. Involvement of more than 3 vertebrae produces a “KHYPHUS” deformity. Kyphosis is an unstable lesion and tends to progress atleast until there is bony fusion anteriorly. With progression of the kyphotic deformity the products of infection are retropulsed against the cord and produce a compression

 

 

form of paraplegia. Abalation of growth potential in the anterior column occurs as the the vertebral end plates are destroyed, however, posterior growth potential persists, this leads to further kyphosis. Therefore adults have lesser deformity at presentation and lesser increase during phase 1(Active phase) and virtually no change after disease cure. Children have a higher deformity at presentation, a greater tendency to collapse during the active phase and variable progression in phase 2 (Healed phase). With changes in posterior elements the progression in kyphosis may tend to late onset paraplegia. Anterior debridement creates a large deficit in the anterior structures and produces spinal instability. Hence the graft becomes prone to failure or resorption especially when more than two vertebrae have been excised. Therefore, after reconstruction of anterior column either by bone graft or cage following debridement supplemented with posterior instrumentation and fusion is advocated. It can be done in two stages (Moon) or in one stage (Sundaraj). Outcome of these surgeries have been quite encouraging.

 

 

Bio Degradable Implants in Orthopaedics Dr Ronald Menezes Assoc Prof, FMMC, Mangalore

 

Introduction: In modern orthopaedic implant development most of the focus has been on developing devices that are stronger, cheaper, durable and more acceptable to the body. Though metallic implants have served the purpose remarkably well, there are certain unique inherent problems with their use and this has tilted the thrust of implant development towards biodegradable materials. The common problems seen with metallic implants are: 1. Stress shielding phenomenon, pain, local irritation. 2. Risk of endogenous infection due to retained metallic implants. 3. Release of metallic ions from these implants has been documented, though the long term effects of these are not yet known. Because of these reasons, there is a need for a second surgery for implant removal once the bone has healed. In the past few decades a lot of research has been done and significant improvement has been achieved in the development of bioabsorbable osteosynthetic devices. With an array of bioabsorbable implants available in the market, one needs to know their properties, clinical situations wherein they can be used and also their limitations. Bioabsorbable Materials Polyglycolic acid (PGA) was the first totally synthetic bioabsorbable suture developed and was introduced in 1970 as Dexon. This was followed in 1975 by Vicryl, a copolymer of 92% PGA and 8% polylactic acid (PLA). Polydioxanone (PDS) was introduced in 1981 and was the first bioabsorbable material to be made into screws. Currently, PGA, PDS, polylevolactic acid (PLLA), and racemic poly (d,l-lactic acid) (PDLLA) are the primary alpha polyesters used for bioabsorbable implants. PGA is degraded by hydrolysis primarily to pyruvic acid, and is excreted as carbon dioxide and water. PDLLA is similarly hydrolyzed via the tricarboxylic acid cycle to carbon dioxide and water and excreted by respiration. PDS also is hydrolyzed, but it primarily is excreted in the urine. The biomechanical properties of these polymers also are affected by their chemical composition, manufacturing process, physical dimensions, environmental factors, and time. Biodegradable implants cannot be

 

 

contoured intraoperatively because they have a high glass transition temperature, that is, the temperature at which the compound becomes as hard as glass. The implants can be given greater tensile and flexural strength by orienting the fibers in the implant in the longitudinal axis of the implant (self-reinforcement). These absorbable polymers are subject to creep and stress relaxation. Claes showed that self-reinforced PLA (SR-PLA) and PDLLA-PLLA screws lost 20% of their compressive force within 20 minutes. Similarly, because these implants are absorbable, they lose strength relatively rapidly. SR-PGA rods are at 50% strength at 2 weeks and 13% strength at 4 weeks. The slowest degradation and loss of strength is exhibited by PLLA. Structure, strength and properties Polyglycolic acid (PGA) is a hard, tough, crystalline polymer with an average molecular weight of 20,000 to 145,000 and a melting point of 224-230°C. Polylactic acid on the other hand is a polymer with initial molecular weights of 180,000 to 530,000 and a melting point of about 174°C. In orthopaedic implants, poly-L-lactic acid (PLLA) has been used more extensively because it retains its initial strength longer than poly-D-lactic acid (PDLA). PGA belongs to the category of fast degrading polymers. Intraosseously implanted PGA screws have been shown to completely disappear within 6 months. PLLA on the other hand has a very long degradation time and has been shown to persist in tissues for as long as 5 years post implantation. For Orthopaedic usage, the main hindrance to development of bioabsorbable implants has been the question of obtaining sufficient initial strength and retaining this strength in the bone. With the use of self reinforcing (SR) technique the material was sintered together at high temperature and pressure, resulting in initial strengths 5 to 10 times higher than those implants manufactured with melt moulding technique. Though initial strengths of SR-PLLA screws are lower than SR-PGA, strength retention in the former is longer than the latter. Nowadays, bioabsorbable implants show no difference in the stiffness, linear load & failure mode when compared with metallic devices.

 

 

Degradation Crystalline polymers have a regular internal structure and because of the orderly arrangement are slow to degrade. Amorphous polymers have a random structure and are completely and more easily degraded. Semi-crystalline polymers have crystalline and amorphous (random structure) regions. Hydrolysis begins at the amorphous area leaving the more slowly degrading crystalline debris.Some earlier biodegradable implants have had problems with degradation time and tissue reactions. One commonly used material, Polyglycolide (PGA), is hydrophilic and degrades very quickly, losing virtually all strength within one month and all mass within 6-12 months. Adverse reactions can occur if the rate of degradation exceeds the limit of tissue tolerance and incidence of adverse tissue reactions to implants made of PGA have been reported from 2.0 to 46.7%. So PGA in isolation is rarely used these days in the manufacture of bioabsorbable implants. Poly L Lactic Acid (PLLA), has a much slower rate of absorption. This homopolymer of L Lactide is highly crystalline due to the ordered pattern of the polymer chains, and has been documented to take more than five years to absorb. The newer generation of implants remain predominantly amorphous after manufacturing due to controlled production processes of copolymers. D Lactide when copolymerized with L Lactide, increases the amorphous nature of these implants. This increases the bioabsorbability of these devices. The ideal material is perhaps one that has a "medium" degradation time of around 2 years, as by then the purpose of the implant has been served. Advantages 1.The biggest advantage is that since these implants have the potential for being completely absorbed, the need for a second operation for removal is overcome and long-term interference with tendons, nerves and the growing skeleton is avoided. 2. Additionally, the risk of implant-associated stress shielding, peri-implant osteoporosis and infections is reduced. 3. An important aspect is that these implants do not interfere with clinical imaging. This allows the use of modalities like MRI in knee and shoulder injuries at any stage after surgical implantation. 4. The other advantages include biodegradability of implants placed across mobile articular surfaces, and acceptable biocompatibility and resorption properties that reduces concern about complications.

