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Tamil Nadu Orthopaedic Journal Volume 41, Issue 1, February2015 An official Journal of Tamil Nadu Orthopaedic Association

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Page 1: Tamil Nadu Orthopaedic Journaltnojonline.com/wp-content/uploads/2018/04/journal-feb2015.pdf · Tamil Nadu Orthopaedic Journal Volume 41, Issue 1, February2015 An official Journal

Tamil NaduOrthopaedic Journal

Volume 41, Issue 1, February2015

An official Journal of Tamil Nadu Orthopaedic Association

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TAMILNADU ORTHOPAEDIC ASSOCIATION

OFFICE BEARERS 2014-2015

President SecretaryDr. Nalli R Uvaraj Dr. S. Muthuraman

Immediate Past President President ElectDr. R. Selvaraj Dr. C. Raja Ravi Varma

Vice- President Immediate Past SecretaryDr. R. Sivakumar Dr. V. Singaravadivelu

Joint Secretary EditorDr. M. Antony Vimal Raj Dr. J. Dheenadhayalan

Fellowship SecretaryDr. G. Premnath

Executive Committee Members

Chennai MaduraiDr. Annamalai Regupathy (Treasurer) Dr. P.V. Thirumalai MuruganDr. P. Balakrishnan Dr. T.C. Prem Kumar

Coimbatore North Zone South ZoneDr. Major K. Kamalanathan Dr. S.V. Justin Arockiaraj Dr. A. Francis Roy

Dr. M. Ilanchezhian

West Zone East Zone Central ZoneDr. R.T. Parthasarathy Dr. M.C. Chinnadurai Dr. J. Christopher BabuDr. C. Palanikumar

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Editor

Dr. J. Dheenadayalan

Assistant Editors

Dr. Sugavanam Dr. Navaladi Shankar Dr. Thanappan

Members of the Editorial Board

Prof. R. Selvaraj Prof. V. Singaravadivelu Prof. Nalli R Uvaraj

Dr. C. RajaRavi Varma Dr. Raj Ganesh Dr. M. Subbaiah

Prof. Narayan Reddy Dr. P. Dhanasekar Raja Dr. S. Natarajan

Dr. Elangovan Chellappa

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Tamilnadu Orthopaedic Journal Volume 41, Issue 1, February 2015

Contents

GENERAL

AM I DOING AN ETHICAL ORTHOPAEDIC PRACTICE ? 1

Prof. A. Devadoss, Chairman & Chief of OrthopaedicsDevadoss Multi Speciality HospitalInstitute of Orthopaedic Research and Accident Surgery, Madurai.

RECENT ADVANCES IN POSTOPERATIVE PAIN MANAGEMENT IN

ORTHOPAEDIC SURGERIES 3

Rtn. Dr Balavenkatasubramanian, Senior Consultant Anaesthesiologist,

Department of Anaesthesia, Ganga Medical Centre & Hospitals Pvt. Ltd., Coimbatore.

SPINE

DELAYED SURGICAL MANAGEMENT OF TRAUMATIC BIFACETAL CERVICAL

DISLOCATIONS THROUGH ANTERIOR - POSTERIOR -ANTERIOR APPROACH

- SHORT TERM RESULTS 9

Prof. Nalli R Uvaraj, Dr. S. SaravananSpine Surgery Unit, Institute of Orthopaedics and Traumatology,Madras Medical College and Rajiv Gandhi Govt. General Hospital, Chennai.

MODIC VERTEBRAL ENDPLATE CHANGES - PREVALENCE, PATTERNS AND

ETIOLOGIC GENETIC ASSOCIATION ANALYSIS OF 71 GENETIC POLYMORPHISMS

IN 809 PATIENTS 13

Dr. P. Rishi M Kanna, Ms Ranjani Raja Reddy, Dr. Natesan Senthil,Dr. Muthuraja Raveendran, Dr. Kenneth MC Cheung, Dr. Danny Chan, Dr Patrick,Dr. Ajoy Prasad Shetty, Dr. S Rajasekaran

Ganga Medical Centre and Hospital, Coimbatore.

FUNCTIONAL OUTCOME OF REVISION LUMBAR SURGERY FOR FAILED BACK

SURGERY SYNDROME 24

Prof. Nalli R Uvaraj, Dr.R.Neelakannan,Ortho Spine Surgery Unit, Institute of Orthopaedics and Traumatology,Madras Medical College, Chennai.

PAEDIATRIC ODONTOID SYNCHONDROSIS INJURY TREATED

CONSERVATIVELY- A CASE REPORT 29

Prof. Nalli R Uvaraj, Dr. R. NeelakannanOrtho Spine Surgery Unit, Institute Of Orthopaedics and Traumatology,Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai.

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TRAUMA

“SWASHBUCKLER APPROACH”- A MODIFIED ANTERIOR APPROACH FOR

DISTAL FEMUR FRACTURES 32

Dr.Rajkumar.N, , Dr Arunkumar K V, Dr.Rajasekaran.SGanga Hospitals and Medical Research Centre PVt., Ltd., Coimbatore.

EVALUATION OF FUNCTIONAL AND RADIOLOGICAL OUTCOME FOLLOWING

PROXIMAL FEMUR LOCKING LATE FIXATION IN PERTROCHANTERIC FRACTURES 38

Dr.Sumesh.S, Prof. N.Jambu, Dr.L.Senthil, Prof. B.SamuelChittaranjanDept.Of Orthopaedics, Sri Ramachandra University (SRU), Chennai,

FUNCTIONAL AND RADIOLOGICAL OUTCOME OF COMPLEX TIBIAL PLATEAU

FRACTURES TREATED BY COLUMN SPECIFIC FIXATION 44

Dr. Muthukumar Balaji S, Dr.Selvaraj, Dr.Sathish Devadoss., Prof.Dr.A.Devadoss.Devadoss Multi Speciality HospitalInstitute of Orthopaedic Research and Accident Surgery, Madurai.

ARTHROPLASTY

TOTAL HIP ARTHROPLASTY IN TROCHANTERIC FRACTURES:A SHORT TERM FOLLOW-UP 49

Dr. Sidhant S Goyal, Prof. M. Mohan KumarDepartment of Orthopaedics, Sri Ramachandra University, Chennai.

MISCELLANEOUS

FUNCTIONAL OUTCOME OF ONE STAGE RECONSRUCTION OF POSTERIOR CRUCIATE +LIGAMENTCOMBINED INJURIES OF THE KNEE IN CHRONIC INSTABILITIES 53Dr S R Sundararajan, Dr S RajasekaranGanga Hospitals and Medical Research Centrre, Coimbatore

PRIMARY AGGRESSIVE CHONDROBLASTOMA OF THE PROXIMAL FEMUR TREATED

WITH EXTENDED CURETTAGE AND RECONSTRUCTION: A CASE REPORT AND

REVIEW OF LITERATURE 58Manohar.T.M, Antony.V, Kumar.L, Arun anand.P, Selvakumar, Bosco Aju, Vijayashankar.K,Obuli Vijayshankar.O, Department of Orthopaedics,Government Mohan Kumaramanagalam Medical College Hospital, Salem.

COST EFFECTIVE NEGATIVE PRESSURE WOUND THERAPY IN ORTHOPAEDICS 62Dr. Syam Prasad Sasank Kasa, Dr. L.Senthil, Dr.N.Jambu,Dr.B.Samuel ChittaranjanDepartment of orthopaedics, Sri Ramachandra Medical Collage, Chennai.

SLIPPED DISTAL FEMORAL EPIPHYSIS IN CONGENITAL INSENSITIVITY TO PAIN 66Dr. M Javed, Dr. C RexRex Orthopaedic Hospital,Coimbatore

GUIDELINES TO AUTHORS

TNOA MEMBERSHIP APPLICATION FORM

IOA MEMBERSHIP APPLICATION FORM

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EDITORIAL

Dear Members,

Greetings to all of you

It has been great pleasure to be an editor and cherished all the happy moments involving the Tamil Nadu

Orthopaedic Association. It has been my proud moments to bring all the journals year after year and I feel proud

and privileged. I have improved the layout and content of the journal and made it Bi-annual.

The journal would grow strong if only all the members contribute and welcome the issues. In the forthcoming

issues, more importance would be given to an article with case series rather than case reports. The big necessity

is that we are not able to receive articles in advance and hence it is increasingly difficult to get editorial board

review and later double blind peer review process. For this reason I have requested the executive committee to

bring proposal that all the journal articles sent for TNOACON is also available to the editor. In essence the Editor

will be a part of scientific committee year after year so that he will have access to all the articles. This will enable

the editor to get going with review process.

I request all members to participate and be enthusiastic in manuscript submission in large numbers. The

best thesis in each institute could be written as paper and sent for publication and hence I request the head of the

departments of each medical college and DNB institutes to kindly consider this request so that it will help in

continuous supply of articles for the journal All the members please send your comments and help to get the journal

to have letter to the editor column.

I will be ending my tenure this year and wish the incoming editor good luck and continue the process so

that we will have our journal indexed.

Thanking you

With regards

Dheenadhayalan J

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20151

AM I DOING AN ETHICAL ORTHOPEADICPRACTICE ?

Prof. A. Devadoss, Chairman & Chief of OrthopaedicsDevadoss Multi Speciality Hospital

Institute of Orthopaedic Research and Accident Surgery, Madurai.

When we started Orthopaedic practice fivedecades ago, most of the fractures and orthopaedicconditions were treated conservatively and producedmore malunions, deformities. However, with themodern technological advance in metallurgy, instrumen-tations and implants we are in a more advantageousposition to give the best treatment for our patients But itends up in doing wrong selection of implants, wrongselection of patients and wrong technique leading on tocomplications and further leading on to misery for thepatients and the surgeon. It is not the surgeon’s wish,however he is not following ethical practice.

Ethics is the Science of human duty,there is a clear link between ethics and the law. Ethicstends to concentrate on values and the law on rights.

Benson et-al noted that our patients andgovernment grant us privileges but expect us to be guidedby ethical principles. For entry into the post graduatetraining in orthopaedics, entrance examinations goodtraining and certification and seek to ensure that thesestandards are maintained throughout the professional lifetime. In return, the Orthopaedic surgeon is expected totreat her patients with skill, care and consideration.

HONESTY AND INTERGRITY:It is important we treat our patients with full

honesty and integrity. This is usually comes during thetraining period from the teacher who should be the rolemodel. If anything goes wrong during surgery or aftersurgery, we must be honest in telling the patient whathas gone wrong and reassure them that all theprecautions were taken and now everything is in orderand you will be on the road to recovery. We mustmanage problems with compassion and understanding.If a patient complains about our care, we must respondpromptly, fully and honestly, and be prepared to apologisewhen appropriate.

LIMITATIONS AND EXPERIENCE:The Practicing Orthopaedic surgeon should

know his experience, limitations, skill and expertise. Ifthere is a complex fracture of acetabulum, it may bevery difficult to manage in a small set up. The surgeon

must be prepared to refer the case to more experiencedcolleague when necessary, we should never promiseexcellent clinical results when the outcome isunpredicable, for example, in treating a fracture neck offemur in the younger age group. We must avoidcriticism of a colleague in front of othe colleagues,trainees or patients. We should support our colleagueswho are the subject of unjust claims be lame.

INFORMED CONSENT:It is a mandatory part of our clinical practice. It

is not a piece of paper writing about the surgery andgetting the signature. It has lot of medico legalimplications. Suppose we are going to do Total KneeReplacement in a 62 year old lady, it is essential to tellthem in detail, the risks, alternatives, advantages anddisadvantages of the surgery she is going to undergo.All explanations must be under stood by the patient andalso by the close relatives and to be written in thelanguage they speak and witness signature must beobtained. The treatment that is offered must be basedon the need for the patient and not for the financial gainfor the surgeon.

ORTHOPAEDIC TEACHERS :The Orthopaedic trainer must have adequate

knowledge in the field of orthopaedic surgery and withan excellent surgical skill and impart knowledge both fromthe examination point of view and the ethical standardsneeded to look after patients with skill and care. It isimportant the teacher must ensure that the trainees un-derstand the importance of compassion, understandingand appropriate explanation in treating patients.

ADVERTISEMENTS:The American Medical Associations ethical

code on advertising states simply that we should not de-ceive the public. But it says that a doctor may publicizehim or herself through any commercial publicity or otherform of communication. Advertising in modern times isinevitable. But we should not mislead the patient by per-suasive self promotion. We should all remember thatadvertising can both benefit and harm careers. The

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20152

Prof. A. Devadoss

younger generation of orthopaedic surgeons must becareful and do the publicity in a milder way and showyour work, so that other patients are brought to you byword of mouth.

CONCLUSION :We are all gifted by God to be an orthopaedic

surgeon. We should not be greedy. We should treat allour patients with honesty, compassion, skill and care in

order to preserve the long tradition of respect and estab-lished trust our patients and colleagues place in us. Wemust produce more excellent orthopaedic teachers in ourstate and organize more CME programmes to train ex-cellent orthopaedic surgeons to serve our society at large.

REFERENCE:Benson MK, Bourne R, Hanley E. Jr. Ethics in Orthopaedic Surgery,JBJS (Br) 2005 87-B – 1449 – 1451.

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20153

`RECENT ADVANCES IN POSTOPERATIVE PAIN MANAGEMENT IN

ORTHOPAEDIC SURGERIES

Rtn. Dr Balavenkatasubramanian, Senior Consultant Anaesthesiologist,Department of Anaesthesia, Ganga Medical Centre & Hospitals Pvt. Ltd., Coimbatore.

One of the most important aspect of modernday anaesthesia practise is to provide adequate pain re-lief in the postoperative period. Acute Pain Service isemerging as a subspeciality of Anaesthesia services fo-cussing on enhancing recovery by providing adequateanalgesia. Acute pain service has on its roles Pain nurse,Nurse Anaesthetists, Physician Asssitants, Clinical Phar-macologists other than the Anaesthesiologists. The scope of providing good analgesia has en-hanced in the last few years due to the advent of newtechniques, new gadgets, new drugs, better understand-ing of pathophysiology of pain, elucidating the pain path-way, conceptualisation of Pre-emptive analgesia, deci-phering proinflammatory chemical substances and theirinfluence on postoperative pain, use of site specific an-algesia with the help of perineural catheters, availabilityof long acting local anaesthetic solutions like Liposomallocal anaesthetic solutions and emphasis on simple tech-niques like LIA-local Infiltration Analgesia. Though the scope and understanding about painmanagement has become better, the truth revealed bymany recent studies clearly indicate that still the num-ber of patients suffering from postoperative pain is quitehigh, the studies indicate nearly 80% patients suffer frompain and nearly 20% suffer from severe pain. Hence itis very important to focus more on this important aspectof patient care.The International Association for the Study of Pain IASPdefines pain as “ An unpleasantsensoryand emotionalexperienceassociated withactual or potential tissue dam-age or described in terms of such damage.

Immediate Consequences of Acute Posteoperativepain:Emotional and physical suffering for the patient and rela-tives•Sleep disturbance•Respiratory complications (may lead to lung collapse,retention of secretions and pneumonia)

•Cardiovascular side effects (hypertension andarrhythmias)•Increased oxygen consumption•Impaired gastrointestinal motility•Delays mobilization and increases risk of thromboem-bolism

Long term consequences of postoperative pain:•Sleep disturbance (with negative impact on mood andmobilisation)•Risk of behavioural changes•Poor wound healing•Delay in long-term recovery

Pain therapy has to be individualised and thefactors influencing the multimodal analgesia will includethe age of the patient, pre-existing medical illness, thetype of surgery and the extent of tissue damage and thepatients previous experiences of suffering from acute orchronic pain.

Multimodal Analgesia:Multimodal Analgesia is the terminology used in

the modern day practise. It essentially means incorpo-rating more that one drug to provide good analgesia, asthe drugs act on different parts of the pain pathway.Several of these drugs act synergistically to enhance painrelief without producing side effects. The main empha-sis in multimodal analgesia is to decrease the dose ofopioids used and hence decrease the complications ofopioid overdose.

Pain Assesment:Lack of pain assessment is the root cause of

inadequate pain control. Systematic approach to painassessment is thus vital. Pain should be assessed both atrest and during active movements. Postoperative painassessment should consider the intensity of pain, loca-tion, duration and description of pain.

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20154

The commonly used tool is:

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20155

Adequate Dosing schedule to be adhered to maintainthe miminmum effective level of the drug concentrationto produce adequate pain relief. This is important to pre-vent toxic drug level and also prevent episodes of se-vere pain in between two prescribed dosing.Current Medications:1. Opioids2. NSAIDS3. Paracetamol4. Prgabalin and Gabapentin5. Ketamine6. Local Anaesthetic solutions7. Dexamethasone8. Tramadol

Opioids:Opioids continue to play a crucial role in the manage-ment of perioperative pain. However with the use ofMultimodal analgesia the requirements of opioids havecome down. The commonly used opioids are enumer-ated below. Of the Opioids, Fentanyl is the drug of choicewhile dealing with patients with haemodynamic instabil-ity. Opioids are currently available in many differentforms. They are marketed as transdermal patches andlolypops apart from oral and intravenous routes.

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20156

NSAIDS:NSAIDS prevent prostaglandin synthesis both in the spinalcord and in the periphery. They provide moderate post-operative analgesia and would result in opioid sparing by30percent. These group of drugs have to be used withcaution in geriatric patients,patients with acid peptic dis-ease and contraindicated in patients with renalimpairement.

Paracetamol:The advent of intravenous paracetamol has truly helpedin moving yet another step forward in decreasing thepostoperative pain and also enhancing the opioid sparingeffect. The adult needs 4 grams per day. The first doseof 1 gram is given at induction, the second dose after 4hours after the first dose and then every 6th hourly.Paracetamol is safe in renal impaired patients. To beused with caution in patients with liver disease.

Ketamine:Ketamine is being extensively used in several centres.The loading dose is 0.5mg/kg and the infusion is startedwith a dose ranging from 2 to 10 microgarm/kg/hour.

Clonidine:Clonidine is extensively used in the perioperative period .It is used as an adjuvant to Local anaesthetic solutions.In epidurals the dose recommended is 1-2 microgram/kg. Intrathecally the minimum dose which produces clini-cal effect is 15microgram. We need to closely monitor

these patients for bradycardia and hypotension. Clonidineis also being used along with Local anaestheic solutionin peripheral nerve blocks in a dose of 1 microgram/kg.

TramadolTramadol is a weak opioid. It is helpful in treating mod-erate pain.The main advantage is that it does not causerespiratory depression.Adjuvants and Hyperalgesia:The following adjuvants have been found to prevent hy-peralgesia1. Ketamine2. Clonidine3. Gabapentinoids: Pregabalin and Gabapentin4. Magnesium5. Intravenous Lidocaine

Patient Controlled Analgesia:Patient Controlled analgesia has gained acceptance andhas been found to be very safe.• Mode: PCA mode, Continuous mode, PCA + Con-tinuous mode• Multiple routes: include IV, SC, epidural or periph-eral nerve catheters• Drug concentration: in milligrams per milliliters• Lock-out interval: period during which the patientcannot initiate another dose, a safety feature to preventoverdose• Hourly Limit: Maximum drug doses which can be

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20157

delivered within the a one hour period.• Loading dose – can be given by physician/nurse• Demand dosing – to be taken by patient when re-quired• Continuous infusion + demand dosing

Advantages of PCA:• Patient controlled analgesia (PCA) minimizes the ef-fects of drug peaks and troughs variability in individualpatients.• PCA provides superior postoperative analgesia andimproves patient satisfaction when compared with tra-ditional PRN analgesic regimens.• Patient need not wait for the nurse to receive the dose• Saves nurses’ time

Breakthrough pain• Transitory increase of pain in a patient who was rela-tively stable and adequately controlled baseline pain• Can be due to Incident pain (due to movement)/ Idio-pathic (without a known cause) /End-of-dose failure

Approaches• Adjusting the scheduled analgesic regimen (e.g. in-creasing the dose)• IV Opioids, or IV/oral NSAIDs as required

Regional Anaesthesia and Analgesia:The last two decades has witnessed increasing use ofregional anaesthetic techniques in the management ofperioperative pain.

The following advancements is worth highlighting:1. Single shot nerve blocks2.Continuous Perineural Catheters3. Continuous Epidural Catheters/ Patient ControlledEpidural Analgesia4. Continuous Spinal Catheters5. LIA Technique: Continuous Local Infiltration Analge-sia6. Liposomal Local Anaesthetic solutions: Single shotblock with these agents results in analgesia for 3 to 5days. This is because of the slow sustained release ofLocal Anaesthetic solution from the Liposomal Lamela.7. Continuous Pravertebral Blocks8. Continuous Intrapleural Analgesia9. Continuous TAP blocks10. Continuous Rectus Sheath BlockThese regional anaesthetic procedures provide site spe-cific analgesia.They are safe and not associated with respiratory de-pression. They provide excellent analgesia. When usedin multimodal analgesia decreases the use of opioids.Themost important aspect of continuous regional techniquesis the motor weakness that is associated and the result-ant possible fall of the patient. Catheter migration andinfection are some of the possible situations that we mightface while using this techniques.Currently we have both stimulating and Non stimulatingcatheters specifically designed for nerve blocks. Theadvent of Ultrasound has further enhanced the successrates of these blocks.

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20158

Future:Future holds promise as the newer gadgets that are be-ing developed like advanced intravenous infusion pumpswhich work on biofeedbacks, transdermal patches, longacting liposomal drugs and site specific perineural infu-sions with modern catheters seem to move us towards

conquering pain in the postoperative period.However, education of the physicians, nurses, physio-therapists, physician assistants, clinical pharmacologistsand establishing systems and protocols will go a longway in making our patients comfortable in the postop-erative period.

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 20159

DELAYED SURGICAL MANAGEMENT OF TRAUMATIC BIFACETAL

CERVICAL DISLOCATIONS THROUGH ANTERIOR - POSTERIOR -ANTERIOR APPROACH - SHORT TERM RESULTS

Prof. Nalli R Uvaraj, Dr. S. SaravananSpine Surgery Unit, Institute of Orthopaedics and Traumatology,

Madras Medical College and Rajiv Gandhi Govt. General Hospital, Chennai.

INTRODUCTIONFlexion-distractive forces on the neck may dis-

rupt the subaxial spine, causing injuries which range inseverity from facet subluxation to frank dislocation1. Abilateral fracture dislocation of a facet joint is a distrac-tive flexion injury of stage 3 or stage 4 according to theclassification of Allen et al2 and is an unstable three-column injury. Bifacetal dislocation adds to the risk ofthe development of quadriplegia and respiratory embar-rassment and even death. An acute bifacetal dislocationis initially treated by closed reduction on skull tractionunder close observation. If this fails, treatment is by openreduction using either an anterior or posterior approach,followed by instrumented or halo vest stabilisation. Themanagement of a patient who presents late i.e., morethan three weeks after the initial injury is challenging,and differs from that of the patient who is seenearly3.There have been few studies on the managementof late bifacetal dislocations3-7.

ObjectiveTo highlight the difficulties encountered during

delayed surgical management of cervical spine disloca-tions with or without neurological deficit and proposinga newer concept of management.

