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Tamil Nadu Orthopaedic Journal Vol.43, Issue 2, Aug20171

BICONDYLAR FRACTURE OF TIBIA - AN ENIGMA IN

MANAGEMENT

Dr. S. Sundararajan, Dr. R. GanesanPriya Orthopaedic centre, Udumalpet

INTRODUCTIONFractures of the tibial condyles are common

fractures around the knee. They account for only 1.2%of all fractures in adults. Most of these intra articularfractures pose a challenging problem in management asthey are intra articular and lead on to early degenerativearthritis if managed improperly. The problem ofmanagement can be faced easily if the surgeon is wellconversed with the pathology and anatomy as well asthe technical details of the imp lants used. When boththe condyles are involved, the management iscomplicated as to whether the fracture needs fixation ofboth columns or one column fixation is sufficient. Thispaper looks into the problems and tries to find a solutionfrom our experience supported by literature.

HISTORY (1):-Sir Astley Cooper first described fractures of the

proximal tibia in 1825. Anger treated most minimallydisplaced fractures with early knee traction mobilization.Rasmussen introduced open reduction and internalfixation (ORIF) of tibial condylar fractures, andSarmiento popularized functional cast bracing of mosttibial condylar fractures

CLASSIFICATIONS:-In 1900, Muller proposed a classification system

for tibial plateau fractures that categorized fracturesaccording to the amount of articular involvement.

In 1956, Hohl and Luck proposed a classificationof plateau fractures that included undisplaced, local-depression, split-depression, and splitting fractures. Hohllater (1967) expanded the classification to includecomminuted fractures.In 1981, Moore proposed aclassification system for fracture-dislocation of thetibial condyle that took into consideration soft-tissueinjury.

Schatzker et al proposed a classification systemof condyle fractures based on the fracture pattern andfragment anatomy in 1979.(2) This classification system,which is widely accepted and used today, divides thesefractures into the following six types:

• Type I - This is a wedge or split fracture of thelateral aspect of the plateau, usually as a result of valgusand axial forces; the wedge fragment is not compressed(depressed), because the underlying cancellous bone isstrong; this pattern is usually seen in younger patients• Type II - This is a lateral wedge or split fractureassociated with compression; themechanism of injury is similar to that of a type I fracture,but the underlying bone may be osteoporotic and unableto resist depression, or the force may have been greater(see the first and second images below)• Type III - This is a pure compression fracture ofthe lateral plateau; as a result of an axialforce, the depression is usually located laterally orcentrally, but it may involve any portion of the articularsurface (see the third image below)• Type IV - This is a fracture that involves themedial plateau; as a result of either varus or axialcompression forces, the pattern may be either split aloneor split with compression; because this fracture involvesthe larger and stronger medial plateau, the forcescausing this type are generally greater than thoseassociated with types I, II, or III (see the fourth imagebelow)• Type V - This fracture includes split elements ofboth the medial and the lateral condyles and may includemedial or lateral articular compression, usually as aresult of a pure axial force occurring while the knee is inextension• Type VI - This is a complex, bicondylar fracturein which the condylar componentsseparate from the diaphysis; depression and impactionof fracture fragments are the rule;this pattern results from high-energy trauma and diversecombinations of forces.

The other popular classification is by ASIF. Inthis Type A is extra articular fracture, Type B is intraarticular fracture and Type C are intra articular fracturewith metaphyseal extension.

Recently, a new three-column classificationapproach was proposed by Luo based on multiplanarCT images. Three-Column classification provides a

TNOA PROF. T.K. SHANMUGASUNDARAM MEDAL


higher agreement among different surgeons and couldbe popularized and widely practiced (3)

INVESTIGATIONS:-RadiographyMost tibial plateau fractures are easy to identify

on standard anteroposterior (AP) and lateral projectionsof the knee.

Oblique projections should be added if a nondisplaced tibial plateau fracture is suspected but not seenon the standard projections. An AP projection of theknee, angled 15° caudally (tibial plateau view), canprovide a more accurate assessment of the depth ofplateau surface depression.

Traction radiographs provide a clearer image ofthe fracture configuration after anatomic alignment isrestored.Areas of bone loss resulting from comminutioncan be mapped, and the appropriate size and length ofthe necessary implants can be ascertained.

Corresponding views of the uninjured knee andextremity are necessary for each patient to receiveaccurate restoration of length and alignment of the leg.

Computed tomographyBy acquiring thin axial slices through the knee

and reconstructing the image data in the sagittal andcoronal planes, computed tomography (CT) providesmore detailed information. The information obtainedfrom a CT scan can help determine the best surgicalapproach based on the fracture planes seen on thecomputer images. Three-dimensional spiral CTreconstructions yield a better and more accuratedemonstration of the tibial plateau fracture. Theypresent the anatomy in the view the surgeon will seewhen surgery is performed. Magnetic resonanceimaging

Magnetic resonance imaging (MRI) isacknowledged as a reliable and accurate tool forassessing meniscal, collateral, and cruciate ligamentousinjury, as well as for identifying occult fractures of thetibial plateau.

MANAGEMENT:-As these fractures are intra articular, it is ideal to

go for surgical management in the form of accuratereduction, fixation followed by early mobilization.

Before planning surgery, it is essential to considerthe condition of soft tissues as there is bound to bedamage to the surrounding soft tissues in displacedfractures and fracture dislocations.

Surgical management may be internal fixation orexternal fixation.Internal fixation can be with buttressplates and screws, locking plates and screws and insome screws alone.

External fixation can be Ilizarov fixator or hybridfixators. Joint spanning fixators are used as temporarymeasure. Minimally invasive articular realignment andscrew fixation can be combined with external fixation.

MATERIALS & METHODSOn a retrospective study of bicondyle fractures

of tibia operated from 2008 to 2014, there were 20 casesin which there was follow up of more than a year. Therewere 12 males and 8 females. The involvement of rightside was 8 and the left was 12. The age group was from18 to 65 years (Average 42.4 years).The mode of violence include the following1. RTA - 122. Fall at home-. 8

The patients were operated following the routineinvestigations under spinal anaesthesia. 5 patientsunderwent CT scan. All other patients were operatedwithout CT scan.

The involvement of medial condyle was presentin all and specific posteromedial condyle involvementwas present in 6 patients.

There were 8 cases which were subjected toopen reduction and the remaining patients wereoperated by minimally invasive technique. The fractureswere fixed with proximal tibial buttress plates andscrews in 6 patients and lateral proximal tibial lockingplates and screws in 14 patients. There were 4 patientswho had fixation on the medial side alone and 5 patientshad fixation from both sides.All patients were operated under spinal anaesthesia.Some patients were operated withoutimage intensifier. All the patients were operated undertourniquet control. 6 patients underwent bone graftingfrom iliac crest.The co morbidities were1. Diabetes mellitus - 52. Hypertension - 43. Anaemia - 24. Associated injuriesa. Clavicle fracture - 1 b.Lateral popliteal nerve palsy - 1 c.Fibula neck fracture - 5

There were 3 open fractures.The duration between injury and hospitalization

varied from 3 hrs to 5 days. The duration betweenhospitalization and surgery was from 6 hrs to 3 days.The reason for delay were1. Control of co morbidconditions

2. Consent of the patient3. Approval from insurance companyPost operatively the patients were mobilised in 48

hours and weight bearing was delayed till 6 weeks when


partial weight bearing was allowed. All the fractureswere followed up periodically with radiographs till thefractures united.The follow up ranged from 14 months to 120 months(Average 63 months)

RESULTSThere were no cases of superficial or deep

infections. All the wounds healed primarily. 3 patientshave undergone implant removal electively.

The results were analysed using Rasmussenfunctional and anatomical grading as well as Lysholmgrading.

Rasmussen gradingFUNCTIONAL GRADINGA. SUBJECTIVEa. PAINi. No pain 6ii. Occasional pain 5iii. Stabbing pain in

certain positions 4iv. Intense, constant pain after activity 2v. Night pain/ Rest pain 0b. WALKING CAPACITYi. Normal 6ii. Walking outdoors 1 hour 4iii. Short walks outdoors 15 minutes 2iv. Walking indoors only 1v. Wheel chair/ Bedridden 0B. CLINICAL SIGNSa. EXTENSIONi. Normal 6ii. Lack of extension 10* 4iii. Lack of extension > 10* 2b. TOTAL RANGE OF MOVEMENTi. At least 140 6ii. At least 120 5iii. At least 90 4iv. At least 60 2v. At least 30 1vi. 0 0c. STABILITYi. Normal in extension and 20* flexion 6ii. Abnormal in 20* flexion 5iii. Instability in extension < 10* 4iv. Instability in > 10* 2

EXCELLENT: 21 – 27 GOOD: 11 – 20FAIR: 7 – 10 POOR: 6 AND BELOW

ANATOMICAL GRADINGA. DEPRESSION

a. Not present 6b. < 5 mm 4c. 6 to 10 mm 2d. > 10 mm 0B. CONDYLAR WIDENINGa. Not present 6b. < 5 mm 4c. 6 to 10 mm 2d. > 10 mm 0C. ANGULATIONa. Not present 6b. < 10 degrees 4c. 10 to 20 degrees 2d. > 20 degrees 0

EXCELLENT: 11 – 18 GOOD: 7 –12FAIR: 1 - 6 POOR: 0

Lysholm gradingThis questionnaire is designed to give information as tohow the knee problems have affected the ability of thepatient to manage in everyday life