 

 

5. As bioabsorbable implants get resorbed inside tissues, they offer advantages in specific fracture fixations like in the foot and ankle, where removal of the hardware is often mandatory prior to mobilization. Hence they will be beneficial in syndesmotic disruptions and Lisfranc's dislocations. Current uses Biodegradable implants are available for stabilization of fractures, osteotomies, bone grafts and fusions particularly in cancellous bones. They are also used for reattachment of ligaments, tendons, meniscal tears and other soft tissue structures. They are used in : Knee: Interference and transfixation screws: In ACL reconstruction. Use of bioabsorbable interference screws is a valuable alternative to metallic implants, as MRI is the only technique which allows good visualization of the transplant and evaluation of the healing process. Absence of artifacts allows use of this modality for postoperative follow-up Biodegradable pins : In arthroscopic fixation of Osteochondral fractures. Meniscal tacks and biodegradable suture anchors :In soft tissue reconstruction while tackling complex knee injuries. Shoulder: Biodegradable implants provide viable options for the repair and reconstruction of many intra-articular and extra-articular abnormalities in the shoulder, including rotator cuff tears, shoulder instability, and biceps lesions that require labrum repair or biceps tendon tenodesis. Spine: Bioresorbable implants have significant potential for use in spine surgery. They are used as interbody spacers in lumbar interbody fusion. Bioabsorbable anterior cervical plates have been used and studied as alternatives to metal plates when a graft containment device is required. Paediatric Orthopaedics:

 

 

The use of bioresorbable materials in paediatric conditions was perhaps the earliest recorded use in orthopaedic literature. The applications have been widely varied, and the results very successful. Self reinforced absorbable rods were suitable for fixation of physeal fractures in children. SR-PLLA screws were successfully used for fixation of subtalar extraarticular arthrodesis in children. Bioabsorbable fixation technique for pediatric olecranon fractures has been described Foot and Ankle: Self reinforced absorbable rods have been used in medial malleolar fractures, ankle fractures, and in intra articular osteochondral fractures of talus. Outside the trauma situation they are used in the fixation of osteotomies for hallux valgus. Bioabsorbable implants offer specific advantages in the foot where removal of the hardware is mandatory in some fixations like syndesmotic disruptions and Lisfranc's dislocations. Hand: The available literature at the present time is scarce about biodegradable implant usage in the hand. However mini-plating systems are available for fixation of fractures, osteotomies and arthrodesis in the wrist and hand . Preliminary reports have found usage of self-reinforced polyl/dl-lactide 70/30 miniplate and 1.5-mm or 2.0-mm screws in fractures and osteotomies leading to bone union uneventfully. Miscellaneous: There are bioabsorbable implants now available for use in humeral condyle, distal radius and ulna, radial head and other metaphyseal areas. Bioabsorbable meshes are available for acetabular reconstructions. Bioabsorbable implants are also variously used in craniomaxillofacial surgery and dental surgery. Disadvantages 1.Inadequate stiffness and weakness when compared to metal implants can pose implantation difficulties like, screw breakage during insertion and can also make early mobilization precarious. 2.The other potential disadvantages include inflammatory responses leading to rapid loss of initial implant strength and higher re -fracture rates. Areas of concern regarding faster resorbed implants are due to the fact that the body mechanisms are not able to clear away the products of

 

 

degradation, when they are produced at a faster rate. This leads to a foreign body reaction, which however has only been recorded in the clinical situation. 3. Many manufacturers are introducing coloured implants, as sometimes visualization inside the joint maybe a problem with non coloured devices. This is definitely easier to implant but the literature records significantly higher rates of inflammatory reactions with the use of coloured implants. Future Bioabsorbable implant research is an evolving science. Resorbable plates can be covalently linked with compounds such as HRP, IL-2, and BMP-2 and represents a novel protein delivery technique. BMP-2 covalently linked to resorbable plates has been used to facilitate bone healing. Covalent linking of compounds to plates represents a novel method for delivering concentrated levels of growth factors to a specific site hence potentially extending their half-life. An area for future development would have to focus on developing implants that degrade at the "medium term". Since the screw that persists in its track for 5 years or more does not offer the advantage of bioresorbability, newer molecules may have to be studied. In vitro studies have shown promising results of antibiotic elution from bioabsorbable microspheres and beads. Animal in vivo tests have shown that antibiotic impregnated polymers can successfully treat induced osteomyelitis in rabbits and dogs. All in all, this is a concept that has perhaps come to stay. What the future holds in this sphere, is something we will have to wait and see.

CONGENITAL CLUBFOOT Pathoanatomy and management Dr Hithesh Shah KMC, Manipal

 

Pathological anatomy The deformities in clubfoot: In the hindfoot (hindfoot consists of calcaneum & talus) Equinus at ankle joint Adduction at subtalar joint Inversion at subtalar joint (adduction and inversion at the subtalar joint together called hindfoot varus) In the forefoot (forefoot consists of the foot distal to the mid-tarsal joint) a. Equinus at the midtarsal joint b. Adduction at the midtarsal joint The following anatomical changes are observed in clubfoot: ▬ Talus: The primary deformity in clubfoot consists of a deviation of the anterior section of the talus (talar neck) in a medial and plantar direction. The angle between the trochlea of the talus and the talar neck is greater in neonates than in adults, and greater still in clubfoot. The talar neck is also shortened and the typical shoulder is lacking. The anterior articular surface is rotated inwardly. The whole talus is smaller than normal and ossification is delayed. ▬ Calcaneus: The deformation of the calcaneus is much less pronounced than that of the talus. The calcaneus shows a slight medial deviation and the sustentaculum tali is slightly hypoplastic. ▬ Metatarsal and forefoot bones: These are slightly hypoplastic, i.e. shortened but normal in width. ▬ Tibia: The internal rotation of the tibia is masked by the posterior displacement of the fibula, giving the impression that the lower leg is externally rotated. Clubfoot patients do not show an increased incidence of rotational deviations of the tibia compared with their normal-footed counterparts. ▬ Ankle joint : The deviation of the talus and the raised position of the calcaneus cause the talus to be pushed forward

 

 

out of the ankle mortise. A third of the talar joint surface does not articulate in a case of clubfoot. Whether medial rotation also takes place at the same time remains a contentious issue. ▬ Subtalar joint : The calcaneus is rotated medially and tilted ventro-caudally in relation to the talus, i.e. the normal upward slope in a dorsal to ventral direction is absent. ▬ Talonavicular joint: The navicular bone is displaced in a medial and plantar direction in relation to the talus. In a pronounced case of clubfoot, the lateral section of the anterior talar surface does not articulate with the navicular. ▬ Soft tissue changes: The soft tissues on the anteromedial and posterolateral sides of the talus are shortened. All tissue types (skin, ligaments, tendons, muscles, blood vessels, nerves) are contracted to the same extent. Tendo Achilles contracture accounts for cause of hind foot equines. Tibialis posterior contracture accounts for cause of hind foot varus, forefoot adduction andfForefoot inversion. Planter muscles (intrinsic muscles of foot) account for forefoot adduction and equines. The structures most affected by shortening are the posterior fibulocalcaneal and talocalcaneal ligaments, the talonavicular joint capsule, the talocalcaneonavicular ligament, the tendon of the posterior tibial muscle and the fibrous ligament at the intersection of the tendons of the flexor hallucis longus and flexor digitorum longus muscles. Another striking finding is atrophy of the calf muscles. Treatment of idiopathic clubfeet One should start the treatment as soon as possible as deformities may become rigid with time. Infants presenting less than 1 year of age: Serial manipulation & plaster casts. Serial casting is the primary method used for the newborn with a congenital clubfoot. Different techniques of manipulation have been described, including those of Kite, Ponseti and Dimeglio. They differ in the fine detail but share common principles. Once should correct the one deformity at a time and sequence of deformity correction must be forefoot deformities followed by hindfoot varus and correction of the hind foot equines must be

 

 

last (to prevent rocker bottom deformity). Manipulation should be done without sedation or anaesthesia without force. Above knee casts should be applied with knee in 90 degree flexion with foot in corrected position. Cast must be changed every week or biweekly. The deformity must be assessed clinically and radiologically after few plasters. If correction is satisfactory, the child should be prescribed Denis Browne splint (to be used till child begins to walk). If correction remains unsatisfactory, then one has to decide for performing soft tissue release. Currently there is enthusiasm for Ponseti’s technique. This method is an improvement over serial stretching and taping techniques and it is encouraging to witness the correction that can be achieved after three to five cast changes. Much of the correction is in the forefoot and ‘turning’ of the hindfoot into valgus; the majority will require a percutaneous tenotomy of the Achilles tendon for resolution of equinus. Correction is followed by a regime of using Denis Browne boots with a derotation bar – continuously for three months before relaxing into a night-time only protocol until age of three years. This sequence of serial casting with or without tenotomy can be utilized for children as old as 12–14 months, with confidence in the knowledge that the divided tendon will heal. It can also be repeated if the first sequence only permits partial resolution. In children presenting between 1-3 years of age & if non-operative treatment fails: Children with clubfeet that fail to respond completely after at least two applications of the Ponseti technique are potential candidates for open surgical release. They are in a minority and probably represent a different aetiological and prognostic group; often they are cases with bilateral involvement. Surgical techniques differ from the type of skin incision to degree of ‘release’ – from specific structures which must be freed in every case. There are practical advantages to leaving this surgery until after the age of nine months (the surgery is technically easier and post-surgical therapy is assisted by a child who is beginning to walk by the time the cast is removed). Children do not always present for treatment in the early post-natal period. Worldwide, particularly in developing world, it is