MATERIAL & METHODSBetween January 2010 and July 2014 eight pa-

tients (six men and two women) were taken up for treat-ment for bifacetal dislocation of the sub axial cervicalspine with a mean age of 43 years (15 to 70 years).Four patients had fallen down from a height, two hadfall of heavy object on the neck, one sustained injurydue to road traffic accident and one had fallen downfrom a running train all sustaining bifacetal cervical spinedislocation. The mean interval between injury and op-erative intervention was 9 weeks (3weeks to 28weeks).Three patients were neglected dislocations asthey had not taken medical help after the injury and pre-sented late, whereas the remaining patients though pre-senting soon after injury were managed late due to vari-ous reasons. Based upon existing literature patients taken

up for definitive treatment after 3 weeks were consid-ered as late management.All the patients had persistent neck pain and limitation ofmovements of the cervical spine.The neurological sta-tus was graded according to the ASIA Impairment Scale.Three patient had no deficit (grade E) and two patientspresented with grade D and one patient with grade Aand C each.Anteroposterior (AP) and lateral radiographs,CT scan and MR scan of the cervical spine obtained inall the patients showed a bifacetal dislocation of thesubaxial cervical spine. One patient had a fracture dislo-cation with fracture of the C7 vertebra, three with dislo-cation at C4-5 and C6-C7 each and two at C5-6 levels.

Closed reduction was attempted while payingclose attention to the neurological status of the patient.We failed to obtain reduction in all patients. Open re-duction was carried out as a three-stage procedure un-der a single anaesthesia. Surgery was performed withpatient positioned on a Stryker’s frame to aid turning ofpatient at various stages of surgery.

In all the cases, anterior cervical discectomy wascarried out by the left-sided Smith-Robinson approachfollowed by wound closure and turning the patientprone.Through a posterior mid-line approach at the ap-propriate level the locked facets were exposed. The facetjoints were found to be enveloped by fibrous tissue andirreducible. Release of the soft tissues and fibrous tis-sues around facet joints were carried out and the facetjoint reduced by levering the proximal over distal facetwith a blunt dissector. In two patients facetectomy wasdone to aid reduction. Stabilisation was done posteriorlywith lateral mass pedicle screws and rods or reconstruc-tion plate and cortical screws. After wound closure thepatient was turned supine and the anterior wound wasreopened. Any remaining disc material was extractedout from the disc space followed by insertion of an ap-propriate size bone graft and stabilization with cervicallocking plate. In all patients postoperative period wasuneventful.

Postoperatively patients were immobilized withhard cervical collar and discharged after suture removalon the twelth postoperative day. The patient details are

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given in the table 1 below.

Fig 1 shows lateral radiograph of a patient presenting11weeks after injury with bifacetal dislocation at C4-5and midsagittal T2-weightedMR scan showing bifacetaldislocation with compression of the cervical cord.

Fig 2 shows immediate postoperative antero posteriorand lateral radiograph of the cervical spine showing goodalignment and stabilisation of the dislocated vertebrae.

Fig 3 shows antero posterior and lateral radiograph ofthe cervical spine showing maintenance of good align-ment of vertebrae at 10 months follow up.

RESULTS:The mean follow up period was 23.5 months

(6 months-62 months). Four patients (50%) hadcomplete pain relief at last follow up. There were nograft complications like dislodgement of graft or graftresorption. The spinal alignment was well maintained inall cases at final follow-up. Three patients withincomplete spinal cord injury (grade D) improved tonormal, one patient in grade C improved to grade Dand the remaining one from grade A to grade C. Therewas no neurological deterioration in any of the patients.

As attaining reduction was difficult in onepatient who had fracture dislocation, a suboptimalreduction was accepted and fixed with reconstructionplates and screws. This patient had pull out of screwsduring the follow up period but with satisfactorymaintenance of spinal alignment.

Fig 4 shows a midsaggital CT cut showing bifacetal dis-location at C6-C7 with fracture of C7 vertebra and mid-sagittal T2-weightedMR scan showing bifacetal dislo-cation with compression of the cord.

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Fig 5 shows the antero posterior and lateral radiographof the patient during follow up with screw pull out.

DISCUSSION:Flexion injuries of the lower cervical spine are

relatively common. Bilateral facet dislocations are asso-ciated with significant soft-tissue damage and a high in-cidence of neurological injury. These injuries are highlyunstable. Timely reduction is recommended to stabilizethe spine.

The goal of treatment is to achieve anatomicalalignment and a stable motion segment. Open reductionof bilateral facet dislocations can be achieved by eitheran anterior, posterior, or combined approach. Preopera-tively, MR imaging is necessary to exclude the presenceof a disc herniation. In such a situation, an anterior ap-proach is needed to excise the extruded disc before at-tempting reduction of the dislocation8.

Controversies exist in literature as to the surgi-cal approaches for delayed open reduction and opera-tive treatment of bifacetal cervical spine dislocation.Verbiest10 used anterior approach removing anterior lon-gitudinal ligament and intervertebral disc, which, accord-ing to him, prevents reduction through cicatrisation.Bartels and Donk5 performed anterior micro discectomyfirst but were unable to reduce the vertebrae. Hence aposterior facetectomy was done followed by anteriordistraction and fixation and posterior fixation in 2 cases.Based on this experience and the fact that fibrous tissuearound uncovertebral joints prevent reduction throughanterior approach, a posterior facetectomy was done firstfollowed by anterior micro discectomy, distraction andbone grafting of disc space after achieving reduction.This was followed by a posterior fixation. Similarly JainAK9 and and Liu P3 in their series showed that posterior

facetectomy is essential for reduction of the lockedfacets.Thus it is shown that posterior facetectomy isessential for achieving reduction. Therefore, completereduction was possible only after circumferential releaseof these fibrous tissues from both posterior and anterioraspects and so a combined approach is the only option.

The authors approach for delayed surgicalmanagement of cervical dislocation is anterior releasefollowed by posterior release and reduction. The cervicalspine is subsequently stabilised after attaining alignmentby an instrumented anterior cervical fusion. The entiresurgical procedure is done under a single anaesthesiawith the help of a Stryker’s frame which aids in turningthe patient during the various stages of the surgicalprocedure. Based upon the concept that the anteriorstructures (anterior longitudinal ligament and traumatisedintervertebral disc) undergo cicatrisation and preventsreduction of the dislocation, the anterior release is doneby an anterior approach. In the presence of a prolapsedintervertebral disc, anterior discectomy also preventsdisplacement of the injured disc into the spinal canalduring reduction of dislocation.This is followed byadequate release of the facet joints, reduction andstabilisation which was found to be easier due to theanterior release. Also due to this anterior release,facetectomy may not be necessary in all cases exceptthe late neglected dislocations. After restoration of thespinal alignment it is maintained by a well performedinstrumented anterior cervical fusion. The author feelsthat this anterior – posterior - anterior approach is lesstraumatic for performing late reduction of bifacetaldislocation of the subaxial cervical spine.

As regardswise the posterior instrumentation, thededicated lateral mass screw system has been found to besuperior to the reconstruction plates and screws. The lateralmass screw system has the advantage in that it can beinserted with precision and has better pull out strength.

CONCLUSIONBased on our recent experience with delayed

surgical management of traumatic bifacetal dislocationof the subaxial cervical spine, we propose the followingsurgical treatment algorithm: Stage 1: Open Anteriorrelease and Cervical discectomy, Stage 2: Posteriorfacetal release, reduction and stabilization and Stage 3:Anterior instrumented fusion.The lateral mass screwsystem because of its merits is preferred in posteriorstabilization procedures.

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REFERENCES1.Platzer P, Hauswirth N, Jaindl M, et al. Delayed or missed diagnosisof cervicalspine injuries. J Trauma 2006;61:150-5.62. Allen BL, Ferguson RL, Lehmann TR, et al. A mechanisticclassification of closed, indirect fractures and dislocations of thelower cervical spine. Spine 1982;7:1-27.3. Liu P, Zhao J, Liu F, Liu M, Fan W. A novel operative approach for thetreatment of old distractive flexion injuries of subaxial cervical spine.Spine 2008;33:1459-64.4. Kahn A, Leggon R, Lindsey RA. Cervical facet dislocation: managementfollowing delayed diagnosis. Orthopedics 1998;21:1089-91.5. Bartels R, Donk R. Delayed management of traumatic bilateral cervicalfacet dislocation: surgical strategy. J Neurosurg 2002;97(3 Suppl):362-5.

6. Hassan M. Treatment of old dislocations of the lower cervicalspine. Int Orthop 2002;26:263-7.7. Payer M, Tessitore E. Delayed surgical management of a traumaticbilateral cervical facet dislocation by an anterior-posterior-anteriorapproach. J Clin Neurosci 2007;14:782-68. An HS: Cervical spine trauma. Spine 23:2713–2729, 19989. Jain AK, Dhammi IK, Singh AP, et al. Neglected traumaticdislocation of the subaxial cervical spine. J Bone Joint Surg Br2010;92(2):246-9. 10. Verbiest H. Anterior operative approach in cases of spinal-cordcompression by old irreducible displacement or fresh fracture ofcervical spine. Contribution to operative repair of deformed vertebralbodies. J Neurosurg 1962;19:389-400.

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MODIC VERTEBRAL ENDPLATE CHANGES

PREVALENCE, PATTERNS AND ETIOLOGIC GENETIC ASSOCIATION

ANALYSIS OF 71 GENETIC POLYMORPHISMS IN 809 PATIENTS

Dr. P. Rishi M Kanna, Ms Ranjani Raja Reddy, Dr. Natesan Senthil,Dr. Muthuraja RaveendranDr. Kenneth MC Cheung, Dr. Danny Chan, Dr Patrick, Dr. Ajoy Prasad Shetty, Dr. S Rajasekaran

Ganga Medical Centre and Hospital, Coimbatore.

ABSTRACTIntroductionModic changes (MC) are vertebral end plate signal changes observed in sagittal magnetic resonance imagingsequences. Though the true significance of MC is not known, a significant association between non-specificlow back pain and MC have been described in different studies. Recently the role of genetic factors in theetiology of MC is being evaluated by different researchers. Interleukin-1A (IL1A) and matrix metalloproteinase-3 (MMP3) polymorphisms together were associated with type II Modic changes in one study. However there islack of studies on a larger patient subset, and candidate genes involved in other disc degeneration phenotypeshave not been studied. The present study purports to evaluate the prevalence of MC and the potential role ofgenetic polymorphisms in 40 candidate genes (including 71 SNPs) in a large cohort.Materials and Methods:The study was a cross sectional study of patients presenting at the Spine Unit of a tertiary referral hospital.An individual was included in the study based on the following criteria: any sex, between the age group of18 to 70 years, no evidence of other spinal diseases, no history of previous lumbar spine surgery and nohistory of significant spinal injury. The MRI included T1 and T2 weighted axial, and sagittal sections of thelumbar spine (T12- S1) and a screening MRI- T2 weighted sagittal images of the whole spine. The presenceand type of Modic changes were assessed in the sagittal T1 and T2 sequences. The genetic associationanalysis of all the potential SNPs was made with reference to the presence or absence of the presence of MC(case versus control analysis).The blood samples were collected from the study population in EDTA containing tubes and stored at -80ºC forlaboratory analysis. DNA was extracted and Seventy one SNPs in 40 candidate genes were selected for analysisbased on previous genetic studies on lumbar discs. Genotyping of SNPs of case and control samples wasperformed using the Sequenome® platform. The SNPs prevalent in all the target genes of study populationwas predicted and association test was performed by using PLINK software based on the nature of SNPs.ResultsThere were 809 individuals who satisfied the inclusion criteria, consisting of 455 males and 354 females. Themean age of the patients was 36.7 ± 10.8 years. Based on the presence of MC at any one of the five lumbar discs,the total population was divided into 702 controls and 107 cases. Among the 107 cases, 64 patients had single levelMC (7.9%), 32 had double level MC (3.9%), five each had three and four level MC (0.6%) and one patient hadmulti-level MC. Modic changes were identified in 251 endplates among the 1070 endplates. MC was morecommonly situated in the lower endplates (149, 59.4%) than in the upper endplates (102, 40.6%). L4-5 endplateswere the most commonly affected level (n=77, 30.7%) followed by L5-S1 (n=66, 26.3%), L3-4 (n=60, 23.9%), L2-3 (n=31, 12.4%) and L1-2 (n=17, 6.8%).Among the 251 endplates with MC, Type 2 MC was the most commonly observed pattern (n=206, 82%), followedby Type 1 (n=27, 10.8%) and Type 3 (n=18, 7.2%). Mirroring endplate MC was observed in 75 discs (29.8%) amongthe total 535 discs of the 107 cases. Type 2 MC was the most common observed pattern (n=66, 88%) followed byType 1 (n=7, 9.3%) and Type 3 (n=2, 2.7%) MC. Mixed patterns were observed in 9 discs including two (I and IIpattern) and seven (II and III pattern).Among the 40 candidate genes studied, two of them showed significant association with the presence of MC. Thers2228570 SNP of Vitamin D receptor (VDR) gene (p=0.02) and rs17099008 SNP of Matrix Metallo proteinase(MMP 20) (p= 0.03) were significantly associated with MC in the study population. Eighty four patients hadexclusively type 2 MC. The rs2066826 SNP of cyclo-oxygenase (COX2) gene (p=0.01) and rs11247361 of InsulinGrowth Factor Receptor (IGF1R) (p=0.03) were significantly associated with Type 2 MC.ConclusionThe significance and etiology of Modic changes are not clear but have been increasingly implicated in lowback pain. Understanding the etiopathogenetic mechanisms of Modic changes would tremendously help usto plan preventive and therapeutic strategies. The possibility of genetic factors in the causation of Modicchanges is being probed recently. The present study identifies genetic polymorphisms of VDR, MMP 20,COX 2 and IGF1R to be significantly associated with MC in a large population. These associations have notbeen reported previously.

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INTRODUCTIONModic changes (MC) are vertebral end plate

signal changes observed in sagittal magnetic resonanceimaging sequences (1). Three types have been de-scribed, where type 1 refers to hypointense T1 andhyperintense T2 signal changes, type 2 refers tohyperintense signals in both T1 and T2 images and type3 refers to hypointense signal changes in T1 and T2images. MC has been described in the lumbar, thoracicand cervical spine but it is predominantly observed inthe lumbar spine.Though the true significance of MC is not known, a sig-nificant association between non-specific low back painand MC have been described in different studies (2,3).Studies have observed significant association betweenModic changes and the presence of lumbar disc degen-eration also (4,5). The prevalence of MC varies from 18to 62% in patients with low back pain, with type I andtype II being the most common observed patterns (2,3).The etiopathogenesis of MC is still not clear and bothmechanical and biochemical reasons have been de-scribed. With the initiation of disc degeneration, the in-creased stress on the end plates can result inmicrofractures and fissures within the end plates andthis could be a major source of MC. The histopathologi-cal observation of microfissures and neovascularisationwithin the end plates in type 1 MC supports this biome-chanical theory. Several authors have suggested thatbiochemical factors including infection and inflamma-tion could be the cause of MC. Albert et al postulatedthat with the presence of disc herniation andneovascularisation, anaerobic bacteria can lodge in theendplates initiating edema and inflammation (6). Elevatedlevels of inflammatory mediators such as interleukinsand pro-inflammatory cytokines have been detected inend plates with MC (7).Genetic factors have gained credence recently as pos-sible etiologic mechanism for disc degeneration, low backpain and sciatica. Since low back pain and disc degen-eration represent a structural failure of disc, genes cod-ing for the structural components of intervertebral discs,genes involved in matrix turnover and organization, suchas collagen, aggrecan, and matrix metalloproteinaseshave been linked in the mechanical failure of the disc(8,9). Recently the role of genetic factors in the etiologyof MC is being evaluated by different researchers.Maataa et al studied 831 twins for heritability of MCand concluded that MC is heritable with 16–43% preva-lence of MC heritability (10). In 2008, Karppinen et alstudied the possible genetic associations of MC. Thir-teen variations in 8 genes were genotyped in an occu-pational cohort of 159 male train engineers and 69 malepaper mill workers. One hundred and twenty eight (56%)

patients were found to have Modic changes at one ormore disc levels. None of the single nucleotide polymor-phisms (SNP) was significantly associated with Modicchanges but when gene-gene interactions were evalu-ated, interleukin-1A (IL1A) and matrix metalloproteinase-3 (MMP3) polymorphisms together were associated withtype II Modic changes (11). However there is lack ofstudies on a larger patient subset, and candidate genesinvolved in other disc degeneration phenotypes have notbeen studied. The present study purports to evaluate thepotential role of genetic polymorphisms in 40 candidategenes (including 71 SNPs) with MC in a larger cohort.

MATERIALS AND METHODS:Recruitment of study subjects and division into case-con-trol cohortsInstitutional review board approval was obtained beforestarting the study. The study was a cross sectional studyand the study population was recruited from patientspresenting at the Spine Unit of a tertiary referral hospi-tal. An individual was included in the study based on thefollowing criteria: any sex, between the age group of 18to 70 years, no evidence of other spinal diseases (con-genital, pathological, inflammatory, infective), no historyof previous lumbar spine surgery and no history of sig-nificant spinal injury. Clinical phenotypes such as backpain, neurological symptoms and signs of radiculopathywere not considered as criteria. Any patient who re-quired a MRI of the lumbar spine and who met the in-clusion criteria was explained about the study and if con-sented, was included in the project. Healthy human vol-unteers working (hospital personnel) were also includedin the study. A well informed, thoroughly explained, de-tailed informed written consent of the study subjects wereobtained.Radiological evaluation & interpretation of MRIAll individuals were screened by a whole spine MRI.The MRI included T1 and T2 weighted axial, and sagit-tal sections of the lumbar spine (T12- S1) and a screen-ing MRI- T2 weighted sagittal images of the whole spine(1.5 Tesla MRI, Siemens, Germany). The scanning pro-tocol was as follows: sagittal T1 turbo spine echo se-quence of recovery time 400-750ms, echo time 10-13ms,slice thickness 4 mm and field of view 360 x 360 andsagittal T2 turbo spin echo sequence of recovery time2800- 3400 ms, echo time 50 -100ms, slice thickness of4 mm and field of view was 360 x 360 mm. For thepurpose of analysis of MC, only the lumbar region wasstudied. All five lumbar discs from L1 to S1 were ana-lyzed, and in patients with transitional lumbo-sacral ver-tebra, the last five mobile discs were studied. The pres-ence and type of Modic changes were assessed in thesagittal T1 and T2 sequences (Figures 1-3). Presence

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of endplate signal changes in the anterior and posteriorcorners of the vertebral body near the disc and signalchanges subjacent to the entire endplate were consid-ered while signal changes adjacent to Schmorl’s nodeswere excluded. Five sagittal sequences including one mid-sagittal and four parasagittal sections were studied in allpatients. Evaluation of the MC types was performed bytwo independent observers (two spine surgeons). Theinter-observer reliability between them was excellent(kappa statistic of 0.82 ± 0.07). Any dispute betweenthe two observers was settled by consensus. The ge-netic association analysis of all the potential SNPs wasmade with reference to the presence or absence of thepresence of MC (case versus control analysis). Thoseindividuals without MC in any of the lumbar discs wereconsidered as controls while those with MC in either orboth the endplates at any one of the lumbar disc levelswere considered as cases.Selection of Putative Candidate SNPsThe blood samples were collected from the study popu-lation in EDTA containing tubes and stored at -80ºC forlaboratory analysis. DNA was extracted from the fro-zen human blood. The quality and quantity of DNA waschecked by Agarose gel electrophoresis and spectro-photometry.

Type 1: MODIC CHANGES AT L3-4 INFERIORENDPLATE. Hypointense T1 signal and HyperintenseT2 signal changes are seen

Type 2: MODIC CHANGES AT L5-S1 SUPERIORENDPLATE. Hyperintense T1 signal and T2 signalchanges are seen

Type 3: MODIC CHANGES AT L5-S1 INFERIORENDPLATE. Hypointense T1 signal and and T2 signalchanges are seen

Seventy one SNPs in 40 candidate genes were selectedfor analysis based on previous genetic studies on lum-bar disc degeneration including candidate genes whichencode for vital disc components, potential genes whichhave been implicated in other multi-factorial etiologicdiseases, and genes involved in important intracellularsignaling mechanisms. Genotyping of SNPs of case andcontrol samples was performed using the Sequenome®platform. The Mass ARRAY Assay Design softwarewas used to design amplification and allele-specific ex-tension primers. The extension primer was designed tohybridize to the amplicon near the SNP site for the ex-tension of a single base or a few bases depending on thegenotype of the allele. PCR reactions were set up in

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384 well plates using 5 ng of genomic DNA as template.The final base-extension products were desalted usingSpectroClean resin (Sequenom) mixed with 3-hydroxypicolinic acid and analyzed using a modifiedBrucker Autoflex MALDI-TOF mass spectrometer. TheSpectroAquire and MassARRAY Typer Software pack-ages (Sequenom, San Diego, CA, USA) were used forinterpretation and Typer analyser V3.4.0.18 was usedto review and analyse all data.Association analysisPLINK was used for all the downstream analysis andvalidation data. The SNPs prevalent in all the target genesof study population was predicted and association testwas performed by using PLINK software based on thenature of SNPs. Probability value and odds ratio wereestimated for all the 71 SNPs, and also tested their sig-

nificance towards MC. LD pattern for the significantgene was performed by Haploview software with thehelp of The International HapMap Project.

RESULTSThere were 809 individuals who satisfied the inclusioncriteria, consisting of 455 males and 354 females. Thestudy subjects included 204 healthy volunteers and 605patients (Table 1). The mean age of the patients was36.7 ± 10.8 years. Based on the presence of MC at anyone of the five lumbar discs, the total population wasdivided into 702 controls and 107 cases. There was nosignificant difference between the controls and cases interms of age (35.9 ± 10.5 versus 42.2 ± 10.9) and male:female distribution (56%:44% versus 54%:46%).

Among the 107 cases, 64 patients had single level MC(7.9%), 32 had double level MC (3.9%), five each hadthree and four level MC (0.6%) and one patient hadmulti-level MC (Table 2). Modic changes were identi-fied in 251 endplates among the 1070 endplates. MCwere more commonly situated in the lower endplates

(149, 59.4%) than in the upper endplates (102, 40.6%).L4-5 endplates were the most commonly affected level(n=77, 30.7%) followed by L5-S1 (n=66, 26.3%), L3-4(n=60, 23.9%), L2-3 (n=31, 12.4%) and L1-2 (n=17,6.8%) (Table 3).

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Among the 251 endplates with MC, Type 2 MC was themost commonly observed pattern (n=206, 82%), followedby Type 1 (n=27, 10.8%) and Type 3 (n=18, 7.2%). Weanalysed the presence of mirroring endplate MC on ei-ther side of a particular disc (i.e., the presence of sameType 1,2 or 3 changes on both sides of a lumbar disc).Mirroring endplate MC was observed in 75 discs (29.8%)

among the total 535 discs of the 107 cases. Type 2 MCwas the most common observed pattern (n=66, 88%)followed by Type 1 (n=7, 9.3%) and Type 3 (n=2, 2.7%)MC. Mixed patterns were observed in 9 discs includingtwo (I and II pattern) and seven (II and III pattern).Mixed I and III pattern was not observed (Table 4).

Among the 40 candidate genes studied (Table 7), twoof them showed significant association with the pres-ence of MC. The rs2228570 SNP of Vitamin D recep-tor (VDR) gene (p=0.02) and rs17099008 SNP of Ma-

trix Metallo proteinase (MMP 20) (p= 0.03) were sig-nificantly associated with MC in the study population(Table 5).

