THE PHYSIS

THE OFFICIAL JOURNAL OF THEJK CHAPTER OF THE IOA

JUNE-2019

SYMPOSIUMTHE KNEEVOLUME-1 | ISSUE-2

THE PHYSIS

THE OFFICIAL JOURNAL OF THE JK CHAPTER OF THE

INDIAN ORTHOPAEDIC ASSOCIATION

PUBLISHED BY

THE JAMMU AND KASHMIR ORTHOPAEDIC ASSOCIATION

VOLUME-1 | ISSUE-2

THE PHYSIS

OFFICIAL JOURNAL OF THE JKOA

FIRST PUBLISHED BY THE JKOA IN 2019

Science and technology are constantly changing fields. New research and

experience broaden the scope of information and knowledge. The authors have

tried their best in giving information available to them while preparing the

material for this journal. Although all efforts have been made to ensure optimum

accuracy of the material, yet it is quite possible some errors might have been left

uncorrected. The publisher, the printer and the editors, will not be held

responsible for any inadvertent errors, omissions or inaccuracies.

Cover Credit: Master Hamza Hamid

JAMMU AND KASHMIR ORTHOPAEDIC ASSOCIATION

THE EDITORIAL

MESSAGE

EDITORIAL BOARD

THE JKOA EXECUTIVE BODY

PERSPECTIVE. GROWTH OF JKOA 01

PERSONALITY. GAVRIL ABRAMOVICH ILIZAROV 02

A SHORT REVIEW OF OSGOOD SCHLATTERS DISEASE 05

THE HIGH TIBIAL OSTEOTOMY. A REVIEW 11

MENISCAL INJURIES 17

THE PATELLAR FRACTURE 26

OSTEOCHONDRAL INJURIES 36

TECHNICAL TIP 44

CASE REPORT 46

NEWSLETTER SECTION. A LOOK AT THE PAST YEAR 49

INFORMATION FOR AUTHORS 58

C O N T E N T S

The Jammu Kashmir Chapter of the Indian Orthopaedic Association has had an eventful first year of its

existence. In pursuit of making the association well rounded, the association conducted its first two

conferences in Jammu and Kashmir over the last year. Both conferences elicited a warm response from the

delegates. Faculty from all over India participated in the conferences and the educational and teaching standard

was quite fulfilling.

The first issue of The Physis Journal also came out during this period. The journal is directly aimed at the young

and budding orthopaedic surgeons. The journal was put together by the editorial board and was very well

received. The JKOA decided to expand the editorial board to improve the vitality and quality of the ideas going

into the formulation of the journal. The result is the 2nd issue of the journal currently in your hands. The new

members of the board come from various institutes of India and will surely add to the value of the journal.

The process of constructing the first issue of the journal was interesting and educational. As we went back and

forth on ideas, the journal began to grow and take shape. Everything that we could discuss was pored over and

dissected. The second issue has also been the handiwork of the editorial board mainly. However, in the future

the JKOA members are expected to participate wholeheartedly in submitting review articles, case reports and

technical tips for enriching the future issues of this journal. A journal is only as good as its base of authors. The

address for submission is once again reproduced below.

This inaugural issue focused mainly on the foot and the ankle. In pursuit of the same methodology, this issue

has a small symposim on disorders around the knee. The thought process is that if one area is properly read

about, it would encourage the development of good all-round orthopaedic surgeons ultimately. In the future

issues we hope to continue the 'symposium' methodology.

We would definitely want to have some feedback from the readers about this. All of us are open to suggestions.

The journal includes a section which is a newsletter on the activities of the JKOA. We hope that you enjoy that

section too. Future contributions for this section are welcome too.

Our thanks to Sheen Graphics for the wonderful work they have put in.

We are thankful that we have been offered help by Systopic Labs in getting the Journal published.

We must take this opportunity to extend thanks to Mr. Shafiq Ahmad for the immense help he rendered in the

publication process.

The e-mail address for communication is thephysisjournal@gmail.com.

We would love to hear from you.

The Editorial Board

EDITORIAL

It is indeed heartening to note that the J & K Chapter is publishing the 2nd Issue of it’s Official Journal. I

believe that the Journal is the face of any Academic Association and I congratulate all members for the same.

The year 2018/19 has been an year of achievements for the J & K Chapter

1. 1st year of its official affiliation with the IOA

2. 1st J & K Chapter conference at Srinagar was successfully organised and I was fortunate to attend

3. 1st time participation in the Jhunjhunwala trophy for Best State Chapter with less than 400

members and Winning the 2nd prize.

4. 1st Official issue of the Journal

This speaks volumes of the commitment of Dr. Rajesh K Gupta as Secretary and Dr. Naseer Mir as

President and the contribution of all members at large.

Keep up the good work.

Enroll maximum members from your State into the mainstream IOA

Wishing you all the best and a Very Happy Healthy Prosperous and Joyous Year.

Warm Regards

Dr. Atul Srivastava

Hon. Secretary IOA

MESSAGE

Dr. Atul SrivastavaHon. Secretary IOA

MessageFROM THE SECRETARY IOA

EDITORIAL BOARD

CHIEF EDITORS

DR LOVI PADHA DR ALTAF KAWOOSA DR ABDUL GHANI

EXECUTIVE EDITOR

DR SHABIR A DHAR

ASSOCIATE EDITORS

DR SIDDHARTH SHARMA DR ASIF NAZIR BABA DR AGNIVESH TIKOO DR KHALID MUZAFFAR

JKOA EXECUTIVE BODY

PRESIDENT Prof N. A. Mir

VICE PRESIDENT Dr. Lovi Padha

Dr. AR Badoo Dr. Sanjeev Gupta

HON. SECRETARYProf Rajesh K Gupta

TREASURERDr. Manish Singh

Dr. I. K Wangnoo

EXECUTIVE MEMBERS

– 1 –

PERSPECTIVE

Dr. Rajesh Gupta

In the last couple of years our chapter has grown

exponentially with the efforts of all the worthy

members. From Nov. 2019 till date the number of

life members has increased from 135 to 150. We are

also having 25 associate members. I am very happy that academic activities now are

going on all over the state. Because of these activities

& growth of our chapter & also activities of our

members at the national & international level our

chapter has been awarded 2nd best chapter by Indian

Orthopaedic Association in the category of small

states ( Jhunjhunwala award). We will be getting the

award at IOACON at Kolkata in November 2019. It

is indeed a proud movement for all of us as we got

the award in the first year of our affiliation with the

IOA. We have to keep up this momentum & even

work harder so that we can bag first place this year.

Our 2nd annual conference was held in Jammu from

8th to 10th Feb 2019. It was a combined meeting

with the 38 th NZIOACON. Dr Anil Gupta was the

organising secretary. About 200 delegates attended

the conference. There were 5 preconference

workshops on clubfoot, pelvic acetabular fractures,

osteotomies in relation to hip, basic spine & total hip

replacement. The conference was inaugurated by Sh

Vijay Kumar, the health & medical education advisor

to the hon'ble governor of J&K. Dr Atul Srivastva

IOA secretary & Dr Manish Dhawan treasurer IOA

were our IOA representatives. There were two

orations. Dr Ashai Memorial oration was delivered

by Dr Ram Prabhu & Dr Pachnanda Memorial

oration was delivered by Dr SS Yadav.

During the conference website of JKOA was

launched ( http://www.jkoa.in).

The first issue of the official journal of JKOA

(PHYSIS) was also released during the conference.

Here I must acknowledge the great efforts of the

whole of the editorial team especially Dr Shabir

Dhar.

We also expanded our editorial board by including

Dr Agnivesh Tickoo, Dr Sidharath Sharma, Dr

Khalid Muzzafar & Dr Asif Nazir Baba.

We also constituted our medico legal & ethical teams

so that issues related to medicolegal & ethical aspects

of our members are taken care of.

Our next annual conference will be held in

Government Bone & Joint Hospital Barzulla

Srinagar in June 2020.

At last my sincere request to all the worth members

to contribute more for the growth of our chapter.

Thanks

Dr Rajesh Gupta

Growth of JKOA over the last year

[Dr Rajesh Gupta Works at the The Acharya Shri Chander Hospital Jammu]

– 2 –

PERSONALITY

Dr Shabir A Dhar, Dr Tarsem Lal

Gavriil Abramovich IlizarovThe Magician from Kurgan

Gavriil Abramovich Ilizarov was born a sixth

child to a poor Jewish peasant family in Poland

in June 1921. His initial years were hard. He

worked in the fields as he did not obtain any

formal education till 11 years of age. He

attended a vocational school after that which

was primarily meant to help the peasant

children. He excelled at school and in 1939

entered the Crimea Medical School in

Simferopol. After finishing the school in

1944 Ilizarov was sent to a rural hospital in

Dolgovka, a village in Kurgan Oblast in

Siberia, 2000 km east of Moscow. This area

had a large number of people who had been

wounded in the World War. These patients

had deformity, segmental bone defects, non-

union and osteomyelitis.

Under such difficult conditions, Ilizarov, who

had no formal surgical training had to face a

difficult choice of amputation or attempting

salvage. It was under these circumstances that

he developed the concept of 'distraction

osteogenesis'. As an orthopaedician with

minimal resources, he made use of whatever

was available in Kurgan to develop ingenious

methods of treatment of complicated

orthopaedic cases. The area had a tank

factory and a bicycle factory. Ilizarov's initial

constructs used tank tread material to make

rings and bicycle spokes as wires.

Serendipity led Ilizarov to discover the

existence of 'distraction osteogenesis'. While

treating a war veteran for a shortened tibia,

ilizarov placed an external fixator and did a

corticotomy. His intention was to lengthen the

bone whilst creating a defect. He intended to

fill the defect with bone graft once the

required length had been obtained. By

chance he forgot to remove the fixator

before proceeding on a vacation. On return

he got a radiograph done. To his surprise he

found that there was no gap and bone had

formed there.

In 1950s rumours about Ilizarov's methods

spread across Russia. People flocked to his

two-story hospital and he applied the law of

tension stress to the benefit of many patients.

Gradual traction on living tissues was found to

[Dr Shabir A Dhar and Dr Tarsem Lal Work at SKIMS MC Bemina]

– 3 –

stimulate and maintain the regeneration and

active growth of certain tissues. For long

time, Ilizarov faced skepticism, resistance

and political intrigues from the medical

establishment in Moscow which tried to

defame him as a "quack". However, the

steadily increasing statistics of successful

treatments of patients led to a growing fame

of Ilizarov throughout the country. He

became known among patients as the

"magician from Kurgan".

Despite such marvelous work, it took Ilizarov

decades to be recognized for his work. His

breakthrough moment in terms of fame came

in 1968 when he treated Valery Brumel, a

world record holder and gold medalist high

jumper for stiff non-union of the tibia and

lengthened it by 3.5 cm. it is worthwhile to

remember that Brumel had spent about three

years for unsuccessful treatments in various

clinics and underwent seven invasive and 25

non-invasive surgeries. This catapulted

Ilizarov into fame in the medical circles in

USSR. However, the technique could not

reach the outside world due to the Iron

curtain.

Another chance interaction opened up this

methodology to the western world. Thor

Heyerdahl a Norwegian explorer wanted to

prove that there were contacts between the

Mesopotamian and the Indus valley

civilizations. He assembled a crew of three

people Carolo Mauri from Italy and Yuri

Senkevich from Soviet Union. Carolo Mauri

suffered from stiff non union of the tibia.

On urgings by Senkevich, Mauri travelled to

Kurgan n 1980 during the Cold War in the

Soviet Union. He was treated by Ilizarov for a

tibial fracture that healed incorrectly after a

skiing accident ten years earlier. Italian

doctors had long given up hope of any

surgical improvement to the leg. Ilizarov

distracted the stiff non-union in his tibia by 2

cm, healing the pseudarthrosis, corrected an

equinus deformity by distraction and

lengthened his leg. Mauri dubbed Ilizarov

"the Michelangelo of Orthopaedics". In the

meantime he was made the Director of the

Kurgan Research Institute for experimental

and clinical orthopaedics and trauma in 1971.