 

 

quite common to encounter a child with clubfoot after the child has begun to walk or even later. In these older children non-operative methods may be less effective (as secondary adaptive changes are likely), leaving soft tissue release as the mainstay of correction. Soft tissue surgical techniques include an isolated posterior release, a posteromedial release or a complete circumferential subtalar release. If the forefoot and hindfoot varus deformities are well corrected by serial casts and the residual deformity equinus, a posterior soft tissue release will suffice. However, in the majority of cases needing soft tissue surgery (in the event of failure or incomplete resolution from serial casts), all components of the original deformity will be present to some degree; in such feet a posterior and medial soft tissue release is necessary. In severe and stiff deformities, only a complete subtalar release will enable the calcaneum to rotate out of adduction and varus and enable adequate correction of equinus. Postero-medial soft tissue release The Achilles tendon is lengthened by z-plasty. The posterior capsules of the ankle and subtalar joints are divided and the posterior talofibular ligament is sectioned. The neurovascular bundle is mobilized and the sheath of the flexor hallucis longus tendon is divided. The entire medial capsule of the subtalar joint and the superficial deltoid ligament are divided. The tibialis posterior tendon is lengthened and the talonavicular joint capsule is divided and the navicular is reduced after releasing the spring ligament. The abductor hallucis muscle is sectioned. On dorsiflexion of the foot, if the flexor hallucis tendon is found to be taut with the great toe going into excessive flexion, a tenotomy of the tendon is performed. Post operative management: the patient must be treated in cast for 3 months. After that the correction must be maintained with the special shoe with following modifications. The shoe contains no heel (to prevent recurrence of equines), straight medial last (to prevent recurrence of forefoot adduction) and lateral sole wedge (to prevent recurrence of inversion).

 

 

In children presenting over 3 – 4 years of age and in case of a relapse (recurrence): Tendon transfers: In children over the age of three years a tendon transfer can address some residual deformity and should be considered, provided the deformity is passively correctable or is corrected at the time of transfer. Ponsti group does not consider tendon transfer as a surgery for relapse. Complete transfer of the tibialis anterior tendon is performed in nearly half of cases undergoing treatment by the Ponseti method Tibialis anterior transfer (complete/ split): Complete tibialis anterior transfer to the lateral aspect of the dorsum of the foot. It is usual to seat the detached tendon into the lateral cuneiform. The procedure is carried out around three years of age if some return of forefoot deformity is detected and is preceded by a few serial casts. Some surgeons advocate using the lateral half of the tibialis anterior which is transferred to the lateral aspect of the foot, and either anchored to the peroneus brevis tendon or to the cuboid bone Soft tissue release may have to be combined with bony surgery such as : For forefoot adduction – Evan’s operation ( calcaneo-cuboid fusion) Lengthening the medial column-Open wedge osteotomy of the medial cuneiform. Shortening the lateral column-Closed wedge osteotomy of the cuboid Closed wedge osteotomy of the anterior end of the calcaneum For hindfoot varus – Dwyer’s operation (calcaneal osteotomy) Osteotomies to correct hindfoot varus These can be used to correct isolated hindfoot deformities in older children if the subtalar joint retains some movement. By translating the point of contact of the os calcis with the floor lateral to the middle of the ankle, the osteotomy restores the eversion lever through the subtalar joint. This effect can be

 

 

achieved through a lateral closing wedge osteotomy of calcaneum or lateral translation osteotomy. Medial open wedge osteotomies of calcaneum achieve the same but can be fraught with wound healing problems. In skeletally mature children Triple fusion (fusion of subtalar, talo-navicular & calcaneo-cuboid joints after excision of wedge of bone to correct the deformities) is a salvage procedure. It should ideally be performed after the age of 12 when most foot growth has already occurred.

 

 

FRACTURE DISLOCATIONS OF HIP DR. K. S. ARIF Assoc prof, YMC, Mangalore

 

INTRODUCTION : Large-force trauma (eg, motor vehicle accidents, pedestrians struck by automobiles) are the most common causes of hip dislocations.This type of injury is also associated with high-energy impact athletic events (eg, American football, rugby, water skiing, alpine skiing/snowboarding, gymnastics, running, basketball, race car driving, equestrian sports).Diagnosing and correctly treating these injuries to avoid long-term sequelae of avascular necrosis and osteoarthritis is imperative. EPIDEMIOLOGY: Caused due to High energy trauma: RTA, Falls from height, industrial accidents, athletic injuries.Posterior dislocation:Approx 85-90% of all dislocations.50% of patients : concomitant fractures elsewhere.Unrestrained motor vehicle accident occupants are at a significantly higher risk.Sciatic nerve injury: 10% to 20% of posterior dislocations Femoral head fractures are commonly associated with hip dislocations.These fractures complicate 10% of posterior hip dislocations.Most are shear or cleavage type, although recently, more indentation-type or crush-type fractures have been recognized with the increased use of computed tomography (CT).Indentation fractures are more commonly associated with anterior hip dislocations Relevant Anatomy : The hip articulation has a ball-and-socket configuration with stability conferred by bony and ligamentous restraints, as well as the congruity of the femoral head with the acetabulum.The acetabulum is formed from the confluence of the ischium, ilium, and pubis at the triradiate cartilage.Forty percent of the femoral head is covered by the bony acetabulum at any position of hip motion. The effect of the labrum is to deepen the acetabulum and increase the stability of the joint. The hip joint capsule is formed by thick longitudinal fibers supplemented by much stronger ligamentous condensations (iliofemoral, pubofemoral, and ischiofemoral

 

 

ligaments) that run in a spiral fashion, preventing excessive hip extension. The main vascular supply to the femoral head originates from the medial and lateral femoral circumflex arteries, branches of the profunda femoral artery. An extracapsular vascular ring is formed at the base of the femoral neck with ascending cervical branches that pierce the hip joint at the level of the capsular insertion. These branches ascend along the femoral neck and enter the bone just inferior to the cartilage of the femoral head. The artery of the ligamentum teres, a branch of the obturator artery contribute blood supply to the epiphyseal region of the femoral head. The sciatic nerve exits the pelvis at the greater sciatic notch. A certain degree of variability exists in the relationship of the nerve with the piriformis muscle and short external rotators of the hip. Most frequently, the sciatic nerve exits the pelvis deep to the muscle belly of the piriformis, but occasionaly at times may pierce the muscle. Stability depends on : Depth of acetabulum, supplemented by labrum Tension and strength of capsule and ligaments Strength of surrounding muscles Length and obliquity of neck of femur MECHANISM OF INJURY : Hip dislocations almost always result from high-energy trauma, such as motor vehicle accident, fall from a height, or industrial accident. Force transmission to the hip joint occurs with application to one of three common sources: The anterior surface of the flexed knee striking an object The sole of the foot, with the ipsilateral knee extended The Greater Trochanter Less frequently, the dislocating force may be applied to the posterior pelvis with the ipsilateral foot or knee acting as the counterforce. Direction of dislocation (anterior versus posterior) is determined by the direction of the pathologic force and the position of the lower extremity at the time of injury POSTERIOR DISLOCATIONS

 

 

They are much more frequent than anterior hip dislocations.They result from trauma to the flexed knee (e.g., dashboard injury) with the hip in varying degrees of flexion: If the hip is in the neutral or slightly adducted position at the time of impact, a dislocation without acetabular fracture will likely occur.