LYSHOLM KNEE SCORING SCALE1.Limp:a) None 5b) Slight or periodical 3c) Severe and constant 02. Support:a) None 5b) Stick or crutch 2c) Weight-bearing impossible 03. Locking:a) No locking and no

catching sensations 15b) Catching sensation but no locking 10c) Locking occasionally 6d) Locking frequently 2e) Locked joint on examination 04. Instability:a) Never giving way 25b) Rarely during athletics or

other severe exertion 20c) Frequently during athletics/other

severe exertion(or incapable of participation) 15

d)Occasionally in daily activities 10e) Often in daily activities 5f) Every step 0

5. Pain:a) None 25


b) Inconstant and slight duringsevere exertion 20

c) Marked during severe exertion 15d) Marked on or after walking

more than 2 km 10e) Marked on or after walking

less than 2 km 5f) Constant 0

6. Swelling:a) None 10b) On severe exertion 6c) On ordinary exertion 2d) Constant 0

7. Stair-climbing:a) No problems 10b) Slightly impaired 6c) One step at a time 2d) Impossible 0

8. Squatting:a) No problems 5b) Slightly impaired 4c) Not beyond 90° 2d) Impossible 0

TOTAL POINTSGRADE :-

Grading the Lysholm Knee Scoring Scale<65 Poor 65-83 Fair 84-90 Good>90 Excellent

The results according to Rasmussen criteria are asfollows

Functionalgrade:

EXCELLENT 15GOOD 3FAIR 2POOR 0

Anatomicalgrade:


The results according to Lysholm grading are asfollows :


DISCUSSIONBicondylar tibial plateau fracture management

remains therapeutically challenging, partly because ofmultiplanar articular comminution.

The goal of treatment in these fractures is stablewell aligned congruent joint with painless range ofmotion and function. The soft tissue envelope, fracturepattern, bone stock and degree of comminution alsoheavily influence the decision-making process and iscritically important to the surgical success.

These goals can be reached if we can analysethe structure of the fracture pattern and plan thetreatment.

An algorithm of Scan? Span ? Plan is useful inmanagement of these fractures.

A CT scan, preferably 3 D, will be a useful toolto assess the anatomy of the fracture, useful tocomplete the classification which is essential formanagement and prognosis and will throw light onsuspicious fragments.

Spanning the joint in the form of a joint spanningexternal fixation system is useful to reduce the pain.The post traumatic edema comes down dramatically. Italso reduces the soft tissue trauma till the definitivefixation is done. Spanning makes the alignment betterand eases the technique of internal fixation. Calcanealpin traction also brings about similar advantages. In onepatient we used this to reduce the dislocation associatedwith this fracture and also to allow the blebs to subside.After this the planning has to be done with the followingin mind.1. Assess the fragments anatomy2. Decide about medial/ lateral stabilisation3. Decide about MIPO/ ORIF4. Decide about the length of stabilisation5. Decide about the post op protocol

The choice of fixation rests with1. Plate and screws2. External fixation3. External fixation with screw supplementation (4)

The common observation in the proximal tibialfractures is that the lateral tibial condyle is depressedfirst and then split in the violence. On the medial side it


is the split of the condyle first and then depression of thefractured fragments. The medial tibial split occurs mostof the time in coronal plane.

The shape of the condyles may be one of thecontributing factors to cause the damage like this. Thesplit posteromedial fragment is an entity which if notrecognized may lead on to deformity and jointincongruity.

According to Eggli et al most of the complexbicondylar fractures follow a regular pattern in that themedial compartment is split in a mediolateral directionwith a posteromedial main fragment, combined withvarious amounts of multi fragmental lateralcompartment depression.(5)

An intact fibula may be predictive of lesscomminution of the plafond. (6) In our series also wefound whenever the fibula was fractured thecomminution was more.

In the series of Tscherne et al, a stepwiseapproach is used in complex knee trauma. Primarytreatment includes closed reduction, wounddebridement, if necessary, and external fixation of thefemur and lower leg. Plate fixation was done onlysecondarily. (7)

Historically, displaced bicondylar fractures weretreated with separate lateral and medial plates. A single,midline incision or a Mercedes Benz incision provided aconvenient approach to dual plating of these fractures.However, the amount of soft tissue dissection needed toadequately expose the fracture through this approachdevitalizes comminuted bone fragments and has beenshown to have a high complication rate. (8)

Barei et al described the benefits using twoincisions for dual plating. (9)

When the fracture of the medial tibial condyle ispart of the bicondylar fracture, any attempt to fix it fromthe lateral aspect may not be always successful. This ismore true in cases where the fixed angle plates andscrews are used.

Single lateral plating has been advocated as ameans of decreasing the risk of skin damage, ligamentdamage, operation time, surgical site infection andshorter hospitalization period. Experimental and clinicalevidence reported by Mueller et al., Gosling et al. andHiggins et al. established that a single lateral lockedplate ensured reliable fixation. In all these studies, themain risk was secondary displacement. (10,11)According to M. Ehlinger et al also single laterallocking plate ensured stable reduction of tibial plateaufractures with a medial component.(12,13)

Yoo et al. reported that standard dual platingprovided greater mechanical strength than a singlelateral locked plate. (14)

According to Rui Jiang, the medial double platestechnique is biomechanically the best fixation methodfor fracture dislocations involving the proximal tibia,while lateral locked plate technique is not indicated tothis kind of fracture due to its insufficient stability. (15)

The literature review also shows Barei DP et alshowed that forty-two of 57 injuries (74%)demonstrated a postero medial fragment that compriseda mean of 58% of the articular surface of the medialtibial plateau (range, 19%-98%) and a mean of 23% ofthe entire tibial plateau articular surface (range, 8%-47%).(16)

According to Higgins et al, of 111 bicondylar tibialplateau fractures analyzed, this fragment occurred in 65cases (59% incidence) and on average accounted for 25%of the total tibial plateau joint surface. There was greaterthan 5 mm of articular displacement in 55% of cases. Theposteromedial fragment exhibits a vertical fracture pattern(average sagittal angle 73 degrees), suggestive of shearinstability and vertical displacement. (17)

The displaced and depressed medial fragmentshould be elevated well and stabilized preferably with amedial buttress plate and screws rather than thelaterally placed locking compression plate (18).

When the medial condyle is involved as a whole,it is safe to go for a lateral plate and if that fails toestablish the medial buttress then it is wise to gomedially and fix that also. This has been stressed wellby Meng- Hsuan Lee et al in the Journal of Orthopaedicsurgery and research, 2014.

The amount of depression and tilt acceptable hasbeen documented by Honkonen( 19) In 2010, Luo et alintroduced a floating position using 1 preparation anddrape for posteromedial and anterolateral approaches.The patient was placed in the lateral decubitus positionwith the injured leg up. The lower leg and pelvis werefirst rotated to a prone position to perform posteromedialapproach to fix the posterior and medial tibial plateaufractures with an inverted L-shaped incision. Then, thelower leg and pelvis were rotated back to the lateralposition to perform an anterolateral approach to fix thelateral tibial plateau (20).

Shi- Ming Chang et al used rotation of the healthylower leg and pelvis. By preparing and draping both legs,the contra lateral healthy hip is flexed and adducted overthe injured leg. This maneuver makes the patient’slower trunk rotate and results in the injured limb rotatedlaterally, providing better access and visualization of theposterior coronal fragment in the medial plateau. Thisfloating supine position allows for a healthy-sidemaneuver, which is safer than the injured- sidemanipulation (21). The proximal buttressing effect ofvarious plates differs. The 5 mm systems which use just


2 screws proximally have inadequate fixation for acomminuted medial condyle. The 4 mm or 3,5 mmsystems which use the raft principle with 4 screwsproximally have diverging screws and may hold theposteromedial fragment also.

We have used open reduction when we used nonlocking implants for economical reasons. Bone graft wasdone in such patients with depressed fragments whichwere elevated under image control. Otherwise the sametechnique is followed whichever implant is used.

The presence of blebs many times makes usplace screws closer to each other contradictory to theprinciples of LCP. We were afraid to pass screws at thesite of blebs initially. Gradually we overcame theapprehension and now keep them away according tothe principle. Similarly shorter implants were usedinitially which was changed later days. The learningcurve could be realized in our work as we operated onmore patients and grew confident.

Post operative rehabilitation was definitely lesspainful when we used smaller incisions. But the finalresults match the same for both.

The results indicate that the poor results are dueto inadequate stabilisation resulting in early or latecollapse of the medial pillar.

CONCLUSION1. Lateral plating is sufficient in most of the bicondylarfractures2. When there is an involvement of posteromedialcondyle it should be fixed first by preferably openreduction3. There is no significant difference in the long termoutcome between locking plates and buttress plates.4. Medial collapse occurs if care is not taken in primaryreduction and fixation.