Italian surgeons were so impressed with this

that they invited Ilizarov to speak at the Italian

AO conference in Bellagio. It was the first time

that the outside world heard about Ilizarov. At

the end of the lectures, Ilizarov earned a ten-

minute standing ovation. After this the

Ilizarov methodology spread rapidly to the

rest of the world. While Codivilla, Putti and

Wagner were already working on limb

lengthening, it was Ilizarov who made it an

absolute science. He discovered the law of

tension stress, the principle of distraction

osteogenesis and taught us the rate and

rhythm of distraction.

Bibliography

1. Gavriil A. Ilizarov. Transosseous Osteosynthesis.

Theoretical and Clinical Aspects of the Regeneration

and Growth of Tissue. Translated by Stuart A. Green.

Springer, Berlin, Heidelberg, New York, 1992, ISBN 3-

540-53534-9. New edition 2011, ISBN 978-3642843907.

2. "Small Bone Innovations, Inc. Extends its Exclusive

– 4 –

Training Agreement with Russian Ilizarov Scientific

Center for an Additional 5 Years". China Weekly News.

17 August 2010. Archived from the original on 28 March

2015.

3. Svetlana Ilizarov (2006). "The Ilizarov Method: History

and Scope". In S. Robert Rozbruch and Svetlana Ilizarov

(eds.). Limb Lengthening and Reconstruction Surgery.

CRC Press. pp. 3–6

4. Christian Jürgens, Hergo Schmidt, U. Schümann, B.

Fink: Der Ilisarow-Ringfixateur und seine technische

Anwendung. Der Unfallchirurg 95 (1992), p. 529–533.

5. Klaus Seide, Dietmar Wolter : Universe l l e

dreidimensionale Korrektur und Reposition mit dem

Ringfixateur unter Anwendung der Hexapod-

Anordnung. Der Unfallchirurg 99(1996), p. 422–424.

– 5 –

BACKGROUND

In 1903, Robert Osgood (1873-1956), a US

orthopedic surgeon, and Carl Schlatter

(1864-1934), a Swiss surgeon, concurrently

described the disease that now bears their

names. Osgood-Schlatter disease (OSD) is a

common causes of knee pain in active

adolescents.

INTRODUCTION

OSD is a traction phenomenon resulting

from repetitive quadriceps contraction

through the patellar tendon at its insertion

upon the skeletally immature tibial tubercle

[1]. This occurs in preadolescence during a

time when the tibial tubercle is susceptible to

strain. A similar process can occur at the

patella-patellar tendon junction, which is

referred to as Sinding-Larsen-Johansson

syndrome (the adolescent equivalent of

jumper's knee). The primary cause of this

condition is the stress from the patellar

tendon at its point of insertion [2, 3]. In a

recent study, the shortening of the rectus

femoris muscle was also reported to be one

of the main factors associated with the

presence of OSD in adolescents.

The injury mechanism in adults is usually

related to the direct impact on the tubercle,

rather than contraction of the quadriceps as

seen in adolescents [4].

ETIOLOGY

Because of a lack of a precise etiology and

therefore definition, some practitioners may

find differentiating OSD from avulsion

fractures of the tibial tubercle to be difficult.

In general if the patient is unable to

ambulate, an acute avulsion fracture of the

tibial tubercle is more likely. OSD patients

typically can ambulate, albeit with pain.

There is a partial loss of continuity of the

patellar tendon-cartilage-bone junction of

the tibial tuberosity. An inflammatory

process starts in the region and ends with

patellar tendinitis, multiple subacute

fractures, ir regular ossification with

underlying bone. When an individual with an

injured t ibial tubercle continues to

participate in sports, more and more

REVIEW ARTICLE

Prof NA Mir, Prof Rajesh Gupta, Dr Lovi Padha

A Short Review of Osgood Schlatters Disease

[Prof. NA Mir Works at the SKIMS Medical College Bemina, Prof. Gupta Works at the Acharya Shri Chander Hospital Jammu and Dr. Lovi Padha works at the JK Medcity Jammu]

– 6 –

microavulsions develop, and the reparative

process may result in a markedly pronounced

prominence of the tubercle, with longer-

term cosmetic and functional implications. A

separated fragment may develop at the

patellar tendon insertion and may lead to

chronic, nonunion-type pain.

In a magnetic resonance imaging (MRI)

study of 20 patients with OSD, the patellar

tendon was noted to attach more proximally

and in a broader area to the tibia in patients

with OSD [5]. Approximately 50% of

patients with OSD relate a history of

precipitating trauma.

EPIDEMIOLOGY

OSD is the most common apophysitide

disorder among children and its incidence

has been reported at 21% among adolescent

athletes compared to only 4.5% among non-

athletes. One Finnish study found that OSD

affected 13% of athletes. [6,7].

OSD occurs more frequently in boys, with a

male-to-female ratio of 3:1.

OSD usually is seen in the adolescent years,

after a patient has undergone a rapid growth

spurt the previous year. Girls who are

affected are typically aged 10-11 years but

can range from age 8-12 years. Boys who are

affected are typically aged 13-14 years but

can range from age 12-15 years [8].

It is bilateral in 30-40% cases [4].

CLINICAL FEATURES

Osg ood-Sch la t te r d i sease i s eas i l y

recognized in the adolescent with complaints

of pain which is localized to the area of the

tibial tubercle. Discomfort is usually

generated with running, kneeling, ascending

or descending stair [9,10].

Weakness of the quadriceps and pain on

resisted knee extension are common signs, as

is an enlarged tubercle. D'Ambrosia and

MacDonald report reproduction of pain

with passive knee flexion, which Jakob et a1.

attribute to a hypertrophied quadriceps

group exhibiting decreased flexibility

[11,12,13, 14,15, 16]. Tenderness, swelling,

thickening of the patellar tendon and

enlargement of the tibial tuberosity are often

observed during physical examination.

Patients may walk with an antalgic gait.

During palpation, a firm mass (bone

irregularities) is often observed in chronic

conditions. Acute cases may present with an

extensor lag. There is no sign of effusion or

instability, and passive range of motion in the

knee is full. The frequency of quadriceps and

hamstring muscle tightness is common

[17,18].

The differential diagnosis of OSD includes

osteochondri t is dissecans, S inding-

Larsen–Johansson syndrome, patella-

femoral syndrome, patellar dislocation or

subluxation, chondromalacia patellae,

avulsion fracture of the tibial tuberosity, pes

anserinus bursitis, tumor and infection. If

the pain is worse at night or during rest, a

differential diagnosis should be considered.

They should be accreted with a detailed

– 7 –

history, focused physical examination and

radiography of the patient [19,20].

RADIOLOGY

The lateral radiograph is most helpful in

evaluating the extensor mechanism.

Radiological evaluation may indicate

superficial ossicle in the patellar tendon, soft

tissue swelling anterior to the tibial tuberosity

and thickening of ligamentum patellae.

Ultrasound (US), magnetic resonance

imag ing (MRI ) and compu te r i z ed

tomography (CT) are other imaging

modalities used for the diagnosis of OSD.

US may show the thickened patellar tendon

better than plain radiography. It can also

d e m o n s t r a t e p r e t i b i a l s w e l l i n g ,

fragmentation of the ossification center and

excessive fluid collection in the infrapatellar

bursa [3].

In MRI, T2-weighted imaging, increased

hyperintense irregular signal intensity

superior to epiphyseal line in the proximal

part of the tibia can be viewed. It may play a

role in the future in the staging of the disease

and prognosticating the clinical course, as the

role of MRI in diagnosis, prognostication

and management is currently limited [2].

TREATMENT

Numerous inter ventions have been

proposed in the literature for the treatment

of OSD. Unfortunately, scarce evidence is

available from randomised clinical trials and

systematic reviews to support physical

therapy interventions while lesser quality

studies and expert opinions abound [21].The treatment of OSD is guided by the

severity of the symptoms. OSD is a self-

limited disease and generally ceases with

skeletal maturity. Improvement can be

gradual.

The condition may recur for 12–18 months

before complete resolution at skeletal

maturity. This correlates with the closure of

the apophysis.

1. Stretching. With a systematic

review and mult iple exper t

opinions, there is strong evidence

to support the use of stretches for

tight musculature secondary to

OSD in the literature. To address

both the anterior and posterior

knee musculature, several experts

also recommend stretching both

the hamstrings and quadriceps or

stretching in general [22,23]. 2. Quadriceps strengthening is

recommended in Antich and

Brewster's systematic review of

the literature in which they state

t h a t i s o m e t r i c q u a d r i c e p s

exercises, straight leg raises, and

short arc quadriceps sets should be

considered standards of care. It is

noted again that exercises should

be performed only if they are pain

free to decrease the risk of an

avulsion fracture during treatment

[24,25].

3. Knee orthosis. In a case series of

– 8 –

17 patients and 24 knees, Levine

and Kashyap, reported successful

management of OSD using an

infra-patella strap worn during

active periods of the day after 6–8

weeks of use [7]. Two knee

orthoses, the patellofemoral knee

orthoses with an H buttress and

the infra-patel la half-moon

buttress, are also recommended

and specially designed for relief of

symptoms associated with OSD

[26].

4. Iontophoresis. The literature

p rov ides s t rong bu t da ted

evidence for iontophoresis. Antich

and Brewster's (1985) systematic

review noted that iontophoresis

aides pain relief in the tibial

tubercle area. Antich and Brewster

(1985) recommended initiating a

maximum trial period of three

treatments with a 20 minute

duration up to 5.0 milliamps (mA)

e v e r y o t h e r d a y w i t h

d e x a m e t h a s o n e - s o d i u m -

phosphate and 1 cc HCl injected

over the positive electrode to

determine the effectiveness of

treatment before proceeding [24].

5. Patient education. These include:

rest; activity modification; heat

modalities for warm-up; cold

modalities after aggravating

a c t iv i t i e s f o r o e d e m a a n d

inflammation and proper shock-

absorbent footwear. As such, the

therapist should educate their

clients on these topics to improve

both prognosis and function [24].

6. A l t h o u g h c o n s e r v a t i v e

m a n a g e m e n t h a s b e e n

conventional ly favored, for

patients who have intolerable

symptoms, surgical intervention

can be successful [27,28].

7. No prospective, interventional

studies evaluate the treatment of

Osgood-Schlatter disease. One

case series followed the natural

course of the disease in 261

patients (365 symptomatic knees)

for 12 to 24 months; 237 (90.8%)

pat ients responded wel l to

restriction of sports activity and

nonsteroidal anti-inflammatory

agents. The 24 patients who did

not improve with conservative

measures underwent surgical

excision of ossicles, and all

returned to normal activities

(mean time, 4.5 weeks) [5].

8. Refractory cases have been treated

w i th a va r i e t y o f su rg i c a l

interventions. In 1 case series, 67

patients (70 knees) (mean age 19.6,

77% male) with at least 18 months

of symptoms despite conservative

treatment underwent resection of

an ossicle (62 cases) or excision of

– 9 –

prominent tibial tubercle (8 cases).

These patients were followed for

2.2 years, with 56 (90%) patients

with ossicle-resection able to

return to maximal sports activity

without pain, tenderness, loss of

motion, or atrophy [29].

9. Another case series compared 22

patients who1 underwent drilling

of the tibial tubercle (with or

without the removal of the tibial

tubercle) with 22 patients who had

excision of loose ossicles or

cartilage. Seventeen of the 22

(77%) patients with ossicle

excision had complete resolution

of symptoms compared with 8 of

the 22 (36%) in the patients who

underwent tibial tubercle drilling

[30].

10. T h e t w o m o s t c o m m o n

procedures performed are ossicle

excision and tibial tubercle

prominence resection [31]. Ossicle

removal is supposed to be the best

method in the surgical treatment

o f O S D [ 3 2 ] . T u b e r c l e

prominence resection has also

shown good results in recalcitrant

cases [33] . Procedures that

promote early fusion of the

apophysis of the tuberosity to the

diaphysis, such as pegging the

tubercle to the tibial metaphysis

with autogenous bone graft or

drilling the tuberosity, have not

been recommended.