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Since Type 2 MC was most commonly observed in ourstudy, we performed a sub-group analysis in this group.Eighty four patients had exclusively type 2 MC. Thers2066826 SNP of cyclo-oxygenase (COX2) gene

(p=0.01) and rs11247361 of Insulin Growth Factor Re-ceptor (IGF1R) (p=0.03) were significantly associatedwith Type 2 MC (Table 6).

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DISCUSSIONIn the present study population of 809 individuals, ge-netic polymorphisms of VDR, MMP 20 were significantlyassociated with MC. Modic changes are vertebralendplate and adjacent bone marrow changes observedin sagittal MR sequences. Though De Roos et al de-scribed it for the first time (5), Modic was credited forclassifying these changes into three categories: type Ichanges show a low signal intensity in T1-weighted im-ages and a high SI in T2-weighted images, type II changesshow a high signal in both in T1 and T2 sequences andtype III changes show a low signal in both T1 and T2sequences (1). Type I changes are presumed to indicatean active inflammatory process in the subchondral re-gion, whereas type II changes are presumed to reflectfatty degeneration of the bone marrow. Type III changespossibly indicate sclerosis in the subchondral region.

The prevalence of MC varies in different stud-ies from 18-62% and the prevalence of each type alsovaries. Based on previous studies, type I and type II arethe most common patterns in the lumbar spine. The in-consistent results regarding the prevalence of MC stud-ies could probably be due to differences in number ofpatients, inclusion criteria, and study design. Chung etal. in their study of 59 asymptomatic subjects observedthat type 2 changes (n=38) were more frequent thantype I changes (n=11) in 590 lumbar vertebral endplates(12). In our study also, Type 2 MC was the most com-monly observed pattern (n=206, 82%). Type 1 (10.8%)and Type 3 (7.2%) were very infrequent. Among thedifferent lumbar levels, Modic et al. observed that thedistribution of MC at L4–L5 or L5–S1 were most com-mon. These observations were confirmed by Kuisma etal. They also observed that the distribution of type I andII was more in anterior 1/3 of vertebra than in posterior2/3 of vertebra and the distribution of type II was pre-dominant in the superior endplate versus in the inferiorendplate (13). In the present study, Modic changes weremore commonly situated in the lower endplates (149,59.4%) than in the upper endplates (102, 40.6%). L4-5endplates were the most commonly affected level (77,30.7%) followed by L5-S1 (26.3%), L3-4 (23.9%), L2-3 (12.4%) and L1-2 (6.8%).

Pathophysiologically MC has been consideredto arise following both biomechanical and biochemicalinsults to the endplate. With progressive lumbar disc de-

generation, the increased stress on the endplates causescalcification and micro-fractures. Such changes may leadto an uneven distribution of loads across the entire discand thus may contribute to endplate fissures. Suchendplate breaks can cause neovascularisation, edemaand inflammatory response. This is observed as Type 1Modic changes. Altered endplate function interferes withthe nutrition to the discs perpetuating further degenera-tion of the nucleus pulposus. Modic et al. have demon-strated that MC type I is characterized by disruption andfissures of the endplates. Once the acute inflammationsettles, the inflammatory tissue is replaced by fatty mar-row in the subchondral region which is seen ashyperintense signal changes in T1 and T2 sequences(Type II MC). In chronic situations, sclerosis and calci-fication in the sub-chondral marrow is visualized as typeIII MC.

Apart from biomechanical stress induced by thedegenerated discs on the endplate, active inflammationinduced by inflammatory cells, interleukins and cytokinesseems to play a big role in the pathogenesis of MC. Asignificant association between low back pain and MChas been described in several studies which also sup-ports the role of inflammation in MC. Using the immu-nohistochemical method, Ohtori et al. found that proteingene product 9.5 (PGP)-immunoreactive nerve fibersand tumor necrosis factor (TNF)-immunoreactive cellsin the endplates from patients with MC was significantlymore than in normal endplates on MRI (14). In our study,we did not study the association between clinical pheno-types such as low back pain and MC and hence couldnot comment on this.

In the present study, among the 71 SNPs stud-ied, two SNPs (VDR and MMP 20) had a significantassociation with the presence of MC. Previous two stud-ies on the genetic association of MC have observed dif-ferent genes to be implicated including IL1 cluster,MMP3, ADAMTS and TNF- á. Karpinnen et al studiedeight genes (COL9A2, COL9A3, COL11A2, IL1A,IL1B, IL6, MMP3, and VDR) in an occupational cohortof 159 male train engineers and 69 male paper mill work-ers. All the subjects underwent MRI and evaluated forMC. The authors have specifically studied Type II MCand observed that none of the SNPs was significantlyassociated with Modic changes when analyzed indepen-dently, but when gene-gene interactions were evaluated,

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interleukin-1A (IL1A) and IL1 gene cluster together withMMP3 polymorphisms were associated with type IIModic changes (11). In the present study, MMP 20 hada significant association. Though Interleukin 1 and MMP3 polymorphisms were studied, we could not derive anyassociation. In the study by Karpinnen et al, out of the228 subjects, 128 (56%) were found to have MC at oneor more disc levels. In our study, 107 subjects had MC,the incidence being 13% out of 809 individuals. The wideage range, inclusion criteria and variable occupation pro-file of the study subjects could be the reason for thelesser incidence in the present study. In a subsequentstudy by the same authors but on a patient group from adifferent geographical area, they observed that among108 men from three different occupations, the presenceof the minor allele of IL1A was associated with Modicchanges (10). Though both these studies underline theimportance of the IL1A gene in the pathophysiology ofModic changes, we did not observe association with anyof the IL 1 genes (IL18RAP, IL1A, IL1B, IL1F5, IL1F10and IL1RN) in our study.

The rs2228570 SNP of Vitamin D receptor(VDR) gene had a strong association (p=0.02) with thepresence of MC in our study. Vitamin D receptor is asteroid receptor and plays an important role in normalbone mineralization and remodelling. It has two describedpolymorphisms in its gene (FokI and TaqI) which havebeen implicated in several orthopaedic conditions suchas osteoporosis, osteoarthritis and lumbar disc degen-eration. VDR was the first reported gene associated withdisc degeneration in a study of monozygotic twins in aFinnish population (15). This association was later con-firmed in a study of 205 Japanese volunteers with theTaqI polymorphism being more frequently associated withmultilevel disc disease, severe disc degeneration and discherniation (16). The association of the TaqI polymor-phism to DDD was further substantiated in a Chinesestudy. This association was observed to be age depen-dant and in the Chinese cohort, positive assoiciation wasobserved only for changes in the MRI signal intensity ofthe nucleus pulposus but not for structural defects suchas annular tears and Schmorl’s nodes (17). In a study of342 individuals, Rajasekaran et al studied genetic asso-ciation of 58 SNPs with different MRI parameters ofdisc degeneration including Pfirrmann’s grading, annu-lar tear, disc bulge, Schmorl’s nodes and endplate dam-age score (18). Eleven of the 58 SNPs provided evi-dence of association with either one of the phenotypes.Interestingly the frequency of the risk t-allele of VDRwas very low in this study and an association could notbe found. The VDR frequency also varies significantlydifferent between the three major ethnic populationsevaluated in the other studies, being 8% in Asians, 31%

in Africans and 43% in Caucasians. The mechanism bywhich the Taq I polymorphism predisposes to disc de-generation and Modic changes is not clear.

The rs17099008 SNP of Matrix Metallo protein-ase (MMP 20) (p= 0.03) was significantly associatedwith MC. MMPs are a group of enzymes that partici-pate in the degradation of the major structural compo-nents of the intervertebral disc and are known to be in-volved in the normal turnover and pathologic degrada-tion of the extracellular matrix in connective tissue.MMP-20 also known as enamel metalloproteinase orenamelysin is an enzyme that in humans is encoded bythe MMP20 gene. Though other MMPs like MMP 3and 10 have been linked to disc degeneration and Modicchanges, the association of MMP 20 with Modic changeshas been observed for the first time. MMP-3 has a po-tential role in proteoglycan degradation and has beenshown to be involved in disc degeneration. There is alsoevidence of induced MMP-3 expression related to me-chanical load and inflammation. In the study by Karpinnenet al, they observed that the combination of the T-C hap-lotype of IL1A and the MMP3 minor 5A allele was as-sociated with eightfold odd on Modic changes amongmiddle-aged Finnish men. It can be presumed that simi-lar mechanisms play a role in the causation of Modicchanges through genetic polymorphisms of MMP 20.

In the sub-group analysis of 84 patients who hadexclusively type 2 MC, the rs2066826 SNP of cyclo-oxygenase (COX2) gene (p=0.01) and rs11247361 ofInsulin Growth Factor Receptor (IGF1R) (p=0.03) weresignificantly associated with Type 2 MC. Previous stud-ies have stated that Type II MC to be significantly asso-ciated with low back pain. Similarly cyclooxgenase 2has been identified to be expressed profoundly in pa-tients with symptomatic lumbar disc herniation. Sincethe association between Type II MC and COX2 poly-morphisms is a new observation, it opens up interestingpossibilities of inflammation as the cause of pain in pa-tients with MC and the role of anti-inflammatory steroi-dal and non-steroidal drugs in the management of pain-ful MC. Insulin-like growth factor 1 (IGF-1) and its re-ceptor (insulin-like growth factor 1 receptor, IGF1R) playsignificant role in the regulation of extracellular matrixsynthesis and play a crucial role in maintaining the nor-mal functions of the intervertebral disc. Several studieshave identified decreased expression of IGF1R as a pos-sible etiological factor for disc degeneration. Li et al stud-ied lumbar discs of mice of different age groups andobserved significantly less amounts of proteoglycan andtype-II collagen, and higher total degenerative score inIGF1R defective mice than in wild-type mice. They con-cluded that reduced expression of IGF1R would lead toaccelerated degeneration of lumbar discs (19). There

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are no previous reports on the association of IGF1R poly-morphism and MC but it is possible that defective IGF1Rcould initiate matrix disintegration, fissures and endplatedamages.

CONCLUSIONModic changes are common endplate changes

observed in about 13% of population. The significanceand etiology of these changes are not clear but havebeen increasingly implicated in low back pain. Under-standing the etiopathogenetic mechanisms of Modicchanges would tremendously help us to plan preventiveand therapeutic strategies. The possibility of genetic fac-tors in the causation of Modic changes is being probedrecently. The present study identifies genetic polymor-phisms of VDR, MMP 20, COX 2 and IGF1R to besignificantly associated with MC in a large population.These associations have not been reported previously.Previously described associations with inflammatorygenes such as Interleukins were not proved in our popu-lation.

REFERENCES1.Modic MT, Steinberg PM, Ross JS, Masaryk TJ, Carter JR (1988)Degenerative disk disease: assessment of changes in vertebral body marrowwith MR imaging. Radiology 166:193–1992.Albert HB, Manniche C (2007) Modic changes following lumbar discherniation. Eur Spine J 16:977–982.3.Kjaer P, Korsholm L, Bendix T, Sorensen JS, Leboeuf-Yde C (2006)Modic changes and their associations with clinical findings. Eur Spine J15:1312–1319.4.Modic MT, Masaryk TJ, Ross JS, et al. Imaging of degenerative diskdisease. Radiology 1988;168:177–86.5.de Roos A, Kressel H, Spritzer C, et al. MR imaging of marrow changesadjacent to end plates in degenerative lumbar disk disease. AJR Am JRoentgenol 1987;149:531–4.6.Albert HB, Kjaer P, Jensen TS, Sorensen JS, Bendix T, Manniche C(2008) Modic changes: possible causes and relation to low back pain. MedHypotheses 70:361–3687.Burke JG, Watson RW, McCormack D, Dowling FE, Walsh MG,Fitzpatrick JM (2002) Intervertebral discs which cause low back painsecrete high levels of proinflammatory mediators. J Bone Joint Surg Br

84:196–201.8.Battie ́MC, Videman T, Gibbons LE, et al. Volvo award in clinical sciences.Determinants of lumbar disc degeneration. A study relating lifetime exposureand magnetic resonance imaging findings in identical twins. Spine 1995;20:2601–12.9.Sambrook PN, MacGregor AJ, Spector TD. Genetic influences on cervicaland lumbar disc degeneration: a magnetic resonance imaging study intwins. Arthritis Rheum 1999;42:366–72.10.Määttä JH1, Kraatari M, Wolber L, Niinimäki J, Wadge S, KarppinenJ, Williams FM. Vertebral endplate change as a feature of intervertebraldisc degeneration: a heritability study. Eur Spine J. 2014 May 15. [Epubahead of print]11.Karppinen J1, Daavittila I, Solovieva S, Kuisma M, Taimela S, Natri A,Haapea M, Korpelainen R, Niinimäki J, Tervonen O, Ala-Kokko L,Männikkö M. Genetic factors are associated with modic changes in endplatesof lumbar vertebral bodies.Spine (Phila Pa 1976). 2008 May15;33(11):1236-41.12.Chung CB, Vande Berg BC, Tavernier T, Cotten A, Laredo JD, Vallee Cet al (2004) End plate marrow changes in the asymptomatic lumbosacralspine: frequency, distribution and correlation with age and degenerativechanges. Skeletal Radiol 33:399–404.13.Kuisma M, Karppinen J, Niinimaki J, Ojala R, Haapea M, HeliovaaraM et al (2007) Modic changes in endplates of lumbar vertebral bodies:prevalence and association with low back and sciatic pain among middle-aged male workers. Spine 32:1116– 1122.14.Ohtori S, Inoue G, Ito T, Koshi T, Ozawa T, Doya H et al (2006) Tumornecrosis factor-immunoreactive cells and PGP 9.5- immunoreactive nervefibers in vertebral endplates of patients with discogenic low back pain andModic Type 1 or Type 2 changes on MRI. Spine 31:1026–1031.15.Videman T, Leppavuori J, Kaprio J, et al. Intragenic polymorphisms ofthe vitamin D receptor gene associated with intervertebral discdegeneration. Spine 1998;23:2477–85.16.Kawaguchi Y, Kanamori M, Ishihara H, et al. The association of lumbardisc disease with Vitamin-D receptor gene polymorphism. J Bone JointSurg Am 2002;84:2022–8.17.Cheung KM, Chan D, Karppinen J, Chen Y, Jim JJ et al. Association ofthe Taq I allele in vitamin D receptor with degenerative disc disease anddisc bulge in a Chinese population. Spine2006;31(10):1143-8.18.Rajasekaran S1, Kanna RM, Senthil N, Raveendran M, Cheung KM,Chan D, Subramaniam S, Shetty AP. Phenotype variations affect geneticassociation studies of degenerative disc disease: conclusions of analysis ofgenetic association of 58 single nucleotide polymorphisms with highlyspecific phenotypes for disc degeneration in 332 subjects. Spine J. 2013Oct;13(10):1309-20.Epub 2013 Jun 21.19.Li B1, Zheng XF, Ni BB, Yang YH, Jiang SD, Lu H, Jiang LS. Reducedexpression of insulin-like growth factor 1 receptor leads to acceleratedintervertebral disc degeneration in mice. Int J Immunopathol Pharmacol.2013 Apr-Jun;26(2):337-47.

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Abstract:Introduction:According to literature the overall success rate for revision lumbar sur-gery for failed back surgery syndrome (FBSS) is 12% to 82 %. The outcome dependson various factors like pain free interval, the cause for FBSS, follow up period andsurgeon factor. We have tried to evaluate these factors in about 20 patients both ret-rospectively and prospectively.Methods: The study was conducted among 20 patients. Various factors like age, sex,pain free interval (PFI), number of previous surgeries, neurological deficit, surgicaltechnique, use of fusion or non fusion techniques were analysed and their effects onthe outcome were studied. Preoperatively and post operatively evaluation was doneby ODI score, VAS score and radiographs.Results: The overall successful outcome of this study is 60%.There was no differ-ence between the fusion and non fusion groups. The instability group had a betteroutcome than the other patients. One patient had dural tear and 2 patients had infec-tion as complication.Conclusions:Proper preoperative evaluation and diagnosis is of paramount impor-tance in the management of failed back surgery syndrome.High success rate followingthe revision lumbar surgery depends on a good preoperative planning, finding out thespecific pathology and targeting it appropriately leads to gratifying results.Key words: Pain free interval, fusion, Failed back surgery syndrome, ODI score , VASscore

FUNCTIONAL OUTCOME OF REVISION LUMBAR SURGERY

FOR FAILED BACK SURGERY SYNDROME

Prof. Nalli R Uvaraj, Dr.R.Neelakannan,Ortho Spine Surgery Unit, Institute of Orthopaedics and Traumatology,

Madras Medical College, Chennai.

INTRODUCTIONAbout 40% of patients undergoing lumbar sur-

geries for low back pain come with significant amountof pain after the surgery1.Among these patients manyfall under the entity called Failed back syndrome whichis defined as the persistent or recurrent low back painafter one or more than one lumbar surgeries1. Its inci-dence is 15%. Various causes of Failed back syndromeare either mechanical like recurrent disc herniations,spinal stenosis,post laminectomy instability,flat backsyndrome,and pseudoarthrosis and non mechanical likearachnoiditis and epidural scar formation.These patientsare divided into two basic groups (1) in whom surgeryis never indicated (2) surgery is indicated but inad-equately performed.Appropriate patient selection is animportant factor in the outcome after spinal surgery.Thesuccess rate following revision surgeries are usuallybetween 12-82%. This is mainly based on the cause of

revision lumbar surgery.It has been observed that as thefollow-up period increases the success rate decreasesand as the number of surgeries increase the successrate decreases.This study evaluated the functional out-come of revision surgeries and the various factors whichinfluences the outcome of these surgeries.

MATERIALS AND METHODSTwenty patients consisting of 8 men and 12

women were included in this study which was both pro-spective and retrospective. All patients were operatedby the senior surgeon of the unit. Patients with post op-erative bacterial infections were excluded from the study.The age group ranged from 23-60 years with a mean of41.15years.Patients with chronic, persistent or recurrentor worsened pain following a spinal surgery were evalu-ated clinically and radiographically and the causes for

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recurrent pain were narrowed down .The patients hadlow back pain or radiating pain or the combination ofboth. The physical symptoms were correlated with theradiological findings of X rays, CT myelogram and MRIfor the diagnosis. Among these patients 17 were oper-ated once and 3 were operated twice. Six patients had apain free interval (PFI) less than 6 months and 14 pa-tients more than 6 months. Among these patients 5 hadinstrumentation failure and 7 patients had instability and8 had recurrent disc prolapse.Revision surgeries con-sisted of implant exit and redo posterior stabilisation (4patients), decompression and posterior stabilisation ( 2patients), posterior stabilisation alone ( 2 patients), pos-terior stabilisation and fusion (6 patients), revisiondiscectomy (5 patients) and anterior stabilisation (1 case).

RESULTSPost operatively the patients were followed up

regularly for 6 months. During the follow up radiologi-cal, clinical and neurological evaluation were done. Pa-tients were evaluated clinically by using Visual AnalogueScale (VAS), Oswestry Disability Index (ODI) and ASIAscore. The results were graded as (1) Excellent - if thepatient felt no pain, did not require any medication andreturned to his or her original work, (2) Good- if the painis much improved, requires little medication and the pa-tient returned to work, (3) Fair- if pain improved moder-ately, requires frequent medication with change to lighter

work and (4) Poor-if there is no improvement or hasdevelopment of more pain, requiring frequent medica-tion and is bed ridden most of the time.

Five patients were graded as excellent, sevenas good , five as fair and three as with poor outcome.Among the twelve patients ( 5 excellent and 7 good)with successful outcome results in younger patients (<35 yrs) were better than in old patients(> 35 yrs ) andresults among the male patients were better than thefemale patients. Based on the etiology, the success rateof instability cases (71.4%) were better than othergroups like instrumentation failure ( 40% ) and recurrentdisc disease (62.5%).Results among the patients whohad undergone surgery more than once had a better out-come than the patients who had undergone one revisionsurgery.Patients with pain free interval (PFI) more than6 months had successful outcome than the patients withPFI less than 6 months. Based on the surgical proce-dure patients were divided into fusion group (10 patients)and non fusion group(10 patients ). The outcome amongthese groups were equal. The mean pre operative ODIscore was 54.35 and post operative ODI score was 28.2at 6 months and 21.8 by 9months (T value -11.023 ; df19 p value - < 0.000). The mean preoperative VAS scorewas 7.8 and the mean postoperative VAS score was 4.8(T value-6.381,df-19, p value - < 0.000 ).In the presentstudy one patient developed a dural tear (5%) and 3 hadinfection (15%).

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DISCUSSIONThe successful outcome following a revision surgery forfailed back syndrome ranges from 12-82%13.The op-erative criteria used for primary spine surgeries maynot be applicable to revision surgery. Stewart et al6 inhis study concluded that there exists differences in theoperative criteria, follow up criteria and criteria for suc-cess explaining why there were difference of opinionbetween the researchers on which factor favourssuccessful outcome in failed back surgery syndrome.The overall success rate in our study is 60% which iscomparable to similar studies like the study conductedby ChakBor Wong et al1,where the success rate was83.9% and 72% in the study conducted by Stewart etal6. The postoperative ODI score and VAS scorecompared to the preoperative ODI and VAS scoresshowed favourable outcome which is statisticallysignificant ( VAS-T value-6.381,df-19, p value- < 0.000& ODI score- T-value- 11.023, df-19,p value- < 0.000).

In this study younger patients ( < 35 yrs) had afavourable outcome of 75% compared to the older agegroup ( > 35 yrs) in which the outcome was 56.3% Thisdifference may be due to the ongoing degenerativechanges in the spine as age increases or may be due tothe higher compliance of the younger individuals forpostoperative rehabilitation3. But this observation did nothave any statistical significance ( chisquare value of0.469, df-1,p value -0.494).

This study also showed a marginal increase inthe successful outcome in male patients (62.5%) com-pared to the female patients (58.3%). However thisobservation was again not statistically significant. ( chisquare 0.035, df-1, p value – 0.852).

The most common cause of failed back syn-drome in this study was recurrent disc herniations( 40%),as compared to 20% in Stewart et al6 study and 22.% inChakBor Wang et al1 study. Waddell et al10 in his studystated that probability of successful outcome decreaseswith the number of surgeries performed. Kim et al11

showed in his study that there was about 66% ofsuccess for revision surgeries and 55% in re revisionsurgery. In this present study the average previous sur-

gery was 1.13 as compared to 1.3 in study by Stewart etal6.Contrary to the earlier studies this study showed thatin patients with more than one revision surgery the out-come was better. However these results were not sta-tistically significant (Chi square value-0.065, df-1,p value-0.798).

The average pain free interval in this study was30.95 (0-156) months. Finnegan et al3 concluded thatthe patients with pain free interval of < 12 months willhave extensive fibrosis than patients with pain free in-terval > 12 months who may have other reasons for pain.Biondi et al8 and Waddell et al10 also in their studiesshowed that the patients with pain free interval > 6 monthswill have better outcome than the patients with pain freeinterval <6 months. In the study conducted byChakBorWong et al1 patients with PFI >6 months had better re-sults than patients with PFI < 6 months, but there wasno statistical significance in this observation.In thepresent study also we experienced a similar result witha success rate of 71.4% in patients with PFI > 6monthsand 16.6% in patients with PFI < 6 months which isstatistically significant with p value of 0.03( Chi square-4.432, df- 1).There were five patients with neurologicaldeficit having undergone revision surgery in this study.The overall outcome in these patients however was 40%.This is attributed to the poor activity level following therevision surgery due to the neurological deficit.In otherwords, the positive outcome for patients with no neuro-logical deficit were successfully predicted. Although apoor outcome was experienced in all these patients, therewas some recovery in the motor power ( ASIA scale) atlong term follow resulting in better outcome.