If the hip is in slight abduction, an associated fracture of the posterior-superior rim of the acetabulum usually occurs. ANTERIOR DISLOCATIONS These comprise 10% to 15% of traumatic hip dislocations.They result from external rotation and abduction of the hip.The degree of hip flexion determines whether a superior or inferior type of anterior hip dislocation results: Inferior (obturator) dislocation is the result of simultaneous abduction, external rotation, and hip flexion. Superior (iliac or pubic) dislocation is the result of simultaneous abduction, external rotation, and hip extension. CENTRAL DISLOCATIONS: Rarest of the dislocations. They result from direct blow over greater trochanter. Clinical Examination : Full trauma survey is essential because of the high-energy nature of these injuries. Many patients are obtunded or unconscious when they arrive in the emergency room as a result of associated injuries. Concomitant intraabdominal, chest, and other musculoskeletal injuries, such as acetabular, pelvic, or spine fractures, are common. Patients presenting with dislocations of the hip typically are unable to move the lower extremity and are in severe discomfort. The classic appearance of an individual with a posterior hip dislocation is a patient in severe pain with the hip in a position of flexion, internal rotation, and adduction. Patients with an anterior dislocation hold the hip in marked external rotation with mild flexion and abduction. The appearance and alignment of the extremity, however, can be dramatically altered by ipsilateral extremity injuries. A careful neurovascular examination is essential, because injury to the sciatic nerve or femoral neurovascular structures may occur at time of

 

 

dislocation. Sciatic nerve injury may occur with stretching of the nerve over the posteriorly dislocated femoral head. Posterior wall fragments from the acetabulum may also pierce or partially lacerate the nerve. Usually, the peroneal portion of the nerve is affected, with little if any dysfunction of the tibial nerve. Rarely, injury to the femoral artery, vein, or nerve may occur as a result of an anterior dislocation. RADIOGRAPHIC EVALUATION An anteroposterior (AP) radiograph of the pelvis is essential, as well as a cross-table lateral view of the affected hip. On the AP view of the pelvis: The femoral heads should appear similar in size, and the joint spaces should be symmetric throughout. In posterior dislocations, the affected femoral head will appear smaller than the normal femoral head. In anterior dislocation, the femoral head will appear slightly larger than the normal hip because of magnification of the femoral head to the x-ray cassette. The Shenton line should be smooth and continuous. The relative appearance of the greater and lesser trochanters may indicate pathologic internal or external rotation of the hip. The adducted or abducted position of the femoral shaft should also be noted. One must evaluate the femoral neck to rule out the presence of a femoral neck fracture before any manipulative reduction. A cross-table lateral view of the affected hip may help distinguish a posterior from an anterior dislocation. Use of 45-degree oblique (Judet) views of the hip may be helpful to ascertain the presence of osteochondral fragments, the integrity of the acetabulum, and the congruence of the joint spaces. Femoral head depressions and fractures may also be seen. Computed tomography (CT) scans are usually obtained following closed reduction of a dislocated hip. If closed reduction is not possible and an open reduction is planned, a computed tomography scan should be obtained to detect the presence of intra-articular fragments and to rule out associated femoral head and acetabular fractures. The role of magnetic resonance imaging in the evaluation of hip dislocations has not been established; it may prove useful in the evaluation of the integrity of the labrum and the vascularity of the femoral head

 

 

CLASSIFICATION : Posterior dislocations Stewart and Milford classification:

Thompson & Epstein classification : Pipkin classification :

ANTERIOR DISLOCATIONS Epstein Classification (described by their anatomic location): 1.Pubic (superior)

 

 

a. With no fracture (simple). b. With fracture of the head of the femur. c. With fracture of the acetabulum. 2.Obturator (inferior) a. With no fracture (simple). b. With fracture of the head of the femur. c. With fracture of the acetabulum. Treatment – Aim: Avoiding complications by emergent reduction By providing a congruent and Stable joint. Introduction - It is an orthopaedic emergency. Delaying its reduction increases the risk of avascular necrosis of the femoral head. Golden period within 6 hours of the injury. Dislocated hip takes precedence over any other orthopaedic injury. Closed reduction of the hip initially should be attempted in the emergency room under intravenous sedation or general anesthesia, if readily available. Traction in line with the affected femur and small amounts of rotation and abduction and adduction complete the reduction. Allis maneuver is performed for posterior dislocations as previously described with the patient supine, while the stimson maneuver is similarly performed with the patient prone. Closed Reduction Techniques Gravity method of Stimson(Fig – 1) -

 

 

The patient is laid prone on a table or cart with both lower extremities hanging off the end. An assistant stabilizes the pelvis, while the involved hip and knee are flexed 90 degrees. The surgeon grasps the leg just distal to the flexed knee and applies a longitudinal force. Gentle internal and external rotation of the hip may aid the reduction.

Fig – 1 Allis Maneuver (Fig-2) With the patient supine, the pelvis is stabilized by an assistant applying pressure to the anterior superior iliac spines. The surgeon applies longitudinal traction in the direct line of the deformity followed by flexion of the hip to 90 degrees while continuing traction. Internal and external rotations of the hip are performed until reduction is achieved.

 

 

Fig- 2

Bigelow Maneuver (Fig- 3) - With the patient supine, the pelvis is stabilized by an assistant applying pressure to the anterior superior iliac spines. The surgeon grasps the affected limb by the ankle and places his or her opposite forearm beneath the patient's flexed knee. Longitudinal traction is applied in the direction of the patient's deformity, followed by flexion of the patient's hip to 90 degrees or more, while maintaining it in an adducted, internally rotated position and continuing traction. The femoral head is levered into the

 

 

acetabulum by the combination of abduction, external rotation, and extension of the hip.

Fig - 3

East Baltimore Lift –(Fig 4) With the patient supine, the surgeon stands on the affected side with an assistant on the opposite side. The patient's leg is flexed so that the hip and knee are at 90 degrees. The surgeon places his or her arm that is closest to the patient's head under the proximal calf of the patient, cradling the leg in his or her elbow with his or her hand resting on the shoulder of the assistant. The surgeon's other hand grips the patient's ankle. The assistant's arm passes under the proximal calf of the patient (similar to the surgeon's) and rests on the surgeon's shoulder. The surgeon and assistant squat slightly with knees bent. They straighten up

 

 

together to apply traction to the hip without straining their backs. The surgeon rotates the leg at the ankle. A second assistant stabilizes the pelvis.

Fig 4 After reduction: after the hip is reduced all five standard x-rays views of the pelvis are obtained. Ap Both judet (45-degree oblique) views An inlet and outlet view of the pelvis Failed closed reduction of the hip can be caused by- Buttonholing of the femoral head through the capsule Inversion of the Labrum Interposition of the Piriformis into the Acetabulum. If closed reduction fails - Anteroposterior, Judet views, and CT scan of the pelvis should be obtained quickly to assess the imposing factor. If the hip is reduced incongruently - A Femoral traction pin should be placed and the hip (Femoral head) distracted using skeletal traction to avoid further articular damage until the offending structures can be removed.