11. DeBerardino et al. recommended

an arthroscopic technique with

recalcitrant OSD lesions. They

revea led two pat ients wi th

excellent short-term results [34].

CONCLUSION

OSD is a self-limiting condition which

occurs commonly in adolescence. Patients

who have a history of a rapid spurt of

growth and participate in intense sports in

their early age present with anterior knee pain

during activities. Conservative treatment IS

efficient in the acute stage. However

symptoms may continue in severe cases. It

may affect patients' daily activity and reduce

performance in sports. There has been a

reported successful experience about

surgical treatment of unresolved OSD

patients.

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magnetic resonance investigation. J Pediatr Orthop B

13(6):379–382

3. Hirano A, Fukubayashi T, Ishii T, Ochiai N (2002)

Magnetic resonance imaging of Osgood–Schlatter

disease: the course of the disease. Skeletal Radiol

31(6):334–342

4. de Lucena GL, dos Santos Gomes C, Guerra RO

(2011) Prevalence and associated factors of

Osgood–Schlatter syndrome in a population-based

sample of Brazilian adolescents. Am J Sports Med

39(2):415–420.

– 10 –

5. Hussain A, Hagroo GA. Osgood-Schlatter disease.

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6. Kaeding CC, Whitehead R (1998) Musculoskeletal

injuries in adolescents. Prim Care: Clin Office Prac 25(1):

211–23.

7. Levine J, Kashyap S (1981) A new conservative

treatment of Osgood-Schlatter disease. Clin Orthop

Relat Res (158): 126–8

8. Kujala UM, Kvist M, Heinonen O (1985) Osgood-

Schlatter's disease in adolescent athletes. Retrospective

study of incidence and duration. Am J Sports Med 74(4):

431-436.

9. Katz JF: Nonarticular osteochondroses. Clin Orthop

158:70-76. 1981

10. Mital MA, Matza RA: Osgood-Schlatter disease: The

painful puzzler. Phys Sportsmed 560-73, 1977.

11. Mital MA, Matza RA, Cohen J: The so-called

unresolved Osgood- Schlatter lesion. J Bone Joint Surg

(Am) 62:732-739, 1980.

12. Grass AL: Treatment of Osgood-Schlatter injury. JAMA

240:212- 213. 1978

13. Smillie IS: Injuries to the Knee Joint, Ed. 5. Edinburgh:

Churchill Livingstone. 1978

14. D'Ambrosia RD, MacDonald GL: Pitfalls in the

diagnosis of Osgood-Schlatter disease. Clin Orthop 11

0:206-209, 1975

16. Jakob RP. Von Gumppenberg S. Engelhardt P: Does

Osgood-Schlatter disease influence the position of the

patella? J Bone Joint Surg (Br) 63579-582, 1981

17. Gholve PA, Scher DM, Khakharia S, Widmann RF,

Green DW (2007) Osgood Schlatter syndrome. Curr

Opin Pediatr 19(1):44–50

18. Cakmak S, Tekin L, Akarsu S (2014) Long-term

outcome of Osgood–Schlatter disease: not always

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23(10):1127 e1121–1127 e1123

– 11 –

REVIEW ARTICLE

Dr Tahir A Dar, Prof Naseer A Mir, Prof Saheel Maajid, Prof JA Bhat

The High Tibial Osteotomy.

A Brief Review

[All Authors Work at the SKIMS MC Bemina Srinagar Kashmir]

INTRODUCTION

The high tibial osteotomy [HTO] is a

p r o c e d u r e t o a d d r e s s t h e m e d i a l

compartment osteoarthritis of the knee.

High tibia osteotomy (HTO) is intended to

transfer the mechanical axis from medial to

slightly lateral to the midline of the knee to

decrease the load and subsequently delay the

progress of osteoarthritis (OA). The

procedure was introduced by Jackson and

Waugh in 1961 [1]. However, the procedure

became popular after Coventry described it

in 1965 [2]. Many techniques have been

developed (i.e. closing wedge, opening

wedge, dome and 'en chevron' osteotomies),

but opening (medial) and closing (lateral)

wedge osteotomies are the most commonly

used [3,4]. In all methods a partial unloading

of the medial compartment with a slight

overcorrection of the mechanical axis (from

6 to 10° of valgus) is aimed for. Shaw and

Moulton [5], in their biomechanical cadaver

study, showed that to obtain a complete

medial compartment unload the valgus

correction should be at least 25°. Even

though the efficacy of HTO is accepted

worldwide, there are still some debated issues

about osteotomies. These include the choice

between opening or closing wedge tibial

osteotomy, the graft selection in opening

wedge osteotomies, the type of fixation, the

comparison with unicompartmental knee

arthroplasty (UKA) and whether HTO

affects a subsequent total joint replacement

(TKR) [6].

INDICATIONS

There are some evidences that stretch the

indications to ankle problems in patients

who have pain and instability because of a

varus ankle malalignment [7]. Other

indications in the presence of varus knee are

meniscal transplantation after total medial

meniscectomy, isolated chondral defect in

the medial compartment of a varus knee,

secondary degenerative arthritis in a varus

knee with medial joint line pain, and

ligamentous instability with varus thrust in

– 12 –

which correction of the varus deformity

unloads the reconstructed ligament while it

heals [8,9,10,11,12]. It, however goes without

saying that the main indication for HTO is

medial compartment osteoarthritis.

The review of the literature shows that some

conditions are correlated with a poorer

prognosis and these include:

(1) severe articular destruction (III

or more according to the

Ahlbäck classification)

(2) advanced age

(3) patellofemoral arthrosis

(4) markedly decreased range of

motion [13, 14]

(5) p r e v i o u s a r t h r o s c o p i c

débridements

(6) joint instability [15,16]

(7) lateral tibial thrust [15,16]

Most authors agree that HTO is more

appropriate than unicompartmental knee

arthroplasty for overweight patients, but the

influence of body mass index on the results

of HTO remains controversial [15].

The ideal candidate for HTO is an individual

who is between 60 to 65 years of age with

isolated medial osteoarthritis with a varus

deformity and good range of motion (ROM)

and without ligamentous instability [17].

TYPES OF OSTEOTOMIES

Jackson and Waugh in 1961 involved division

and removal of the head of the fibula, with a

subsequent dome osteotomy below the level

of the tuberosity, and immobilization in a

full-length plaster cast [1].

Coventry presented on a new stepped staple,

to overcome the previous issues with

conventional staples being unable to fully

engage the distal end of the osteotomy site

[2].

Different techniques later developed include

the development of a special blade plate,

leaving the anterior cortex of the distal

fragment and the posterior cortex of the

proximal fragment intact to create an

interlocking effect at the osteotomy site,

elevation of the tibial tuberosity, and oblique

osteotomies for oblique plain corrections.

Leaving a hinge of bone intact increases

stability of the osteotomy site but can also

have effects on the tibial slope after bony

union. However, the lateral closing wedge

procedure requires a fibular osteotomy or a

release of the proximal tibiofibular joint,

which can resu l t in neurovascu la r

complications. Lateral bone resection can

cause shortening of the lower limb. In

addition, stem impingement or metal

augmentation is unavoidable in a subsequent

total knee replacement due to the proximal

tibial deformity and bone loss of the lateral

condyle. [18,19,20,21,22,23]

The lateral closing wedge osteotomy has

gradually given way to the Medial open

wedge HTO technique. This technique has

been claimed as being technically easier, with

reproducible and predictable correction of

– 13 –

malalignment, good maintenance of bone

stock, and lower risk of injury to the peroneal

nerve. However, the technique has been

associated with high nonunion rates, long

period of weight-bearing restriction, and leg

lengthening. [24,25,26,27]

Chevron osteotomy is a procedure in which

an inverse V-shaped bone cut is made, a

lateral wedge is inserted medially, and rigid

metal plate fixation is performed. Although

this technique does not cause bone loss or

require bone grafting, it has not been

frequently employed due to its technical

difficulty and invasiveness. The progressive

callus distraction is performed through an

opening wedge osteotomy and external

fixation using an axial or ring fixator.

PLANNING

Patient factors. Patient's age, career, level of

activity, previous history of surgery on the

knee, and expectation should be taken into

consideration before deciding upon surgery.

Closing wedge HTO may be more effective

in heavy smokers.

Radiographic assessment. Bilateral weight-

bearing anterior-posterior views in full

extension, tunnel views with the knee in 30

degrees of flexion, Rosenberg views with the

knee in 45 degrees of flexion, lateral views,

and skyline views. The severity of medial

osteoarthritis and bone loss can be evaluated

from the anterior-posterior views and

patellar height can be measured from the

lateral views using InsallSalvati, Blackburne-

Peel, or Caton-Deschamps index [28].

Correction assessment. Fujisawa et al

reported that the postoperative mechanical

axis should pass through the lateral one third

of the tibial plateau [14]. Jakob and Jacobi

suggested that correction of the mechanical

axis depends on the thickness of the cartilage

in the medial compartment: if one third of

the medial cartilage is lost, the mechanical

axis should pass 10-15% lateral from the

center of the tibial plateau; if two thirds of

the cartilage is lost, the axis should pass 20-

25% lateral; and if all is lost, the axis should

pass 30-35% lateral [30].

CARTILAGE REGENERATION

Studies indicate that a correction of

malalignment of the knee is beneficial for the

recovery and maintenance of articular

cartilage, even without additional cartilage

restoration procedures. As such, it has been

thought that correction of malalignment of

the knee is closely related to the success of

cartilage restoration procedures of the knee.

It is with this concept that various studies

have been conducted to investigate the

functional outcomes and success of cartilage

restoration techniques when intrinsic

malalignment of the knee has been corrected

in the same setting. The wide-ranging types

of cartilage restoration procedures set the

premise for interesting studies based on

various permutations of such techniques

along with an HTO [31,32,33].

– 14 –

POSTERIOR TIBIAL SLOPE AND

PATELLAR HEIGHT

Lateral closing wedge osteotomy causes an

elevation of the tibial tuberosity due to

shortening of the proximal tibia during the

procedure, which increases patellar height

and is useful for patella baja [34]. Medial

opening wedge osteotomy causes a decrease

in patellar height because the tibial tuberosity

is lowered due to opening of the proximal

tibia during the procedure [35]. Lateral

closing wedge osteotomy can result in a

decrease in posterior tibial slope that causes

hyperextension and overload on the

posterior cruciate ligament (PCL), which

contributes to reduction in anterior

instability. Medial opening wedge osteotomy

heightens the likelihood of increased

posterior slope that restricts extension and

causes overload on the ACL. Accordingly,

this procedure is recommended in knees

with chronic PCL injuries and posterolateral

instability that has been inversely correlated

with posterior tibial slope.

COMPLICATIONS

The following complications are known to

occur in high tibial osteotomy.

1. Fracture of the medial or lateral

hinge

2. Intraarticular fracture

3. Non union in open wedge

osteotomy is reported to be 0.7-

4.4%

4. Patella infera secondary to

contracture

5. The incidence of common

peroneal nerve palsy caused by

nerve damage during HTO is 2-

16% and fibular shaft osteotomy

(at 15 cm distal to the fibular

head) can be useful for reduction

of such damage. The reported

rate of infection following

external fixation is 2.3-54.5%,

whereas that of infection

following internal fixation is

≤ 4 % . O t h e r p o s s i b l e

complications include fixation

failure, loss of correction,

pseudoarthrosis, deep venous

t h r o m b o s i s , p u l m o n a r y

embolism, and compartment

syndrome [34].

OUTCOMES

G ood long-term results are closely related

to correct patient selection, surgical

technique, rigid fixation, and postop

protocol. Ten-year survival rates for closed

wedge osteotomy were reported from 51%

by Naudie et al to 93.2% by Koshino et al

(15,32,36,37). The best results by Koshino

was related to some post operation factors

including no flexion contracture, valgus

anatomical angle of 10°, and concomitant

patellofemoral decompression procedure if

indicated.