Kim et al11 in his study revealed that the resultsfor recurrent disc diseases were better than the steno-sis patients. Finnegan et al3 stated that the outcome ofrevision surgery is better in patients with mechanical com-pression like recurrent disc disease and dynamic insta-bility. ChakBor Wong etal1 also experienced a similarresults with good functional outcome for recurrent discdiseases(78.6%), Instability(93.32%), and pseudoar-throses ( 94%). The present study showed a similar kindof result with successful outcome of 71.14% in instabil-ity cases, 62.5% outcome in recurrent disc cases, and

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40% in the instrumentation failure cases. The good func-tional outcome in the instability cases is mainly attrib-uted to the spinal fusion which is achieved either throughan interbody fusion or through the posterolateral bonegrafting. The poor outcome following revision surgeryfor instrumentation failure may be attributed to the neu-rological deficit among two of the three patients whichaffects the activity level of the patient and infection inone patient which increases the morbidity.Cinnoti et al4

has opined that spinal fusion is not necessary in revisionsurgery for recurrent disc disease.

But Fritsch et al12 in his study stated that pa-tients with spinal fusion for recurrent disc disease expe-rienced a better outcome compared with the patientswithout fusion. The laminectomy and discectomy donein the index procedure produces instability and pain andcauses continuous epidural and nerve irritation leadingto epidural fibrosis. In the present study fusion was donefor 5 of the 7 instability patients of which 4 patients hadgood outcome.

Out of eight recurrent disc patients fusion wasdone in only 2 patients but still a good functional out-come was obtained in 62.5%. One of the patients withL5-S1 recurrent disc disease following laminectomy anddiscectomy had a pain free interval of 10 years.Duringthe initial follow up period she had a better outcome butas the follow up period increased the ODI score increasedindicating disability. This was due to the instability atthe L5-S1 level that had developed during 48 months offollow up. Therefore it is concluded that the successfuloutcome in the nonfusion group may be due to the shortterm follow up, which needs further long term follow upto come to a conclusion. However in the present studythere is no statistical significance between the fusion andnonfusion groups ( chi square test- 0.000 df-1 ,p value1.000).

Fig 1 shows antero posterior and lateral radiograph ofa 45 year old patient presenting 18 months after under-going surgery for Grade I isthmic spondylolisthesis withpain and failed spinal implants.

Fig 2 shows antero posterior and lateral radiograph ofthe lumbosacral spine 14 months after the patient hadundergone revision surgery in the form of redo posteriorstabilisation and trans foraminal lumbar interbody fusion(TLIF).

Fig 3 shows the good clinical outcome in the patient at12 months follow-up.

REFERENCES1.Clinical Outcomes of Revision Lumbar Spinal Surgery in 124 Patientswith a Minimum of Two Years of Follow-up;Chak-Bor Wong, MD; Wen-Jer Chen, MD; Lih-Huei Chen, MD; Chi-ChienNiu, MD;Po-Liang Lai,MD.2.Biondi, J., and Greenberg, B. J.: Redecompression and fusion in failedback syndrome patients. J. Spinal Disord., 3: 362-369,1990.3.Finnegan, W. J.; Fenlin, J. M.; Marvel, J. P.; Nardini, R. J.; and Rothman,R. H.: Results of surgical intervention in the symptomatic multiply-operatedback patient. Analysis of sixty-seven cases followed for three to sevenyears. J. Bone and Joint Surg., 61-A: 1077-1082,Oct. 1979.4.Ipsilateral recurrent lumbar disc herniationA PROSPECTIVE,CONTROLLED STUDYG. Cinotti, G. S. Roysam, S. M. Eisenstein, F.Postacchini.5.Finnegan WJ Tenline JM, Marvel JP, et al results of surgical interventionin the symptomatic multiply operated back patients.

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6.Stewart G, Sachs BL. Patient outcomes after reoperation on thelumbar spine. J Bone Joint Surg [Am] 1996;78:706-11.7.North RB, Campbell JN, James CS, Conover-Walker MK,Wang H,Piantadosi S, Rybock JD, Long DM. Failed back surgery syndrome:5-year follow-up in 102 patients undergoing repeated operation.Neurosurgery 1991; 28:685-90.8.Biondi J, Greenberg BJ. Redecompression and fusion in failed backsyndrome patient. J Spine Disord 1990;3:362-9.Stewart G, Sachs BL. Patient outcomes after reoperationon thelumbar spine. J Bone Joint Surg [Am] 1996;78:706-11.

10.Waddell G, Kummel EG, Lotto WN, Graham JD, Hall H,McCullochJA. Failed lumbar disc surgery and repeatedsurgery followingindustrial injury. J Bone Joint Surg[Am] 1979;61:201-7.11.Kim CH, Chung CK, Park CS, et al. Reoperation Rate After Surgeryfor LumbarHerniated Intervertebral Disc Disease: NationwideCohort Study.Spine (Philadelphia 1976)2013;38:581.12.Fritsch EW, HeiselJ, RuppS. Thefailed back surgerysyndrome:reasons,intraoperative findings, and long-term results: areport of 182 operative treatments. Spine 1996;21:626-3313.Bernard TN. Repeated lumbar spine surgery: factorsinfluencingoutcome. Spine 1993;18:2196-200.

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PAEDIATRIC ODONTOID SYNCHONDROSIS INJURY TREATED

CONSERVATIVELY- A CASE REPORT

Prof. Nalli R Uvaraj, Dr. R. NeelakannanOrtho Spine Surgery Unit, Institute Of Orthopaedics and Traumatology,

Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai.

INTRODUCTIONPaediatric odontoid fractures are very rare,

which account for 10% of all cervical spine fracturesand dislocations in children1. Cervical spine injuries in-volving patients less than 7 years are located mainly inthe upper cervical region , 75% of these involving theodontoid process3. The most common modality of injuryare road traffic accidents and fall from height3.

Odontoid process of the axis vertebra developsfrom two ossification centers, one for the body and an-other for the tip . The odontoid process represents thebody of atlas which gets fused with the axis vertebraby 7 years of age. Upto the age of 7 years, the odontoidis separated from the body of axis by a cartilage tissueknown as sychondrosis. Pathologically it is neither agrowth plate nor a disc material. This region provides aweak spot which is prone for subluxations3. In paediat-ric patients subluxations are more common thanfractures.These injuries are commonly associated withhead injuries and facial injuries which accounts for theneurological damage and morbidity. In this case reportwe describe an odontoid synchondrosis injury whichwas treated conservatively by Minerva cast application.

Case report:A 3 year old male child reported to the emer-

gency room with a history of wall collapse. In the initialsurvey the child had facial edema and paucity of move-ments of left upper limb. His upper airway was ad-equate and hemodyanamics stable.

The initial trauma series x rays showed an an-terior listhesis of C1 cervical spine over the C2 vertebra(Fig.1). CT and MRI scans of cervical spine clearlyshowed a synchondrosis injury of C2 odontoid (Fig.2 &3). CT scan of the facial bones showed bicondylar man-dibular fracture and left para symphysis injury, for whichinternal fixation was done.

Figure 1 : : Anteriorly displaced odontoid process withanterior listhesis of C1 vertebra over C2 vertebra in a3-year-old boy..

Figure.2: CT scan of cervical spine showing a synchon-drosis injury of C2 odontoid with anterior displacement.

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Figure.3: MRI scan of cervical spine showing a syn-chondrosis injury of C2 odontoid with anterior displace-ment and cervical cord stretching over body of C2 ver-tebra. .

Closed reduction of synchondrosis injury of odontoid wasattempted on the 10 day of admission under image in-tensifier guidance. Reduction was achieved by extend-ing the neck with a towel underneath. The reductionwas found to be stable and satisfying and immobilisationwas done with a Minerva jacket application.

Figure 4: Post reduction lateral radiograph of cervicalspine showing satisfactory reduction of synchondrosisinjury of C2 odontoid.

Figure.5: Minerva jacket immobilisation of patient afterattempted closed reduction of synchondrosis injury ofC2 odontoid for 6 weeks.

The Minerva jacket was removed after 6 weeksand the patient was discharged with soft cervical collarimmobilisation and was regularly followed up. The pa-tients neurology improved steadily and at final follow-up1 ½ years after injury , the shoulder, arm and elbowmuscle powers recovered fully except for the hand gripon the left side.

Lateral radiograph of the cervical spine at 6months follow-up showed good union of synchondrosisinjury of C2 odontoid with satisfactory spinalalignment(Fig.6) Final follow-up lateral radiographsshowed good remodelling of the fractured C2 vertebrawith good spinal alignment (Fig.7) .

MRI of the cervical spine done at 1 year followup showed pseudomeningocele of C4- D1 nerve rootsindicating old avulsion injury.

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Figure 6: Lateral radiograph of cervical spine at 6months follow-up showing good union of synchon-drosis injury of C2 odontoid (black arrow)with satis-factory spinal alignment..

Figure 7: Lateral radiograph of cervical spine at 18months follow-up showing union of synchondrosis in-jury of C2 odontoid with good remodelling at fracturesite.and restoration of good spinal alignment..

DISCUSSIONPaediatric odontoid fractures are uncommon

injuries typically occuring under 7 yrs of age. They arecommonly managed conservatively by closed reductionand immobilisation.Although complete reduction of thetranslation is not necessary, at least 50% apposition shouldbe obtained to provide adequate cervical alignment1. Non-union may result because of inadequate immobilisation5.An intact periosteal sleeve on the anterior surface of thevertebral body extending up to the odontoid provides sta-bility and leads to excellent healing in most cases1.

Immobilisation may be achieved by either Halovest or Minnerva jacket application.The thin skull andopen immature bone frequently do not allow halo appli-cation in preschool children. Pin-site infection, pin loos-ening, and dura penetration are likely to occur with haloapplication in children. Baum et al reported that only 8%of adults with a halo showed major problems versus 39%of children. Dormans et al reported a 68%complicationrate with a halo device in children, and the most fre-quent complication was pin-site infection2.Halo applica-tion also requires expertise. Minerva jacket applicationis the classic method for immobilizing the cervical spine, it is cheaper, can be applied in an emergency situationand does not require any special instruments.The onlycomplication that is anticipated is decubitus ulcer. Sur-gery with internal fixation is rarely reported1 and is indi-cated only if external immobilization has failed to main-tain reduction or achieve stability.

CONCLUSIONOdontoid fractures in children less than 7 yrs

are effectively managed conservatively by closedreduction and minerva cast which is superior than haloapplication. Though minerva jacket immobilisationrequires close monitoring4, it is an ideal method of choicefor immobilising odontoid fractures in children.

REFERENCES1.Warner WC Jr. Cervical spine injuries in children. Rockwood andWilkins’ Fractures in Children.Philadelphia: Lippincott Williams &Wilkins; 2010:685–722.2. Toru Uchiyama, Youichi Kawaji, Koji Moriya, Hisao Kohda, andHiroshi Denda, Two Cases of Odontoid Fracture in PreschoolChildren: J Spinal Disord Tech _ Volume 19, Number 3, May 20063. Martin Mortazavi & Pankaj A. Gore & Steve Chang & R. ShaneTubbs & Nicholas Theodore : Pediatric cervical spine injuries: acomprehensive review. Childs Nerv Syst, 2010.4. M. Blauth,U. Schmidt,D. Otte C. Krettek; Fractures of the odontoidprocess in small children:biomechanical analysis and report of threecases. Eur Spine J (1996) 5 : 63-705.Taylor TKF, Hall F, Ryan M (1987)Odontoid fractures in children.J Bone Joint Surg [Am] 69:167.

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Tamil Nadu Orthopaedic Journal Vol.41, Issue 1, February 201532

“SWASHBUCKLER APPROACH”- A MODIFIED ANTERIOR

APPROACH FOR DISTAL FEMUR FRACTURES

Dr.Rajkumar.N, , Dr Arunkumar K V, Dr.Rajasekaran.SGanga Hospitals and Medical Research Centre PVt., Ltd., Coimbatore.

INTRODUCTIONDistal femur fractures are among the most com-

plex fractures to be treated. Accounting to the increasein road traffic accidents in our society, the presentationof these kinds of complex fractures has become a com-mon scenario in the present society. The mode of injuryhas gradually shifted from low energy violence to highenergy violence over the past couple of decades1, 2; ac-cordingly the pattern of fracture has also shifted fromsimple extra articular fractures to complex comminutedfractures involving the articular and metaphyseal region.The treatment of distal femur fractures has also changedwith the early literatures supporting conservative man-agement to the recent literature proving internal fixationproviding early functional recovery in these fractures.Many recent studies have showed locking plate osteo-synthesis has become the gold standard treatment formanagement of complex distal femur fracture3. Theanatomic reduction of articular surface and the intercondylar region have given good functional outcome withless post traumatic arthritis4-11.Direct open reduction ofarticular surface have given better results compared toindirect reduction techniques12,13.Most commonly usedapproach for fracture fixation in distal femur is lateralapproach described by Marcy in 194714,15. Inherentlythis approach does not give much articular exposure. In 1999, Starr et al., described their Swashbucklerapproach a modified anterior approach for fracturesof the distal femur which allows excellent exposure ofarticular surface and distal metaphyseal region with mini-mal damage to the quadriceps muscle bellies.16With thisin the background we have analysed patients with distalfemur fracture treated with locking compression platingusing Swashbucklers approach.

AIMS AND OBJECTIVESTo study distal femur fractures treated by lock-

ing plate osteosynthesis using Swashbuckler approachby analysing the following parameters.

a. Functional outcome.b. Radiological outcome.c. Rate of Infection.d. Rate of Non-union, delayed union.TYPE OF STUDY:Retrospective Analysis

MATERIALS & METHODThe study was conducted after getting the insti-

tutional review board approval in accordance with theapproved protocol. All patients who were admitted to our hospitalsince September 2009 to september 2012 with distal fe-mur fracture meeting the inclusion & exclusion criteriawere analysed retrospectively for functional & radio-logical outcome. The minimum follow up was 14 monthsand the maximum follow up was 3years.

Inclusion criteria:a) Closed distal femur fractures.b) Open distal femur fractures.

(Gustillo & Anderson Type I, II, IIIA.)c) AO/OTA Classification Type 3.3 fractures.

Exclusion Criteria:a) Open distal femur fracture –Gustillo &

Anderson Type III B & IIIC.b) Periprosthetic fractures.c) Peri implant fractures.d) Pathological fractures.e) Floating Knee Injuries.

SURGICAL METHOD:All the patients who underwent this procedure were

given combined spinal epidural anaesthesia. The patient waspositioned in supine with a triangular pillow underneath thefractured knee to aid in fracture reduction.

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POSITION OF PATIENT ONOPERATING TABLE

TRIANGULAR PILLOW

Locking plates was used for fixationin all fractures.

Surface marking of the Skin IncisionThe skin incision is midline, anterior over the knee,

and then courses laterally as it is extended proximally.

The incision is carried down to the fascia overlyingthe quadriceps muscles. This fascia is split in line with

the skin incision and lifted off the underlying vastuslateralis muscle belly

As dissection is carried farther laterally, the fascia overthe quadriceps becomes confluent with the iliotibial band.The iliotibial band is retracted laterally, away from theunderlying muscle. The lateral parapatellar retinaculum

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is incised to separate it from the vastus lateralis musclebelly, and a lateral parapatellar arthrotomy is performedSeparation of the iliotibial band from the vastus lateralisis carried down to the lateral intermuscular septum, whichis confluent with the iliotibial band. The septum is fol-lowed to the shaft of the femur. The origin of the vastusmedialis is primarily from the posterior aspect of the fe-mur, along the medial lip of the linea aspera. The adduc-tor magnus inserts along the linea aspera and at the medialepicondyle of the distal femur. This lack of muscle at-tachment at the anterior aspect of the distal third of thefemur allows excellent visualization of the bone oncethe quadriceps have been retracted medially. Subperi-osteal stripping of the distal femur is not needed, andmedial bone fragments should be left undisturbed.

Once the vastus lateralis has been reflected off thelateral intermuscular septum, a retractor placed underthe quadriceps muscle can be used to expose the fe-mur and evert the patella medially and expose the me-dial femoral condyle

Open reduction and internal fixation are then performed.For fractures with significant proximal extension, mobi-lization of the entire vastus lateralis is not needed. A side

plate can be easily passed underneath the vastus lateralisand affixed to the bone. In such a situation, screws canbe placed through small stab wounds in the vastus lateralismuscle belly. After open reduction and internal fixationare complete, the retractors are removed, thus allowingthe intact vastus lateralis to fall back against the inter-muscular septum. The midline split in the fascia overly-ing the quadriceps muscles is repaired, along with thelateral parapatellar arthrotomy. The skin and subcutane-ous tissues are then closed.

Post operatively all patients were mobilized onsecond post operative day. Passive mobilization of theknee was started on second post operative day by con-tinuous passive motion (CPM) machine and then activeknee bending allowed as patient tolerated

FOLLOW UPAll the patients were retrospectively analysed for radio-logical and functional outcomeFracture is considered to be united if bridging callus isseen over 3 of 4 cortices and no pain on weight bearingFunctional outcome is assessed and graded according toNeers scoring and lower extremity functional scoring(LEFS)Radiological examination is done to look for fractureunion and coronal & Sagittal plane malalignment and lossof alignment.Normal coronal alignment was considered 5°-7° valgus,and normal sagittal alignment was neutral.Malalignment was defined as greater than a 5° devia-tion from normal coronal or sagittal alignment.Loss of alignment was defined as greater than a 3°change in angular measurements between postopera-tive and follow-up radiographs.

RESULTSThe study group included 82 patients with 61

male and 21 female patients.

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The average age in the study was 47.1 years with agegroup ranging from 18 to 87 years

AGE DISTRIBUTIONThe most common mode of injury was road traffic acci-dent. The next common injury was fall from height.

The most common fracture pattern according to AOclassification was 33 C 2 accounting for 35 among the82 patients.

AO CLASSIFICATION

TIME TO UNIONThe average time to union in our study was 4.5monthswith union being defined as full weight bearing walkingwithout pain at fracture site and callus formation in morethan three cortices.MALALIGNMENT12 patients (14.6%) had mal alignment in the study. Thenormal alignment is being defined as 5-7 degree 0f val-gus in coronal alignment and zero degree or neutral in

saggital alignment. Flexion of the distal fragment wasthe most common mal alignment followed by varus fixa-tion.

RANGE OF MOVEMENTS:The average knee flexion was 95.6 degrees. The malepatients had better range of motion compared to femalepatients. 12% of the patient in the study group had ex-tensor lag which improved by quadriceps strenghtheningexcersises

FUNCTIONAL OUTCOME:In functional outcome, 82% of patient had excellent func-tional outcome according to Neer’s grading. Accordingto Lower extremity functional scale 85% of patients hadgood functional outcome.

COMPLICATIONS:INFECTION:In this study we had 4 cases (4.8%) with surgical siteinfection, of which two were treated with intravenousantibiotics and the other two required surgical debride-ment. Among the two patients who were treated by sur-gical debridement, one patient required implant removaland LRS application due to persistent infection.

IMPLANT FAILURE:We had 3 cases (3.6%) of implant failure which weretreated with revision plate osteosynthesis and bone graft-ing. One implant failure in this group was due a non com-pliant patient who started early weight bearing mobiliza-tion even before he was advised.

NON UNION:We had 4 cases (4.8%) which went in for non union.They were treated by autologous bone grafting. In twopatients due to huge bone defect allograft from tissuebank was used in combination with autografts. All thefour patients went in for union after the secondary pro-cedure.

DISCUSSIONIn this study, the distal femur fracture is most commonin males who are in their second decade of life. Themost common mode of injury is road traffic accidents.The most common type of fracture pattern according toAO classification is 33 C2. All this can be attributed tothe increase in the high velocity injuries in our society.With the increase in high velocity injuries, the fracturepattern also shows severe comminution also involvingthe articular region. The necessity of good articular re-duction in the management of intraarticular distal femo-ral fractures has been emphasized by numerous au-

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thors4,5,7,8,11,17. The most commonly used lateral approachdescribed by marcy has the disadvantage of not havinggood articular exposure. In 1999, Starr et al., describedtheir swash buckler approach to distal femur which al-lows good exposure to the articular surface comparedto other conventional approaches to distal femur. Fewother extensive approaches also give excellent articularview but the extensor mechanism will be disturbed.On the other hand this approach gives good articularexposure without disturbing the extensor mechanism. Inthis study using the Swashbuckler approach we wereable to get good articular reconstruction by direct visual-ization of the articular surface and also good reductionof the medial metaphyseal fragments which is not pos-sible in direct lateral approach. The time to union was4.5 months in our study which early in comparsion tostudy by other authors where they have reported theunion time between 5-6 months.

In our experience, return of range of motion andquadriceps strength have been more rapid and more com-plete when using this approach than when using the con-ventional lateral approach to the femur. We have notfound tibial tubercle osteotomy necessary with this ap-proach because exposure of the distal femur throughthe lateral parapatellar arthrotomy is excellent.

The functional outcome in the study shows goodoutcome by Neer’s grading (82%) and lower extremityfunctional score (85%). This can be attributed to goodreduction , stable fixation and early mobilization of thejoint. In complication we had 4 surgical site infection(4.8%), 3 implant failure (3.6%) , 4 nonunion (4.8%).The complication rates were similar to other studies.

CONCLUSIONThe functional outcome is good and the time to

union is less by this approaches. This can be attributedto the excellent articular reduction following good expo-sure by this approach. Swashbuckler approach givesdirect visual to all critical areas of the distal femur, in-cluding the trochlea, entire medial compartment, and bothposterior femoral condyles resulting in good anatomicalreduction and stable fixation .Quadriceps muscle belliesare spared which facilitates good functional outcome anddoes not compromise future arthroplasty surgery Hencewe conclude that Swashbuckler approach is an excel-lent approach for fixation of distal femur fractures

CASE EXAMPLE:Mrs.Baby (ID No.12042448)

IMMEDIATE POST OP.

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AFTER UNION

REFERENCES1 .Martinet O, Cordey J, Harder Y,et al. The Epidemiology of fracturesof distal femur.Injury 2000;31(3):C62-3.2. Kolmert L, Wulff K. Epidemiology and treatment of distal femoralfractures in adult.Acta Orthop Scand1982;53:957-62.3. Kubiak EN, Fulkerson E, Strauss E, Egol KA. The evolution of lockedplates. J Bone Joint Surgery Am,2006 Dec: 88 Suppl 4: 189-200.4. Olerud S. Operative treatment of supracondylar-condylarfractures of the femur. Technique and results in fifteen cases. TheJournal of bone and joint surgery 1972; 54:1015-32.5. Schatzker J, Lambert DC. Supracondylar fractures of the femur.Clinical Orthopaedics and Related Research 1979;138:77-128.6. Schatzker J, Horne G, Waddell J. The Toronto experience with thesupracondylar fracture of the femur 1966-1972. Injury 1974; 6;113-28.7. Giles JB, Delee JC, Heckman JD,Keever JE. Supracondylar-Intercondylar fractures of the femur treated with a supracondylarplate and lag screw. The Journal of bone and joint surgery1982;64:864-70.8. Johnson EE. Combined direct and indirect reduction of comminutedfour-part intra-articular T-type fractures of the distal femur. ClinicalOrthopaedics and Related Research 1988;231:154–62.