 

 

If the hip is irreducible by closed means - Open reduction of the hip should be done immediately. Associated Femoral head or Acetabular fractures can wait a few days for definitive treatment. Open reduction : Hip approach – Determined by the direction of the dislocation. Posterior dislocations – Posterior Kocher-Langenbeck type of approach. Anterior dislocations – Direct anterior approach of Smith-Petersen or By the Anterolateral or Direct Lateral approaches of Watson-Jones and Hardinge respectively. Technique: Regardless of the direction of the dislocation, assess the capsule first. If the femoral head is Buttonholed- Extend the traumatic capsulotomy in a T-Shaped fashion along the acetabular rim, carefully preserving the labrum, if possible. Inspect the joint for intervening Capsule, Labrum, Piriformis muscle, or Bony fragments. If necessary, Retract or Distract the hip either manually or with skeletal traction applied through a fracture table or femoral distractor for better assessment of the joint. Once the joint has been cleared of debris, reduce the hip joint by releasing the traction. Repair the capsule along with the labrum. Close the wound routinely for the chosen approach. Postoperative care Weight-Bearing Ambulation: Reduced within 6 hours, Rest for several days to 2 weeks followed by Mobilization Continuous passive motion to avoid the Intra-Articular Adhesions and Arthritis Extremes of motion are avoided for 6 to 8 weeks to allow for Capsular healing Reduced after 6 hours, Delay full weight-bearing in these cases for 8 to 12 weeks.

 

 

Gait Training - Once patient regains control of the affected limb should be out of bed to a chair within a few days and up on crutches or a walker within 1 week, Toe-Touch weight-bearing . Postoperative traction and protected weight-bearing - decrease the incidence of femoral head collapse from Avascular necrosis (benefits proved). Patients are advised to avoid putting the hip in the position of the dislocation, and Hip Abductor and Flexor strengthening and Gentle Range-of-Motion exercises are initiated. An Abduction Pillow is useful in the postoperative period in sedated and noncompliant patients with previous Posterior dislocation. Complications Prereduction – Most dangerous is a missed associated injury Nondisplaced hip fractures Complete Neurologic and Vascular assessment will provide a necessary baseline for the Postreduction examination Sciatic nerve dysfunction (common in fracture dislocations). Peroneal division is most often affected Recovery occurs in approximately 70% Recovery does not occur Patients may be offered tendon transfer Exploration of the nerve is generally not recommended. Postreduction- Neurologic function of the limb should be reassessed. Sciatic nerve function needs to be documented. If nerve function impaired after the reduction, then surgical exploration of the nerve is recommended to ensure it is not trapped within the joint. Plain films and CT small fragments interposed within the articular surface must not be missed. Late complications – Avascular Necrosis (4% to 22%). Osteoarthritis/ Traumatic arthritis (common complication). Thromboembolism Joint Stiffness Recurrent Instability (Occurs extremely rarely). Heterotopic Ossificans

 

 

Most common after open reduction of a posterior dislocation. Sciatic Nerve palsy (up to 13% ) Usually from Heterotopic Ossification either compressing the nerve or causing it to be stretched. It is important to continue to examine the nerve function at each postinjury visit, because early decompression may favour Neurologic return. ASSOCIATED WITH FRACTURES Pipkin type 1 Dislocation with Femoral Head fracture – Closed reduction of Pipkin type i Fracture-Dislocations should be performed as advocated by Stewart and Milford. Four factors are crucial: The concentricity of the reduced Femoral head in the Acetabulum The accuracy of the reduction of the displaced femoral head fragment The size of the femoral head fragment The stability of the reduction. Pipkin type 2 Dislocation with Femoral Head fracture- Closed reduction is attempted immediately if the reduction is nonanatomical and nonconcentric, open reduction should be done. If a posterior dislocation is irreducible, or a large femoral head fragment remains posterior to the hip after closed reduction, we use a posterior approach with the patient in the lateral decubitus position on a standard radiolucent operating table. This approach allows access to the structures that impede reduction but makes manipulation and fixation of the anteroinferior femoral head fragment difficult unless the hip is dislocated. After internal fixation, the patient is mobilized with touch-down weight bearing for 3 months. Pipkin type 3 Dislocation with Femoral neck fracture The treatment of Pipkin type iii fracture-dislocations is controversial. In younger patients, open reduction of the dislocation, fixation of the femoral neck fracture, and use of some type of vascularized graft have been attempted, but reports of these procedures are sporadic, and long-term follow-up studies are unavailable. Hemiarthroplasty usually is recommended for older patients. Pipkin type 4 Dislocation with Acetabular Fracture In Pipkin type iv injuries, treatment usually is determined by the type of acetabular fracture.

 

 

Open reduction and reconstruction of the Acetabulum usually are recommended, but late problems may be encountered with this method. In young patients, if concentric reduction with reasonable joint congruity cannot be obtained by closed means, open reduction and internal fixation of all major fragments are justified. In older patients or in patients with significant preexisting disease within the joint, some type of replacement arthroplasty may be considered, depending on the type of fracture and the extent of Acetabular involvement. Central fracture dislocation – Resuscitation and treatment of Shock Meantime affected side to be Immobilized in Traction Conservative vs. Open reduction: open reduction in studies has been found to be difficult and ineffective in improving end result 75 % pts achieve good results by non operative management. Conservative treatment – Skeletal traction: Russell Hamilton method, lateral traction Active and Assisted flexion exercises encouraged immediately Group 2 dislocations left alone: Mould a new acetabulum within framework of fragments Traction maintained for not greater than 6 weeks, full weight bearing after 3-4 months Open Reduction and Internal fixation – Indicated in type 1 fractures with femoral head completely dislocated from under intact weight bearing surface with not more than2-3 large acetabular fragments; “double dome deformity” of Knight and Smith Should be corrected as soon as possible Hip approached through posterior approach/ smith peterson approach Orif with small plate screwed into adjacent parts of iliac and ischial components Post op immobilization in spica for 6 weeks Non weight bearing for 3 months.

EVALUATION OF KNEE SWELLING Dr Lawrence John Mathias, Assoc Prof KSHEMA, Mangalore

 

Knee swellings perse are swellings confined to to the limits of the synovial membrane and are due to accumulation of excessive synovial fluid, blood or pus. Less commonly the knee swells beyond the limits of the synovial membrane such as in fractures, infections and tumors of the distal femur. The knee is susceptible to traumatic injury and is often the site of systemic disease and therefore an understanding of these injury patterns and disorders is critical to making a diagnosis and a treatment plan for knee effusions A thorough history and meticulous physical establish the diagnosis in a vast majority of cases, with appropriate manual testing, diagnostic imaging studies and arthrocentesis aiding in the diagnosis Etiology of knee effusion Trauma: Ligamentous injury, Intraarticular fracture, Meniscal injury, Inflamatory: Rheumatoid arthritis, Reiters Infections: Septic arthritis, Tuberculosis, Degenerative:Osteo arthroses, Overuse syndrome Metabolic: Gout, Pseudo gout, Neoplastic: Malignant, Osteosarcoma, Synovial sarcoma, Benign, Aneurysmal bone cyst, Giant cell tumor History: Key findings of the history in patients with knee effusion: Finding Diagnosis High velocity injury, Inability to bear weight,“POP”

Fracture

Cut or pivot mechanism Knee gave way “POP”felt or heard with injury

ACL injury

Blow to proximal tibia PCL injury Squat kneel associated with a twist, Clicking Locking, Pain with rotational movement

Meniscal injury

Fever chills infectious arthritis Occupational /recreational repetitive overuse syndrome

 

 

Movement Night pain , Evening rise of temp Tuberculosis Symmetrical small joint Involvement rheumatoid arthritis Spine and hip pain with stiffness seronegative

arthropathy Physical examination: Systematic Neurovascular status Opposite limb Inspection: Gait, instability, antalgic, knock knee, waddling alignment, varus, valgus Attitude : 20-30 degree flexion deformity severe effusion Abrasions, ecchymosis with trauma Diffuse swelling beyond the knee-cellulitis, fractures of distal femur Horseshoe shaped swelling is characteristic of knee effusion Localized swelling- prepatellar,infrapatellar,popliteal Palpation: Temperature, Tenderness, Articulating structures, Patella-gap-in fractures of the patella Retropatellar tenderness-in osteoarthroses and chondromalacia patellae Synovial thickening: boggy feel of the synovium in the suprapatellar region and the edge of the thickened synovium can be rolled under the finger at its suprapatellar reflection Effusions in the knee: A) Fluctuation: press the suprapatellar pouch with one hand and feel the impulse with the thumb and fingers of the other hand placed on either side of the patella or ligamentum patellae b)Patellar tap: press the suprapatellar pouch in the direction of the knee with one hand and with the index finger of the other hand push the patella posteriorly and feel it striking the condyles of the femur Movement: Pain, crepitus Test for meniscal and ligamentous injury

 

 

Imaging Radiographs- standard AP /lateral views and Axial patella view to asses patella fractutre, patellofemoral articulation, Tunnel AP view for osteochondral lesions, Oblique view for tibial plateau fractures

Appearance

Viscosity

wbc count

mucin clot

Crystal

Organism

Normal

clear

viscous 100/cmm Good - -

OA

clear

viscous 500/cmm Good - -

Gout Turbid low 15,000-30,000

good-poor

+ -

Inflam.