– 15 –

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(2006) A 12–28-year followup study of closing wedge

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(2008) Long-term outcome after high tibial osteotomy.

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15. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ

(1999) TheInstall Award. Survivorship of the high tibial

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16. Rudan JF, Simurda MA (1990) High tibial osteotomy.

Aprospective clinical and roentgenographic review. Clin

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tibial osteotomy in the varus knee. J Am Acad Orthop

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18. Koshino T, Morii T, Wada J, Saito H, Ozawa N,

Noyori K. High tibial osteotomy with fixation by a blade

plate for medial compartment osteoarthritis of the knee.

Orthop Clin North Am 1989;20:227-43.

19. Ogata K. Interlocking wedge osteotomy of the proximal

tibia for gonarthrosis. Clin Orthop Relat Res

1984;186:129-34.

20. Putnam MD, Mears DC, Fu FH. Combined maquet

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21. Williams AT. Tibial realignment by oblique wedge

osteotomy. A new method based on accurate

measurement. Int Orthop 1986;10:171-6.

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Bone Joint Surg Am 1984;66:1040-8.

24. Chae DJ, Shetty GM, Wang KH, Montalban AS Jr.,

Kim JI, Nha KW. Early complications of medial

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26. Brinkman JM, Lobenhoffer P, Agneskirchner JD,

Staubli AE, Wymenga AB, van Heerwaarden RJ.

Osteotomies around the knee: Patient selection, stability

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Bone Joint Surg Br 2008;90:1548-57.

27. Wright JM, Crockett HC, Slawski DP, Madsen MW,

Windsor RE. High tibial osteotomy. J Am Acad Orthop

Surg 2005;13:279-89.

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measurement of patellar height: a review of the methods

of imaging. J Bone Joint Surg Br. 2010;92:1045-53

29. Fujisawa Y, Masuhara K, Shiomi S. The effect of high

tibial osteotomy on osteoarthritis of the knee. An

arthroscopic study of 54 knee joints. Orthop Clin North

Am. 1979;10:585- 608.

30. Jakob RP, Jacobi M. Closing wedge osteotomy of the

tibial head in treatment of single compartment arthrosis.

Orthopade. 2004;33:143-52.

31. Kanamiya T, Naito M, Hara M, Yoshimura I. The

influences of biomechanical factors on cartilage

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32. Koshino T, Wada S, Ara Y, Saito T. Regeneration of

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the knee. Knee 2003;10:229-36.

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Südkamp NP, Köstler W. Open-wedge osteotomy

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34. Hohmann E, Bryant A, Imhoff AB. The effect of

closed wedge high tibial osteotomy on tibial slope: a

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Arthrosc. 2006;14:454-9.

35. Wright JM, Crockett HC, Slawski DP, Madsen MW,

Windsor RE. High tibial osteotomy. J Am Acad Orthop

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36. Aglietti P, Buzzi R, Vena LM, Baldini A, Mondaini

A. High tibial valgus osteotomy for medial gonarthrosis:

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37. Billings A, Scott DF, Camargo MP, Hofmann AA.

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– 17 –

REVIEW ARTICLE

Dr. Khalid Muzzafar, Dr. Muhammad Haseeb

Meniscal Injuries: A Review

Dr Khalid Muzaffar Works as Assistant Professor and Head, Department of Orthopaedics, GMC Doda. Dr Muhammad Haseeb Works as Speciality Registrar, Department of Orthopaedics Royal London Hospital, London.

INTRODUCTION:

Meniscal injuries are a common cause for

pain and functional impairment of the knee

joint. Initially it was thought that meniscus

was a unnecessary appendage and could be

sacrificed.[1] it was only after Fairbank

described radiographic changes in the knees

following menisectomy and poor results of

total meniscectomy that conservative

approach towards meniscal injuries was

considered.[2] This meniscal preservation

lately has led to development of new surgical

techniques to restore the native structure of

the meniscus so as to restore function and

biomechanics of the knee. Meniscal tear

surgeries are among most common surgical

procedures performed in orthopaedics.

ANATOMY:

On gross examination menisci are smooth,

lubricated tissue. They are crescent-shaped

wedges of fibrocartilage located on the

medial and lateral aspects of the knee joint.

The wedges are flat on the tibial side and

concave on the femoral side to accommodate

the femoral articular surface. The peripheral

one third of the wedge is thick and vascular

often called as Red zone, the wedge tappers

on inner border and is avascular in inner two

thirds, also referred to as white zone (Figure

1).[3] Both menisci differ from one another

in shape.

Medial meniscus: The medial meniscus is

C shaped and occupies about 50% of the

area of the medial compartment. The

anterior horn of medial meniscus is attached

firmly to the tibia anterior to the anterior

cruciate ligament (ACL). The posterior horn

is attached in front of the attachment of the

posterior cruciate ligament (PCL). The outer

border of the medial meniscus merges with

the knee joint capsule making it less mobile

and prone to injuries. The coronary ligament

attaches the meniscus to the upper tibia.

Fig. 1

– 18 –

Lateral meniscus: The lateral meniscus

covers 70% of the lateral tibial plateau. The

transverse (intermeniscal) ligament attaches

the anterior horns of the lateral and medial

menisci. The posterior horn of the lateral

meniscus is attached to the PCL and medial

f e m o r a l c o n d y l e t h r o u g h t h e

meniscofemoral ligaments of Wrisberg (the

posterior meniscalfemoral ligament) and

Humphrey (the anterior meniscal-femoral

ligament). It is also attached to the popliteus

tendon.[4] The lateral meniscus is more

mobile and is not anchored to the lateral

collateral ligament. The anchor of the lateral

meniscus to the femur and the popliteal

tendon couples its motion with that of the

femoral condyle during rotation. It is

therefore less likely to be injured. Discoid

lateral meniscus is a variant of lateral

meniscus. It was thought to be due to

developmental arrest, however Clark and

Ogden proved otherwise.[5] Discoid

meniscus have been classified into complete,

incomplete and the Wrisberg type. Complete

and incomplete have good posterior

anchorage, while Wrisberg lacks posterior

anchorage. Discoid meniscus causes a

snapping or popping knee.

The main function of the menisci is

tibiofemoral load transmission, shock

absorption, and lubrication of the joint.[6]

The menisci compensate for significant

incongruity between the femoral and tibial

articulating surfaces. The human menisci

transmit 30–55% of the load in a standing

position.6 After meniscectomy, tibiofemoral

contact area decreases leading to contact

stresses these changes ultimately cause joint

degeneration. They also help to distribute

synovial fluid throughout the joint and aid in

the nutrition of the articular cartilage. The

menisci also contribute to the stability of the

knee, largely as secondary soft tissue

restraints which prevent anterior tibial

displacement.

CLINICAL PRESENTATION:

The meniscal injuries have a bimodal age

distribution in young active sports person

and in elderly people. In young people most

common reason is a non contact sports

injury which occurs while decelerating,

rotating on knee, or landing and jumping on

the knee. However in old age tear is mostly

degenerative with patient unaware of it until

mechanical symptoms occur. Locking,

buckling, catching are suggestive symptoms

of a meniscal injury. Some patients may even

claim to have heard popping sensations

during injury. Swelling often occurs a day or

two later, immediate swelling usually is a sign

of bleeding into the knee. The swelling

associate with the meniscal injury may be

recurrent. Most of the symptoms are non

specific.

Clinical evaluation starts with the gait

examination, a painful limp is usually present

more so in acute injuries. Care should be

taken to access thigh muscle wasting, knee

joint effusion and joint line tenderness.

Proper examination for ligamentous and

– 19 –

other soft tissue injuries should be done to

rule out injury to these structures. The

stability of the knee should be assessed for

concurrent ligamentous injury.

Following specific tests for meniscal injuries

have been described.

McMurray test: with patient supine, hip and

knee is flexed, medial meniscus is accessed by

external rotation of foot and extension of

knee, while lateral meniscus is accessed by

internal rotation of foot and extension of

knee. Feeling of a clunk is considered a

positive test. A specificity of 100% is

reported with this test.[7]

Apley's Grind test: This test is used to

d i s t ingu i sh be tween men i sca l and

ligamentous involvement. With the patient in

a prone position, the knee flexed at 90°, and

the leg stabilized by the examiner's knee,

distract the knee while rotating the tibia

internally and externally. Pain during this

m a n e u v e r i n d i c a t e s l i g a m e n t o u s

involvement. Then, compress the knee while

internally and externally rotating the tibia

again. Pain during this maneuver indicates a

meniscal tear. This test is currently

discouraged.[7]

Bounce home test: The patient is supine

with heel held in the examiner's hand. The

examiner fully flexes the knee and then

passively extends the knee. If the knee does

not reach complete extension or has a

rubbery end feel, test is considered positive.

The knee movement may be blocked by a

torn meniscus.

O'Donoghue test: With the patient prone,

the examiner flexes the knee 90°. The

examiner rotates the tibia internally and

externally twice, then fully extends the knee

and repeats the rotations. Increased pain

during rotation in either or both knee

positions indicates a meniscal tear or joint

capsule irritation. With a valgus force to a

flexed and laterally rotated knee, the medial

meniscus, medial collateral ligament (MCL),

and the ACL all may be injured, representing

the O'Donoghue triad.

Thesally test: The examiner supports the

patient by holding his or her outstretched

hands while the patient stands flat footed on

the floor. The patient then rotates knee and

body, internally and externally, three times,

keeping the knee in slight flexion 5°. The

same procedure is then carried out with the

knee flexed at 20°. The test is always

performed first on the normal knee first.

Discomfort or sense of catching or locking is

considered positive.[8]

The reliability of the different tests and signs

for meniscal lesion has been studied by

several authors.

Fowler et al evaluated the predictive value of

common clinical tests for the diagnosis of

meniscal tears in 161 patients. They

evaluated joint line tenderness, pain on

forced flexion, the presence of a positive

McMurray test, positive Apley grind, and

distraction tests, and the presence of a block

– 20 –

to extension. They compared clinical

findings with arthroscopic findings. The

authors have found that no one test was

predictive for the diagnosis of a meniscal

tear.[9] A combination of several positive

tests is highly indicative of a meniscal tear.

RADIOLOGICAL EVALUATION:

Plain Xrays of the knee should always be

asked. These help to rule out any bony injury,

arthritic changes, loose body and joint

malalignment.

MRI is the benchmark for the non invasive

investigation for the meniscal injuries.

Meniscal signals shown by MRI have four

grades:

• uniformly low signal intensity (normal

meniscus) : Grade 0

• irregular increases in intrameniscal

signal: Grade 1

• linear increased signal patterns not

extending to meniscal surface: Grade2

• abnormal signal extends to the

articular surface: Grade 3

While g rades 0–2 have no surgica l

significance, grade 3 represents a meniscal

tear.[10,11] One of the reasons for many

fa l se pos i t ive MRI repor ts i s over

interpretation of grade 2 signals.

Several studies have shown equal accuracy

for clinical examination and MRI in

diagnosing meniscal tear, however MRI helps

to access the extent, location and type of tear,

besides any associated cruciate ligament or

chondral injury [12,13,14]

CLASSIFICATION:

Meniscal tears have been classified in various

ways depending on aetiology, location,

pattern and MRI findings. However the most

reliable and valid classification is the

International Society of Arthroscopy, Knee

Surgery and Orthopaedic Sports Medicine

classification.[15] which is a elaborate

classification taking into account Tear depth,

Rim Width, Radial Location, Tear pattern,

Quality of the tissue, Length of tear

percentage of meniscus (surface area) that

was excised.

TREATMENT:

With the reports of osteoarthritis in knees

after menisectomy and keeping in view the

functions of the meniscus, preservation,

repair or reconstruction of meniscus is now

the standard form of care. The choice of

treatment usually should take into account

age, activity level, aetiology, patients

expectations and lesion morphology.