REFERENCES1. Tibial Plateau Fractures, Author: Srinivasa Vidyadhara, MBBS,MS, DNB; Chief Editor: Thomas M DeBerardino, MD MEDSCAPEUpdated: Aug 27, 20152. The tibial plateau fracture: the Toronto experience: 1968–1975.Schatzker J, McBroom R, Bruce D. - Clin Orthop Relat Res.1979;138:94–104.3. Three-Column Fixation for Complex Tibial Plateau FracturesCong-Feng Luo, Hui Sun, Bo Zhang and Bing-Fang Zeng, Journalof orthopaedic trauma24(11):683-92 · September 20104. Outcome of complex tibial plateaufractures treated with external fixator, Indian Journal of orthopaedics,Sushil H Mankar, Anil V Golhar, Mayank Shukla, Prashant SBadwaik, Mohammad Faizan, Sameer Kalkotwar Year : 2012 |Volume : 46 | Issue : 5 | Page : 570-5745. Unstable Bicondylar Tibial Plateau Fractures: A ClinicalInvestigation, Eggli, Stefan MD; Hartel, Maximilian J MD; Kohl,

Sandro MD; Haupt, Uli MD; Exadaktylos, Aristomenis K MD; Röder,Christoph MD Journal of Orthopaedic Trauma: November /December 2008 - Volume22 - Issue 10 - pp 673-6796. Ipsilateral intact fibula as a predictor of tibial plafond fracturepattern and severity. Luk PC;Charlton TP; Lee J; Thordarson DB, Foot Ankle Int. 2013;34(10):1421-6 (ISSN: 1071-1007)7. Tibial plateau fractures. Management and expected results. TscherneH, Lobenhoffer P. Clin Orthop Relat Res. 1993 Jul; (292):87-100.8. Treatment of Bicondylar Tibial Plateau Fractures With LateralLocking Plates, Richard L. Uhl, MD; Jonathon Gainor, MD; JoelHorning, MD, Orthopedics, May 2008 - Volume 31 · Issue 59. Functional Outcomes of Severe Bicondylar Tibial Plateau FracturesTreated with DualIncisions and Medial and Lateral Plates. J Bone Joint Surg Am, 2006Aug; 88 (8): 1713 -1721.David P. Barei, MD, FRCS(C); Sean E. Nork, MD; William J. Mills,MD; Chad P. Coles, MD, FRCS(C); M. Bradford Henley, MD;Stephen K. Benirschke, MD10. Single lateral locked screw plating of bicondylar tibial plateaufractures. Gosling T, Schandelmaier P, Muller M, Hankemeier S,Wagner M, Krettek C. Clin Orthop Relat Res. 2005 Oct; 439:207-14.11. Biomechanical analysis of bicondylar tibial plateau fixation: howdoes lateral locking plate fixation compare to dual plate fixation?Higgins TF, Klatt J, Bachus KN. J Orthop Trauma. 2007 May;21(5):301-6.12. Reliability of locked plating in tibial plateau fractures with amedial component, M. Ehlinger, M. Rahme, B.-K. Moor, A. Di Marco, D. Brinkert, P. Adam, F.Bonnomet, Orthopaedics & Traumatology: Surgery & Research,Volume 98, Issue 2, April 2012, Pages 173–17913. Reliability of locked plating in tibial plateau fractures with amedial component M. Ehlinger,M. Rahme, B.-K. Moor, A. Di Marco, D. Brinkert, P. Adam, F.Bonnomet Orthopaedics & Traumatology: Surgery & Research,Volume 98, Issue 2, Pages 173-17914. Stabilization of theposteromedial fragment in bicondylar tibial plateau fractures: amechanical comparison of locking and nonlocking single and dualplating methods, B.J. Yoo, D.M. Beingessner, D.P. Barei, J Trauma,69 (2010), pp. 148–15515. Biomechanical evaluation of different fixation methods for fracturedislocation involving the proximal tibia ,Rui Jiang, Cong-Feng Luo ,Bing-Fang Zeng, Clin Biomech, 23 (2008), pp. 1059–106416. Frequency and fracture morphology of the posteromedial fragmentin bicondylar tibial plateau fracture patterns. Barei DP, O’Mara TJ,Taitsman LA, Dunbar RP, Nork SE. Journal of Ortho trauma 2008,Mar; 22(3):176-82. (20)17. Incidence and morphology of the posteromedial fragment inbicondylar tibial plateau fractures. Higgins TF, Kemper D, Klatt J. JOrthop Trauma. 2009 Jan; 23(1):45-51.18. Medial buttress versus lateral locked plating in a cadaver medialtibial plateau fracture model. Ratcliff JR et, J Orthop Trauma. 2007Aug; 21(7):444-819. Indications for surgical treatment of tibial condyle fractures.Honkonen SE, Clin Orthop Relat Res. 1994 May;(302):199-20520. Three-column fixation for complex tibial plateau fractures. LuoCF1, Sun H, Zhang B, Zeng BF. J Orthop Trauma. 2010Nov;24(11):683-92.21. Posterior Coronal Plating of Bicondylar Tibial Plateau FracturesThrough Posteromedial and Anterolateral Approaches in a HealthyFloating Supine Position, Orthopedics - July 2012 - Volume 35 · Issue7: 583-588 Shi-Min Chang, MD, PhD; Xin Wang, MD; Jia-qianZhou, MD; Yi-Gang Huang, MD, PhD; Xiao-Zhong Zhu, MD


AN INNOVATION FOR PERFECT REDUCTION IN

HYPEREXTENSION INJURY OF ISOLATED ANTEROMEDIAL TIBIAL

PLATEAU FRACTURE

Dr J DheenadhayalanGanga hospital, Coimbatore

ABSTRACTObjective:Isolated anteromedial tibial plateau fracture following an hyperextension injury is arare fracture pattern. Reduction and fixation using the conventional techniques isdifficult and less satisfactory. The aim of this report is to present a novel reduction andfixation technique for such pattern of fracture.Patients and methods:Surgery involved a novel indirect reduction technique followed by fixation using medialLCP. Minimal soft tissue dissection and the fixation by raft technique, and there wasno need for bone grafting or bone substitutes. Patient was followed to look forradiological and functional outcome.Results:Perfect Anatomical reduction was achieved by indirect means with minimal softtissue dissection, and with early rehabilitation , excellent functional outcome wasachievedConclusion:The indirect hyperextension reduction technique is a novel reductionmanoeuvre and can provide anatomical reduction with good radiological and functionaloutcome in patients with isolated depressed anteromedial tibial condyle fracturefollowing hyperextension injury. Easy to use and reproducible.

INTRODUCTIONTibial plateau fractures account for

approximately 1% of all fractures (1). With increasingnumber of high velocity trauma, rare fracture patternsof proximal tibia are becoming more frequent.Management of tibial condyle fracture traditionallyinvolves direct open reduction and fixation, which isdictated by the fracture pattern and morphology.However, the conventional techniques of proximal tibiafracture management may be less optimal for some rarepatterns. Isolated depressed anteromedial rim fractureof medial tibial plateau following an hyperextensioninjury is one such rare fracture pattern with only a smallnumber of case reports in the literature. Such injury iscaused by a posteriorly directed force on theanteromedial aspect of the knee resulting inhyperextension or a twisting injury with externalrotation of the Knee(2). The hyperextension frequently

causes posterolateral (PL) corner injuries with high riskfor additional ligamentous injury, such as ACL orPCL(3). However, less commonly such injuries mayalso result in isolated depressed tibialcondylefractures(4). Owing to comminution anddepression of fracture fragments, recreating the tibialslope becomes difficult. Careful assessment of CT scanis required in understanding such pattern and requiresfracture specific surgical approach and fixation strategy.In this report, we present a novel technique of managingsuch hyperextension injuries, using indirect reductiontechnique, together with a literature review of thiscondition.Although the overall incidence of these injuriesis relatively low, it is important for surgeons to recognizethese injury patterns and treat them appropriately tooptimize patient outcome. We believe this case reportintroduces new insights into this unique fracture patternand help in better clinical outcome for these patients.

TNOA PROF. P. DHANARAJAN MEDAL


Case ReportA 33 year old female presented with severe pain

and swelling of left knee and inability to bear weight onleft leg since two days following being struck by a carresulting in hyperextension injury to left knee. Initialtreatment in the form of temporary splinting was doneon the day of injury.

On physical examination, patient had knee jointeffusion with severe tenderness over medial tibialcondyle. Overlying skin was healthy with no blisters orwounds. Dorsalis pedis and posterior tibial pulses werewell felt and neurological examination wasunremarkable. Compartment syndrome was ruled out.Initial radiographs and computerized

Tomography (CT) showed a displaced fractureof the anteromedial margin of medial tibial plateau withsignificant anterior depression(Fig 1,2).

Considering the displaced nature of fracture,open reduction and internal fixation using a mediallocking plate was planned.

Fig.1. Preoperative radiographs showing medialcondyle fracture with depressed anterior fragments.

Fig.2. Preoperative CT scan images showingdepressed condylar fracture.

Surgical TechniqueUnder spinal anaesthesia, patient was positioned

supine on operating table. Under tourniquet control,standard anteromedial incision of approximately 10 cmsis given over the left knee. After careful dissection ofsoft tissues, the medial condylar fracture fragment isexposed and everted open to visualise the underlyingdepressed fracture fragments.Capsulotomy was done tolook for intra articular reduction and to rule out meniscialtears(Fig3). Rather than the conventional method ofpushing the fragments through the everted medialcondyle, a novel technique was used to reduce thisfragments.