9. Mize RD, Bucholz RW, Grogan DP. Surgical treatment of displaced,comminuted fractures of the distal end of the femur. The Journal ofBone and Joint Surgery 1982;64:871–9.10. Johnson KD, Hicken G. Distal femoral fractures. OrthopedicClinics of North America 1987;18:115–32.11. Rademakers MV, Kerkhoffs GM, Sierevelt IN, Raaymakers EL,Marti RK. Intraarticular fractures of the distal femur- a long-termfollow-up study of surgically treated patients. Journal of OrthopaedicTrauma 2004;18:213–9.12. Bolhofner BR, Carmen B, Clifford P. The results of open reductionand internal fixation of distal femur fractures using a biologic (indirect)reduction technique. Journal of Orthopaedic Trauma 1996;10:372–7.13. Ostrum RF, Geel C. Indirect reduction and internal fixation ofsupracondylarfemur fractures without bone graft. Journal ofOrthopaedic Trauma 1995;9:278–84.14. Marcy GH. The posterolateral approach to the femur. The Journalof Bone & Joint Surgery 1947;29:676–8.15. Muller ME, Allgower M, Schneider R, Willenegger H. Manual ofinternal fixation: techniques recommended by the AO-ASIF group.3rd ed. Berlin: Springer-Verlag;1991.16. Starr AJ, Jones AL, Reinert CM. The ‘‘Swashbuckler’’: a modifiedanterior approach for fractures of the distal femur. Journal ofOrthopaedic Trauma 1999;13:138–40.17. Healy WL, Brooker AF. Distal femoral fractures. Comparison ofopen and closed methods of treatment. Clinical Orthopaedics andRelated Research 1983;174:166–71.

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EVALUATION OF FUNCTIONAL AND RADIOLOGICAL OUTCOME

FOLLOWING PROXIMAL FEMUR LOCKING LATE FIXATION IN

PERTROCHANTERIC FRACTURES

Dr.Sumesh.S, Prof. N.Jambu, Dr.L.Senthil, Prof. B.SamuelChittaranjanDept.Of Orthopaedics, Sri Ramachandra University (SRU), Chennai,

Abstract:

Aim: To evaluate functional and radiological outcome following proximal femur lock-ing plate fixation for stable and unstable per-trochanteric fractures.

Materials and Methods: 14 patients of mean age of 55 years were treated at SRMCwith proximal femur locking plate fixation for per-trochanteric fractures. Fracture re-duction, placement of proximal locking screws, time to union, medialisation of shaft,neck-shaft angle, limb shortening, varus collapse, and functional outcome (using theSchatzker & Lambert criteria at final follow up) were assessed.

Results: In our study, the mean time to union was 14 weeks(12-14 weeks) and themean limb shortening was 0.5cm(0-1cm). No patient had medialization of the shaft;varus collapse occurred in 2 patients; and implant screw breakage occurred in 2patients.The functional outcome was excellent in 4 patients, good in 6, fair in 3 andpoor in 1.

Conclusion: Union was achieved in stable and unstable trochanteric fractures withoutsignificant complications and neck shaft angle was maintained following proximal fe-mur plate fixation. The fracture reduction and placement of the 3 proximal lockingscrews into the neck and head of femur determines the outcome of the fracture.Therefore this device can be a feasible alternative to proximal femur nailing and DHSfixation in certain difficult situations.

KEYWORDS: unstable trochantreric fracture, proximal femur locking plate

INTRODUCTIONIntertrochanteric and subtrochanteric fractures

account for 50% of all fractures of the proximalfemur.Early surgical intervention is advocated in major-ity of these patients to reduce the complications associ-ated with long-term immobilization like deep veinthrombosis,thrombophlebitis,pulomary embolism,urinaryand lung infections,decubitus ulcers.Various extramed-ullary and intramedullary implants are being used for thesefractures. Comminution of the lateral trochanteric wall,postero-medial communition, reverse oblique fractures

etc. are unstable fractures which have had poor resultswith the regular methods of fixation.Proximal femur lock-ing plate is an fixed angle stable construct, with lockingcancellous screws at 95, 120 and 135 degrees, whichcan be used in these situations in open as well asminimally invasive per cutaneous plate osteosynthesis(MIPPO) technique. Our aim in this study is to evaluateradiological and functional outcome at the end of 1 yearfollowing proximalfemur locking plate fixation for inter-trochanteric and subtrochanteric fractures.

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Figure 2: Preoperative view

MATERIALS AND METHODSIn our study 14 patients (10 male and 4 female

patients) with pertrochanteric fractures underwent proxi-mal femur locking plate fixation in our hospital.SHARMA proximal femur locking plate was used in allcases. Intertrochanteric fractures were classified ac-cording to Boyd and Griffin and Sub-trochanteric frac-tures were classified according to Seinsheimer’s(1).Meanage of the patients was 55.2years(26-82 years) .Imme-diate post-operative x-rays were taken. Patients werefollowed up at 6 weeks, 3 months, 6 months and 1 yearafter the surgery, with clinical and radiographic assess-ment of the progress of healing and complications. TheSchatzker & Lambert criteria(Annexure 1) were usedto evaluate the functional outcome at the end of oneyear.

SURGICAL TECHNIQUESurgery was performed with the patient in su-

pine position on a fracture table. Closed reduction wasperformed under C-ARM guidance in antero-posteriorand lateral views and secured in traction. Skin incisionwas made over the trochanteric region through lateralapproach. Open reduction was done in cases of failure

of closed reduction. For unstable / comminuted fractures,minimally invasive technique was done under C-armguidance. Care is taken to avoid varus malreduction priorto plate fixation, which will lead to implant failure. Afterfracture reduction, the plate was placed and reductionmaintained by K-wires. Cortical screw inserted for plateand bone contact. Proximally three 5mm non-cannulatedlocking screws were used. The inferior most lockingscrew, 135 degree angled, was inserted into the femoralcalcar. The other locking screws, angled 95 and 120degree, are used and finally the cortical screws areinserted.Bone grafting was not done for any cases.Afterthe surgery, drain, if used, was removed after 48hoursand all the patients were encouraged to start in-bedmobilization.

Non-weight bearing ambulation was started af-ter 2nd post-op day as tolerable. Partial weight bearingwasstarted by 6-8 weeks after signs of callus formation wasseen on follow up X ray. Weight bearing was graduallyincreased up to tolerance level.

RESULTSAmong 16 patients treated with proximal femur

locking plate, one patient died due to congestive heartfailure and lost to follow-up. Another patient had implantfailure due to early weight bearing. In our study, the re-maining 14patients were followed up till 1 year followingsurgery. 9 patients had intertrochanteric and 5 patientshad subtrochanteric fractures.There were no surgicalsite infections and all the patients had healthy surgicalscars healed by primary intention. All patients had frac-ture union.The mean time to union was 14weeks(12-16weeks) and the mean limb shortenings were 0.5cm(0-1cm). No patient had medialization of the shaft;varuscollapse >10 degree occurred in 2 patients; and implantscrew breakage occurred in 2 patients.The functionaloutcome was excellent in 4 patients, good in 6, Fair in 3and Poor in 1.

CASE 1

Figure 1. Proximal Plate with screw

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Figures 3&4: Immediate Post Op; Anteroposterior andLateral views

Figures 5&6: 6 weeks Post Op in AP andLateral views

Figures 7&8: 3 months Post Op in AP and Lateralviews (Frature union seen)

Figures 9&10: 6 months Post Op

Figure 11&12: One year follow up showing breakageof neck of first proximal screw and mild varus collapse

Figure 13: Full range of motion seen after one year

CASE 2

Figures 14&15: Pre Op of sub trochanteric fracture

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Figure 16&17: Immediate Post Op in AP and Lateral views

Figures 18&19: 1year Post Op AP &Lateral views

Figure 20,21&22: Pre Op Inter trochanteric fracturewith sub trochanteric extension

CASE 3

Figure 23&24: Immediate post Op; minimally invasiveper cutaneous plate osteoporosis (MIPPO)

Figure 25&26: 1 year Post Op AP and lateral views

DISCUSSIONIntertrochanteric and sub trochanteric fractures

in young adults are usually the result of high-energy in-jury, such as a motor vehicle accident or fall from a height,whereas in the elderly it results from a simple fall(1).In a case of polytrauma and severely traumatized pa-tients, the concept of damage control in acute manage-ment must be considered and practiced whenever it isappropriate(2)(3).

Evans classified intertrochanteric fractures intostable and unstable types. Unstable fractures are thosewhich are displaced and cannot be reduced, postero-medial cortical communition and reverse oblique frac-tures(4).

Seinsheimer’s classified sub trochanteric frac-tures and introduced the concept of posteromedial corti-cal support and the need for its reduction to producesatisfactory results(1). Integrity of the lateral wall and its

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significance in the fracture healing and implant failure incomminuted lateral wall has been reported(5)(6).Trochanteric fractures treated conservatively is associ-ated with high mortality associated with prolonged bedrest, especially in the elderly(7). It is reserved only forcases of anesthesiological contra-indication.Early surgical intervention is advocated in majority ofthese patients to reduce the complications associated withlong-term immobilization like deep veinthrombosis,thrombophlebitis,pulomary embolism,urinaryand lung infections,decubitus ulcers(6). Achieving stabil-ity and early mobilization in patients sustaining per-tro-chanteric fractures reduces mortality/morbidity of pro-longed immobilization.Horowitz(1966) reported in his retrospective analysismortality rate of 34.6% for the cases treated by tractionand only 17.5% for those treated by surgery(8)

Evans concluded in his study that operative fixation canproduce greater comfort and increased mobility and low-ered mortality following intertrochanteric fractures (4)

External fixation in intertrochanteric fractures can beconsidered to be a semi-conservative method. It may bea reasonable alternative for patients who are of advancedage, have a poor general condition and cannot toleratelong operations(9). However Petsatodis et al, reportedprolonged union time, increased incidence of varus posi-tion of fracture site and inferior functional outcome inunstable fractures(10).The treatment choices for internal fixation include in-tramedullary and extra medullary implants.Dynamic hip screw (DHS) fixation is standard implantof choice in these fractures. DHS provides compres-sion along the femoral neck and if the reduced fractureis stable, load sharing between bone and the implant canoccur(11). Although Madsen et al, reported high techni-cal failure rates (34%) when unstable IT fractures treatedwith DHS alone. According to their study, the failurerates reduced to 9% when unstable fractures were treatedwith DHS and lateral trochanteric stabilizing plate(12).Alsorate of mal-union was significantly higher in unstablefractures when compared to stable fractures treated withDHS fixation(13).Common causes of failure of fixation are instability offracture, failure of fixation device, and the location ofthe screw in the femoral head(14).Dynamic condylar screw plates, when used in unstableintertrochanteric fractures cannot adequately prevent asecondary limb shortening after weight bearing due tolateralization of head/neck fragment from gliding alongthe screw.In unstable fractures, intramedullary implants have bio-mechanical advantage over extra medullary implants dueto shorter lever arm.

Gamma nail is the prototype cephalo-medullary nail, butserious implant related complications such as fracturedshaft of femur, failure of fixation and complications ofdistal locking requiring re-operation has been reported.In 1997 AO/ASIF group developed proximal femur nail(PFN) has been successful in treating unstable fractures.However various authors have reported screw cut outof the head-neck fragment(15).The AO/ASIF group modified the PFN to the Proximalfemoral nail anti rotation (PFNA) to improve rotationaland angular stability. The early results are encouragingwhile long term studies are required to evaluate the useof this implant(15).More recently, locking plates have been designed forthe proximal femur and have become available espe-cially for the management of complex trochanteric frac-tures. The plate is anatomically pre contoured to themetaphyseal zone of the proximal femur. The plate isplaced at the lateral side of the proximal femur and canprovide a stress shield for the lateral fragment, prevent-ing lateral migration of proximal fragments andMedialisation of femur shaft and hence can be used incases with loss of integrity of the lateral wall(6)(16). Theyact as a fixed angle internal fixator device and achievesgreater stability compared with DHS/DCS/Angle bladeplate while avoiding excess bone removal and hence isideal for osteoporotic fractures(16).Correct placement of locking screws is of utmost im-portance, especially the screw into the femoral calcar,which along the posterior and inferior locking screwsenables an angular stable buttress that increases the sta-bility of the fracture(17).One of the biggest advantages is its option to use mini-mally invasive plate osteosynthesis and its improved fixa-tion of osteoporotic bone achieved through screw angu-lation and locking plate interface(18).Biological fixationof comminuted sub trochanteric fractures with PFLPprovides stable fixation with high union rate and fewercomplications(19). According to Guo-Chun Zha et al. intheir study found no cases of cut-out of femoral headscrew possible due to the mechanical advantage of three-dimensional and angular stable fixations(20).In stable fractures treated with DHS, patients can bemade to bear weight immediately following surgery.Whereas in cases of patients treated with PFLP can bemade to start full weight bearing only after radiologicalevidence of callus formation, hence it can be a limitingfactor.In this study, we found that PFLP can be used for stableand unstable per trochanteric fractures and had fewercomplications even in osteoporotic individuals possiblydue the angular stable fixation. There were no cases ofperi-operative complications. We found that all patients

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had fracture union (6-8weeks). One elderly female pa-tient with intertrochanteric fracture treated with PFLP,started weight bearing early and developed proximalmigration of the implant. The patient was advised revi-sion procedure but the patient did not follow up after 3months and hence not included in this study. Anotherelderly male patient died due to congestive heart failure5 months following surgery and was not included. Thecomplications associated with PFLP like implant failure,varus collapse is possible.

CONCLUSIONUnion was achieved in stable and unstable tro-

chanteric fractures without significant complications andneck shaft angle was maintained following proximal fe-mur plate fixation.The fracture reduction and placementof the 3 proximal locking screws into the neck and headof femur, especially the screw placed into femoral cal-car, determines the outcome of the fracture.The plate can also be used using MIPPO technique andhence comminuted fractures can be treated preservingfracture hematoma.One of the major drawbacks of us-ing proximal femur locking plate is that weight bearing isto be controlled and done only after radiological evidenceof callus formation.In our study, proximal femoral lock-ing plate fixation for per-trochanteric fixation producedgood results. Therefore this device can be a feasiblealternative to proximal femur nailing and DHS fixationin certain difficult situations.

REFERENCES1. Rockwood & Green’s Fractures in Adults; 6th Edition [Internet].[cited 2014 Dec 29]. Available from: http:/www.msdlatinamerica.com/ebooks RockwoodGreensFracturesinAdults/2. Giannoudis PV. Surgical priorities in damage control in polytrauma.J Bone Jt Surg [Internet]. 2003 May 1 [cited 2014 Dec 29];85(4):478–83. Available from: http://www.bjj.boneandjoint.org.uk/cgi/doi/10.1302/0301-620X.85B4.142173. Hildebrand F, Giannoudis P, Kretteck C, Pape H-C. Damagecontrol: extremities. Injury [Internet]. 2004 Jul [cited 2014 Dec29];35(7):678–89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/152033084. Birmingham B, Hospital E, From M. Of the femur. 1948;5. Gotfried Y. The Lateral Trochanteric Wall. Clin Orthop Relat Res[Internet]. 2004 Aug [cited 2014 Dec 29];425(425):82–6. Availablef r o m : h t t p : / / c o n t e n t . w k h e a l t h . c o m / l i n k b a c kopenurl?sid=WKPTLP:landingpage&an=00003086-200408000-00011

6. Hu S-J, Zhang S-M, Yu G-R. Treatment of femoral subtrochantericfractures with proximal lateral femur locking plates. Acta Ortop Bras[Internet]. 2012 Dec [cited 2014 Dec 29];20(6):329–33. Availablef r o m : h t t p : / / w w w . p u b m e d c e n t r a l . n i h . g o v /articlerender.fcgi?artid=3861956&tool=pmcentrez&rendertype=abstract7. Sheldon L. The Unstable Intertrochanteric Hip Fracture.Orthopedics [Internet]. 2008 Aug 1 [cited 2014 Dec 29];31(8).Available from: http://www.healio.com/orthopedics/journals/ortho/2008-8-31-8/%7B74a46b61-bd01-481a-ab19-6afd59a8c4e0%7D/the-unstable-intertrochanteric-hip-fracture8. Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE.Survival experience of aged hip fracture patients. Am J Public Health[Internet]. 1989 Mar [cited 2014 Dec 29];79(3):274–8.Availablef r o m : h t t p : / / w w w . p u b m e d c e n t r a l . n i h . g o varticlerender.fcgi?artid=1349546&tool=pmcentrez&rendertype=abstract9. Subasi M, Kesemenli C, Kapukaya A, Necmioglu S. TREATMENTOF INTERTROCHANTERIC FRACTURES BY EXTERNALFIXATION. 2001;67.10. Ovid: Search Results [Internet]. [cited 2014 Dec 29]. Availablefrom: http://ovidsp.tx.ovid.com/sp-3.13.1a/11. Haynes RC, P RG, Miles AW, Weston RB. Failure of femoral headfixation/ : a cadaveric analysis of lag screw cut-out with the gammalocking nail and A0 dynamic hip screw. 1997;28(5):337–41.12. Saarenpää I, Heikkinen T, Jalovaara P. Treatment ofsubtrochanteric fractures. A comparison of the Gamma nail and thedynamic hip screw: short-term outcome in 58 patients. Int Orthop[Internet]. 2007 Mar [cited 2014 Nov 29];31(1):65–70. Availablef r o m : h t t p : / / w w w . p u b m e d c e n t r a l . n i h . g o v /articlerender.fcgi?artid=2267546&tool=pmcentrez&rendertype=abstract13. Setiobudi T, Ortho M, Ng YH, Lim CT, Liang S, Lee K. ClinicalOutcome Following Treatment of Stable and Unstable IntertrochantericFractures with Dynamic Hip Screw. 2011;40(11):482–7.14. Kim W-Y, Han C-H, Park J-I, Kim J-Y. Failure of intertrochantericfracture fixation with a dynamic hip screw in relation to pre-operativefracture stability and osteoporosis. Int Orthop [Internet]. 2001 Jul26 [cited 2014 Dec 29];25(6):360–2. Available from: http://link.springer.com/10.1007/s00264010028715. Mereddy P, Kamath S, Ramakrishnan M, Malik H, Donnachie N.The AO/ASIF proximal femoral nail antirotation (PFNA): a newdesign for the treatment of unstable proximal femoral fractures. Injury[Internet]. 2009 Apr [cited 2014 Dec 10];40(4):428–32. Availablefrom: http://www.ncbi.nlm.nih.gov/pubmed/1923088516. Kumar N, Kataria H, Yadav C, Gadagoli BS, Raj R. Evaluation ofproximal femoral locking plate in unstable extracapsular proximalfemoral fractures: Surgical technique & mid term follow up results. JClin Orthop Trauma [Internet]. Elsevier Ltd; 2014 Sep [cited 2014Dec 29];5(3):137–45. Available from: http://linkinghub.elsevier.com/retrieve/pii/S097656621400072117. Part of the LCP Periarticular Plating. :0–29.18. Zha G-C, Chen Z-L, Qi X-B, Sun J-Y. Treatment of pertrochantericfractures with a proximal femur locking compression plate. Injury[Internet]. Elsevier Ltd; 2011 Nov [cited 2014 Dec 15];42(11):1294–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21356535

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INTRODUCTION:Management of Complex tibial plateau fracture

are clinically challenging and quite difficult. Most classi-fication use the two dimensional radiography for assess-ment of the fractures. These fractures are usually clas-sified Schatzker Type V and VI or a C type injury whenusing the AO/Orthopaedic Trauma Association classifi-cation1. Dual plating is usually recommended as the de-finitive fixation for this kind of fractures. However, thistechnique often is not applicable to work in fractures withmultiplanar articular comminution, often there is a pos-terior shearing or a coronal fracture. The treatment forthe tibial plateau fractures is also based on classificationsystems that use two dimensional radiography. This sys-tem does not include injury patterns with major fracturelines in the coronal plane or those simply not visible onplain radiographs2. Posteromedial fragments are seen in

FUNCTIONAL AND RADIOLOGICAL OUTCOME OF COMPLEX TIBIAL

PLATEAU FRACTURES TREATED BY COLUMN SPECIFIC FIXATION

Dr. Muthukumar Balaji S, Dr.Selvaraj, Dr.Sathish Devadoss., Prof.Dr.A.Devadoss.Devadoss Multi Speciality Hospital

Institute of Orthopaedic Research and Accident Surgery, Madurai.

Abstract:Management of Complex tibial plateau fracture are clinically challenging and quitedifficult. Most classification use the two dimensional radiography for assessment ofthe fractures. The treatment for the tibial plateau fractures is also based on classifica-tion systems that use two dimensional radiography. This system does not include in-jury patterns with major fracture lines in the coronal plane or those simply not visibleon plain radiographs. In our study, we report on the clinical results of using ‘‘three-column fixation’’ technique through combined anterolateral and the posterior ap-proaches. We used prone position for posterior approach(posterior and medial col-umn fixation), and used supine position for anterolateral fixation with two separatedraping. A total of 16 patients were included in the study. All patient were taken up forsurgery with in 18 hrs of the original insult, average of 10 hrs( 6- 18 hrs). mean opera-tive time was 135 minutes including the 15 minutes additional time for second drap-ing. The main components of Rasmussen scoring system are pain, walking capacity,extension lag, range of motion and stability. Excellent and good results wereacceptable.(table 1). The mean rasmussen score in our series is 26.63 with a range (21 to 29). Fourteen patients had excellent outcome , two patients had good result. Nopoor result in this series. Three column fixation is a new fixation concept in treatingcomplex tibial plateau fractures. This method is useful in fragment specific fixationand preventing late varus collapse and provides good functional result in short term.Key words: Tibial plateau fractures, column specific fixation,functional outcome.

59% to 74% of bicondylar fractures. These are impor-tant, because they affect the surgical plan in terms ofpatient positioning, surgical approach, and incision place-ment3. Recently, a new three-column classification ap-proach was proposed by Luo et al based on multiplanarCT images. Several authors have noted computed to-mography (CT)-based three-dimensional considerationof the fracture pattern. In recent years, we have usedthis ‘‘three-column fixation’’ technique to treat themultiplanar complex tibial plateau fractures, which isbased on three-dimensional understanding of these frac-tures. In our study, we report on the clinical results ofusing a ‘‘three-column fixation’’ technique through com-bined anterolateral and the posterior approaches. Weused prone position for posterior approach for posteriorand medial column fixation, and used supine position for

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anterolateral fixation with two separate draping.

MATERIAL AND METHODSThe study was conducted at the Institute for Or-

thopaedic Research and and Accident Surgery (IORAS,Madurai) between march 2012 and November 2014. Thepurpose of this study was to analyze the functional andradiological outcome following the column specific fixa-tion of complex tibial plateau fractures. This is an hospi-tal based prospective study. All surgeries were done bythe same surgical team. A total of 16 patients were in-cluded in the study. All patient were taken up for sur-gery with in 18 hrs of the original insult, average of 10hrs( 6- 18 hrs). All fractures were closed fractures. Allpatients received antibiotic prophylaxis (cefaperazone andsulbactam 1.5 gms) and antibiotics were administeredat the time of induction of anaesthesia. It was continuedfor 48 hrs post operatively.The approach: Patient in prone position, inverted L-Shaped incision made. Sharp dissection is carried deep,and the posterior fascia is incised between the medialgastrocnemius (posterior border of the dissection) andthe pesanserinus anteriorly. The medial collateralligament remains in­ tact anteriorly and deep to thepesanserinus. The pes tendons are mobilized posteriorlyand proximally, keeping their insertion intact. The medialgastrocnemius is then elevated posteriorly and laterally,exposing the posterior tibia. The soleus and popliteusmuscles are then elevated from the medial edge of thetibia by sharp dissection, exposing the fracture site (fig-ure 1a&b). Fractures reduced and temporarily fixed withK- wires then 3.5 mm or 4.5mm T- buttress plates inposterior and medial column. Conventional anterolateralapproach was used to reduce and fix the lateral columnfracture with 4.5 proximal tibia locking compression platein supine position( figure 2). The mean operative timewas 135 minutes including the 15 minutes additional timefor second draping.. Mean blood loss was 210 ml.Tourniquet deflated between two drapings.