Conservative treatment: is often considered

for stable small peripheral vertical tears.

Conservative treatment is also first line

treatment in degenerative tears in elderly

unless locking is present. Non operative

treatment is also the first treatment in acute

knee trauma in form of protection, rest, ice,

compressions and elevation PRICE regimen.

A conservative trail of at least 3 to 6 months

is warranted if mechanical symptoms don't

exist.[16] physiotherapy in form of

– 21 –

quadriceps strengthening exercises, activity

modification and off load bracing has shown

to be of help in patients with degenerative

tears. A recent RCT showed that patients

who underwent surgical debridement and

physiotherapy showed equally good results

as patients who received physiotherapy

only.[17]

Surgical procedure might be necessary if

there is locking or if symptoms persist for

more than 6 months after injury.

Surgical treatment: Diagnostic arthoscopy

is often necessary to determine the optimal

treatment for the meniscal lesion. The main

surgical procedures for the meniscal lesions

can be braoadly divided into menisectomy,

meniscal repair and meniscal reconstruction.

Menisectomy: Menisectomy can either be a

open or arthroscopic procedure. Nearly all

of the procedures now a days are performed

arthroscopically. The procedure can be total

menisectomy in which whole of the

meniscus is removed or partial menisectomy

in which part of meniscus which is deemed

to be irreparable is removed, preserving as

much meniscus as possible. Due to evidence

of knee joint degeneration and altered bio

mechanics of knee joint after total

menisectomy, total menisectomy is rarely

done these days. Partial menisectomy is

usually done in radial tears in avascular zone

or degenerative tears with mechanical

symptoms as they are believed to cause

os teoar thr i t i s in long r un . Par t i a l

menisectomy i s the most common

procedure for treatment of meniscal tears.

Though it has good short term results, the

long term results of procedure have shown a

high progression to osteoarthritis.[18] In

another study it proved to be of no benefit in

degenerative root tears.[19] Current view is

that partial menisectomy should be a very

limited procedure and avoided as far as

possible even in degenerative meniscal

lesions. It can be done in a small subset of

patients with irreparable degenerative tears

causing mechanical block.[16]

Meniscal repair: The first open repair of

meniscus was reported by Annandale.[20,21]

Era of arthroscopic repair started when first

arthroscopic meniscal repair was done by

I k e u c h i . [ 2 2 ] a r t h o s c o p i c r e p a i r

predominates the open repair now a days.

Open repair is occasionally used particularly

if posterior meniscal tears in a very tight

m e d i a l c o m p a r t m e n t n e e d t o b e

repaired.[23] the long term success of

meniscal repair is between 70 to 92%.[24]

Eggli et al reported successful outcome in

73% after follow up of 7 and a half years.

Favourable factors for outcome were injury

duration less than 8 weeks, peripheral tears, a

small tear of less than 2.5cm, age less than 30

years. Lateral meniscus had better outcome

than medial meniscus.[25] the most

important condition for good recovery is a

stable knee, unstable knee often leads to

failures. Suturing techniques for repair of

tear can be inside out, outside in or all inside.

– 22 –

Fig. 2

Inside out suturing: It is strongest out of

the three[26]. It is suitable for anterior and

middle 1/3 section of the meniscus. Tear is

fixed by placement of sutures from intra-

articular region with help of special cannulae

to extracapsular area.

Outside in technique: In this technique

sutures are passed through two spinal

needles from the meniscal body to meniscal

rim, the two ends of the passed suture are

then tied over the capsule.

All inside technique: This is done with the

help of special implants called fixators.

These can be arrow head, hook devices,

staples or anchors (Figure 2). These impants

are made of polylactic acid and cause implant

induced synovitis, which limitis their use.

Flexible, suture based implants are more

commonly used now.[27] advantages of

these all inside implants is that they are

technically less demanding and quick, but

they have less strength than the sutures.

Besides these repairing techniques, certain

procedures have been described in literature

to augment healing in meniscal tears

particularly in avascular areas.

Trephination technique: it involves

making radial holes in meniscus to aid

ingrowth of vascular tissue. Combined with

suturing it shows improved results.[28]

Synovial abrasion: abrading synovial tissue

around meniscal repair area will increase

vasculature and improve healing.[29]

Fibrin clot technique: Patients venous

blood is mixed with a glass baguette, this

paste is then kept in between torn edges, this

has a positive effect on healing due to

chemotactic and mitogenic factors.[30]

Meniscal reconstruction: These are the

procedure which are used to replace a

partially or totally resected meniscus.

Though preservation is currently the main

aim of treatment, sometimes due to

irrepairable injury or previous surgery

reconstruction remains the only option. The

two procedures for reconstruction are

m e n i s c a l s c a f f o l d s o r m e n i s c u s

transplantation.

Meniscal scaffolds: These are used to fill

the defects in resected meniscus by allowing

growth of vasculature and cell migration to

form meniscal tissue. Two main types of

scaffolds are the collagen meniscus implant

and urethane scaffold.[31,32] These are cell

free and biodegradable scaffolds. Favourable

reports regarding their clinical efficacy and

long term results have been reported.[33]

lately cell scaffolds have been introduced.

– 23 –

Meniscal transplantation: To prevent

arthritis is young patients with a deficient

meniscus, transplantation remains an option.

Experimentally autografts, allografts, xeno

grafts and synthetic implants have been used.

The benefit of these in preventing

osteoar thr i t i s in long ter m is s t i l l

questionable.[34] Allograft transplantation

has shown good to excellent results in 84%

cases in a meta analysis in athletes. These

procedures have favourable outcome only if

articular cartilage is smooth and body mass

index in less than 30. Discussions on

transplantation still continue with good

short term and medium term results.[35]

Long term studies are needed.

R E H A B I L I T A T I O N A F T E R

MENISCAL REPAIR

Two protocols have been followed in the

rehabilitation of patient with meniscal

repair: The conservative protocol and the

aggressive protocol. In conservative

protocol 6 weeks of partial loading , slow

increase in knee movements in controlled

brace and avoiding sports for 6 months is

followed, while as aggressive protocol allows

immediate loading and unlimited knee

movements and return to sports as long as

patient can tolerate. In a comparative study

there was no difference in failure rates of the

two methods.[36] However result vary on lot

of factors besides the rehabilitation

protocol, it becomes impossible to compare

results of various series. Most surgeons

follow the conservative protocol.

CONCLUSION

Meniscal injuries are one of the common

reasons for knee pain and disability. Proper

clinical evaluation is needed to decide best

possible treatment for a particular patient.

Conservative treatment usually suffices in

degenerative tears without mechanical

symptoms. Treatment should be aggressive

in young athletic patients who have a fresh

injury. Current treatment focuses more on

preservation of the meniscal tissue. Focus

should be on repair rather than removal.

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– 26 –

INTRODUCTION:

Patella is the largest sesamoid bone in the

body. It functions to increase the moment

arm of the extensor mechanism of the

quadriceps by 30%[1]. The cartilage on the

articular surface of patella is very thick,

measuring up to 5.5mm[2,3]. Fractures of

patella may result from direct, indirect or

combined injury patterns and account for

approximately 1% of all skeletal fractures[2,

4]. Direct injuries may occur after a fall from

height or from dashboard impact in a motor

vehicle collision. Indirect injuries result from

force full contraction of the quadriceps with

the knee in a flexed position. Majority of the

fractures have a transverse pattern. Fracture

may occur through the body, apex or distal

pole of patella.

Open injuries are quite common due to

anterior location of patella and thin

overlying soft tissue envelope. Saline load

test5 is advised in occult open fractures.

Early intervention gives satisfactory

outcome in these cases[6].

Concomitant injuries occur commonly in

association with patella fractures and more

so in high energy injuries[7]. More often the

associated injuries occur in ipsilateral lower

limb esp distal femur or proximal tibia

fractures[6].

Patients typically present with the history of

particular mechanism of injury. Complaints

of anterior knee pain, swelling and difficult

wa lk ing are common. On phys ica l

examination, there is usually an acute

hemarthrosis and tenderness. A palpable

defect may be felt between the fracture

fragments. Patient will be unable to do a

straight leg raise or extend a partially flexed

knee against gravity if extensor mechanism is

disrupted.

DIAGNOSIS:

Radiography: Plain radiography is typically

sufficient to confirm the diagnosis of patellar

fracture or extensor mechanism injury.

Anteroposterior, Lateral and Axial views of

the kneel joint should be obtained (Fig.1).

REVIEW ARTICLE

Dr. Shakeel Ahmad, Dr. Rouf Ibrahim, Dr. Pervaiz Ahmad.

Treatment Strategies for Patella Fracture- A Review

[All Authors Work at the SKIMS Medical College Bemina]

– 27 –

Patellar height should be assessed using

Insall-Salwati ratio[8] and Blumensaat's

line[9].

Fig.1

CT scan: CT is rarely done in the evaluation

and management of isolated patellar

fractures. CT scan allows for improved

assessment of articular congruity and

fracture comminution. CT scan provides a

more important role in the evaluation of

stress fracture[10], non-union and malunion.

Routine use of CT scan may result in

increased surgical indications[11]. MRI: MRI plays an important role in

evaluation of suspected extensor mechanism

injuries[12] as well as chondral injuries

associated with patellar dislocations[13].

However, MRI in acute patellar fractures is

also not routinely used.

CLASSIFICATION:

Patellar fracture classification is typically

descriptive and based on fracture pattern,

degree of displacement or mechanism of

injury. Currently, OTA classification is used

for standardizing classification of patella

fractures for clinical research[14, 15, 16].

Patella fracture is usually clinically classified

as displaced and undisplaced. Displaced

fractures are defined by separation of

fracture fragments by more than 3 mm or

articular incongruity of more than 2 mm.

The injury can further be sub-categorized on

the basis of geometric configuration of the

fracture lines into following types (Fig.2);

Transverse

Stellate

Vertical or longitudinal

Apical or marginal

Osteochondral

Patellar sleeve fractures

Fig.2

– 28 –

TREATMENT:

The goals of surgical intervention are:

• Maximal preservation of the bone

• Restoration of the articular congruity

• Preservation of the functional integrity

and strength of the extensor mechanism

Currently, the main treatment options for

patellar fractures are:

• Nonoperative management

• Open reduction and internal fixation

• Partial patellectomy

• Complete patellectomy

NON-OPERATIVE TREATMENT

Nonoperative treatment may be indicated

for patellar fractures with <3 mm of

fragment displacement, <2 mm of articular

incongruity, intact extensor mechanism and

severe osteopenia.

Non-operative treatment should also be

considered when significant patient

comorbidities make operative intervention

dangerous[2].

Non-operative management consisting of

immobilization for 4 weeks results in good to

excellent results in 99% of patients with an

intact extensor mechanism, less than 3 mm

displacement and less than 2 mm of articular

step-off [2, 4].

Prolonged immobilization can result in knee

joint stiffness, quadriceps wasting and joint

adhesions[17]

Melvin and Mehta[2], recommended weight

bearing as tolerated in a knee immobilizer

locked in extension with straight leg raises as

tolerated followed by active and active

assisted range of motion at 2 weeks.

OPERATIVE TREATMENT

There are numerous operative treatment

methods including tension band, modified

tension band, osteosynthesis with plates and

screws, suture repair, circlage wiring,

percutaneous reduction and internal

fixation, arthroscopy assisted reduction and

internal fixation, external fixation, partial

patellectomy and total patellectomy for

patella fracture[2,18 - 22].

Operative treatment is indicated for patellar

fractures with >3 mm of fragment

d i sp lacement , >2 mm of ar t icu lar

incongruity, osteochondral fractures with

associated intra-articular loose bodies, a

compromised extensor mechanism with loss

of active extension.

Tension band fixation: It is the most

commonly used technique for simple

transverse fractures. Tension band fixation is

usually performed through an anterior

longitudinal incision. The classic technique

consists of two parallel vertical kirschner

wires with a tension band passing anteriorly

over the patella and posterior to the kirschner

wires. This technique has been found to be

associated with prominent hardware

requiring removal, implant migration, wire

breakage, loss of reduction and muscle

– 29 –

atrophy.