Fig.3. Depressed fracture fragments seen followingeversion of medical cortical wall

The leg was lifted by holding it at the ankle. Dueto lack of bony support anteriorly(because the of thedepressed fracture fragments), the knee joint went intohyperextension. This manoeuvre essentially brought theleg in same position as it was at the time of injury.Holding the leg in this position, the tibial condyles weretransfixed to the femoral condyle using two 2mm trans-articular k-wires. Now, the leg was allowed to graduallygo down on the table. Owing to the k-wires, the tibialcondyles maintained their reduced position in relation tothe femoral condyle while the rest of the leg fell backdue to gravity. This results in a gap anteriorly betweenthe tibial condyles and the metaphysis suggesting thatthe depressed anterior fragments have been reduced.This manoeuvre led to indirect reduction of tibialcondyles. Reduction of articular surface and tibial slopewas confirmed under image intensifier in both antero-posterior and lateral views. The trans- articular k-wireswere now replaced with two cross k-wires extending tillthe tibial subchondral region(Fig 4 a-h). The medialcondylar fragments were reduced and fracture fixedusing Synthes 3.5 mm medial proximal tibia LCP plate.Following fixation, knee joint was assessed for


ligamentous instability. Hyperextension was not seennow and knee stability tests ruled out any ligamentousinjury(Fig 5). Wounds were closed in layers with a drainin situ and compression dressing applied. The operativetime was 80 mins and blood loss was less than 100 ml.The surgical site healed well. Complications likeinfection, neurovascular injury or compartmentsyndrome were not encountered.

Fig 4 (a-h) Showing surgical steps that are to befollowed for reduction of depressed anteromedial

condyle fragment.

Fig.5 No hyperextension was seen at knee joint afterfixation of fracture

Post operative protocol:-

Under adequate analgesia, active and active assistedrange of motion exercises were started from postoperative day one. Toe touch weight bearing was startedon day 2 and patient was discharged from hospital onsecond postoperative day. Partial weight bearing wasstarted at three weeks and weight bearing wasprogressively increased under pain-free limits.Fullweight bearing was started 6 weeks after surgery.Patient was asked to follow up on outpatient basis every6 weekly till union of the fracture occurred. Radiographstaken at 6 months showed adequate consolidation offracture(Fig 6).Patient was allowed to return to work 6 weeks aftersurgery and she achieved pre-surgery activity levels by6th month. At final assessment, patient had no extensionlag with range of motion from 0-120°. She was able todo all her routine activities without any symptoms.Functional assessment was done using KOOS score (5)

and found the outcome to be highly satisfactory(Fig 7).

DISCUSSIONIsolated anteromedial tibial plateau fracture

following an hyperextension injury is a rare pattern withvery few case reports in the literature (6–10). Theseinjuries frequently result in knee instability due to tear ofPL corner or tear of PCL, ACL, LCL in isolation or incombinations (11,12). Impingement fracture of theanteromedial tibial margin following an hyperextensioninjury was first described by Cohen et al. (6) in 2001.The postulated mechanism of injury is hyperextension(leading to PCL and PLC injury), and combined varusrotation and posterior tibial translation (resulting incompression anteromedial rim fracture). The authorshad mentioned that this fracture could only occur in thepresence of grade III PCL and PLC rupture. Associatedligament injuries causes tibial translation anddissemination of forces, thus resulting in less energytransfer to bone and less significant fractures. In 2001,chiba et al(7) reported 12 patients with injuries to thePosterolateral Aspect of the Knee accompanied byCompression Fracture of the anterior Part of the MedialTibial Plateau. They proposed that such compressionfractures should be an important diagnostic sign of injuryto posterolateral aspect of the knee. Of their 12 patients,11 patients had ligamentous injury while only one patienthad isolated anteromedial condyle fracture with nocruciate ligament injury. They concluded that acompression fracture of the anterior part of the medialtibial plateau indicates a coexistent PL aspect injury,and that especially a small compression fracturestrongly suggests an accompanying PCL injury, aswell(7). Similar findings were reported by bennett et al(8) and others (7,9,10,13,14) . Our case is rare becauseof absence ofPL corner ligament injury and significantdepression of fractured condyle. In 2013, P. Chanasit etal (4) reported a case of anteromedial rim fracturewithout any significant ligament injury. However, thepatient was suffering from hypermobile joints with laxligaments. Following fixation, we performed variousclinical tests like varus stress test, posterior drawer test,external rotation-recurvatum test etc.(13) and found theknee to be stable.

Conventionally, tibial condyle fractures have beentreated with open reduction and fixation(15). Thisresults in excessive stripping of soft tissues andincreased risk of infection, delayed rehabilitation andpoor functional outcome. Though the variables relatedto functional outcome of tibial condyle fractures havebeen controversial, fracture reduction quality isconsidered an important and independent predictor forclinical outcome (16). Anatomical reduction of


depressed and comminuted anteromedial fragments isdifficult by conventional techniques. In our patient, wehave achieved anatomical reduction using indirectmethods, thus reducing the operative time, soft tissuestripping and risk of infection. As per our knowledge,there is no literature that specifically mentions suchreduction manoeuvre for hyperextension injuries.

Thus, our case introduces new insights into thisrare fracture, not only in terms of fracture pattern andits reduction but also in terms of absence of associatedsignificant ligament injury and no associated ligamentlaxity.

The ideal indication for this technique is anisolated anteromedial depressed fracture following anhyperextension injury. Associated ligamentous injuryshould be assessed and managed concomitantly.

The advantages of this technique are(1) Simple and easy technique(2) Soft tissue stripping is avoided(3)Easily reproducible(4)Less time consuming and(5)Early rehabilitation.In conclusion, Hyperextensionreduction technique is an effective reduction techniquefor isolated depressed anteromedial tibial condylefractures. When used in indicated fracture patterns,excellent radiological and functional outcome can beanticipated.

Conflict of interestNone of the other authors have any conflicts of interestto declare.

REFERENCES1.Browner BD, editor. Skeletal trauma: basic science, management,and reconstruction/ ; [getfull access and more at ExpertConsult.com]. 5. ed. Philadelphia, Pa:Elsevier, Saunders; 2015.2. Covey DC. Injuries of the posterolateral corner of the knee. J BoneJoint Surg Am. 2001 Jan;83-A(1):106–18.3. Veltri DM, Warren RF. Anatomy, biomechanics, and physicalfindings in posterolateral knee instability. Clin Sports Med. 1994

Jul;13(3):599–614.4. Chanasit P, Sa-Ngasoongsong P, Chanplakorn P, Jaovisidha S,Suphachatwong C, Wajanavisit W. Anteromedial Marginal Fractureof Medial Tibial Plateau without Significant Knee Ligamentous Injuryin Hypermobility Patient: a Case Report and Review of Literature.Orthop Rev. 2013 Jun 7;5(2):56–8.5. van Dreumel RLM, van Wunnik BPW, Janssen L, Simons PCG,Janzing HMJ. Mid- to long-term functional outcome after openreduction and internal fixation of tibial plateau fractures. Injury. 2015Aug;46(8):1608–12.6.Cohen AP, King D, Gibbon AJ. Impingement fracture of theanteromedial tibial margin: a radiographic sign of combinedposterolateral complex and posterior cruciate ligament disruption.Skeletal Radiol. 2001 Feb;30(2):114–6.7. Chiba T, Sugita T, Onuma M, Kawamata T, Umehara J. Injuries tothe posterolateral aspect of the knee accompanied by compressionfracture of the anterior part of the medial tibial plateau. Arthrosc JArthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int ArthroscAssoc. 2001 Jul;17(6):642–7.8. Bennett DL, George MJ, El-KhouryGY, Stanley MD, Sundaram M. Anterior rim tibial plateau fracturesand posterolateral corner knee injury. Emerg Radiol. 2003Oct;10(2):76–83.9. Engelsohn E, Umans H, Difelice GS. Marginal fractures of themedial tibial plateau:possible association with medial meniscal root tear. Skeletal Radiol.2007 Jan;36(1):73–6.10. Yoo JH, Kim EH, Yim SJ, Lee BI. A case of compression fractureof medial tibial plateau and medial femoral condyle combined withposterior cruciate ligament and posterolateral corner injury. TheKnee. 2009 Jan;16(1):83–6.11. DeLee JC, Riley MB, Rockwood CA. Acute posterolateral rotatoryinstability of the knee. Am J Sports Med. 1983 Aug;11(4):199–207.12. Baker CL, Norwood LA, Hughston JC. Acute posterolateralrotatory instability of the knee. J Bone Joint Surg Am. 1983Jun;65(5):614–8.13. Kakarlapudi TK, Bickerstaff DR. Knee instability: isolated andcomplex. Br J SportsMed. 2000 Oct;34(5):395–400.14. Shepherd L, Abdollahi K, Lee J, Vangsness CT. The prevalence ofsoft tissue injuries in nonoperative tibial plateau fractures asdetermined by magnetic resonance imaging. J Orthop Trauma. 2002Oct;16(9):628–31.15. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCosterTA, et al. Fracture and dislocation classification compendium - 2007:Orthopaedic Trauma Association classification, database and outcomescommittee. J Orthop Trauma. 2007 Dec;21(10Suppl):S1–133.16. Yao Y, Lv H, Zan J, Li J, Zhu N, Jing J. Functional outcomes ofbicondylar tibial plateau fractures treated with dual buttress platesand risk factors: a case series. Injury. 2014 Dec;45(12):1980–4.