Medial head of gastronemius

Semimembranosus & pes-anserinus

Figure 1a

Figure 1 b

Figure 2

Standard anteroposterior and lateral radiographs weretaken at follow up ( post op, 6 wks, 3 months, 6 months,12 months ) and were evaluated for fracture healingand joint congruity. Postoperative CT scanning to quan-titate articular reductions were not done.

RESULTSAmong the 16 cases, 9 were right and 7 were

left tibiae. The mean follow up was 17 months( range 8to 28 months). Average age of patients in our serieswas 34 yrs(19-57years). The neurovascular status ofthe fractured limb , presence of compartment syndrome,and any blisters were noted. We used Rasmussen func-tional scoring and radiological assessment. The maincomponents of Rasmussen scoring system are pain,walking capacity, extension lag, range of motion and sta-bility4. Total points was 30. Excellent and good resultswere acceptable.(table 1). The mean rasmussen scorein our series is 26.63 with a range ( 21 to 29). Fourteenpatients had excellent outcome , two patients had goodresult. No poor result in this series.

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DISCUSSIONThe current classification systems of tibial pla-

teau fractures are based on two-dimensional imaging.This misleads the surgeons to pay attention to medialand lateral column without considering posterior columnin tibial plateau fractures, especially for the posterome-dial corner. We report on column specific fixation con-cept - three column fixation, which is dependent on theunderstanding of the fractures using CT scans5. Thisnew approach is safe and effective in managing com-plex Schatzker V and VI tibial plateau fractures. Boththe Schatzker and AO/Orthopaedic Trauma Associationsystems classify these fractures according to the ap-pearance on anteroposterior and lateral radiographs. Ina cohort of 42 cases with tibial plateau fractures, whichwere assessed by plain radiographs and three-dimen-sional CT separately 43% (18 of 42) of the fractureswere underevaluated by plain radiographs2. Three-col-umn classification , which is dependent on the under-standing of the fractures using CT scans as well as the3D reconstruction can identify the posterior column frac-tures and has been shown to have considerableinterobserver reliability, higher than conventionalSchatzker and AO/OTA classifications6.

Unilateral locking plates have often been usedto treat these complex tibial plateau fractures. Clinically,they are not strong enough to hold these fragments andfail to prevent secondary varus when compared with adirect posterior–medial buttress plate7. A bilateral dualplating technique using a posterior– medial approachcombined with an anterior–lateral approach has beensuggested by many authors8. This posteromedial

approach, in the supine position, can deal with the pos-teromedial fragment, but it is impossible to obtain a di-rect reduction when there is an articular depression inthe lateral part of the posterior column. Posterior–lat-eral depressed fracture fragments are impossible to dealwith in the supine position and can only be reduced andbuttressed posteriorly in the prone position

A small percentage of tibial plateau fracturesneed the ‘‘three-column fixation’’ technique1. Withoutcareful planning, these ‘‘three-column fractures’’ usu-ally proceed to failure of reduction and fixation. In ourstudy we used combined postero-medial approach forposterior, medial column fixation in prone position andanterolateral approach for lateral column fixation in su-pine position. In our series 88% patients had excellentand 12% had good result by Rasmussen functional scor-ing and radiological outcome. Although this approachprolongs the operation time, there were no deep infec-tion in our series.

The average radiographic bony union and weightbearing period was 13 weeks (10 to 18 weeks). 14 casesshowed excellent functional scoring (figure 3 and 4), 2cases (figure 5) showed good functional scoring. Sec-ondary varus collapse( 3 degree) occured in one pa-tient. One case showed articular step of more than 4mm. The average range of motion of affected kneewas 3 to 110 degree after 12 months post sugery. Wefound the approach to be reliable and reproduceable, withgood functional outcome in short term followup and com-parable to other studies using different methods9,10.

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Figure 3 : case 5 at a 1 yr followup Figure 4 : case 15 , at 20 months follow up

Superficial skin break down of the anterolateral incisionoccured in 3 patient. Treated by vaccum assisted clo-sure and secondary closure later. No Deep infection inthis series. Compartment syndrome occured in one pa-tient. Fasciotomy done at 36 hrs. Split skin graft done48hrs later. This patient went on to have full functionalrange of motion and excellent outcome.

Additional operative time, hardware conflict and likeli-hood of infection are the major disadvantages. Longterm follow up is needed to determine if this approach isadvantageous in terms of functional outcome and in pre-venting secondary osteoarthritis compared to dual orsingle anterolateral plating

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Figure 5: case 10 at 15 months follow up.

CONCLUSION:Three column fixation is a new fixation concept intreating complex tibial plateau fractures. This methodis useful in fragment specific fixation and preventinglate varus collapse and provides good functional re-sult in short term. But needs long term follow-up to

know outcome in terms of Osteoarthritic changes in theknee.

REFERENCES1.Luo CF, Sun H, Zhang B, Zeng BF: Three-column fixation forcomplex tibial plateau fractures. J Orthop Trauma 2010, 24:683–6922.Higgins TF, Kemper D, Klatt J. Incidence and morphology of theposteromedial fragment in bicondylar tibial plateau fractures.JOrthop Trauma. 2009;23:45–53.Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, BenirschkeSK:Functional outcomes of severe bicondylar tibial plateaufracturestreated with dual incisions and medial and lateral plates:J Bone JointSurg. 2006;88:1713–1721.4.Rasmussen: Impairment of Knee joint stability as and indicationfor surgical treatment :J Bone Joint Surg Am,  1973 Oct;55(7):1331-1350.5.Wicky S, Blaser PF, Blanc CH: Comparison between standardradiography and spiral CT with 3D reconstruction in the evaluation,classification and management of tibial plateau fractures. Eur Radiol.2000;10:1227–1232.6.Yi Zhu, Cheng-Fang Hu, Guang Yang, Dong Cheng and Cong-Feng Luo. Inter-observer reliability assessment of the Schatzker,AO/OTA and three-column classification of tibial plateau fractures.Journal of Trauma Management & Outcomes; 2013, 7:77.Barei DP, Nork SE, Mills WJ, et al. Complications associated withinternal fixation of high-energy bicondylar tibial plateau fracturesutilizing a two incision technique. J Orthop Trauma. 2004;18:649–6578.Mueller KL, Karunakar MA, Frankenburg EP, et al. Bicondylartibial plateau fractures: a biomechanical study. Clin Orthop RelatRes.2003;412:189–195.9.G Thiruvengita Prasad, T Suresh Kumar, R Krishna Kumar,Ganapathy K Murthy, Nandkumar Sundaram. Functional outcomeof Schatzker type V and VI tibial plateau fractures treated with dualplates; Indian Journal of Orthopaedics; Mar 2013, 47(2):188-9410.Tul B Pun, Vignesh P Krishnamoorthy, Pradeep M Poonnoose,Anil T Oommen, Ravi J Korula. Outcome of Schatzker type V and VItibial plateau fractures: Indian Journal of Orthopaedics; Jan2014:48(1);35-41

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TOTAL HIP ARTHROPLASTY IN TROCHANTERIC FRACTURES:A SHORT TERM FOLLOW-UP

Dr. Sidhant S Goyal, Prof. M. Mohan KumarDepartment of Orthopaedics, Sri Ramachandra University, Chennai.

AbstractIntroduction: Internal fixation in trochanteric fractures of elderly patients often pre-cludes the early mobilisation with full weight bearing. Overall failure rate of internalfixation in trochanteric fractures has been reported to be 3–16.5%. Prognosis can alsoworsen because of fracture instability, comminution and osteoporosis. To avoid thecomplications associated with internal fixation, we planned to do THA for trochantericfractures for selected patients.Aim: This study was done to evaluate the clinical, functional and radiological outcomesof total hip arthroplasty (THA) following trochanteric fractures.Material & Methods:All our patients were community ambulators and not dependent forself-care. Total of twenty three patients were identified and classified on the AO Mullerclassification for trochanteric fractures. A retrospective study of patients treated withTHA was analysed for two years.Results: Average age was 77 years with follow-up period of 1.7 years. Harris hip scorewas used to analyse the outcome. Two patients had lost follow up. Two patients dieddue to other medical aliments at sixth and eighth months. The Harris hip score at onemonth was 66 ± 7 (mean ± standard deviation); at three months 72 ± 6; at one year 74± 5; at two years 76 ± 6. Average time taken to return to normal daily activities was 28days (range 24–33). No loosening or infection of the implants was observed. The Har-ris Hip score was calculated was Excellent: 20%; Good: 60%; Fair: 10%; Poor: 10%.Discussions:Complications related to restricted weight bearing and prolonged bed restin trochanteric fractures treated with internal fixation are avoided. None of our pa-tients had dislocation in the immediate postoperative period. Dislocation was seen inthree patients at two, four and six months after surgery. All three were caused bysignificant trauma and treated by closed reduction and immobilisation.Conclusions: Total hip arthroplasty is a valid treatment option for mobile and mentallyhealthy elderly patients with intertrochanteric fractures. This procedure offers quickrecovery with little risk of mechanical failure avoids the risks associated with internalfixation and enables the patient to maintain a good level of function immediately aftersurgery.

INTRODUCTIONUnstable intertrochanteric fractures in elderly patientsare associated with high rates of morbidity and mortal-ity[1, 2]. Comminution, osteoporosis, and instability of-ten preclude the early resumption of full weight bearingin spite of use of internal fixation[2]. Reported overallfailure rate with internal fixation in trochanteric frac-tures has been reported to be 3–16.5%[3, 4]. In the eld-erly, fracture instability, comminution and osteoporosis

worsen the prognosis[4, 5]. Moreover, there is a highrate of general complications associated with internalfixation due to prolonged recovery time taken after sur-gery[6, 7].Various authors have reported successful outcomes af-ter use of hemiarthroplasty and THA in these patients[8].After hip arthroplasty, patients can bear weight immedi-ately, they can be encouraged to walk early and exer-

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cise the involved limb, thus reducing the period of bedrest and rate of complications[11, 12]. Our study wasmade with the purpose of presenting the clinical and roent-genographic results that were obtained with total hip ar-throplasty as a [primary] treatment for intertrochantericfractures in elderly patients and to review the resultsreported in the literature.

PATIENTS AND METHODSIn a retrospective study, between May 2012 and

June 2014, a total of 23 consecutive patients of agegreater than 70 years (average 77 years) havingtrochanteric fractures classified with AO Mullerclassification for trochanteric fractures (A2.2 and A2.3)were treated by THA. Four patients were lost in follow-up and were excluded from the study making thenumber of patients in the study 19. The followup periodwas two years. There were 14 males and 9 females. 12cases injured the right side and 11on the left side. Allpatients were given perioperative enoxaparin andsupport stockings as deep vein thromboprophylaxis.Surgical technique:

All patients were treated within 2-3days of ad-mission after all the pre-operative fitness. Patients wereoperated upon under spinal or general anaesthesia bythe same team of surgeons. They were prepared forsurgery as for routine total hip replacement and posi-tioned in a lateral position on the table. One assistantheld the limb in traction to avoid further displacement ofthe fragments. We used the posterolateral approach tothe hip in all cases. After splitting the fibres of the glu-teus maximus,was retracted to expose the short exter-nal rotator muscles of the hip. These were divided closeto their insertion and an inverted T shaped incision wasmade on the joint capsule. Fragments of the greater tro-chanter were fixed with the help ofstainless steel wire.The femoral neck was osteotomised andthe femoral headwas removed.

The acetabulum was prepared and uncementedacetabular cup (Depuy Synthes, Duraloc Cup) was im-planted. The femur was positioned by internal rotationand adduction. After careful detection, the femoral ca-nal was prepared by graduated reaming using rasps. Theuncemented femoral component (Depuy Synthes,CORAIL Stem) was inserted and positioned inside thefemoral canal.

Fixation of the greater trochanter was reinforcedwith sutures wherever required. Isolated displaced frag-ments of the lesser trochanter were not reduced. Rangeof motion and stability were checked after reduction.The capsule was repaired followed by reattachment ofthe short external rotators to the femur. All wound clo-sures were carried out over the closed suction drain.

Postoperative follow-up:Postoperatively the limb was kept in abduction

by using an abduction wedge/pillow. Haemoglobin (Hb)level and packed cell volume (PCV) were assessed 12hours after surgery. Blood transfusions were given whenrequired. Drains were removed after 48 hours and checkfilms were done. The breathing exercises and staticexercises for calves, quadriceps and gluteal muscleswere taught from the first day itself. Patients wereallowed to sit and stand out of bed twice daily from thesecond postoperative day and ranges of motion exer-cises were begun. All patients were instructed to avoidexcessive flexion and adduction. A pillow was kept be-tween the thighs during the night for the first three weeksto prevent excessive adduction. An abduction brace wasused during the daytime. Gait training with the help of awalker was started from the third postoperative day. Thepatient was discharged after complete rehabilitation. Av-erage duration of stay in the hospital was 9.5 days (range,7–13). Further care was continued in the rehabilitationdepartment until the patient was independent enough forself-care. Patients were followed at monthly intervalsfor three months, one year and two years. The patientswere clinically and radiologically evaluated at each visitand Harris hip scores were calculated.

RESULTSThe mean operative time was 110 minutes (range,

60–165min). Average intraoperative blood loss was 295ml (range, 150–500ml) and the average postoperativedrainage was 160 ml (range, 40–290ml). On an aver-age, two units of supplemental transfused blood wererequired per patient. Follow-up period ranged for twoyears with a mean duration of 1.7 years. Twopatientswere lost follow up. One patient died in the sixthmonth of surgery following a road traffic accident. An-other one died at eighth month of causes unrelated tothe fracture/surgery. In total we lost four follow ups i.etwo lost follow up and two died making a total of nine-teen patients. The Harris hip score at one month was 66± 7, at three months it was 72 ± 6, at one year 74 ± 5,and at the two-year follow-upwas 76 ± 6. In 19 patientswho had completed two years of follow-up, the scorewas 76 ± 8. Patients returned to their normal daily ac-tivities after 28 days (range, 24–33). Six patients showednon-union of the lesser trochanter. Limb lengthening of0.5–1.0 cm was noticed in 9 patients. None of thepatients showed implant loosening, femoral subsidenceor infection up to the last follow-up. Three patients haddislocation of the affected hip after two months, fourmonths and six months of surgery. All three dislocationscaused by significant trauma and were managed byclosed reduction.

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Fig. (1) a: Pre-operative Right trochanteric fractures typeAOA2.3; b: Immediate Post operative x-ray, Corial stemwith Duraloc cup seen; c: Post operative 9 monthsfollow-up, no implant loosening seen.

DISCUSSIONThe incidence of all hip fractures is approxi-

mately 80 per 100,000 persons and is expected to doubleover the next 50 years as the population ages. Amongall hip fractures intertrochanteric fractures make up to45%. Many of these fractures are stable two-part frac-tures that can be treated satisfactorily with a sliding hipscrew. But 35–40% is unstable three and four part frac-tures that are associated with high rates of morbidityand mortality. The reported overall failure rate with in-ternal fixation is from 3-16.5% in intertrochanteric frac-tures. There are even higher incidences in unstable frac-tures.

The common problems associated by treatmentwith internal fixation are pulmonary embolism, deepvenous thrombosis and pneumonia. The complicationsare related to restricted weightbearing and prolongedbed rest. In elderly patients, instability of the fracturesand osteoporosis result in poor fixation that cannot tol-erate immediate weight bearing [11]. According to data,mortality rate in hospital ranges from 0.03 to 10.5%,while one year mortality reaches 22%.

Many authors have used hemiarthroplasty andtotal hip arthroplasty as primary treatment of these frac-tures, due to high failure rate and complications associ-ated with internal fixation. Tronzo reported the use oflong straight-stem prosthesis for intertrochanteric frac-tures in 1974 [9]. In 1979, Stern and Goldstein reported43 cases of comminuted intertrochanteric fracturestreated by long-stem Leinbach prostheses [10]. Later,many authors suggested the use of hip replacement totreat comminuted intertrochanteric fractures,emphasising the rapid weight-bearing allowed from thefirst postoperative day and faster return of the patientsto a pre-fracture ambulatory state. Elderly patients, whoare often unable to cooperate with partial weight-bear-ing required after an internal fixation, accept full weight-bearing easily [11, 12]. This reduces the period of bedrest and its associated complications.

In a recent study, Faldini et al. reported use ofhemiarthroplasty and total hip replacement in 54 patients[8]. They concluded that hip replacement permits a morerapid recovery with immediate weight-bearing and fa-cilitates nursing care better than other fixation techniques.

Haentjens et al., in two different studies, con-cluded that arthroplasty gives better results than internalfixation in unstable intertrochanteric fractures in elderlyosteoporotic patients [11, 12]. The author noted that ar-throplasty permits rapid recovery with immediate weight-bearing, and maintenanceof a good level of function withlittle risk of mechanical failure.We performed total hip replacement in all ourpatients.The data available reports in cases of neck offemur fractures that total hip arthroplasty are a betterimplant than hemiarthroplasty. Acetabular erosion is themajor risk associated with hemiarthroplasty.

Repeated articulations may lead to lesions inacetabular cartilage severe enough to limit the activityresulting in higher revision surgery.Compromised articu-lar cartilage in the hips of normal elderly patients putsthem at a greater risk. Total hip arthroplasty demonstratessuperior longevity when compared to hemiarthroplasty.

Dislocation is the major concern after total hiparthroplasty. In patients with intertrochanteric fractureundergoingtotal hip arthroplasty, the reported rate of dis-location is 0–44.5% [11]. Postoperative dislocations areassociated with higher rate of pulmonary complicationsand bed sores.We took utmost perioperative and post-operative precautions to minimise the risk of dislocation.This included optimal orientation of the acetabular com-ponent, use of an acetabular component with a long pos-terior wall, and repair of the capsule. Postoperativelywe used an abduction brace for three weeks, physio-therapy and supervision in activities of daily living. Noneof our patients had dislocation in the immediate postop-erative period. Dislocation was seen in three patients attwo, four and six months after surgery. All three of themwere caused by significant trauma and were managedby closed reduction and rest.

Fig: (2) a: Pre-operative Right trochanteric fractures typeAOA2.3; b: Immediate Post operative, Corial stem withDuraloc cup seen; c: Post operative 3 months follow-up;

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Fig: (2) d: Posterior dislocation of stem at four months postoperative following trauma; e: Post operative reduction.

In our study, THA was associated with betterfunctional outcomes than those reported with the use ofinternal fixation. One year mortality in our study was9% (8.69). This mortality rate is comparable to whatother authors have reported with the use of internal fixa-tion or replacement. Patients were able to perform theirnormal activities within a month and they showed pro-gressive improvement in the first three months. All pa-tients demonstrated good functional achievement in spiteof their advanced age.

The pre-fracture activity of the patient shouldbe always taken into consideration when making a deci-sion for surgery. Though we did not make an objectiveassessment of pre-fracture mobility and activity, all ourpatients were community ambulators before injury andwere not dependent for self-care. Such patients areexpected to lead an active life after treatment and totalhip replacement is a better option than hemiarthroplasty.We recommend that total hip arthroplasty is a valid treat-ment option for mobile and mentally healthy patients.The procedure offers quick recovery with a little risk ofmechanical failure avoids the risks associated with in-ternal fixation and enables the patient to maintain a good

level of function beginning in the immediate postopera-tive period.

REFERENCES1.White BL, Fisher WD, Laurin CA (1987) Rate of mortality forelderly patients after fracture of the hip in the 1980’s. J Bone JointSurg 69-A:1335–13402.Said GS, Farouk O, El-Sayed A, Said HG (2006) Salvage of faileddynamic hip screw fixation of intertrochanteric fractures. Injury37:194–2023.Haentjens P, Casteleyn PP, Opedecam P (1994) Hip arthroplasty forfailed internal fixation of intertrochanteric and subtrochanteric fracturesin the elderly patient. Arch Orthop Trauma Surg 113(4):222–2274.Davis TR, Sher JL, Horsman A, Simpson M, Porter BB, CheckettsRG (1990) Intertrochanteric femoral fractures. Mechanical failureafter internal fixation. J Bone Joint Surg Br 72:26–315.KimWY, Han CH, Park JI, Kim JY (2001) Failure of intertrochantericfracture fixation with a dynamic hip screw in relation to pre-operativefracture stability and osteoporosis. IntOrthop 25(6):360–3626.Baumgaertner MR, Curtin SL, Lindskog DM (1998) Intramedullaryversus extramedullary fixation for the treatment of intertrochanterichip fractures. ClinOrthop 348:87–947.Brostrom LA, Barrios C, Kronberg M, Stark A, Walheim G (1992)Clinical features and walking ability in the early postoperative periodafter treatment of trochanteric hip fractures. Results with specialreference to fracture type and surgical treatment. Ann ChirGynaecol81:66–718.Faldini C, Grandi G, Romagnoli M, Pagkrati S, Digennaro V, FaldiniO, Giannini S (2006) Surgical treatment of unstable intertrochantericfractures by bipolar hip replacement or total hip replacement in elderlyosteoporotic patients. J OrthopTraumatol 7(3):117–1219.Tronzo RG (1974) The use of an endoprosthesis for severely comminutedtrochanteric fractures. OrthopClin North Am 5 (4):679–68110.Stern MB, Goldstein T (1979) Primary treatment of comminutedintertrochanteric fractures of the hip with a Leinbach prosthesis.IntOrthop 3(1):67–7011.Haentjens P, Casteleyn PP, De Boeck H, Handleberg F, OpedcamP (1989) Treatment of unstable intertrochanteric and subtrochantericfractures in elderly patients. Primary bipolar arthroplasty comparedwith internal fixation. J Bone Joint Surg Am 71:1214–122512.Haentjens P, Casteleyn PP, Opdecam P (1989) Primary bipolararthroplasty or total hip arthroplasty for the treatment of unstableintertrochanteric and subtrochanteric fractures in elderly patients.ActaOrthopBelg 60(Suppl 1):124–12813.Vahl AC, Jacobs PBD, Patka P, Haarman HJ (1994)Hemiarthroplasty in elderly, debilitated patientswith an unstablefemoral fracture in the trochanteric region. ActaOrthopedicaBelgica60:274–27814.Rodop O, Kiral A, Kaplan H, Akmaz I (2002) Primary bipolarhemiprosthesis for unstable intertrochanteric fractures. IntOrthop26:233–237

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Abstract

PurposeThe aim of our study is to evaluate the functional outcome of patients with PCL com-bined injuries with one stage reconstruction by arthroscopic ACL, PCL reconstruc-tion with open Posterolateralcorner reconstruction using autologous grafts.