Various methods of tension band technique

have evolved since the start of operative

fixation of patellar fractures. Important to

mention among these include (Fig.3)

A: Standard tension band. B: Modified

anterior tension band (MATB). C: MATB

with vertical figure-of-8 wire. D: Magnusson

wiring. E: Cerclage wiring. F: Parallel lag

screws. G: Lotke longitudinal anterior band.

H: MATB with horizontal figure-of-8 wire. I:

Cannulated screws with figure-of-8 wire. J:

Pyrford technique. K: Separate vertical

wiring (lateral view). L: Basket plate.

A study by Benjamin et al.[23] compared the

strength of four different fixation strategies

(tension band wiring, modified tension band

wiring over Kirschner wires, and Ecker

long i tud ina l anter ior banding , and

circumferential circlage wiring) in a

transverse patellar fracture and retinacular

disruption model. The modified anterior

tension band technique of transosseus K-

wire fixation with anterior banding

demonstrated superior strength to all other

constructs

Tian et al[24] performed a retrospective

review comparing a modified tension band

technique using Kirschner wires with a

modified tension band technique using

cannulated screws. They found improved

fracture reduction, a reduced healing score,

and better Iowa knee scores with the

cannulated screw modification. Additionally,

the implant migration rate and the second

operation rate were 15.4% and 5.7%,

respectively, for the Kirschner wire, with no

complications in the cannulated screw

cohort. In a cadaveric study, Carpenter et

al[25] found that a modified tension band

with cannulated screws had a higher load to

failure than cannulated screws alone or a

modified tension band with Kirschner wires.

Plating: Small plates can be applied to the

anterior surface of the patella in the setting

of comminution to provide additional

stability. Taylor et al[26] reported techniques

and outcomes of plate fixation for patella

fractures. They presented 8 patients with

patella fractures or nonunion treated with a

combination of plate and interfragmentary

screw fixation. All of their patients went on

to union at a mean of 3.2 months with an

average total arc of knee motion of 129°.

There were no cases of hardware removal for

symptomatic implants.

Thelen et al[27] used a 2.7-mm, fixed-angle

plating construct for transverse patella

fractures in cadavers and compared with

Kirschner wire tension band fixation and

– 30 –

cannulated screw tension band fixation.

After 100 cycles of full extension to 90° of

flexion, the fixed-angle plating group

averaged less than 1 mm of displacement,

compared with 7.1 and 3.7 mm in the

Kirschner wire and cannulated screw tension

band groups, respectively. Banks et al[28]

compared the tension band construct with

cannulated screws with a tension band

construct with a locking plate in a cadaveric

transverse patella fracture model. The locked

plate tension band models had similar load to

failure, significantly higher ultimate fixation

strength, and slightly lower stiffness at final

loading compared with the cannulated screw

tension band construct. In a foam patella

model, Wurm et al[29] found that the tension

band construct had a 33% lower load to

failure and 5 times larger fracture gap

displacement than the locking plate

construct.

Screw Fixation: There is not much

literature on isolated screw fixation for

patella fractures. Wang et al[30] published a

retrospective review of transverse patella

fractures treated with modified tension

bands compared with those treated with

parallel interfragmentary screws in a lag

design fashion. They found parallel titanium

screw fixation to have a shorter operative

time, a lower loss of fixation, and lower rates

of symptomatic hardware and second

surgery.

Tandogan et al[31] reported on 5 patients

with displaced patella fractures without

extensor mechanism disruption treated with

ar throscopic assisted reduction and

percutaneous screw fixat ion. Their

technique returned all but 1 patient to full

range of motion with no implant failure or

i n f e c t i on . Cadave r i c s t ud i e s have

demonstrated that cannulated screws have a

lower load to failure than cannulated screws

with a modified tension band technique[25].

Minimally Invasive and Percutaneous

Techniques: Percutaneous treatment of

patella fractures has been proposed as a

means to preserve vascular supply and to

decrease insult to the soft tissue envelope. In

a randomized, controlled trial of 53 patients,

Luna-Pizarro et al[32] compared the

percutaneous patellar osteosynthesis system

technique with open surgery for operative

patella fractures. They found that the

percutaneous patellar osteosynthesis system

resulted in shorter surgical time, less pain,

better range of motion, fewer complications,

and similar functional scores at 2 years

postoperatively.

A minimally invasive technique for tension

band fixation of transverse patella fractures

using the cable pin system (Cable-Ready,

Zimmer, Warsaw, Indiana) was evaluated by

Mao et al[33]. A total of 31 patients were

followed for an average of 21 months.

Fracture union occurred at a mean of 7.2

weeks with an average of 91° of active

flexion at that time. Full range of motion was

achieved in 93.5% of the patients at final

follow-up and excellent results in 30 of 31

– 31 –

patients.

External Fixation: Wardak et al[20] used a

compressive external fixation system for the

treatment of 84 displaced primarily

transverse patella fractures, of which 31%

were open fractures. The device was left in

place for a total of 6 weeks on average, at

which time all fractures had attained union.

Pin tract infection and/or wire site irritation

occurred in 12% but resolved after device

removal without further surgical procedures.

Articular surface incongruity of 2 mm or

greater was seen in 11% of patients, all of

whom had radiographic evidence of arthritis

at 18 months postoperatively. No secondary

surgical procedures were required. The

authors concluded that their compression

external fixation system was a safe and

effective method for treating patella

fractures, especially in cases with a poor soft

tissue envelope, in salvage situations, and in

locations with limited resources.

Partial patellectomy: Partial patellectomy

may be indicated when comminution of the

distal pole or a fragment of the patella is

extensive and cannot be stabilized with

internal fixation. In addition, fragments that

are dysvascular or free with limited soft tissue

attachments and likely to become loose

bodies within the knee joint should be

removed. Partial patellectomy should be

avoided when the entire patella is salvageable

or a tendon repair can be performed without

removal of bony fragments. Par tial

Patellectomy performed by first excising

comminuted bone fragments and then

passing nonabsorbable braided suture from

the patellar tendon through drill holes in the

patella, similar to a traditional patellar tendon

repair. Bone fragments can often be

incorporated into the repair. Partial

patellectomy has been described as a means

to preserve the moment arm of the patella

resulting in less loss of strength, ligament

instability, and quadriceps atrophy when

compared with total patellectomy34.

Bonnaig et al[35] compared 26 patients who

underwent patella open reduction and

internal fixation with 26 patients who

underwent partial patellectomy and found no

difference in outcomes between the two

groups.

Total patellectomy: Total patellectomy is

occasionally performed for highly displaced,

comminuted fractures in which stable

fixation cannot be achieved and when no

large fragments can be retained, failed

internal fixation and patellar osteomyelitis.

When total patellectomy is performed,

extensor lag is one of the most common

complications. Total patellectomy is

primarily of historical interest and is rarely

performed, being reserved for instances of

substantial bone loss or as a salvage

procedure[2,4]. Complete patellectomy

eliminates the mechanical advantage

provided by the patella to the extensor

mechanism and results in a 49% reduction in

knee extension strength[34,36]. A modified

technique described by Günal et al[37] using

– 32 –

a vastus medialis advancement resulted in

less pain, less activity limitation, better

quadriceps strength, improved cosmesis, and

better functional performance than

patellectomy alone. However, the authors

stated that the patella should be preserved if

possible.

OPEN FRACTURES

The pa te l l a rema ins subcutaneous

throughout its length, and patella fractures

are open 6% to 13% of the time[2,7]. Open

patella fractures tend to result from higher

energy mechanisms than closed patella

fractures, with motor vehicle accidents

causing 94% of open patella fractures and

falls causing 62% of closed patella fractures

in the same study. Additionally, associated

injuries occur in 81% of open fractures

compared with 31% of closed patella

fractures[7]. Treatment of open patella

fractures should follow the same principles

as treatment of all open fractures: timely,

appropriate antibiotics followed by urgent

irrigation and thorough debridement with

definitive fixation and wound closure as soon

as possible[2,7]. Outcomes following open

patella fractures are typically inferior to those

following closed patella fractures. Secondary

procedures are more common in open

patella fractures (up to 65%), and delayed

wound coverage/closure is associated with

increased risk of deep infection[7,38,39].

COMPLICATIONS

Patient factors have a direct effect on

outcomes after surgical treatment of patella

fractures; history of a cerebrovascular

accident has been found to induce a 6-fold

increased risk of infection and a nearly 15-fold

increased risk of nonunion[40]. Diabetic

patients have more than 8 times increased

likelihood of reoperation for all causes[40].

Symptomatic hardware, especially in patients

treated with a tension band, is common and

may occur in up to 60% of patients, often

result ing in the need for hardware

removal[2,41]. Hardware failure occurs in 8%

to 22% of patients, most commonly when

Kirschner wires are used, and both local and

distant hardware migration has been

described[42-44]. Higher fixation failure rates

have been found with increasing patient age

and use of Kirschner wires with or without

tension band fixation. Increasing duration of

follow-up is associated with reoperation and

hardware removal, indicating that patellar

fixation implants may become more

noticeable and symptomatic as time increases

after surgery[45].After operative treatment,

nonunion and delayed union occurs in 2% to

12.5% of patients and the infection rate ranges

from 0 to 5%; both are increased in open

fractures. Knee stiffness can best be mitigated

by solid fixation and early range of motion.

Postoperative radiographic and clinical

osteoarthritis are both more common

following displaced patella fractures than in

the general population and are best minimized

by anatomic reduction, solid fixation, and early

range of motion[2, 46].

– 33 –

REHABILITATION

Although numerous clinical protocols have

been described, there has been minimal

research about the outcomes of specific

clinical protocols[2, 47]. Most surgeons

recommend gentle early knee range of

motion and full weight bearing in a knee

brace locked in extension. Flexion is typically

allowed to 30° within 2 weeks following

su rg i c a l fixa t ion w i th p rog re s s ive

advancement. This may be delayed in cases

of extensive comminution or tenuous

fixation[2, 47].

CONCLUSION

Patella fractures represent a broad spectrum

of injuries ranging from subtle non-

displaced fractures to open comminuted

fractures with significant bone loss.

Treatment should be directed to obtaining an

anatomic reduction and using a fixation

method that maximizes stability while

minimizing hardware prominence. Surgeons

should select fixation techniques that best

address the fracture pattern being treated, as

there is l i tt le high-quality evidence

comparing treatment methods. Despite all

of the advances in surgical treatment

options, functional impairment, pain, and

decreased quadr iceps s t rength and

e n d u r a n c e p e r s i s t t o 1 2 m o n t h s

postoperatively and beyond48. Knee joint

mobilization and range of motion as early as

fixation stability permits will help to

minimize posttraumatic arthritis and allow

optimal postoperative recovery.

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– 36 –

INTRODUCTION:

The knee joint is composed of three

compar tments - med ia l and l a t e ra l

tibiofemoral, and the patellofemoral

compartments. The articular surface is

covered by hyaline cartilage[1]. Articular

cartilage consists of a sparse population of

chondrocytes embedded within a highly

hydrated extracellular matrix composed of

collagen, mainly type II collagen, and

proteoglycans (PGs)[2]. Grossly, the

articular cartilage appears as a smooth,

homogeneous tissue approximately 2 to 5

mm thick. The structure of the cartilage

creates a low-friction surface allows it to

withstand multiple forces generated during

different movements of the knee.

For adequate functioning of the joint,

preservation of anatomical and physiological

properties of the cartilage is of utmost

importance. Because the cartilage lacks

blood vessels, lymphocytes and the

chondrocytes lack capability to multiply and

differentiate the chondral and osteochondral

lesions of the knee remain one of the biggest

challenges for the orthopaedic surgeon [3].