A NOVEL MODIFIED TRANSFORAMINAL LUMBAR INTERBODY

FUSION TECHNIQUE TO DECREASE THE INCIDENCE OF SEVERE

INTRACTABLE POST OPERATIVE REDICULOPATHY:A PROSPECTIVE

ANALYSIS OF 216 PATIENTS.Dr. M. Subbiah

Velammal Medical College Hospital and Research Institute, Madurai

TNOA PROF. M. RAMANATHAN MEDAL

ABSTRACTObjectives:To identify the incidence of severe post-operative radiculopathy on the side ofcage insertion affecting early postoperative recovery following modifiedtransforaminal lumbar interbody fusion(TLIF) with a bullet cage.Materials&Methods:A prospective analysis of 216 patients who underwent modified-TLIF(Hemi-TLIF)was done. Inferior facet of cranial vertebra alone was osteotomized for cageinsertion while superior facet of caudal vertebra was retained to protect exitingnerve root. The incidence of severe radiculopathy in post-operative periodaffecting early recovery was assessed by VAS.Results:Of the 216 patients, severe postoperative radiculopathy on the side of cageinsertion was observed only in 3 patients(1.4%) with a VAS score of 10 who neededprolonged hospitalization for its recovery. L3-L4 was the fused level in them whilenone of those in L4-5 and L5-S1 group had similar radiculopathy.Discussion:The reported incidence of severe postoperative intractable radiculopathyfollowing PLIF&TLIF procedure is between 7-10% necessitating furthertreatment. Excessive medial dural retraction in PLIF and injury to nerve rootduring cage insertion in TLIF results in battered root syndrome. Our modified-TLIF approach decreases its incidence by providing adequate space for cageinsertion without excessive dural retraction in addition to protecting injury toexiting nerve root by the retained superior facet.Conclusion:Lumbar interbody fusion by modified-TLIF(Hemi-TLIF) approach involvingexcision of inferior facet alone significantly decreases the incidence of severepostoperative radiculopathy aiding early recovery. However, we recommed thisprocedure only for L4-5 and L5-S1 levels where the spinal canal is relatively largerwhen compared to higher lumbar levels.

INTRODUCTIONLumbar interbody fusion is a commonly

performed procedure for many disorders and addition ofpedicle screw instrumentation has been proven toimprove fusion rate by providing direct vertebralstability(1,2). Posterior lumbar interbody fusion(PLIF)and transforaminal lumbar interbody fusion(TLIF) arethe two common fusion techniques by posteriorapproach to avoid the complications of anterior lumbarinterbody fusion. Discectomy and fusion in PLIF isdone by retracting the dura through the laminectomy

defect without damaging facet joints while TLIFinvolves fusion without dural retraction by completeexcision of superior and inferior articular processesof facet joint. Of all potential complications ofPLIF and TLIF, persistent post-operative severeintractable radiculopathy due to “battered rootsyndrome” is reported in 7-14% of patients significantlyaffecting their early postoperative recoverynecessitating further treatment(3,4). Thispostoperative radiculitis is attributed to excessive


medial retraction of dural sheath and traversing nerveroot in PLIF and to exiting nerve root injury during cageinsertion in TLIF(5).

We analysed the incidence of severepostoperative radiculopathy on the side of cage insertionin lumbar interbody fusion using a single obliquePLIF cage instead of standard TLIF cage by modifiedTLIF approach(Hemi-TLIF) where in only the inferiorfacet of cranial vertebra was osteotomized unilaterallyretaining the superior facet of caudal vertebra to preventinjury to the exiting nerve root in addition to providingspace for cage insertion without excessive duralretraction.

MATERIALS AND METHODS216 patients who underwent lumbar interbody

fusion by modified TLIF approach using a singleoblique bullet cage were prospectively analysed. 142of them were males and the remaining 74 werefemales. The mean age of the patients was 52years(Range:24-76 years). The indications for surgerywere lumbar spondylolisthesis, degenerative discdisease, failed back surgery syndrome andspondylodiscitis. All these patients underwentsurgery as they were not responding to adequate trialof conservative management. Plain radiographs oflumbosacral spine and MRI were obtained in all patientspreoperatively.

Surgical procedureAll procedures were performed by a single

surgeon as follows. The patient was postioned prone ina spinal frame under general anaesthesia afteradequate padding of bony prominences. A standardposterior midline exposure of thelevels to be fusedwas done till the lateral border pars interarticularis onboth sides. Pedicle screws were inserted into thevertebral levels to be fused and rods fixed to the screwsbilaterally. Distraction was applied between the screwsto open up the disc space and nuts were tightened.

The interspinous ligament between the cranialand caudal laminae and the inferior half of the cranialspinous process was nibbled till its base where itmerges with the two laminae. The caudal edge of thesuperior lamina was removed with rongeurs till theattachment of ligamentum flavum to its anteriorsurface was visualized. The sagittally oriented lumbarfacet joint on the side of preoperative radicular pain wasexposed by excising the facet joint capsule. The inferiorarticular process of the cranial vertebra on that sidewas osteotomized with a narrow osteotome starting inthe midline at the level of junction between the twolaminae and base of spinous process and proceeding

laterally (Fig 1). The ligamentum flavum was retainedtill the osteotomy of inferior articular process wascompleted to prevent the inadvertent entry ofosteotome into spinal canal. Care was taken to preventinjury to the laterally placed superior articular process ofcaudal vertebra.

Fig 1: Line diagram of the technique of modified-TLIF

After excising the osteotomized inferior facet,the articular cartilage of the superior articularprocess and retained ligamentum flavum wereclearly visualized. The remaining attachment ofligamentum flavum was released from the upper borderof the caudal lamina and medial border of the retainedsuperior facet and removed to expose the dural sac andtraversing nerve root. The exitingnerve root above wasnow protected by the remaining upper half of craniallamina and the superior articular process of caudalvertebra. The medial edge of the superior articularprocess which overhangs into the spinal canal wasremoved with a Kerrison to expose the disc spacelateral to the dura. Discectomy was performed throughthis space between the dural sac and medial edge ofsuperior articular process without retracting thetraversing nerve root. Autografts from the excisedspinous process and inferior articular process waspacked into the disc space. A single PLIF cage packedwith local autografts was introduced obliquely into thedisc space with minimal retraction of dura only duringentry of cage into the disc space. It was directedobliquely to be postioned in such a way that it crossesthe midline in AP view. The retained cranial half of thesuperior lamina and the superior articular process of thecaudal vertebra prevent injury to the exiting nerve rootduring this stage of cage insertion. The contralateralnerve root was decompressed if necessary. Thepedicle screws were compressed and final tightening ofthe nuts were done. Wound was closed in layers over adrain.

The patients were made to sit up on the firstpostoperative day (POD) and mobilized with alumbosacral orthosis after drain removal on the secondPOD. Patients were evaluated for radicular pain in the


immediate postoperative period on the side of cageinsertion and when present the severity was assessedby VAS score for radicular pain. Patients wereevaluated at regular intervals at 4 weeks, 2 months, 4months, 6 months, 1 year and 2 years.

RESULTSThe mean age of patients was 52 years

(Range:24 to 76 years) and mean duration of follow upwas 26 months (Range: 18 to 36 months). 142 patientswere males and the remaining 74 were females. Theindications for fusion was lumbar spondylolisthesis inmajority of patients(n:149), while other indicationsincluded spondylodisciitis (n-41), failed back surgerysyndrome (n-19) and degenerative disc disease (n-7).

The mean operative time was 75 minutes andmean intraoperative blood loss was 150 ml. The meanduration of hospital stay was 6 days (Range:3-21 days).The commonest level fused was L4-5 (n-137) while L5-S1 was fused in 72 and L3-4 in 7 patients. Titaniumbullet cage was used as an interbody spacer in 174patients and poly-ether-ether-ketone (PEEK) cage wasused in 42 patients.

Severe radiculopathy on the side of cageinsertion was seen only in three patients in theimmediate post operative period. The VAS score forleg pain in these three patients was 10 and theyunderwent fusion at the level of L3-L4.They neededprolonged hospital stay for a period of 17-21 days.However, they responded well to conservativemanagement with steroids, opiods and NSAID’s andthey did not require resurgery for rootdecompression or rhizotomy procedures. Mildsensory disturbance in the form of paraesthesia wasobserved in 32 patients on the side of cageinsertion(VAS<3) which did not affect theirpostoperative mobilization protocol. Superficial woundinfection was observed in three patients who neededdebridement and secondary closure of the wound. Duraltear occurred in 9 patients of whom suturing was doneonly in 4. None of the patients with dural teardeveloped wound healing problems, postduralheadache or meningocele.

DISCUSSIONIn addition to maintaining the load bearing

capacity of spine, interbody fusion also aids inachieving sagittal spinal alignment and increases theavailable area of fusion bed to enhance arthrodesis(6).Cloward in 1940 performed the first PLIF (7) which waslater modified by Lin(8). TLIF procedure was pioneeredby Harms in 1998 for spondylolisthesis, scoliosis andpost-discectomy syndrome(9). The reported incidence

of complications following PLIF and TLIF is 36.4%including subsidence of cage, osteolysis, dural tear,intraoperative neurological injury etc (3).

Of these, the most disabling complication isintraoperative neurological injury resulting in “batteredroot syndrome” which is reported to occur in 7-10%of cases causing significant and severe post operativeradiculopathy(3,4). Moatz et al described this entity tobe placing patients at increased risk even when otherfactors are equal when comparing TLIF/PLIF withstandard PLF with instrumentation(3). Battered rootsyndrome was first described by Bertrand in 1975 as apermanent radiculopathy caused by a surgical trauma.He defined it as a reappearance of intractable radicularpain following the relief of sciatic pain by surgery with aconstant burning character. The proposed treatmentmodalities for this condition when not responding toconservative management include rhizotomy, spinalcord stimulation etc. Carragee et al reported acomplication rate of 10-50% including radiculitis,heterotopic ossification etc. associated with the use ofbone morhogenetic protein (BMP) in PLIF and TLIF,however they were not able to correlate post operativeleg pain and heterotopic ossification (10). Postoperativeradiculitis was reported in 14% of patients whounderwent TLIF with rhBMP-2(11). Humphreys et alattributed the need of greater retraction of dura for thehigh incidence of post operative radiculitis in patientsundergoing PLIF(5). Mehta et al. reported an increasedincidence of nerve root complicationsand durotomyfollowing PLIF and TLIF and concluded that PLIF/TLIF should be performed only when the goals ofsurgery cannot be accomplished by decompressionand traditional PLF(13).