MethodsProspective case series of 21 Patients with chronic PCL combined injuries operatedin Ganga hospital from December2005 to July 2009 in the age group of 21-55yearsstudied. All patients underwent thorough clinical examination, knee scoring and pre-operative MRI. Allinside transtibial PCL arthroscopic reconstruction technique andstandard transtibial ACL reconstruction and Open PLC reconstruction were performedusing autografts alone. Mean followup period was 34 months.

ResultsAll were evaluated postoperatively 6th, 12th month and at final followup for instabilityand laxity clinically along with LYSHOLM and IKDC scores. The mean postoperativeIKDC & LYSHOLM scores for ACL+PCL combined injuries were 77.3 & 90.9,im-proved from 28 and 36 preoperativly, 64.2 & 87.6 for PCL+PLC combinedinjuries,improved from 26 and 34. ACL+PCL+PLC combined injuries scores were63 and 77.8,improved from 22 and 30.4 preoperativly Mean posterior laxity of 3.3mm which however did not result in instability.

ConclusionCombined PCL injuries can be managed by one stage reconstruction of all the liga-ments with good functional stable knees with available autogenous grafts.1

FUNCTIONAL OUTCOME OF ONE STAGE RECONSRUCTION OF

POSTERIOR CRUCIATE LIGAMENTCOMBINED INJURIES OF THE

KNEE IN CHRONIC INSTABILITIESDr S R Sundararajan, Dr S Rajasekaran

Ganga Hospitals and Medical Research Centrre, Coimbatore

INTRODUCTION AND AIMS:The treatment of closed dislocation of the knee

joint without associated neurovascular injury is challeng-ing and there is no uniform protocol 1. There is contro-versy exits whether to treat these injuries acutely or latereconstruction .Eventhough many papers came with goodresults in immediate reconstructions 3,4,5,6,it is very diffi-cult to do acute reconstructions in a already traumatisedpatient. It is easy and treatment can be planned in thesemultiligament injuries with late reconstruction. Eventhough

functional outcome after PCL combined injuries were re-ported in literature2,3,4,5,8,12,13. only very few papers hadcome out with single stage reconstruction 2,3,8.

As there is no allografts, challange is to managewith available autografts to reconstruct in these com-bined injuries. The aim of our study was to evaluate thefunctional outcome of patients with chronic PCL com-bined injuries with stage one reconstructions byarthroscopic ACL, PCL reconstruction with open Pos-terolateral corner reconstruction using autogenous grafts.

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MATERIAL AND METHODSThe study included l 21 patients (20 males and

one female) with chronic PCL combined injuries whounderwent surgical reconstruction of the injured ligamentsbetween December 2005 and July 2009 in Ganga hospi-tal. The mean age was 36.3 years (21- 55 years).17patients had road traffic accidents,3 patients had fall andonly patient had sport injury. All patients were initiallyexamined by a senior operating surgeon and a plain stressradiograph and MRI of the knee joint was done. MRIwill help to substantiate the clinical findings and the pres-ence of associated meniscal injuries and arthritis changesof the involved joint. Out of 21 patients six cases hadPCL and Postero-lateral corner injuries and eleven caseshad PCL and ACL injuries and four cases had PCL,ACL and Postero-lateral corner injuries. 2 cases (9.5%)had bilateral knee injury

Associated collateral ligament injuries(9 cases)were managed conservatively. Six patients had medialmeniscus injuries and three had lateral meniscal injuries.All were treated by partial menisectomies. Associatedfractures were found in 6 cases (28.5%) out of which 5cases (24%) had ipsilateral limb injuries. Clinically allthese patients presented with pain and instability. Onexamination,all these patients had grade three posteriordrawer.Patients associated with ACL injuries had posi-tive Lachman test pivot shift test..All 10 cases with pos-terolateral corner injuries demonstrated posterior sub-luxation with external rotation. Six patients hadmediolateral abnormal mobility.

The pre-operative protocol included a strict re-habilitation program to train all patients for the post op-erative physiotherapy and counseling about the post op-erative activity modification. Cases with stiff knees withfixed flexion deformity and with open dislocations of theknee with ligament injury were excluded from the study.

Patients with anterior cruciate ligament and pos-terior cruciate ligaments that is eleven cases were treatedby arthroscopic ACL and PCL reconstruction in the samesitting. The ACL was reconstructed with bone patellartendon graft and titanium screws in five cases and ipsi-lateral hamstring graft with bio absorbable screws in fivepatients and quadriceps graft in one case. PCL was re-constructed with contralateral hamstring graft in all caseswith bio absorbable screws and endobutton(hybrid) infemur and bioabsorbable screws in tibia.

Patients with ACL,PCL and Postero lateral cor-ner injuries( four cases) were treated with arthroscopicACL and PCL reconstruction using bone patellar graftfor ACL and ipsilateral Hamstring graft for PCL. Poste-rolateral corner was reconstructed with contralateralsemitendinosis graft and bioscrew. (fig 1 )

Fig 1 PTG graft for ACL.Hamstrings for PCL,semitendinosis for posterolateral corner

Patients with PCL and Posterolateral injuries (eightcases) were treated with arthrocopic PCL reconstruc-tion using hamstring graft with endobutton andbioscrews(hybrid) in femur and bioscrews in tibia andopen reconstruction of the postero-lateral corner withcontralateral semitendinosis graft and bioscrew in 10 andstaple in 2 cases. Two cases had bilateral knee injuriesmanaged in different periods of time where we usedPTB for PCL in one side and quadriceps graft for ACLin one case.

All patients underwent ligament reconstructionsin single stage. Patients were followed up once in 6weeks and their functional outcome was assessed at theend of six months and one year and their scores werecalculated. IKDC 17 and LYSHOLM scores were takenand clinical assessment was performed and the resultswere tabulated. Radiological assesement was performedusing stress radiograph in 90 degrees flexion andposterior,anterior stabilities were checked in all casesand compared with normal side14.The mean follow upperiod was 34 months (24 to 54 months).

Operative techniqueAll cases were done with epidural anaesthesia

and positioned in the well –leg holder. Examination un-der anaesthesia was performed in all cases and specifi-cally poterolateral corner insufficiency was confirmed.Before harvesting the grafts, arthroscopic examinationwas done and meniscal injuries were dealt with partialmenisectomies.Cartilage lesions were found in 6 casesspecifically in more chronic cases .Hamstring grafts wereharvested from both knees in all cases.BPT graft washarvested in ACL.PCL and posterolateral corner inju-ries. Hamstring graft was harvested through medial in-cision below the tibial tuberosity .Attachments were re-leased and harvested with strippers. Both Gracilis and

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Semitendinosis grafts were quadrupled to get atleast9cm for ACL and 13cm for PCL. After diagnosticarthroscopy,PCL jig was used to make tibial entry atleast2cm below the articular surface.Femoral entry was donewith free hand through the inferior anterolateralportal.After appropriate reaming graft was inserted andfixed with hybrid fixation(endobutton and bioscrew)andtibial fixation with bioscrew (fig 2) with staples in 6 cases.For ACL,tibial tunnel was prepared with jig and femoraltunnel was made through transtibial route,and graft wasfixed with endobutton in femur and bioscrew in the tibiain case of Hamstrings or titanium interference screwswere used in cases of BPT graft(fig 4). All the postero-lateral corner reconstruction was done withsemitendinosis graft(Larsen method)9 and fixed with bioscrew or staple.(fig 3)

Fig 2 Tibial fixation of PCL with Bioscrew in 70degrees of flexion

Fig 3 posterolateral corner fixation with semitendinosisgraft

Fig 4 Tibial fixation of ACL in 20 degrees of flexion

Postoperativly immobilized with knee brace with cush-ion support under the tibia.Non weightbearing withcrutches started on day2 and knee mobilization in proneafter 3 weeks started.Partial weight bearing and activeknee mobilization started after 6 weeks.Full weight bear-ing was allowed after10 weeks.Running and sports re-habilitation started after 6 months.

Fig 5 Posterior laxity of 2.91mm is measured in 90degrees stress x ray

RESULTSPre-operatively main complaints of these patients

were anterior knee pain and instability.Clinical examina-tion revealed grade III laxity in most of the cases exceptin three patients.All these three had ACL and PCL inju-ries with grade II laxity. Postoperative evaluation wasdone in the 6th, 12th month and at final followup forinstability and laxity clinically along with LYSHOLM andIKDC scoring systems and radiologically. The mean post-operative IKDC & LYSHOLM scores were 77.3 & 90.9for ACL+PCL combined injuries improved from 28 and36 preoperatively, 64.2 & 87.6 for PCL+PLC combinedinjuries ,improved from 26 and 34 .63 & 77.8 .

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ACL+PCL+PLC combined injuries had 63 & 77.8 ,im-proved from 22 and 30.4 . Lesser scores were found inpatients with ipsilateral limb injuries and bilateral kneeinjuries. The mean injury operative interval was 33.3weeks (range from 5 days to 36 months.Five patientslost the terminal flexion at the average of 25 degreesand these patients had preoperative flexion loss. Out of21 patients ,17 patients had less than 5mm(average 3.3)posterior drawer and 5 to 10 with firm endpoints in threepatients.One patient had more than 10mm .Radiologicalstress xray in 90 degree flexion(fig 5) revealed 3 to 9mm with average of 4mm laxity posteriorly and 2mmtranslation in anterior stress radiograph, more inACL,PCL and PLC combined injuries.However all thesepatients had no instability clinically except one who hadgrade 3 posterior translation with instability. Out of 10cases with posterolateral corner injuries, abnormal ex-ternal rotations were corrected significantly comparedto the pre operative status in eight patients .we can notcomment about the pain and instability during sports asnone of these patients are sportsperson.

DISCUSSIONIsolated PCL injuries can be managed conser-

vatively if the posterior displacement of tibia less than10mm when compared to the normal side. But in com-bined PCL injuries,displacement is more than 10mm andshould be managed operatively 18.Functional outcomeof PCL combined injuries were reported only in few lit-eratures 2.3,8,12.Both autografts and allografts were usedin in reconstructing multiligamentous injuries..Propertiesof allografts may not be the same as autografts. Veryfew papers have come with good outcome in these inju-ries with autogenous grafts alone 2,7,11.There is also nouniversal protocol in these injuries. As there were feweravailable grafts,it is always Challenge to manage thesecombined injuries.Our results shows that these injuriescan be managed arthroscopically for ACL and PCL si-multaneously and open PLC reconstruction in singlesage with good functional outcome.

There are few literatures with good results insingle stage reconstruction using both autografts and al-lografts 2,3,8,12.Fanelli and Edson 3 studied 35 patients andachieved good posterior stability (normal posteriordrawer in 46%)and side to side difference of 1 to 3mmin 52% and remaining were between 5 to 10mm.Theyalso stated that there was no significant difference be-tween allografts and autografts.In our series averageposterior laxity was 4mm in stress radiograph with sig-nificant improvement from preoperative status .All thepatients achieved good clinical stability except one andwent back to their preinjury jobs.

Washcher et al 4 reported good results with singlestage reconstruction by using allografts alone in 13 pa-tients .They achieved 5.1mm side to side difference inposterior stress radiograph and good clinical stability.Micheal J A Strobel et al 2 reported good results usingHamstrings autografts alone in these combined injuries.Average IKDC score was 71.8 and posterior tibial trans-lation in stress radiograph was 7mm from the preopera-tive status of 15mm.Anterior displacement was 0.94mmcompared to the preoperative status of1.5mm.Eventhough these patients had pain during sportsactivities,none of them had instability.

However it is difficult to manage with Hamstringsalone especially when there is ACL,PCL and PLCinjuries.In these situations we had used ipsilateral PTBgraft for ACL sothat we could use the ipsilateral Ham-strings along with contralateral Gracilis for PCL andcontralateral semitendinosis for PLC.There is no muchdonar site morbidity except extensor muscle loss of 1.5cm.In bilateral knee injuries,still is is difficult when thereis combined injuries .We had to use quadriceps graft inone patient for ACL because of opposite PCL injurywhere we did PTB graft.we analysed the IKDC and

Fig 6 –a patient showing full range of movements afterPCL and PLC reconstruction at follow up.

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Lysholm scores for all combined injuries.In that best soreswere ACL,PCL injuries where the scores were 77.3 and90.9 improved drastically from 28 and 36.Moderatescores were from PCL,PLC injuries and low scores of63 and 77.8 in ACL,PCL,PLC injuries .It is understoodthat magnitude of these injuries are severe and preop-erative scores were also less.

All the ACL injuries got the good results, re-vealed by the negative Lachman and pivot shift clini-cally and stress radiograph in our series ,comparable toother series in literature 10,11.Posterior translation at av-erage of 4mm is comparable to all other series and noneof these patients had instability 2,3,8,12,13.It is very impor-tant to diagnose the posterolateral injuries which will re-vealed by posterior sagging and excessive external rota-tion of tibia compared to the normal side 19.In our serieswe had 10 cases of PLC injuries and we could achivecorrection in eight cases by Larson method 9

Eventhough donar site morbidity is a concern especiallywhen we harvested both PTB and Hamstrings from thesame side,in our part of the world allografts arenotavailable.But we could achieve good results compa-rable to the available series.

CONCLUSIONSingle stage reconstruction of arthroscopic pos-

terior and anterior cruciate ligament injuries and openreconstruction of posterolateral corner can be managedby autografts with good results as shown in our series.Eventhough donar site morbidity is a concern ,most ofthese patients achieved stability and went back to theirpreoperative jobs.

REFERENCES1 Richter  M , Bosch  U , Wippermann  B , Hofmann  A , Krettek  CComparison of surgical repair or reconstruction of the cruciateligaments versus nonsurgical treatment in patients with traumaticknee dislocations. Comparison of surgical repair or reconstructionof the cruciate ligaments versus nonsurgical treatment in patientswith traumatic knee dislocations . Am J Sports Med . 2002;30:7182 Micheal J A Strobel M D,Martin S Shultz M D,Wolf J Peterson MD,H J Erichorn M D Combined Anterior Cruciate Ligament,Posterior Cruciate Ligament, and Posterolateral CornerReconstruction with Autogenous Hamstring Grafts in ChronicInstabilities

3 Fanelli  GC , Edson  CJ . Arthroscopically assisted combined anteriorand posterior cruciate ligament reconstruction in the multiple ligamentinjured knee (2- to 10-year follow-up) Arthroscopy . 2002;18:703-7144 Wascher  DC , Becker  JR , Dexter  JG , Blevins  FT . Reconstructionof the anterior and posterior cruciate ligaments after knee dislocation.Results using fresh-frozen nonirradiated allografts . Am J SportsMed . 1999;27:189-1965 Shapiro  MS , Freedman  EL . Allograft reconstruction of the anteriorand posterior cruciate ligaments after traumatic knee dislocation .Am J Sports Med . 1995;23:580-587 6 Clancy  WG , Sutherland  TB . Combined posterior cruciate ligamentinjuries . Clin Sports Med 1994;13:629-6477 Chen  CH , Chen  WJ , Shih  CH . Arthroscopic reconstruction of theposterior cruciate ligament (A comparison of quadriceps tendonautograft and quadruple hamstring tendon graft) . Arthroscopy .2002;18:603-6128 Mariani  PP , Margheritini  F , Camillieri  G . One-stagearthroscopically assisted anterior and posterior cruciate ligamentreconstruction . Arthroscopy . 2001;17:700-7079 Larson  RV . Isometry of the lateral collateral and popliteofibularligaments and techniques for reconstruction using a freesemitendinosus tendon graft . Oper Tech Sports Med . 2001;9:84-9010 Feller  JA , Webster  KE . A randomized comparison of patellartendon and hamstring tendon anterior cruciate ligamentreconstruction . Am J Sports Med . 2003;31:564-57311 Jansson  KA , Linko  E , Sandelin  J , Harilainen  A . A prospectiverandomized study of patellar versus hamstring tendon autografts for anteriorcruciate ligament reconstruction . Am J Sports Med . 2003;31:12-1812 Fanelli  GC , Edson  CJ . Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and bicepsfemoris tendon tenodesis (2- to 10-year follow-up). Arthroscopy .2004;20:339-34513 Fanelli  GC , Giannotti  BF , Edson  CJ . Arthroscopically assistedcombined posterior cruciate ligament/posterior lateral complexreconstruction . Arthroscopy . 1996;12:521-53014 Jacobsen  K . Stress radiographical measurement of theanteroposterior, medial and lateral stability of the knee joint . ActaOrthop Scand . 1976;47:335-34415 Schulz  MS , Russe  K , Lampakis  G , Strobel  MJ . Reliability ofstress radiography for evaluation of posterior knee laxity . Am JSports Med . 2005;33:502-50616 Markolf  KL , ONeill  G , Jackson  SR , McAllister  DR .Reconstruction of knees with combined cruciate deficiencies (Abiomechanical study) . J Bone Joint Surg Am . 2003;85:1768-177417 Irrgang  JJ , Anderson  AF , Boland  AL . Development and validationof the international knee documentation committee subjective kneeform . Am J Sports Med . 2001;29:600-61318 DM Veltri and RF Warren Isolated and Combined PosteriorCruciate Ligament Injuries J Am Acad Orthop Surg November 1993vol. 1 no. 2 67-7519 Covey  DC . Injuries of the posterolateral corner of the knee . JBone Joint Surg Am . 2001;83:106-118

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PRIMARY AGGRESSIVE CHONDROBLASTOMA OF THE PROXIMALFEMUR TREATED WITH EXTENDED CURETTAGE ANDRECONSTRUCTION: A CASE REPORT AND REVIEW OF

LITERATUREManohar.T.M, Antony.V, Kumar.L, Arun anand.P, Selvakumar, Bosco Aju, Vijayashankar.K, Obuli

Vijayshankar.ODepartment of Orthopaedics, Government Mohan Kumaramanagalam Medical College Hospital,

Salem-636001, Tamilnadu, India.

Abstract:Chondroblastomas are benign and rare but locally aggressive tumors of the

bone that account for 1-2% of all benign bone tumors[1-4].Most of these lesions can besuccessfully treated with curettage and bone grafting. However, considerable rate ofrecurrence have been reported with aggressive lesions.Lesions around the hip havethe highest recurrence rate[5].We report a 20-year-old female with chondroblastoma oftrochanter and proximal femur, treated with extended curettage using high-speedburring and adjuvant therapy with hydrogen peroxide[6]. The defect was reconstructedwith bone cement. Prophylactic stabilisation with a dynamic hip screw was done .At 31months follow-up, the patient had painless normal function of the affected hip withoutlocal recurrence or distant metastasis.Complete healing of the lesion was evidentradiographically.Curettage and high speed burring combined with adjuvant therapyusing hydrogen peroxide represents an effective method for the treatment ofchondroblastoma of proximal femur[6].We recommend prophylactic stabilisation aftercurettage especially at sites with high risk of impending fracture such as the proximalfemur.Key words: chondroblastoma, curettage, high-speed burring, hydrogen peroxide, bonecementation, prophylactic stabilisation.

INTRODUCTIONChondroblastoma is a rare benign chondroid tu-

mor of bone arising from the secondary ossification centerin epiphyseal plates and apophyses. It usually presentsin adolescence and young adults [1,4]. The tumour typi-cally presents as a lytic lesion on an epiphyseal or apo-physeal portion as seen in this case[7].Because of its pe-riarticular location, resection for wide surgical marginswould require complex joint reconstructions and incursignificant morbidity with regard to joint function in thelong term. Therefore, intralesional curettage through abroad cortical window remains the treatment of choicefor most chondroblastomas. However, considerable rateof recurrence (10-35%) after curettage and unsual pul-monary metastases have been reported, especially inaggressive lesions[8,9]. Some authors recommendphenolization or cryotherapy after curettage in order toprevent recurrence.We describe the outcomes of ag-gressive chondroblastoma of the trochanter and proxi-mal femur treated with aggressive curettage using high-

speed burring, followed by chemical cauterization withhydrogen peroxide, combined with bone cementation ofthe defect and prophylactic stabilisation using a dynamichip screw.Case report: A20-year-old female presented with progres-sively increasing pain in the right hip of three monthsduration. There was no history of trauma, fever, loss ofweight or loss of appetite. On examination, tendernesswas present over the right trochanteric region with thick-ening of the greater trochanter. Range of movements ofright hip was restricted due to pain. There was no distalneurovascular deficit or regional lymphadenopathy. Ra-diographs of the right hip showed an osteolytic lesioninvolving the greater trochanter, extending up to the su-perior aspect of femoral neck (Fig.1 A,B). MRI (Mag-netic Resonance Imaging) of the right hip and femurshowed an osteolytic lesion of the greater trochanterextending into the femoral neck with breech in the me-dial cortex (Fig.2). CT (computed tomography)of the

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around the lesion using a high-speed burr, taking care toavoid breaching the cortex. The cavity was thoroughlyirrigated with hydrogen peroxide solution. Since the cavitywas large involving the entire trochanteric region, westabilized the trochanteric region with dynamic hip screwand filled the cavity with PMMA (PolyMethylMethAcrylate) bone cement (Fig.4 C). No intraopera-tive or perioperative complications were noted. Hip andknee mobilization were commenced on the second post-operative day. The patient was kept on strict non-weightbearing for 3 months.

Fig.3 Photo micrograph of histopathology in 100X mag-nification showing sheets of chondroblasts with multi-nucleate giant cells and sinusoids lined by osteoclasts.

Fig.4 Intraoperative picture [A]showing the lesion inthe trochanter, [B]-showing the cavity after curettage,C- After dynamic hip screw fixation and packing thecavity with PMMA bone cement.

The patient was followed up every month forthe first six months and once every three months there-

chest revealed no pulmonary metastasis.

Fig.1 Anteroposterior radiograph[A], Lateral view[B]radiograph of the right hip showing an osteolytic lesionof the trochanter extending into the proximal femoralneck.

Fig.2 Magnetic resonance imaging of the hip showingheterogenous mass in the greater trochanter extendinginto the proximal femoral neck(thin white arrows) witha breach in the medial cortex(thick white arrow) of thefemoral neck. Biopsy was taken and the histopathological ex-amination confirmed the diagnosis of chondroblastomawith secondary aneurysmal bone cyst (Fig.3).We plannedfor complete intralesional curettage of the lesion com-bined with chemical cauterization using hydrogen per-oxide, followed by bone cementing of the defect andprophylactic skeletal stabilization.

Under spinal anesthesia through a lateral ap-proach, a 10cm incision was made centering the tro-chanter. The incision was deepened and vastus lateralissplit to expose the trochanter(Fig.4 A). Osteolytic lesionin the trochanter and femoral neck was completely curet-ted out(Fig.4 B). The curettage was extended 1 mm all

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after. The patient became symptom-free during serialfollow-up visits and had painless normal function withrespect to her activities of daily living. There was nolocal recurrence or distant metastasis at the latest fol-low-up of 31 months. Radiographs at final follow-upshowed complete healing of the lesion. There was noradiolucency at the bone-cement interface. CT scan ofthe chest taken at final follow-up revealed no pulmonarymetastasis.