Due to the lack of access to the vascular

system, visible damage to the cartilage

surface that does not extend into the

subchondral bone does not initiate a

reparative response. Transient proliferation

of chondrocytes near the edges of the defect

has been observed, but the cells do not

proliferate into the defect or produce a

significant amount of matrix. The cells

briefly increase synthesis of type II collagen

and PGs, but the in jur y resul ts in

chondrocyte apoptosis and cessation of

matrix synthesis. Damage to the superficial

zone disrupts the collagen network and

increases the permeability of the matrix,

thereby decreasing the ability of the matrix

to resist tensile and compressive loads. This

results in increased stress in the matrix and

subchondral bone with eventual progression

to osteoarthritis.

Focal chondral defects need to be

differentiated from osteoarthritis of the knee

REVIEW ARTICLE

Dr. Asif Nazir Baba

Osteochondral Injuries of Knee- A Review

[Asif Nazir Baba Works at the Bone & Joint Surgery Hospital, Barzulla]

– 37 –

as the latter is characterized by progressive

loss of articular cartilage, osteophytes,

subchondral cysts, joint space narrowing,

and intermittent inflammation of the joint

tissues.

Incidence: Since majority of osteochondral

lesions are asymptomatic, it is difficult to

assess the actual incidence of these injuries.

Curl et al reviewed 31,516 knee arthroscopies

and detected chondral lesions in 63% of

cases, with 19.2% of these patients having

lesions extending into subchondral bone [4].

Widuchowski et al had observed chondral

lesions in 60% of patients, mostly on patella

and medial femoral condyles [5].

Classification: Cartilaginous lesions of

knee can broadly be classified depending

upon the depth of lesion into mild (partial

thickness), moderate (full thickness) and

severe (extension into the subchondral bone)

[6]. Based on the macroscopic findings,

Outerbridge classified the lesions into four

grades [7]. However, nowadays the defects

are graded macroscopically using the

International cartilage Repair Society (ICRS)

classification which is a simplified form of

scoring system as given by (Table 1) [8,9].

Table 1: Classification of chondral

lesions according to the ICRS system

Etiology: Focal chondral lesions are caused

by trauma, osteochondritis dessicans (OCD)

or ostenecrosis. Trauma is the most common

cause, usually due to accidents or sports

injuries. Patellar dislocation is responsible for

40-50% of ostechondral lesions around

femoral condyle [10]. Osteochondritis

dessicans, first described by Konning in

1888, is usually the result of recurrent

microtrauma to femoral condyle and is

classically located on the lateral aspect of

medial femoral condyle [11]. Osteonecrois

can be primary or secondary to steroid

therapy, alcoholism or meniscal injury [12].

Degenerative defect are the result of

ligamentous instability, meniscal injuries or

malalignment [13].

Clinical features: The most common

symptoms are pain and swelling. Pain is

sudden onset in case of trauma, and vague

and poor ly loca l i zed in OCD and

osteonecrosis. Features of associated

conditions like catching and instability may

be present. In case of a full thickness tear, the

most common symptom is a loose body and

its associated features. Examination

– 38 –

commonly reveals knee effusion. Point

tenderness within joint or above the joint

line, crepitation and wasting of muscles

(quadriceps and vastus medialis) are seen.

Wilson test is positive in case of OCD [14].

Clinical features of associated conditions like

meniscal tear (McMurray, Apley Grinding

test) and ACL injuries (Anterior drawer test,

Lachman test) may be present.

Radiology: Routine radiological evaluation

includes a weightbearing anteroposterior

(AP) and lateral view as well as an axial view

of the patella such as a sunrise or Merchant

view. Rosenberg view, a PA view of the knee

in flexion allows better assessment of the

lateral and posterior aspects of the joint

space. A full length AP view of the entire

extremity from hip to ankle demonstrates

any varus or valgus malalignment. CT

arthrogram is helpful to evaluate the cartilage

integrity and diagnose subtle patellar femoral

maltracking. However, the disadvantage of

CT is the exposure to ionizing radiation.

Magnetic resonance imaging is commonly

used to confirm the presence of chondral

defects, look for associated pathology such

as meniscal and cruciate ligament tears,

visualize cartilage surfaces and detect bone

marrow edema beneath the defect [15].

Magnetic resonance ar thrography is

repor ted to be more accurate than

conventional MRI in the evaluation of

articular cartilage, the assessment of stability

of OCL and the detection of intra-articular

bodies [16]. Diagnostic arthroscopy remains

the “gold standard” for evaluating the joint

surfaces and provides the most accurate

means of diagnosis [17]. Although a surgical

procedure, it can be readily utilized to

diagnose as well as treat cartilaginous injuries

of the knee at the same setting or as a staged

procedure.

MANAGEMENT: The management of

chondral defects of the knee is a challenge

for the orthopaedic surgeon. The fact that

the articular cartilage has limited potential

for repair and healing, make the management

of defects all the more important. The most

important factors to consider are the size of

lesion (measured at least in two planes

perpendicular to each other), depth of

defect, location ( weight-bearing area or not)

and number of defects as all cartilage defects

do not produce the same degree of clinical

symptoms [18]. Other important factors to

be considered are the age of patient, body

mass, act iv i ty demands, assoc ia ted

ligamentous and meniscal injuries, alignment

of knee and the condition of the remaining

cartilage all play a role in determining the

treatment course [19]. The defects need to be

treated as natural history studies show that

FCD may progress to degenerative arthritis

[20]. Although the risk of progression is

multifactorial, the defect size is the most

important factor [21].

Conservative management: Conservative

management is the initial management for

majority of chondral lesions, especially in the

patel lofemoral region. The goal of

– 39 –

conservative treatment is to reduce the

symptoms, not heal the lesion [22].

Conservative management is effective in

patients with mild symptoms, with small

lesions (especially in non-weight bearing

regions) and in patients at high risk for

surgery. There is a wide variation in the

minimum size of lesion that is treated

s u r g i c a l l y, va r y i n g f r o m 0 . 7 5 c m 2 2(Lorentzon) to 1.6 cm (Brittberg) [23, 24, 25,

26]. Since most of the surgical modalities

involve a vigorous rehabilitation protocol

with 6-12 weeks of protected weight bearing,

the patients not willing for same can also be

managed conservatively. Similarly, the

patients with limb mal-alignment will need a

corrective procedure prior to or along with

the cartilage surgery. Ligamentous laxity like

ACL tear or significant meniscal damage in

the form of previous subtotal or total

meniscectomy is a contraindication for

isolated cartilage resurfacing.

The mainstay of conservative management

is activity modification and maintenance of

ideal body weight. High impact activities like

jogging and jumping need to be avoided.

Oral NSAIDs and tramadol are useful for the

temporary swelling and discomfort. Use of

cane, physical therapy, glucosamine, MSM,

Omega -3, intra-articular steroids and

viscosupplementation can also be tried.

However, there is no evidence of structural

improvement with these modalities [27].

Platelet rich plasma (PRP), which is rich in

growth factors like PDGF, TGF-β, bFCF,

ICF, VEGF, is emerging as an attractive

treatment for these lesions.

Surgical management: The ideal aim of

surgical intervention is regeneration of

chondral defect to ultrastructural and

biomechanical competence of hyaline

cartilage. The method chosen depends upon

the size of lesion, location of lesion, age and

a c t i v i t y l e v e l o f p a t i e n t . T h e

c o n t r a i n d i c a t i o n s o f s u r g e r y a r e

inflammatory arthropathy, unstable or

malaligned joint (as isolated procedure),

kissing lesions, infection and obesity.

The surgical options are broadly divided into

three types:

1. Marrow stimulation techniques.

2. Osteochondral transfer- autograft

or allograft

3. A u t o l o g o u s c h o n d r o c y t e

implantation (ACI).

1. Marrow stimulation is based on the

premise that stimulation of the subchondral

bone may release mesenchymal cells from

the bone marrow, thus promoting formation

of new tissue [28]. It is usually done

arthroscopically in grade 3-4 lesions. Marrow

stimulation can be performed by different

techniques. Chondroplasty involves conversion of

uneven cartilage surfaces to a smooth

surface, especially in partial thickness lesions.

This can be achieved by use of motorised

shavers or by radiofrequency. The latter may

– 40 –

lead to high intra-articular temperatures and

potential of damage to the joint cartilage[29].

Microfracture is the most common method

of car t i lage restorat ion by mar row

stimulation [30]. Arthroscopically small

multiple holes, 3-4 mm apart, are made with

awls in the defect to allow egress of marrow

element and formation of superclot which

remodels into fibrocartilage. It is indicated in

small full-thickness defects (< 2-3 cms), less

than one year post-injury and occasionally in

large lesions in older, less-demanding

patients. Contraindications include age > 50

years, concomitant knee pathology, inability

to follow rehabilitation protocol, underlying

AVN and diffuse joint degeneration. The

advantages of the method are its simplicity,

can be done arthroscopically and have less

morbidity. However, the fibrocartilage

formed in this method is inferior to native

hyaline cartilage. The long term results are

not good, as only half of the patients return

to pre-injury sports levels [31, 32].

Complications associated with the procedure

include fracture of subchondral bridge,

incomplete microfractures and hypertrophic

overgrowth.

Subchondral drilling was first described by

Smillie & Dundee [33] and popularized by

Priddie [34] After debridement of lesion the

subchondral bone is drilled with high speed

drill using 2-2.5mm K-wires. Blood perfuses

into the defect bringing with it mesenchymal

cells which proliferate to form fibrocartilage.

Thermal necrosis is the chief drawback of

the technique.

2. Osteochondral Autograft Transfer

(OATS) or mosaicplasty: It allows the

restoration of hyaline cartilage at the defect. 2It is ideally suited for defects upto 2.5cm in

medial or lateral femoroal condyles, and

trochlear groove. The method was first

described by Hangody et al [35]. The

receptor bed is prepared and cylindrical

tunnels 15 mm deep with 1mm spacing are

created. The graft is harvested from non-

weight bearing portion of the joint with a

length of 10-15mm. Finally the graft is

inserted into the defect. This method uses

patients own tissue and thus eliminates risk

of disease transmission, while providing a

superior cartilage. 90% good or excellent

results with early return to sports activity are

r e p o r t e d w i t h t h i s m e t h o d [ 3 6 ] .

Disadvantages include inability to mange

larger defects and the donor site morbidity.

Complications include overfilling of donor

site with fibrocartilage leading to mechanical

symptom and pain, DVT, infection and

hemarthrosis [37].

Osteochondral Allograft Transfer is used

to fill larger defects. Size matched cadaver

donor plugs permit immediate restoration of

joint articular surface. Fresh allograft have

high chondrocyte availability but the risk of

disease transmission is more, while

cryopreservation decreases immunogenicity

and disease transmission at the cost of lower

chondrocyte availability. Implantation is

recommended at 14 to 28 days after

– 41 –

procurement for optimal cell viability [38].

3. Autologous chondrocyte implantation

(ACI): Brittberg (1994) published the first

paper on implantation of chondrocytes for

treating osteochondral defects [39]. ACI is

indicated in young, active patients with full-

th ickness chondra l defect 2-10cm,

surrounded by healthy cartilage. The

technique has superior results compared to

other modalities [40]. The technique has

rapidly evolved over the past 3 decades. The

first generation ACI was a two step

procedure. In the first step the cartilage is

harvested arthroscopically from healthy area

and from this chondrocytes are cultured and

expanded in the laboratory. In the second

stage the defect is prepared by removing

unstable and damaged cartilage. The

prepared chondrocytes are placed in the

defect and the chondrocytes covered by

periosteal flap which is obtained from

proximal medial tibia.

Second generation ACI is similar to first

generation, but the implantation is simplified

by using a synthetic collagen for cell

placement. This obviates need for a

periosteal flap and additional incision and

morbidity associated with it. In addition, spill

over and asymmetric distribution of

chondrocytes following implantation is

avoided. In the third generation ACI the

chondrocytes are embedded in three-

dimensionally constructed scaffolds for cell

growth. They do not require a periosteal

cover and exactly fit into the defect with

fibrin glue.