Discectomy and interbody fusion in PLIF is doneby retracting the dural sheath till the midline orsometimes beyond to access the disc space withoutremoving the superior or inferior articular process of thefacet joint. This excessive retraction of dura mightresult in nerve root damage or severe post operativeneurogenic radicular pain on that side(14) . Interbodyfusion in TLIF is performed through far lateral aspect ofdisc space after removing the superior and inferiorarticular process of facet joint completely. Thiscomplete facet removal exposes the obliquelycoursing exiting nerve root above making it vulnerableto injury and post operative radiculopathy in TLIFoccurs due to occult injury to this exiting nerve root onthe far lateral aspect when cage is inserted.Postoperative radicular pain following TLIF wasreported to occur in 13.8% of patients by Burneikieneet al(15).


The posterior wall of the intervertebral foramenthrough which the spinal nerve root exits is formed bythe lower portion of the pars interarticularis of thelamina of the cranial vertebra superiorly and superiorarticular process of the caudal vertebra inferiorly (16).Our procedure of osteotomizing only the inferiorarticular process of cranial vertebra retaining the parsinterarticularis provided necessary space for cageinsertion without the need for excessive retraction ofdural sheath. In addition, retained superior articularprocess of caudal vertebra embraces the exiting nerveroot preventing it from getting injured duringinserting of cage. Hence, we propose that the problemssecondary to iatrogenic battered nerve root in PLIF andTLIF can be avoided by this technique of hemi-TLIFinvolving the resection of only the inferior articularprocess of the facet joint.

Persistent postoperative severe radiculopathydue to battered nerve root syndrome were reported in7-14% of patients affecting early postoperativerecovery which necessitated further treatmentpostoperatively to relieve pain(3,4,11,15).Postoperative severe radiculopathy in our series ofpatients was significantly less with an incidence of only1.4% (3/216 patients). These three cases who hadsevere postoperative radiculopathy in our study werefound to be at L3-L4 level with which we proposethis procedure to be suitable only for fusions involvingthe L4-L5 and L5-S1 levels where the spinal canal isrelatively larger than L3-L4 and higher lumbar levels.

CONCLUSIONLumbar interbody fusion by our modified-

TLIF(Hemi-TLIF) approach involving excision of theinferior facet of cranial vertebra alone providesadequate space for insertion of cage without the needfor excessive retraction of dura in addition to preventinginjury to exiting nerve root by the retained superior facetof caudal vertebra. This procedure significantlydecreased the incidence of severe post operativeradiculopathy and aids in early post operative recovery.However, we recommed this procedure only at L4-5and L5-S1 levels where the spinal canal is relativelylarger when compared to higher lumbar levels.

REFERENCES1.Hallett A, Huntley JS, Gibson JN. Foraminal stenosis andsingle-level degenerative disc disease: a randomized controlledtrial comparing decompression with decompression andinstrumented fusion. Spine (PhilaPa1976) 2007; 32:1375-80.2. France JC, Yaszemski MJ, Lauerman WC, et al. A randomizedprospective study of posterolateral lumbar fusion: outcomes withand without pedicle screw instrumentation. Spine (Phila Pa 1976)1999; 24:553-60.3. Moatz P, Tortolani PJ. Transforaminal lumbar interbody fusionand posterior lumbar interbody fusion utilizing BMP-2 in thetreatment of degenerative listhesis: Neither safe nor cost effective.Surg Neurol Int:2013;22;4:S-67-73.4. Chrastil J, Patel AA. Complications associated withposterior and transforaminal lumbar interbody fusion. J Am AcadOrthop Surg 2012;20:283-91.5. Humphreys SC, Hodges SD, Patwardhan AG et al (2001)Comparison of posterior and transforaminal approaches tolumbar interbody fusion. Spine 26:567–571.6. Voor MJ, Mehta S, Wang M et al (1998) Biomechanical evaluationof posterior and anterior lumbar interbody fusion techniques. JSpinal Dis 11:328–334.7. Cloward R (1953) The treatment of ruptured lumbar intervertebraldiscs by vertebral body fusion. J Neurosurg 10:154–168.8. Lin PM (1977) A technical modification of Cloward’s posteriorlumbar interbody fusion. Neurosurgery 1:118–124.9. Harms JG, Jeszenszky D. [Die posteriore, lumbale,interkorporelle Fusion in unilateraler transforaminaler Technik].Oper Orthop Traumatol 1998;10:90-102. German.10. Carragee EJ, Hurwitz EL, Weiner BK. A critical review ofrecombinant human bone morphogenetic protein-2 trials in spinalsurgery: Emerging safety concerns and lessons learned. Spine J2011;11:471-91.11. Rihn JA, Patel R, Makda J, Hong J, Anderson DG, Vaccaro AR,et al. Complications associated with single-level transforaminallumbar interbody fusion. Spine J 2009;9:623-9.12. Mehta VA et al. Trans-foraminal versus posterior lumbarinterbody fusion. Comparison of surgical morbidity. Neurol Res,2011;33(1):38-42.13. Deng-lu Yan, Fu-xing Pei, Jian Li, Cheng-long Soo.Comparative study of PILF and TLIF treatment in adultdegenerative spondylolisthesis. Eur Spine J (2008) 17:1311–1316.14. Lumbar degenerative spinal deformity: Surgical options of PLIF,TLIF and MI- TLIF Hwee Weng Dennis Hey, Hwan Tak Hee. IJO -April - June 2010 / Volume 44 / Issue 2.15. Burneikiene S et al. Complications in patients undergoingcombined transforaminal lumbar interbody fusion and posteriorinstrumentation with deformity correction for degenerativescoliosis and spinal stenosis. Surgical Neurology International2012, 3:25.16. Rema D, Rajagopalan N. Morphometry of lumbarintervertebral foramen. Indian J Orthop. 2005;39:3:145-147.


HOW EFFECTIVE IS PERIARTICULAR DRUG INFILTRATION IN

PROVIDING PAIN RELIEF FOLLOWING

TOTAL HIPARTHROPLASTY?

George M Srampickal, Pradeep M Poonnoose, Anil T Oommen, Korula M Jacob, K Vignesh PrasadDepartment of Orthopaedics, Unit 2, Christian Medical College, Vellore.

ABSTRACTIntroduction:While there is a lot of literature on the value of peri-articular injection in total kneereplacement, there is little discussion on its use in the control of pain after Total HipArthroplasty (THA).The aim of the study was to compare the efficacy of periarticularinfiltration of an analgesic cocktail of drugs and epidural infiltration in providingpostoperative pain relief and early functional improvement following (THA)Methodology:In a prospective trial, 30 patients undergoing unilateral THA were randomized toreceive either epidural infiltration with Bupivacaine and Fentanyl, or periarticularinfiltration of an analgesic cocktail of drugs for postoperative pain control. The outcomesstudied were pain levels as determined by the visual analogue scale (VAS), functionalrecovery and drug-related side effects.Results:Periarticular injection (PIA) resulted in significantly less VAS scores (mean VAS of0.67) as compared to epidural analgesia (EA) (mean VAS of 2.08) in the first 24 hoursafter surgery. Even after the first 24-48 hours, the pain scores were significantly lessin the PIA group than in the epidural group (1.13 vs1.92). This difference was lesspronounced by the 10th day (1 vs 1.8). Functional recovery was significantly better inthe periarticular injection group in the first 48 hours following surgery. The meanwalking distance on the first attempt to walk was 55m for those who received PIA, asopposed to 28.5m for those who received epidural. Functional improvementthereafterwas consistently better in the PIA group as compared to the epidural group – thoughthe difference was not statistically significant - number of days taken to climb 14 steps(5.07 vs 6.0 days), days taken to be able to walk 100 meters (4.53 Vs 5.62 days) andthe distance walked on the 10th postoperative day (151 Vs 132 meters).Periarticular injections resulted in significantly less side effects like nausea, vomiting,purities and urinary retention. The overall satisfaction rate with treatment wassignificantly better in those who received PIA (9.73/10) than those who received epiduralanesthesia for pain control (7.9/10).Conclusion:Periarticular injection with the analgesic cocktail of drugs provides significantly betterpain control and functional recovery in the first 24 hours following surgery, with lessdrug related side effects. Periarticular infiltration should be the choice method forpain control following total hip replacement.