Turbid low 15,000-30, 000

good-poor

- -

Septic very turbid

low 80,000-150,000

Poor - +

 

 

MRI to asses meniscal injuries,bone contusion,chondral injury, bone tumors Haematologic examination:complete blood count,CRP, rheumatoid factor Synovial fluid findings Knee Arthroscopy: evaluation and biopsy when intraarticular pathology is uncertain

 

 

Examinat

ion  of  

swollen  

knee  

injury   No  injury  

Pivot,  

audible  

POP  

instabilit

   Direct    

to  the  

knee  

Unable  

Twisted  

knee  

while  wt  

bearing  

Acute  

onset,  

singlel  

joint  

Multiple  

joints,  

morning  

stiffness  

Positive  

Lach-­‐

mans,  

anterior  

Normal,  

Segond    

fracture  

Bruise,  

Echy-­‐

mosis,  

crepitus  

fracture  

     Fever  

warm  

joint,  

Tender-­‐

Joint  line  

tender-­‐

ness,mc

murrays    

Warmth-­‐  

Tender-­‐

ness,  

Synovial  

Subchon

dral  

cysts,  

Oste-­‐

normal  normal  

       Physical  examination  

                                   Radiographs  

Multiple  

joints,  

red  

swollen,  

Erythem

a  

Joint  line  

tender-­‐

Normal  

Or  

Chondro-­‐  

calcinosi

Increase

d  protein  

Dec.  

sugar  

Bloody,  Bloody,fa

tglobules  

Possibly  

bloody  

Dec  

.Sugar  

Cell  

count  

Urate  or  

pyropho

sphate  

crystal,  

Arthrocentesis  

Mechanism  of    injury   Initial  episode  

ACL  

injury  

Fractur

e  

Menisca

l  injury  

Septic  

Arthriti

s  

Gout/  

Pseudo-­‐

gout  

Rheuma

-­‐toid  

Arthriti

s  

Examination  of  swollen  knee    

Recurrent    

IM nailing Dr Syed Nizamuddin Indira Hospital Mangalore

 

INTRODUCTION – 1 I.M nailing has come a long way since Kuntscher introduced it in 1940. They are load sharing devices which act as internal splints offering relative stability. INTRODUCTION – 2 In the process of achieving relative stability of the fracture, biology of fracture healing must get its due respect. STABILITY – 1 I.M nailing occupies a important place in the treatment armamentarium of the stability spectrum of long bone fractures. STABILITY – 2 Combination of fracture pattern & implant construct determines stability. STABILITY – 3 2 main players contributing towards stability & there by determining the successful outcomes are: Non- deformable BONE Deformable NAIL (Resists Axial loading unless the (Resists Bending & Torsion) Fracture type is complex)

 

 

STABILITY – 4 Leading to fracture stability by interference fit independent of any additional inter – fragmentary compression. INDICATIONS – 1 Best Indication is Middiaphysis Best Bone femur → Tibia → may be Humerus → questionably the radius & Ulna Best type & group of fractures are transverse or short oblique. INDICATIONS – 2 The end segments are relative indications due to Potential for Deformities through Malreduction & Instability. (Retrograde femoral nailing) BIOMECHANICS Nail insertion is important for a successful outcome. The Insertion force of the nail depends upon Nail strength Stiffness Design Features Entry Point Size of Canal Size of Proximal Fragment Material Working Length BIOMECHANICS

 

 

(NAIL STRENGTH) Nail must resist bending & Torsion unless the fracture patterns inter digitates. Nail resists torsion poorly. Minimum bending strength of a nail must resist Physiological forces of any given Limb segment. MINIMAL STRENGTH STANDARD for femur is a slotted 12 mm stainless steel nail with 1 mm thick wall. BIOMECHANICS (STIFFNESS) Is related to nail insertion. Factors which contribute towards ideal design properties are Radius of curvature Diameter Wall thickness Radius of Curvature If the radius of curvature is a mismatch with the canal it causes longitudinal Jamming. BIOMECHANICS

 

 

EVOLUTION OF NAILS : NAILING WITH REAMING Classical K nail NAILING WITH REAMING & LOCKING Universal nail – Tight fitting NAILING WITHOUT REAMING OR LOCKING Enders – Lotts – Rush (As they were inserted without reaming they were loose fitting. Since these were thin they could not be locked proximally or distally. Thus resulted to longitudinal and rotational instability. There was frequent need for external stabilization) NAILING WITHOUT REAING WITH LOCKING Solid nail. (Absence of slot increases the torsional stiffness of the implant but carries a reduced capacity to adapt to the shape of the bone) EVOLUTION OF I.M NAILS: The humble slotted cloverleaf nail of Kuntscher has evolved over the last 75 years keeping the Biology & Biomechanics of fracture healing at its core. Thus we have the slotted cloverleaf nail undergoing timely modifications. ) SLOTTED CLOVERLEAF NAIL On insertion the cloverleaf is squeezed together producing increased friction between the surface of nail & bone cortex due to elastic recoil thereby increasing the grip between the bone and the nail.

 

 

INTERLOCKING SCREWS: Addition of interlocking screws by Grosse & Kempf enhanced the mechanical properties of the intramedullary implant & widening the range of indications to even more proximal & distal fractures as well as more complex and unstable patterns. However, if the fracture is more distal, more proximal or more complex, its fixation mainly depends on the interlocking screw & much less on the principle of friction. Elimination of Slots (solid/hollow) - 1 Elimination of Slots (solid/hollow) - 2 Large diameter nails Small diameter nails (MATERIALS) Stainless steel resists bending & torque better than Titanium. However Titanium is more resistant to infection & the modulus of elasticity is closer to bone as compared to stainless steel. (ENTRY POINT - 1) It is essential to place the starting point exactly inline with centre of medullary canal with the limb in the correct position. (ENTRY POINT - HIP) Flex & adduct this measure decreases the length of the incision, especially in obese patients. Incisions should not be placed too posteriorly, since abductor muscle weakness has been recorded after nailing. Guide wire is rarely perfectly positioned in both planes in the first attempt, a correct second pin is inserted using the initial wire as a reference. Once the starting point & direction are perfect, the malpositioned wire is removed.

 

 

Stab incision is 10 cm proximal to tip of greater trochanter & natural antecurvation of femur has to be considered. Slightly curved line is drawn in a proximal direction corresponding to curvature of femur. (ENTRY POINT - KNEE) Due to the triangular cross section, the instrument is not aimed at anterior tibial crest but medial to it inline with the canal. Blumensaat’s line – is a important landmark in the lateral view. A radiodense line representing the cortical roof of inter condylar notch. KNEE RETROGRADE : Protect PCL ENTRY POINT - 4) Eccentric entry point increases hoop stresses in the proximal fragment and can cause fragmentation of proximal portion. Failure to recognize the problem of improper technique results in increased communition & Malalignment of fracture. (SIZE OF CANAL) The size of the canal is important with resistance to insertion. Nail canal mismatch can be controlled. The nail diameter can be chosen to be less than the canal or the canal can be reamed to a larger diameter than the chosen nail. The stability of the construct will be less especially in torsion but with static locking this is overcome. Tight fitting nail or loose fitting nail will control mechanics of insertion, however with locking, there is really no need to risk forcing a truly tight nail into a canal. In order to increase the size of the canal diameter which increases fracture construct stability, it is necessary to ream.