Fig.5 Anteroposterior radiograph[A], Lateralradiograph[A] of the right hip, showing a complete healedlesion and no radiolucency at the bone-cement interfaceat31 months follow up

DISCUSSIONChondroblastomas of the bone are uncommon

lesions and occur in the second decade of life in the vastmajority of cases.Male patients predominate.They arisefrom the secondary ossification centres in epiphysis orapophysis of the long bone.[11,12] The knee and proximalhumerus are the most frequently involved locations.[4,11,12]

Chondroblastomas of the bone may recur aftercurettage, and metastasis to the lung has been reportedin the literature.[14] The age and gender of the patient,the status of growth plate, the aneurysmal bone cyst com-ponent of the tumor, and its location and size have beenlinked to recurrence. In the latest report by Ramappa etal., the only statistical differences between non-recur-ring and recurring tumors were their anatomical loca-tions. Lesions around the hip had the highest recurrencerate.[5] Their explanation for this phenomenon was thedifficulty in gaining access to these lesions because ofthe concern about compromising the blood supply to thefemoral head. Also, this anatomical site is known forharboring more-aggressive lesions, particularly the car-tilage tumor.Many methods ranging from intralesionalcurettage to wide excision have been proposed for thetreatment of chondroblastomas of the bone. Because ofits periarticular location, resection for wide surgical mar-gins would require complex joint reconstructions and in-

cur significant morbidity with regard to joint function inthe long term. Therefore, intralesional curettage througha broad cortical window remains the treatment of choicefor most chondroblastomas. However, there is a consid-erable chance of recurrence following simple curet-tage(10% to 35%).[8,9]

In this case the lesion was treated with high-speed burring after curettage. We agree with the viewsby Springfield that “thorough curettage” is the key tolocal control.[4] We used high-speed burring for localcontrol after curettage, as many authors have suggestedin the management of benign aggressive bone tumorssuch as giant cell tumors.[10,13] In most lesions, 1 to 2mm of bone could be burred out under direct vision aftercurettage with an adequate cortical window. This makesthe intralesional curettage approach a marginal excision,thereby enhancing tumor eradication.

A variety of techniques and chemical agentshave been used as adjuvants to intralesional curettageof benign aggressive bone tumors. These include the useof a high speed burr, irrigating with phenol,aqueous zincchloride, cryotherapy with liquid nitrogen,thermal cau-tery with carbon dioxide laser[14] and the use of defectfilling agents that elute methotrexate or adriamycin. [15] .Concomitant to the use of these adjuvants are complexi-ties and complications(such as damage to adjacent softtissues and neurovascular structures, skin necrosis, frac-tures and systemic toxicity) that are undesirable. We haveused Hydrogen peroxide as adjuvant to achieve localtumour clearance. Hydrogen peroxide is a cheap adju-vant which is readily available in most surgical suitesand is relatively safe to use. It effectively kills tumourcells by releasing free radicals. Its adverse effects onadjacent tissues are also minimal. A good long-term func-tional outcome can be achieved in 87% of cases bymeticulous intralesional curettage combined with adju-vant therapy [13] As CT and MRI showed a breach in themedial cortex of the proximal femur, prophylacticstabilisation with a dynamic hip screw was done. In ad-dition we used PMMA bone cement to fill the large cav-ity in the proximal femoral region. Ramappa et al. rec-ommended that bone cement be chosen over bone graftsto fill the defect after removal of worrisome or recur-rent lesions. They thought that the heat of polymeriza-tion of the cement might destroy residual tumor cellsafter curettage.[16] Furthermore, bone cement offersimmediate stability to the proximal femoral region whichhas a very high risk of impending fracture.

Simple intralesional curettage in the treatmentof chondroblastomas produces a considerable recurrencerate and might be inadequate treatment. Extendedintralesional curettage using a high speed burr combinedwith adjuvant therapy with hydrogen peroxide was found

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to be effective in achieving complete tumor clearance.We recommend prophylactic stabilisation after

curettage especially at sites with high risk of impendingfracture such as the proximal femur. Bone cement canbe used to fill large defects in the periarticular regions asit offers immediate structural stability in addition to kill-ing residual tumor cells.

REFERENCES:1.Campanacci M. Bone and Soft Tissue Tumors: Clinical Features, Imaging,Pathology and Treatment. 2nd ed. New York. Springer. 1999:247-64.2. Dahlin DC, Ivins JC.Benign chondroblastoma A studyof 125 cases.Cancer 1972;30:401-13.3. Schajowicz F, Gallardo HJ.Epiphyseal chondroblastoma of bone. Aclinico- pathological Study of sixty-nine cases. J Bone Joint Surg1970;55B:205-26.4. Springfield DS, Capanna R, Gherlinzoni F, Picci P, Campanacci M.Chondroblastoma.A review of seventycases. J Bone Joint Surg ;67A:748-55. 5.Jaffe HL, Lichtenstein L. Benign chondroblastoma of bone. AReinterpretation of the so-call calcifying or chondromatousgiant cell tumor. Am J Pathol 1942;18:969-91.5. Ramappa AJ, Lee FYI, Tang P, Calson JR, Gebhardt MC, Mankin HJ.Chondroblastoma of bone. J Bone and Joint Surg 2000;82A:1140-5. Calcifyingor chondromatous giant cell tumor. Am J Pathol 1942;18:969-91.6. Malawer MM, Dunham W. Cryosurgery and acrylic cementation as

surgical adjuncts in the treatment of aggressive (benign) bone tumors. ClinOrthop 1991;262:42-57.7. McLeod RA, Beabout JW. The roentgenographic features ofChondroblastoma Am J Roentgenol 1973;118:464-71.8.Chondroblastoma of the ribs. A case report and review of the literature.Clin Orthop 1990; 251:230-4.9. Green P, Whittaker RP. Benign Chondroblastoma. Case report withpulmonary metastasis. J Bone and Joint Surg 1975;57A:418-20.10. Wai EK, Davis AM. Griffin A. Bell RS, Wunder JS. Pathologic fractures of theproximal femur secondary to benign bone tumors. Clin Orthop 2001;393:279-86.11. Jaffe HL, Lichtenstein L. Benign chondroblastoma of bone. AReinterpretation of the so-call12. Huvos AG, Marcove RC. Chondroblastoma of bone: a critical review.Clin Orthop 1973:95:300-12.13. Richardson MJ, Dicknson IC. Giant cell tumor of bone. Bull Hosp JtDis 1998;57(1):6-10.14.Kenan S, Kirby EJ, Buchalter J, Lewis MM. The potential role of thelaser in marginal sterilization of the giant cell tumor following curettage.Bull Hosp Jt Dis Orthop Inst. 1988;48(1):93-101.15.Zhang Y,Hou C, Chen A.[A preliminary clinical observation of giant celltumor of bone treated by Adriamycin-loaded chitosan drug deliverysystem].Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.1998;12(5):280-28216. Riddell RJ, Louis CJ, Bromberger NA. Pulmonary metastases fromchondroblastoma of the tibia: report of a case. J Bone and Joint Surg1973;55B:848-53.17. Rodgers WB, Mankin HJ. Metastatic malignant chondroblastoma. AmJ Orthop 1996; 25:846-9.

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COST EFFECTIVE NEGATIVE PRESSURE WOUND THERAPY

IN ORTHOPAEDICS

Dr. Syam Prasad Sasank Kasa, Dr. L.Senthil, Dr.N.Jambu,Dr.B.Samuel ChittaranjanDepartment of orthopaedics, Sri Ramachandra Medical Collage, Chennai-600116

Abstract

The purpose of this study was to evaluate the use of negative pressure wound therapyin traumatic wounds. . Negative-pressure wound therapy (NPWT) is believed to accel-erate wound healing by altering wound micro vascular blood flow. In our study we haveused cost effective material as an alternative to the more expensive V.A.C set in themanagement of complex wounds.

This study is a prospective evaluation of NPWT in 15 patients with traumatic wounds.In our study we have used locally made NPWT set for wound therapy. We have treatedpatients with complex wounds in which bone and tendons are exposed. Dressing waschanged for every 4 days till the desired granulations tissue is formed for skin cover.

This NPWT has showed excellent growth of granulation tissue in most of the cases.Most patients underwent split skin graft instead of flap cover which was more costeffective for the patient. The cost of this NPWT for 1 week per patient was less than2000 rupees which was more cost effective compared to the cost of commercial VACset which was 10,000 rupees

Key terms: Locally made NPWT, Cost Effective NPWT, Open traumatic wounds

INTRODUCTIONNegative-pressure wound therapy (NPWT) also

known as topical negative pressure is a mode of therapyused to encourage wound healing. It is used both asprimary treatment of chronic and complex wounds andalso as an adjunct treatment for temporary closure andwound preparation preceding surgical procedures suchas skin grafts and flap surgery [1,2]. This therapy hasbeen widely and successfully used, although the physi-ologic basis of its effects is not yet fully understood.Numerous controversies exist regarding the mechanismof action, especially with regards to tissue perfusion. Itis generally believed that increased blood flow inducedby negative pressure plays a beneficial role and severalstudies have measured increased regional blood flowunder negative pressure [2,3,4,5].

NPWT is used to treat minor wounds to com-plex wounds .The limiting factor in the usage of NPWTis the cost factor associated with it. NPWT applied for2 weeks will cost approximately 10,000 to 20,000 . In

our study we designed a NPWT using materials com-monly available in hospital setting. The cost of this sys-tem comes around 2000 to 3000 for 2 weeks. Thisstudy is to determine the efficacy of this system in trau-matic injuries.

MATERIALS AND METHODS This study was done in Sri Ramachandra medi-

cal hospital and research institute. A study group of 15patients were treated with NPWT. The NPWT systemsin current use are effective but the cost of the systemhas remained a matter of concern. Thus we arranged alocally made setup for NPWT. The materials that wereused were commonly available in our hospital and couldbe found in most hospitals.

All wound were thoroughly debrided and irri-gated with normal saline before applying NPWT set.Single layer of gauze is applied over the wound, a sterile(normal sponge sterilized the previous day) sponge was

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cut and contoured to the wound. A slot was made throughthe center of the sponge to allow fixation of the suctiontube. The sponge was pressured onto the wound withthe suction tube and an airtight environment was cre-ated with use of a surgical adhesive dressing. The otherend of the tube was connected to a drain which in turnwas connected to suction apparatus. The suction pres-sure was maintained at 150mmhg. Dressing was changedfor every 4 days till the desired granulation tissues hasformed for Skin cover.

Material required Cost1. Sterile sponge 202. Flexocath tube 2003. Chest drain 7004. Surgical adhesive dressing medium or large 525-550

Total cost 1500

RESULTSOur study group consists of 15 patients. Analy-

sis was done by visual inspection of the wound. In 10cases of foot injury, 7 cases had bone and tendon ex-posed, of which 4 wounds were healed with single SSGand 2 cases required SSG twice. One patient post cal-caneum fracture fixation had wound dehiscence andimplant was exposed. NPWT for 2 weeks reduced sizeof the wound and infection subsided. Exposed implantdid not allow formation of granulation tissue. Hence lo-cal flap cover was done. The other 3 cases took anaverage time of 4 days. 5 cases of other traumatic inju-ries required 1 week of NPWT for split skin graft. We

have treated a wound of minimum size of 3cm x 3cmand maximum size of 13cm x 8.5cm. Total cost of NPWTfor 15 days was Rs 1500 to 2000 depending on the sizeof wound.

Sample cases1) 29years old male with bimalleolar compound fracturewith skin lose and bone and tendons exposed. Dressingchanged 3 times with 5 days interval followed by skincover.

2) 28 years old male with skin loss over knee. Dressingchanged 2 times with 5 day interval followed by skincover

3) 45 year old male with resistant pseudomonas infectedimplant and wound dehiscence following calcaneum frac-ture fixation. Dressing changed 3 times with 5 days in-terval and size of the wound decreased. Granulation tis-sue formation was unsatisfactory due to the exposedimplant. Patient underwent local flap cover.

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DISCUSSIONSince its first application NPWT has been used

widely in the treatment of chronic and acute wounds.Many indications for the use of NPWT have been addedsince its first use. In our study we have included patientswith acute traumatic injuries of the foot and certain openinjuries. The mechanism of action of NPWT is that itcauses strain and stimulates cellular proliferation. It alsocauses mechanical evacuation of interstitial fluid. Thisin turn leads to increased micro circulation and there bysecondary necrosis is reduced [6]. NPWT is believed toaccelerate wound healing by improving tissue oxygen-ation, this is in contrast to study by Yoo-seok Shan whostated that NPWT significantly reduces tissue oxygen-ation.

The cost of NPWT appears to be a limiting fac-tor for its use in developing countries. The commerciallyused VAC systems cost around 10,000 per week.Diaa Othman stated that wound management causes asignificant burden of cost in National health services ofUnited Kingdom. In our indigenous preparation of NPWT

system the cost come around 1000 per week forlarger wounds.

Nauman A Gill stated that 125mmHg of suctionpressure was most effective for his patient. Novak et alused a suction pressure of 125mmHg to 175 mmHg inhis study. In our study a standard pressure of 150mmHgof suction pressure was applied for all patients. Earlystudies showed that applying this amount of pressure toa wound bed had the greatest effect on tissue re-growthand granulation tissue [6]. DeFranzo et al treated 75patients with lower limb wounds and changed the dress-ings every 2 days while Banwell and Téot changed dress-ing every 4 days. Rozen et al used their own NPWT forskin grafts and applied it continuously for 5 to 7 days andreported 100% graft take in chronic ulcers. Gill et alchanged dressing every 4 days in operation-theater toreduce the chance of infection. In our study dressingwas changed every 4 days till desired granulation tissueis obtained. Milind et al in his indigenous NPWT usedromavac drain for diabetic foot ulcers. In our study wehave used Inter Costal Drainage(ICD) tube. The

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advantage of ICD drain is we can connect 2 tubes inbigger wounds for better suction.

The third tube is connected to centralized suc-tion. NPWT is a good option for patients with coexist-ent head injuries, thoracic injuries and abdomen injuriesin which reconstruction is delayed. It also reduces woundcontamination and thereby reduces the chance of noso-comial infections

In our study we had 10 patients with foot inju-ries with bone and tendon exposed. Traditionally thesepatients would have been treated with free flap coverwhich is more expensive. In all these patients granula-tion tissue was obtained with NPWT and only one pa-tient required flap cover. NPWT has a limited role oncethe implant is exposed and when the sinus is small mak-ing it difficult for complete evacuation of fluid.

CONCLUSIONThe results of our study indicate that our cost

effective NPWT system showed comparable results tocommercially available NPWT at a fraction of the cost.Also it is available in almost any hospital and offers goodpatient compliance for healing compound fracturewounds and infected surgical wounds.

REFERENCES1.  Argenta LC, Morykwas MJ, Marks MW, et al. Vacuum-assistedclosure: state of clinic art. Plast Reconstr Surg. 2006;117:127S–142S.  [PubMed]2.  Banwell P, Teot L. Topical negative pressure (TNP): the evolutionof a novel wound therapy. J Tissue Viability. 2006;16:16–24.  [PubMed]3.  Morykwas MJ, Simpson J, Punger K, et al. Vacuum-assistedclosure: state of basic research and physiologic foundation.  PlastReconstr Surg. 2006;117:121S–126S. [PubMed]4.  Timmers MS, Le Cessie S, Banwell P, et al. The effects of varyingdegrees of pressure delivered by negative-pressure wound therapyon skin perfusion. Ann Plast Surg. 2005;55:665–671. [PubMed]

5.  Wackenfors A, Gustafsson R, Sjogren J, et al. Blood flow responsesin the peristernal thoracic wall during vacuum-assisted closuretherapy. Ann Thorac Surg. 2005;79:1724–1730. [PubMed]6. Open Orthop J. 2014; 8: 168–177.Published online Jun 27,2014.  The Evidence-Based Principles of Negative Pressure WoundTherapy in Trauma & Orthopedics Novak A, 1  Wasim SKhan,2  and  Palmer J*,1

7. The Journal of Diabetic Foot Complications, 2013; Volume 5,Issue 3, No. 3, Pages – 73 – 77.Indigenous Negative Pressure WoundTherapy for poor patients in India-an observational case series.Authors:  Milind Ruke, M.S., F.I.C.S., D.H.A., P.G.C.D.F.M., SatishPuranik, M.S.(ORTH)1, Amol Pawar, M.D.2

8. Argenta LC, Morykwas MJ:  Vacuum-assisted closure: a newmethod for wound control and treatment: clinical experience. AnnPlast Surg  1997,  38:563-576.9.  Kanakaris NK, Thanasas C, Keramaris N, Kontakis G, GranickMS, Giannoudis PV. The efficacy of negative pressure wound therapyin the management of lower extremity trauma: review of clinicalevidence.Injury. 2007;38(Suppl 5):S9–S18. [PubMed]10.   Lehner B, Fleischmann W, Becker R, Jukema GN (2011) Firstexperiences with negative pressure wound therapy and instillation inthe treatment of infected orthopaedic implants: a clinical observationalstudy. Int Orthop. doi:10.1007/s00264-011-1274-y  [PMC freearticle]  [PubMed]11.   Runkel N, Krug E, Berg L, Lee C, Hudson D, Birke-Sorensen H,Depoorter M, Dunn R, Jeffery S, Duteille F, Bruhin A, Caravaggi C,Chariker M, Dowsett C, Ferreira F, Martinez JM, Grudzien G, IchiokaS, Ingemansson R, Malmsjo M, Rome P, Vig S, Martin R, Smith J(2011) Evidence-based recommendations for the use of negativepressure wound therapy in traumatic wounds and reconstructivesurgery: steps towards an international consensus. Injury 42 Suppl1:S1–12. doi:10.1016/S0020-1383(11)00041-6[PubMed]12.  Horch RE, Gerngross H, Lang W, Mauckner P, Nord D, PeterRU, Vogt PM, Wetzel-Roth W, Willy C. Indications and safety aspectsof vacuum-assisted wound closure.  MMW FortschrMed. 2005;147(Suppl 1):1–5. [PubMed]14. Application of the Single Use Negative Pressure Wound TherapyDevice (PICO) on a Heterogeneous Group of Surgical and TraumaticWounds.Payne C,  Edwards D.15. The Journal of Diabetic Foot Complications, 2013; Volume 5,Issue 3, No. 3, Pages – 73 – 77.Indigenous Negative Pressure WoundTherapy for poor patients in India-an observational case series.Authors:  Milind Ruke, M.S., F.I.C.S., D.H.A., P.G.C.D.F.M., SatishPuranik, M.S.(ORTH)1, Amol Pawar, M.D.2

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SLIPPED DISTAL FEMORAL EPIPHYSIS IN CONGENITAL

INSENSITIVITY TO PAIN

Dr. M Javed, Dr. C RexRex Orthopaedic Hospital,Coimbatore

INTRODUCTIONCongenital insensitivity to pain (CIP) is a rare

disorder, which comes under group of hereditarysensory and autonomic neuropathies (HSAN). In thiscondition patient has insensitivity to deep pain only, butsuperficial sensation and deep tendon reflexes arenormal. Affected individual most of the times haveassociated anhydrosis. Orthopaedic complications ofcongenital insensitivity to pain are recurrent fractures,dislocations, pseudoarthrosis, osteomyelitis, and Charcotarthropathy1. We are reporting a rare case of congenitalinsensitivity to pain presenting with physeal separation ina child similar to neuropathic joint in adults.

Case reportA 12 year old girl child came with complaints of limpwhile walking and swelling in the left knee of 5 weeksduration.Mother gave history that the girl is a known caseof congenital insensitivity to pain with clear history of nopain on intramuscular injection since birth. She had nosignificant trauma, fever, other joint involvement or anyfeatures of rheumatism. Physical examination of the skin,nails, heart and lungs were unremarkable. On local ex-amination she had no bony tenderness, mild warmth, andmoderate knee effusion. Range of movements was ter-minally restricted, with normal distal pulse, power anddeep tendon reflex. Pin prick sensation was normal. Plainradiograph showed epiphysiolysis of distal femur withwidening of physis. Knee aspirated in emergency de-partment showed straw coloured synovial fluid. Synovialfluid analysis for microscopic and biochemical param-eters were normal.Blood test for infection, clotting pro-file and arthritis profile markers were normal. Examina-tion under anaesthesia demonstrated gross movement atphysis on varus, valgus stress views under fluoroscopyguidance indicating lower femoral physeal seperation.This unstable distal femoral epiphysis was treated undergeneral anaesthesia2 with closed reduction, percutane-ous cross pinning and above knee plaster cast.

Figure 1: clinical picture

Figure 2: Post-OP Radiograph

After 8 weeks the pins were removed in emergencydepartment and knee range of motion exercises started.12 weeks follow-up showed complete disappearanceof swelling around the knee and child had normal walkwith no limp. Radiograph showed increased radio-opac-ity (healing) at physis. At 1 year follow-up girl was per-fectly normal with no signs and symptoms around knee

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and normal physeal growth.

Figure 3: Eight weeks post-op

DISCUSSIONCongenital insensitivity to pain is a rare inher-

ited disorder first described by Dearborn in 19322. Itcan be inherited as autosomal dominant or recessive,and can be sporadic. The disorder is characterized byabsence of reaction to painful stimuli, self-mutilatingbehaviour and anhydrosis. Dyck in 1984 divided theseneuropathies into ûve types3.

Out of 5 subtypes of HSAN, congenital insensi-tivity to pain with anhydrosis (HSAN-IV) and congeni-tal insensitivity to pain (HSAN-V) is very common. TypeIV patients usually develop complication due to anhy-drosis and do not survive beyond 3 years of age. Ourpatient with an impaired sense of pain which was no-ticed from birth, without mental retardation, normalmuscle tone and normal normal nerve conduction veloc-ity suggests the diagnosis of HSAN type 5.

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The aetiology is not clear. One recent studyclaims mutation in the sodium channel(Na

v1.7) encoded

by the SCN9A gene located on the chromo- some 2q24.3causes inability to experience pain4.

Congenital insensitivity to pain usually manifestwith multiple joint involvement and recurrentfractures.We are reporting the first case of isolatedphyseal separation of distal femur as a menifestationdue to congenital insensitivity to pain. Isolated distal fe-mur epiphysiolysis consist of nearly 3% of all physealfractures2. As the aetiopathogenesisofphysealseparation(macro/micro trauma) is similar to neuropathic joint, thesimilar line of management was followed in our case tohasten the healing process by temporary immobilisationwith K-wires and cast5. The disappearance of swellingand normal temperature at the knee is an indication ofnormal healing.

There is no single gold standard drug availablefor this condition. Reports suggest naloxone andnaltrexone can be used to reverse the analgesia6. Butthere is no strong evidence to support these drugs.

Emphasis is given on early diagnosis of orthopaedic prob-lems and prompt treatment, educating parents and pre-vention of accidents. Physeal separation without signifi-cant trauma must prompt an orthopaedic surgeon to thinkabout congenital insensitivity to pain as a differential di-agnosis.

REFERENCES1.E.bar-on et al: Congenital insensitivity to pain, orthopaedicmanifestation.J Bone Joint Surg[Br] 2002;84-B:252-72.Dearborn G. A case of congenital general pure general analgesia.J Nerv Mint Dis1932;75:6123.Dyck PJ. Normal atrophy and degeneration predominantly affectingperipheral sensory and autonomic neurons. In: Dyck PJ, ThomasPK, Grifûn JW, Law PA, Peduslo JF, eds. peripheral neuropathy. 3rdedition. Philadelphia, etc. W.B. Sanders Company 1993:1065-934.Drenth JPH, Waxman SG. Mutations in sodium-channel geneSCN9A cause a spectrum of human genetic pain disorders. J. Clin.Invest 2007;117(12):3603-36095.Garrett BR, Hoffman EB, Carrara H:  The effect of percutaneouspin fixation in the treatment of distal femoral physezalfractures.JBone Joint Surg Br  2011,  93:689-6.Protheroe SM. Congenital insensitivity to pain. Journal of the RoyalSociety of Medicine 1991;84:558-559

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