Total Hip arthroplasty (THA) is one of the mostsuccessful surgical treatment that can be offered forpatients with end stage hip arthritis. More than fiftypercentage of the patients undergoing THA areexperiencing severe pain in the immediate post-operative period (1,2). Benefits associated with THA

can be tarnished due to significant post-operative pain,as a proportion of patients who are having sever post-operative pain will continue to have chronic pain (3,4) .Appropriate pain relief post operatively is necessary forearly recovery and good functional outcome (5). Eventhough a myriad of options are available for post-

TNOA SUB SPECIALITY MEDAL - ARHTROPLASTY


operative pain relief, the most widely used modality isEpidural Analgesia (EA)(6). EA, when compared withgeneral anesthesia, is associated with low intraoperativeblood loss, which shortens the duration of surgery andreduction in perioperative and post-operativetransfusion requirements and a low rate of Deep veinthrombosis(7) . The benefit of epidural analgesia mustbe weighed against its common adverse effects such asurinary retention, hypotension, pruritus, and motor blockthat delays mobilization (8,9). It is an invasive procedureand necessitates restricting the patient’s mobility till theepidural lines are removed Use of multimodal paincontrol with Periarticular Infiltration of Cocktail (PIC) isan alternative for EA. Multiple studies reported thatperiarticular infiltration using multimodal drugs canreduce the postoperative analgesia requirements andreduces the associated side effects (10,11). Wehypothesized that PIC lead to lower early post-operativepain, faster recovery, less opioid consumption and goodpatient satisfaction.

The purpose of the present study was to assessthe efficacy of periarticular infiltration of an analgesiccocktail, in terms of effective pain control and earlyrehabilitation following THR. This was done bycomparing the efficacy and complications with thecurrent method of postoperative pain control at ourinstitution i.e. epidural analgesia.

METHODOLOGYPatients undergoing unilateral uncemented total

hip replacement were recruited for the study. Theywere excluded if they were more than 80 years of age,if they had a history of arrhythmia/cardiaccomplications, if they were undergoing complexprimary or revision arthroplasty and if the opposite hipwas also extremely painful. Ethic approval was soughtfrom the Research Ethics Committee of the institutionprior to the study.

Patients were randomized into two arms by blockrandomization. In one arm, the patients received epiduralanalgesia with 0.1% Bupivacaine and 2mcg/ml ofFentanyl at 4-6ml per hour for 48 hours postoperatively,and in the other, they received periarticular infiltration ofan analgesic cocktail of drugs. The analgesic cocktailconsisted of 50ml of 0.2% Ropivacaine, 10ml Normalsaline, 40mg Depomedrol (Methylprednisolone acetate),10mg Morphine, 30mg Ketorolac, and 1gm Cefazolin.The cocktail was injected into capsule and gluteusminimus- especially around the inferior capsule, andaround the rim of the acetabulum before the femoralstem was inserted. Following reduction of the femoralhead, the gluteus medius, gluteus maximus, tensor fascialata and iliotibial band were injected sequentially.

All patients had perioperative analgesia withother drugs which included Tab. Aceclofenac 100mgtwice daily, Cap. Omeprazole 20mg twice daily, Cap.Pregabalin 75mg twice daily - all started 36 hours beforethe surgery and postoperatively with Inj. Paracetamol(Perfalgan) 1gm IV once every 6 hours for 48 hoursfollowed by Tab. Paracetamol 1gm once every 6 hoursfor 7days. Injection Morphine 5mg (subcutaneous) wasgiven as required for breakthrough pain in the immediatepostoperative period. Those on epidural infusion hadeither bolus doses or an increase in the infusion rate forbreakthrough pain. Intravenous Ondansetron was usedfor postoperative nausea and vomiting.

Surgery was performed under generalanesthesia/ spinal anesthesia using a modified Hardingeanterolateral approach in the lateral position. Prosthesesused were Corail Pinnacle of DePuy Synthes JointReconstruction System and R3cup and Polar/Synergystem of Smith & Nephew. The implants were alluncemented. A closed suction drain was placed underthe iliotibial band before wound closure and removed 48hours later. Tranexamic acid (10-15mg/kg) wasinjectedintravenously 15 minutes before skin incision, and top updoses were given 3 and 6 hours later. Anticoagulationwas initiated postoperatively as per institutionalguidelines.

Patients underwent a standard physiotherapyprogramme that involved foot pump exercises in bedand sitting on the day of surgery. They were encouragedto walk from the second postoperative day with the aidof a walker. The number of days taken to walk 100meters and to climb a flight of 14 steps wasdocumented. The distance walked in 6 minutes with awalker was recorded on the 10th postoperative day.

Pain experienced by the patient postoperativelywas assessed using the Visual Analogue Scale by theprimary investigator on a daily basis. It was also notedevery 4 hours by the hospital pain team for the first 72hours. The maximum VAS score for each day wasnoted.Additional medication used for breakthrough painwas noted.

Side effects like nausea, vomiting, pruritis,headache, urinary retention, cardiovascularcomplications, infection/ postoperative wound ooze,ICU stay, nerve palsy, and mortality were noted.

Statistics: The scores were screened for outlinersand extreme values using Box-Cox plot and histogram(for shape of the distribution).Summery statics wasused to report demographic and clinical characteristics.Mann-Whitney U test was done with non –Normaldistribution with Group (Epidural and Cocktail).Chi-square test was performed for categorical variables andGroup (Epidural and Cocktail). Differences were


considered significant when p<0.05.All statisticalanalysis was performed using SPSS 16.0

RESULTSDuring the period of study, we performed 43

primary THAs. 34 patients satisfied inclusion criteriawere randomized for the study. Four patients who wererandomized for EA was excluded from the studybecause of failure to get an epidural access. 30 patientswere recruited for the study, of which 15 wererandomized to receive the periarticular infiltrationcocktail (PAI) and 15 received epidural analgesia (EA).Patient demographic data is summarized in Table 1.

Periarticular injection (PIA) resulted insignificantly less VAS scores (mean VAS of 0.67) ascompared to epidural analgesia (EA) (mean VAS of2.08) in the first 24 hours after surgery (p<0.001). Evenafter the first 24-48 hours, the pain scores weresignificantly less in the PIA group than in the epiduralgroup (1.13 vs1.92 on the fourth day) (p<0.001). hisdifference was less pronounced by the 10th day (1 vs1.8) (p<0.001). (Fig 1)

Figure 1: Postoperative VAS scores

Functional recovery was significantly better inthe periarticular injection group in the first 48 hoursfollowing surgery. The mean walking distance on thefirst attempt to walk was 55m for those who receivedPIA, as opposed to 28.5m for those who receivedepidural (p=.05).. Functional improvement thereafterwas consistently better in the PIA group as compared tothe epidural group – though the difference was notstatistically significant - number of days taken to climb14 steps (5.07 vs 6.0 days), days taken to be able towalk 100 meters (4.53 Vs 5.62 days) and the distancewalked on the 10th postoperative day (151 Vs 132meters) (Table 3).

In the EI group, one patient had urinary retentionthat needed catheterization, two patients had multipleepisodes of vomiting and one patient had bilateral lowerlimb paresthesia. Two patient required top up ofepidural infusion and one required extra morphineinjection. None of the patients in the PIA group hadsimilar complications. The overall satisfaction rate with


treatment was significantly better in those whoreceived PIA (9.73/10) than those who receivedepidural anesthesia for pain control (7.9/10).

DISCUSSIONFear of postoperative pain often deters patients

from seeking arthroplasty surgery. In additionpostoperative pain has a profound influence on therecovery of function, and it is the leading cause ofdelayed discharge from the hospital (12). One of thekey prerequisites for accelerated recovery anddecreased morbidity following THA is optimized painrelief following surgery – that allows early postoperativemobilization (13). Most often, patients are given painmedications well after the onset of symptoms. It is nowwell known that continuous, around-the-clockadministration of pain medications is far more effectiveat alleviating pain than the standard analgesic ondemand protocol (14). The ideal modality of pain reliefis the one that is administered preoperative,perioperative, and in the postoperative period todecreasing sensitization of pain pathways caused bysurgical trauma (15). The pathophysiology of pain iscomplex and involves multiple peripheral and centralnociceptors and neuropeptides (16).

Many surgeons exclusively rely on opioidanalgesia, for postoperative pain control that targets onlyone aspect of the pain perception. However, manypatients encounter side effects of opioid analgesia likedrowsiness, postoperative nausea and vomiting,respiratory depression, urine retention and boweldysfunction (16,17). A better knowledge of thecomplexity of pain perception has led to thedevelopment of multimodal anesthesia, which targetsadditional aspects of pain perception not addressed bynarcotic medications (16).

The combination of different analgesics withsynergistic effects helps to reduce the use of opioidanalgesics and to allow early mobilization (18). Severaltechniques such as patient controlled analgesia, femoralnerve blocks, epidural analgesia and periarticularinjection of medications have been reported. Whilethere has been a lot of interest in pain after kneereplacement, there is little discussion on its use in hipreplacement.

In this study, we have studied the efficacy ofperiarticular infiltration of a cocktail of drugs incontrolling pain and enabling early functional recovery.The study shows that the periarticular infiltration issignificantly better than the epidural injection - especiallyin the first 24 hours after the surgery. Even after thefirst 24-48 hours, when we would expect the analgesiceffect of the injection to wear out, the pain scores were

consistently less in the PAI group than in theepiduralgroup. Functional ability in the first 24 hours wasalso significantly better in the PAI group. An additionaladvantage of the PAI over the EA is the reducedincidence of side effects like nausea, vomiting andpruritis. Additionally, mobilization is easier, as there areno catheters restricting the patient. The level ofanalgesia was significantly better for the remaininghospital stay as well. Ear ly functional recovery waspossible with PAI, though both groups were able to climb14 steps by the 5th postoperative day. The reason forthe prolonged beneficial effect of the PAI has not beenfully explained by other investigators. Several theorieshave been postulated. It is possible that due to the goodreduction in pain in the immediate postoperative period,the neural sensitization is minimized. The steroid in thecocktail could also have a role in reducing theinflammatory pain postoperatively. In both groups,adequate control of pain provided the patient anopportunity to participate in the physiotherapyprogramme at an early stage and attain functionalindependence within 4- 5 days.