The advantages of ACI are superior results,

utility in larger lesions, defects which have

failed other restorative methods and less

donor site morbidity. However, ACI is

contraindicated in inflammatory arthritis and

pat ients not co-operat ive for long

rehabilitation. The disadvantages of the

method include the need for two stage

procedure, requirement for arthrotomy (first

and second stage) and the high cost of the

procedure,

Conclusion: Chondral defects of knee are

important because cartilage lacks the

potential for repair and the untreated lesion

leads to degenerative changes in the future,

the defect needs to be evaluated properly and

the appropr ia te t rea tment dec ided

considering the size and site of lesion,

patient factor and associated injuries. Each

m e t h o d h a s i t s a d v a n t a g e s a n d

disadvantages, but when applied prudently

all have given good results.

References

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Phys Ther. 1980; 60(12):1556-60.

2. Bastiaansen-Jenniskens YM, Koevoet W, de Bart

AC, van der Linden JC,Zuurmond AM, Weinans H,

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functional properties of engineered cartilage.

Osteoarthritis Cartilage. 2008; 16(3):359-66.

3. Ozório de Almeida Lira Neto, Carlos Eduardo da

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Poehling GG. Cartilage injuries: a review of 31,516 knee

– 42 –

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Bone Joint Surg Am. 1975;57(6):802-10.

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Orthopedics Special Edition. 2000;6:71-76.

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severe damage to weight-bearing cartilage in the knee.

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of deep cartilage defects in the knee with periosteum

transplantation [abstract] Swedish Orthopaedic

Association Meeting; September 1996; Karlstad,

Sweden.

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al. Perichondral grafting for cartilage lesions of the knee.

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tissue after failed cartilage repair procedures. Clin

Orthop Relat Res. 1999; (365):149-62.

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Vangsness CT Jr. Effects of radiofrequency energy on

human articular cartilage: an analysis of 5 systems. Am J

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of existing cartilage repair technology. Sports Med

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32. Gudas R, Kalesinskas RJ, Kimtys V, et al. A

prospective randomized clinical study of mosaic

osteochondral autologous transplantation versus

microfracture for the treatment of osteochondral

defects in the knee joint in young athletes. Arthroscopy.

2005; 21:1066-1075.

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Isaksson O, Peterson L. Treatment of deep cartilage

defects in the knee with autologous chondrocyte

transplantation. N Engl J Med. 1994;331(14):889-95.

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– 44 –

One of the biggest advantages of the

Ilizarov technique is the correction of

rotational deformities. The configuration of

the ring system allows for correction of

angular deformities in multiple planes and

correction of rotations over 360 degrees.

Though all other components of deformity

like correction of limb length discrepancy,

correction of angular deformities and bone

transport are achievable with uniplaner

external fixators like orthofix and rail yet for

correction of rotational components the

configuration of a ring system is mandatory.

How a ring is made to rotate

The rotational assembly consists of multiple

obliquely placed connecting rods that

connect two rings via ilizarov posts. Each set

consists of a connecting rod connecting two

post with routine movable nuts. The whole

de-rotation assembly may consist of three or

more such sets.de-rotation is achieved by

turning the nuts as shown by the arrows in

figure 1. This manoeuvre creates torque

forces that convert linear motion into a

rotational one.

Fig.1 Fig.2

Case example.

32 years old male presented with complex

deformity of the right leg post growth arrest

in the childhood and a shortening of 9 cms.

In addition to angular deformities the patient

had a 90 degree internal rotation of the

affected limb. Fig 2 shows that all other

deformities were corrected and the only

component left is that of rotation. At this

stage the de-rotation assembly was added

across the site of regeneration. After gradual

correction the deformity was fully corrected

as in Fig 3. A twist in the regenerate can be

TECHNICAL TIP

Prof. Altaf Ahmad Kawoosa

Management of Rotational Component ofComplex Deformities with Ilizarov Technique

[Dr Altaf A Kawoosa Works at the Bone & Joint Surgery Hospital, Barzulla]

– 45 –

clearly appreciated in the Fig. 4.

Fig. 3 Fig. 4

How does one know that de- rotation is

happening correctly?

The conventional ring construction should

always be done having all the ring connection

bolts lying in one line anteriorly (in case if

tibia along its anterior border). Once the de

rotation process is started the movement of

distal ring complex relative to the proximal

ones can easily be monitored for correct de

rotation.

Note.

1. De rotation must be performed

before the consol idat ion of

regenerate

2. It is mandatory to watch the distal

neurovascular status as de - rotation

may create a kink in the vessels and

nerves. Since the process is a gradual

one this complication may never

happen

– 46 –

INTRODUCTION

Penetrating injuries of the foot are a

common presenting complaint in the

emergency department. The residents of the

underdeveloped world are especially prone

to suffer such injuries as barefoot walking is

still common. An injury peculiar to shod feet

occurs when a nail penetrates through the

sole of the footwear and leaves behind a

piece of the material from the rubber sole

within the soft tissues of the foot [1,2,3].

This piece of rubber often causes a range of

manifestations as already reported [4]. We

report a case of Osteomyelitis of the

metatarsal head as a delayed manifestation of

the nail slipper injury.

CASE REPORT

A 4-year-old man presented to the OPD of

the department of orthopaedics with pain of

the left foot. The pain was increased by

movement of the toe. The patient reported

that the pain had been present on and off for

1year with varying severity. He reported

significant exacerbations also.

Clinically there was tenderness of the head

of the 3rd metatarsal of the foot. Range of

motion of the toe was painful. An x ray was

advised which showed osteomyelitic changes

in the metatarsal head. A USG showed soft

tissue swelling around the metatarsal head.

MRI was reported as Osteomyelitis. On

being specifically asked the patient reported

penetrating injury of the foot with a nail

through the rubber soled shoe that he had

been wearing at that time. He had got the nail

tract washed and dressed up at that time. It

had healed uneventfully over a 2-week period

and the tenderness had subsided over a 6-

week period. After 3 months of the injury,

the patient had started to develop symptoms

of that had brought him to the hospital.

The patient was offered curettage and

d e b r i d e m e n t w h i c h h e a c c e p t e d .

Intraoperatively the metatarsal head was

found to be surrounded by granulation

tissue. After cleaning the metatarsal head a

CASE REPORT

Prof Anil Gupta, Prof Sanjeev Gupta, Dr Manish Singh, Dr Tahir Afzal, Dr MF Butt

Osteomyelitis of The Metatarsal Head

Caused By The 'Nail Slipper' Injury

[All Authors Work at The GMC Jammu]

– 47 –

hole in the head was found which was a

remnant of the nail tract. A rubber piece 5

mm x 5 mm was retrieved from the

metatarsal head. The material was sent for

culture sensitivity and relevant antibiotics

given for 6 weeks. After 6 weeks the patient

was symptom free.

FIGURE 1; Osteomyelitis picture of the 4th metatarsal head.

FIGURE 2; The metatarsal head with the curretted nail track.

FIGURE 3; The rubber piece retrieved from the metatarsal bone head.

DISCUSSION

A special type of injury that occurs in people

sustaining penetrating injuries from a nail,

while wearing footwear is encountered with

increasing frequency these days [4]. This

injury is referred to as the ''Nail-Slipper

injury''

In the acute setting at the emergency level

management of these injuries is of a very

basic nature. The wound track is cleaned with

antiseptics and daily dressings applied. As the

wound track is small and the rubber foreign

body is usually less than 2 mm, it is ethically

debatable to use wide debridement as a

routine procedure.

The ''Nail-Slipper injury'' is different as

delayed presentation is the norm rather than

an exception. Even if the patient presents at

the time of initial injury, detection of a

rubber foreign body is not possible.

According to Peterson et al. when a history

of penetrating trauma is suggested, its

– 48 –

severity is difficult to estimate clinically. Also,

the initial contamination and damage make

for an excellent medium for microorganisms

[5].

The important thing is to ask for antecedent

history of nail penetration in a range of foot

symptoms and signs. Our case conclusively

demonstrates that the Nail Slipper injury can

present as osteomyelitis of the foot bones as

well.

Bibliography

1. Chachad S, Kamat D (2004) Management of

plantar puncture wounds in children. Clin Paediatr

43:213–216

2. Baldwin G, Golbourne M (1999) Puncture wounds.

Pediatr Rev 20:21–23.

3. Dhillon MS, Prassana HM, Goni V et al (2000)

Wooden splinter induced pseudo tumor of the

metatarsal. Foot Ankle Surg 6:45–48.

4. Dhar SA, Dar TA, Sultan A et al. Delayed

manifestations of the ''Nail-Slipper injury''.

Musculoskelet Surg (2009) 93:149–153.

5. Peterson JJ, Baneroft LW, Kransdorf MJ (2002)

Wooden foreign bodies, imaging appearance. AJR

178:557–562

– 49 –

JKOA NEWSLETTER

IMAGES

THE JKOA//NZIOA CONFERENCE

LET THERE BE MORE LIGHT

– 50 –

THE INAUGURAL MOMENTS. FOR POSTERITY.

THE AUDIENCE. KNOWLEDGEABLE.

– 51 –

THE WORKSHOP

THE WORKSHOP

– 52 –

ORATIONS

– 53 –

LAUNCHING THE JKOA WEBSITE

CHAIRING THE ORATIONS

– 54 –

FIRST SKIMS CONNECT AT SKIMS MC BEMINA

THE PHYSIS IS UP AND RUNNING

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CME AT ANANTNAG

CME AT ANANTNAG

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THE CADAVER COURSE AT SKIMS MC BEMINA

FIRST CADAVERIC PELVIACETABULAR

COURSE AT SKIMS MC BEMINA

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– 58 –

Information For Authors

e next symposium is going to be about ‘THE HIP’.

erefore review articles about the pathologies of the hip are solicited.

Case reports and Technical Tips are allowed pertaining to any topic.

e article will undergo a review by the editorial board before publication.

e address for submission is thephysisjournal@gmail.com

All members of the JKOA are speci�cally requested to submit images for the Newsletter Section

2

3

4

5

6

7

e “PHYSIS” invites articles for its future issues from all interested authors.1

SIR JOHN CHARNLEY

Charnley was born into a middle class family in a northwestern suburb of Manchester, England. His father, Arthur, was a pharmacist. His mother, Lily, was a nurse. Charnley went through the usual boys' course of study at Bury Grammar School from 1919 to 1929. He was not a diligent student but did well in science. In the fall of 1929 he entered the Victoria University of Manchester School of Medicine. In 1935 he received both the Bachelor of Medicine (M.B.) and Bachelor of Surgery (Ch.B.) degrees. He became a Fellow of the Royal College of Surgeons in 1936. When World War II began in 1939, Charnley already had plenty of surgical experience in several prominent British hospitals. He volunteered for military service immediately and was commissioned a lieutenant in the Royal Army Medical Corps in May 1940. at same month he participated in the evacuation of trapped British soldiers from Dunkirk, France. From 1941 to 1944 he was an orthopedic surgeon to the British forces in North Africa. While stationed in Cairo he began inventing and improving orthopedic devices and

instruments. He arrived back in England just before D-Day and returned to civilian life in February 1946. His �rst two books, Closed Treatment of Common Fractures (1950) and Compression Arthrodesis (1953), established his reputation as an innovative and thoughtful biomechanical engineer as well as a surgeon. In 1958 the Manchester Royal In�rmary allowed Charnley to create his own hip surgery facility at Wrightington Hospital. is was the great turning point in his career, because it gave him the resources and staff to perform the kinds of experiments and operations he envisioned. At Wrightington Charnley was incredibly productive. He used polytetra�uorethylene (PTFE), better known as Te�on, and stainless steel to realize his ideas for "low friction arthroplasty," that is, manufacturing and safely implanting strong, durable, biochemically inert arti�cial joints. In 1961 he published his basic results in Lancet, an in�uential British journal of medicine. By the mid-1960s THR had become a routine surgical procedure. He is rightfully known as the father of hip arthroplasty.

JAMMU KASHMIR ORTHOPAEDIC ASSOCIATION

Prin

ted

by S

heen

Gra

phic

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