 

 

(SIZE OF PROXIMAL FRAGMENT) However with a smaller proximal portion, the hoop stresses decrease as the mismatch is less & the proximal fragment is more flexible and better able to accommodate the potential increase in stresses. Working Length is the distance between 2 points of contact of the nail to the bone. Bending stiffness x 1/√wl. Torsion stiffness x 1/wl. WL is short in transverse fractures. WL is long in communited fractures. The complex fragmental fractures the WL is between 2 locking screw. (WORKING LENGTH) The working length is short in transverse fracture. The working length is long in communited fracture. In complex fragmented fractures the working length is between two locking screws. (FRACTURE REDUCTION TECHNIQUE) Reduction in fresh fractures is rarely a problem. However, for delayed nailing additional tools are needed. (FRACTURE REDUCTION TECHNIQUE) INDIRECT DIRECT Femur Tibia Towel Sling Manual

 

 

Racket Tourniquet Schanz Screw Distractors Tube to tube construct (FRACTURE REDUCTION TECHNIQUE) Principles of Schanz screw placement: Screw placement as close to fracture as possible. Unicortical insertion in proximal fragment. Bicortical insertion in distal fragment. Connection with T Handle for easier manipulation. (Orientation in sagittal plane is obtained by feeling the fragments touching each other) REAMING Indications: All Femur & Tibia fractures are reaming unless the patient is multiply injurer, has a pulmonary injury & has return in stock. Contraindications: INFLUENCES OF REAMING DESIGN Blunt reamers Small flutes High axial forces Increase diameter of reamer shaft (Increase pressure & temperature) Increase in risk of pulmonary embolism proportional to different reamer construction. (MECHANICAL EFFECTS) Increase canal diameter Increase contact area

 

 

Accurate size of canal (BIOLOGICAL EFFECTS) Endosteal circulation wiped out Periosteal injury response Systemic effect Reaming with insertion of tight fitting nail will kill upto 70% of the cortex of the bone over the reamed area. (LOCAL EFFECTS) Reversible endosteal damage top blood supply → infection & necrosis, of diaphyseal bone. Cortical necrosis due to heat. Increase in intramedullary pressure. Clogging of bone microcirculation secondary to local extravasation of reaming debris. Incarciration of the reamers. (GENERAL EFFECTS) Pulmonary embolism. Humoral. Neural Infumatory Evokes systemic response ARDS much common in polytrauma patients especially with lung injury. (ADVANTAGE) Enlarge canal. Better fit / stability. Larger / stronger implant. Reaming extrude into fracture site.

 

 

Stimulate bone healing by increasing blood flow to the periosteum. Improves mechanical properties of bone – implant interface by allowin larger diameter implant. In order to increase the size of the canal diameter which increases fracture construct stability it is necessary to ream. Reaming increases the area of contact between the nail & bone. (DISADVANTAGE) Rise in intramedullary pressure. Rise in intramedullary temperature causing devitalized critical layers and bone necrosis. NON REAMING Advantage: Decreased surgical trauma. Endosteal circulation less impaired. Disadvantage: Smaller nails. Decreased cortical contact. CONCLUSIONS Heavily utilized in diaphyseal fractures of long bones. I. M nailing is a form of relative stability. Because it is weak in torque it is very forgiving with regard to entry point. Reaming has mechanical & biological implications. Design features affect biomechanics. Fracture & implant dictate stability.

 

 

NAILING IN THE METAPHYSIS ASSOCIATED WITH ALALIGMENT Due to strong muscle pull & wide medullary canal leading to post fixation instability. Even with locking, blocking screws, placed adjacent to the nail. Prevent translation by decreasing width of the metaphyseal medullary canal forcing the nail to the centre of bone. And increasing the mechanical stiffness of bone - implant construct. Thus poller screw can be used for Alignment Stabilization Manipulation Poller screw is placed perpendicular to the direction in which the implant might displace. Shear forces are transformed into compression forces.

Anatomy & Biomechanics of hip Dr. Sharath K Rao, KIMC Manipal

 

ANATOMY OF THE HIP The hip is a classical ball-and-socket joint. It meets the four characteristics of a synovial or diarthrodial joint: it has a joint cavity; joint surfaces are covered with articular cartilage; it has a synovial membrane producing synovial fluid, and; it is surrounded by a ligamentous capsule. BONY ANATOMY The cup-shaped acetabulum is formed by the innominate bone with contributions from the ilium (approximately 40% of the acetabulum), ischium (40%) and the pubis (20%). In the skeletally immature these three bones are separated by the triradiate cartilage – fusion of this starts to occur around the age of 14 – 16 years and is complete usually by the age of 23. The actual articular surface appears a lunate shaped when viewed looking into the acetabulum. Within the lunate, or horseshoe shaped articular cartilage is a central area – the central inferior acetabular fossa. This fat filled space houses a synovial covered fat pad and also contains the acetabular attachment of the ligamentum teres. Inferior to this, the socket of the hip is completed by the inferior transverse ligament. Attached to the rim of the acetabulum is the fibrocartilaginous labrum. The labrum has been closely studied as tears of the labrum are the most common indication for hip arthroscopy. Although it makes less of a contribution to joint stability than the glenoid labrum in the shoulder it does serve its purpose. It plays a role in normal joint development and in distribution of forces around the joint. It has also been suggested it plays a role in restricting movement of synovial fluid to the peripheral compartment of the hip, thus helping exert a negative pressure effect within the hip joint. The labrum runs around the circumference of the acetabulum terminating inferiorly where the transverse acetabular ligament crosses the inferior aspect of the acetabular fossa. It attaches to the bony rim of the acetabulum and is quite separate from the insertion of the capsule. The labrum receives a vascular supply from the obturator and the superior and inferior gluteal arteries. These ascend in the reflected synovial layer on the capsule and enter the peripheral aspect of the labrum. It has been observed that

 

 

labral tears are most likely to occur at the junction of labrum and articular cartilage - this area has been termed the ‘watershed region’. The femoral head is covered with a corresponding articular cartilage beyond the reaches of the acetabular brim to accommodate the full range of motion. The covered region forms approximately 60 to 70% of a sphere. There is an uncovered area on the central area of the femoral head – the fovea capitis – for the femoral insertion of the ligamentum teres. The ligamentum teres, while containing a blood supply does not contribute to the stability of the joint. It is covered in synovium, so while it is intra-articular it is actually extra-synovial. The head of the femur is attached to the femoral shaft by the femoral neck, which varies in length depending on body size. The neck-shaft angle is usually 125±5° in the normal adult, with coxa valga being the condition when this value exceeds 130° and coxa vara when the inclination is less than 120°. The importance of this feature is that the femoral shaft is laterally displaced from the pelvis, thus facilitating freedom for joint motion. If there is significant deviation in angle outside this typical range, the lever arms used to produce motion by the abductor muscles will either be too small or too large. The neck-shaft angle steadily decreases from 150° after birth to 125° in the adult due to remodelling of bone in response to changing stress patterns. The femoral neck in the average person is also rotated slightly anterior to the coronal plane. This medial rotation is referred to as femoral anteversion. The angle of anteversion is measured as the angle between a mediolateral line through the knee and a line through the femoral head and shaft. The average range for femoral anteversion is from 15 to 20°. The neck is most narrow midway down the neck. Abnormalities in this area and the area adjacent to the articular surface, such as a prominence resulting from a slipped capital femoral epiphysis (SCFE), can upset the normal femoroacetabular articulation leading to Cam type impingement. Conversely, abnormalities of the acetabulum such as osteophyte formation, with increased cover of the femoral head can lead to Pincer type impingement. LIGAMENTS AND CAPSULAR ANATOMY

 

 

The joint capsule is strong. While the ball and deep socket configuration naturally gives the hip great stability the ligamentous capsule undoubtedly contributes significantly. The capsule is formed by an intertwining of three separate entities. The iliofemoral ligament can be seen anterior to the hip in the form of an inverted ‘Y’ or a modified ‘�’. It spans, in a spiralling fashion, from its proximal attachment to the ilium to insert along the intertrochanteric line. It is taught in extension and relaxed in flexion keeping the pelvis from tilting posteriorly in upright stance and limiting adduction of the extended lower limb. It is the strongest ligament in the body with a tensile strength greater than 350N. Inferior and posterior to the iliofemoral ligament, and blending into its medial edge, the pubofemoral ligament contributes to the strength of the anteroinferior portion of the capsule. This is perhaps the weakest of the four ligaments. Posteriorly the ischiofemoral ligament completes the main ligamentous constraints – from it ischial attachment medially it inserts laterally on superolateral aspect of the femoral neck, medial to the base of the greater trochanter. While the ligamentous capsule is very strong, two weak points can be noted - the first anteriorly between the iliofemoral and pubofemoral ligaments, and the second posteriorly between the iliofemoral and ischiofemoral ligaments. Although dislocation is rare in the native hip, with extreme external trauma the hip can dislocate through either of these weak points. MUSCULAR ANATOMY The geometry of the hip permits rotational motion in all directions, necessitating a large number of controlling muscles arising from a wide surface area to provide adequate stability. The 22 muscles acting on the hip joint not only contribute to stability but also provide the forces required for movement of the hip. Approaching the muscular anatomy around the hip can be undertaken in a number of ways. They can be divided into three groups: inner hip muscles, outer hip muscles and muscles belonging to the adductor group. The major flexor of the hip joint is iliopsoas. This comprises psoas major and minor, and iliacus. Psoas major arises from T12-L5 vertebral bodies and insets into the lesser trochanter. It is joined at the level of the inguinal ligament to form the iliopsoas. Iliopsoas is the most powerful hip flexor but it is also aided by sartorius, rectus femoris and tensor fascia latae (TFL). Sartorius, innervated by the femoral nerve, runs from ASIS to

 

 

insert medial to the tibial tuberosity. It also contributes to abduction and external rotation. Rectus femoris also arises from the ASIS and inserts into the tibial tuberosity by way of the patella ligament. The largest and most powerful extensor of the hip is gluteus maximus. It is also the most superficial. Running from the lateral aspect of the dorsal sacral surface, posterior part of the ilium and thoracolumbar fascia it inserts into the iliotibial tract and gluteal tuberosity on the femur. It is also involved in external rotation of the hip with innervations from the inferior gluteal nerve. Its upper and lower fibres contribute to abduction and adduction respectively. The principal abductors include gluteus medius and minimus. Lying beneath the fascia lata, the proximal insertion of gluteus medius into the iliac crest is almost continuous with it. From its broad based proximal attachment it appears like an upside-down triangle inserting into a relatively narrow base on the lateral aspect of the greater trochanter. Gluteus minimus is deep again to gluteus medius arsing proximally from the gluteal surface of the ilium and inserting deep to the gluteus medius on the anterolateral aspect of the greater trochanter - both gluteus medius and minimus are innervated by the superior gluteal nerve. The TFL runs from the ASIS inserting distally into the iliotibial tract. It is also a flexor of the hip joint and internally rotates it. Piriformis runs laterally from the pelvic surface of the sacrum to the apex of the greater trochanter of the femur. It also contributes to external rotation and extension of the hip. Posteriorly, inferior to the piriformis, are the short external rotators all running in a horizontal fashion. From superior to inferior, these consist of the superior gemelli, obturator internus, inferior gemelli, and quadratus femoris. All play a role in external rotation and adduction of the hip and all receive branches from L5-S1 in the sacral plexus. Hip adductors include the obturator externus arising from the outer surface of the obturator membrane and inserting into the trochanteric fossa. It also contributes to external rotation and has its innervation from the obturator nerve. The remaining muscles in this group variably have their proximal origin on the pubic bone and insert distally on the femur below the level of the lesser trochanter or in the case of gracilis into the pes anserinus medial to the tibial tubercle. Pectineus attaches at the

 

 

pectin pubis and inserts into the femur along the pectineal line and linea aspera. It also contributes to external rotation and some flexion. Adductor longus attaches medial to pectineus on the superior pubic ramus and inserts distally to the pectineus along the middle third of the linea aspera – it contributes to hip flexion up to 70°. Adductor brevis arises from the inferior pubic ramus and inserts proximal to adductor longus into the proximal one third of the linea aspera. Adductor magnus arises from the inferior pubic rami, ischial ramus and ischial tuberosity. It inserts distally into the medial lip of the linea aspera but also has a more tendinous insertion into the medial condyle of the femur. It contributes also to extension and external rotation. Adductor minimus runs from the inferior pubic ramus into the medial lip of the linea aspera also contributing to external rotation. Gracilis is the only adductor that inserts distal to the knee joint. It arises inferior to the pubic ramus below the pubis symphysis. All the adductors receive an innervation from the obturator nerve. Pectineus also has a supply from the femoral while the deep aspect of adductor magnus also has a supply from the tibial nerve. As previously stated, the muscles of the hip joint can contribute to movement in several different planes depending on the position of the hip, which is caused by a change in the relationship between a muscle’s line of action and the hip’s axis of rotation. This is referred to as the “inversion of muscular action” and most commonly manifests as a muscle’s secondary function. For example, the gluteus medius and minimus act as abductors when the hip is extended and as internal rotators when the hip is flexed. The adductor longus acts as a flexor at 50° of hip flexion, but as an extensor at 70°. BIOMECHANICS OF THE HIP In a single leg stance, the effective centre of gravity moves distally and away from the supporting leg since the nonsupporting leg is now calculated as part of the body mass acting upon the weight-bearing hip. Typical levels for single leg stance are three times bodyweight, corresponding to a level ratio of 2.5. Thus, anything that increases the lever arm ratio also increases the abductor muscle force required for gait

 

 

and consequently the force on the head of the femur as well. People with short femoral necks have higher hip forces, other things being equal. More significantly people with a wide pelvis also have larger hip forces. This tendency means that women have larger hip forces than men because their pelves must accommodate a birth canal. This fact may be one reason that women have relatively more hip fractures and hip replacements because of arthritis than men do. It is also conceivable that this places women at a biomechanical disadvantage with respect to some athletic activities, although studies do not always show gender differences in the biomechanics of running, particularly endurance running. The effective loading of the joint can be significantly reduced by bringing the centre of gravity closer to the centre of the femoral head. This can be accomplished by limping, however the lateral movements required take a considerable amount of energy and is a much less efficient means of ambulation. Another strategy to reduce joint reaction force involves using a cane or walking stick in the opposite hand. The moment produced from both the cane and abductor muscles together produce a moment equal and opposite to that produced by the effective body weight . The two-dimensional static analysis indicates that thejoint reaction force can be reduced by 50% (from 3 timesbody weight to 1.5 times body weight) when approximately 15% body weight is applied to the cane. The substantial reduction in the joint reaction force, predicted when a cane is used for support arises because the cane-ground reaction force acts at a much larger distance from the centre of the hip than the abductor muscles. Thus, even when a relatively small load is applied to the cane, the contribution it makes to the moment opposing body weight is large enough to significantly decrease the demand placed on the abductor muscles.

Patellofemoral instability Dr Sudharshan Bhandary AJIMS, Mangalore

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

02/07/11 10:14 AM