There are multiple studies comparing theoutcome following EA and Local infiltration of analgesicwith conflicting results (10,11,19,20). Parvataneni HKet al in their prospective randomized study comparedthe effectiveness of periarticular injections with patient-controlled analgesia. The periarticular injections groupdemonstrated significantly lower average pain scoresand higher overall satisfaction than the patient-controlled analgesia. They concluded periarticularinjection with a multimodal protocol is safe and providedexcellent pain control and functional recovery and thatperiarticular injection can substitute for conventionalpain control modalities (10). Kerr and Kohan reportedlocal infiltration analgesia with a mixture of ropivacaine,ketorolac, and adrenaline into the tissues around thesurgical field is a simple, practical, safe, and effectivefor pain management after knee and hip surgery(21).

Jules Elysee et al conducted a similar study in 84patients in a randomized study, with one arm receivingepidural analgesia, and the other arm receiving pericapsularinjections. While the side effects were more with the epiduralgroup, the pain score and functional improvement followingsurgery and time to discharge were not better in the PAIgroup. In fact the opioid consumption was more in the PIAgroup (22). Hofstad and colleagues after their placebocontrolled randomized double blinded trail concluded thatlocal infiltration analgesic with ropivacaine did not provideany extra analgesic effect after THA over and above thatfrom t hemultimodal analgesic regimen(23). Solovyova etal found that periarticular injection did not do any betterthan continuous infusion of saline in terms of pain control


(24). These findings are in contrast to our study.Other studies showed similar results to

our study. Pandazi et al showed that periarticularinfiltration was clearly superior to PCA with morphineafter THA, providing better pain relief and lower opioidconsumption postoperatively (25). Kuchalik et al whilecomparing PAI with intrathecal morphine, found thatlower pain scores was recorded early after surgery inintrathecal group but later, analgesic consumption, painon mobilization, and side-effects were lower in patientsreceiving PIA (26). They concluded that PIA is a betteroption for pain control in patients undergoing THA. Tocounter Solovyova’s results, Murphy et al conducted arandomized study with PAI and placebo for paincontrol, and demonstrated that periarticular injectioncan supplement available postoperative analgesictechniques and reduce postoperative morphinerequirements after THA (27).

CONCLUSIONBoth epidural analgesia and periarticular

infiltration of the analgesic cocktail are effective incontrolling pain after total hip replacement. Periarticularinfiltration provides significantly better pain control forthe first 10 days after surgery. Functional recovery inthe first 48 hours following surgery is significantly betterwith the use of periarticular injection. By the 5thpostoperative day, functional independence is similar inboth groups. Side effects like nausea, vomiting andurinary retention are also less with periarticularinfiltration of the analgesic cocktail. Overall satisfactionwith treatment is significantly better in those whoreceive a periarticular injection. We, therefore concludethat periarticular injection of a cocktail of drugs is moreeffective than epidural analgesia and should be thechoice method for analgesia following total hipreplacement.

REFERENCES1. Follin SL, Charland SL. Acute pain management: operative ormedical procedures and trauma. Ann Pharmacother. 1997Sep;31(9):1068–76.2. Filos KS, Lehmann KA. Current concepts and practice inpostoperative pain management:need for a change? Eur Surg ResEur Chir Forsch Rech Chir Eur. 1999;31(2):97–107.3. Williams O, Fitzpatrick R, Hajat S, Reeves BC, Stimpson A, MorrisRW, et al. Mortality, morbidity, and 1-year outcomes of primaryelective total hip arthroplasty. J Arthroplasty.2002 Feb;17(2):165–71.4. Nikolajsen L, Brandsborg B, Lucht U, Jensen TS, Kehlet H.Chronic pain following total hip arthroplasty: a nationwidequestionnaire study. Acta Anaesthesiol Scand. 2006Apr;50(4):495–500.5. Fischer HBJ, Simanski CJP. A procedure-specific systematicreview and consensus recommendations for analgesia aftertotal hip replacement. Anaesthesia. 2005Dec;60(12):1189–202.

6. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J,d’Athis F. Effects of perioperative analgesic technique on the surgicaloutcome and duration of rehabilitation after major knee surgery.Anesthesiology. 1999 Jul;91(1):8–15.7. Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxialblock versus general anesthesia for elective total hip replacement:a meta-analysis. Anesth Analg. 2006Oct;103(4):1018–25.8. Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia forpain relief following hip or knee replacement. Cochrane DatabaseSyst Rev. 2003;(3):CD003071.9. Wheatley RG, Schug SA, Watson D. Safety and efficacy of postoperativeepidural analgesia. Br J Anaesth. 2001 Jul;87(1):47–61.10.Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, RanawatCS. Controlling pain after total hip and knee arthroplasty using amultimodal protocol with local periarticular injections: a prospectiverandomized study. J Arthroplasty. 2007 Sep;22(6 Suppl 2):33–8.11. Busch CA, Whitehouse MR, Shore BJ, MacDonald SJ, McCaldenRW, Bourne RB. The efficacy of periarticular multimodal druginfiltration in total hip arthroplasty. Clin Orthop. 2010Aug;468(8):2152–9.12. Horlocker TT, Kopp SL, Pagnano MW, Hebl JR. Analgesiafor total hip and knee arthroplasty: a multimodal pathwayfeaturing peripheral nerve block. J Am Acad Orthop Surg. 2006Mar;14(3):126–35.13. Kehlet H, Wilmore DW. Evidence-based surgical care and theevolution of fast-track surgery. Ann Surg. 2008 Aug;248(2):189–98.14. Skinner HB, Shintani EY. Results of a multimodal analgesic trialinvolving patients with total hip or total knee arthroplasty. Am JOrthop Belle Mead NJ. 2004 Feb;33(2):85–92; discussion 92.15. Badner NH, Bourne RB, Rorabeck CH, MacDonald SJ, DoyleJA. Intra-articular injection of bupivacaine in knee-replacementoperations. Results of use for analgesia and for preemptive blockade.J Bone Joint Surg Am. 1996 May;78(5):734–8.16. Dahl V, RÆder JC. Non-opioid postoperative analgesia. ActaAnaesthesiol Scand. 2000 Nov 1;44(10):1191–203.17.Kehlet H, Rung GW, Callesen T. Postoperative opioid analgesia:time for a reconsideration? J Clin Anesth. 1996 Sep;8(6):441–5.18.Kehlet H, Dahl JB. The value of “multimodal” or “balancedanalgesia” in postoperative pain treatment. Anesth Analg. 1993Nov;77(5):1048–56.19. Dobie I, Bennett D, Spence DJ, Murray JM, Beverland DE.Periarticular local anesthesia does not improve pain or mobilityafter THA. Clin Orthop. 2012 Jul;470(7):1958–65.20. Lunn TH,Husted H, Solgaard S, Kristensen BB, Otte KS, Kjersgaard AG,et al.20. Lunn TH, Husted H, Solgaard S, Kristensen BB, Otte KS,Kjersgaard AG, et al. ntraoperative local infiltration analgesia forearly analgesia after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med. 2011Oct;36(5):424–9.21.Kerr DR, Kohan L. Local infiltration analgesia: a techniquefor the control of acute postoperative pain following knee and hipsurgery: A case study of 325 patients. Acta Orthop. 2008 Jan1;79(2):174–83.22.Jules-Elysee KM, Goon AK, Westrich GH etal. Patient-controlled epidural analgesia or multimodal pain regimen withperiarticular injection after total hip arthroplasty: a randomized,double-blind, placebo-controlled study JBJS A 2015 May20;97(10):789-98.23. Hofstad JK, Winther SB, Rian T, Foss OA, Husby OS, WikTS. Perioperative local infiltration anesthesia with ropivacaine hasno effect on postoperative pain after total hip arthroplasty. ActaOrthop. 2015 Nov;86(6):654–8.


24. Solovyova O1, Lewis CG, Abrams JH Local infiltrationanalgesia followed by continuous infusion of local anesthetic solutionfor total hiparthroplasty: a prospective, randomized,double-blind, placebo-controlled study.JBJS 2013 Nov6;95(21):1935-41.25. Pandazi A, Kanellopoulos I, Kalimeris K et al. Periarticularinfiltration for pain relief after total hip arthroplasty: a comparisonwith epidural and PCA analgesia.Arch Orthop Trauma Surg. 2013Nov;133(11):1607-12

26. Kuchálik J, Granath B, Ljunggren A et al Postoperativepain relief after total hip arthroplasty: a randomized, double-blind comparison between intrathecal morphine and localinfiltration analgesia. Br J Anaesth. 2013 Nov;111(5):793-927. Murphy TP, Byrne DP, Curtin P, Baker JF, MulhallKJ. Can a periarticular levobupivacaine injection reducepostoperative opiate consumption during primary hip arthroplasty?Clin Orthop Relat Res. 2012 Apr;470(4):1151-7


TALUS NECK FRACTURE WITH BIMALLEOLAR FRACTURE

A RARE CASE REPORT

Dr. Jagadish Laxmansa Katwa, Dr. M. Ravikumar, Dr. D. Dhanalakshmi,Dr. V. Kannan, Dr. T.E. Ramesh,

Department of Orthopaedic Surgery, Southern Railways head Quarter Hospital, Chennai

ABSTRACT:Talus fractures are infrequent injuries, being second most common tarsal bonesfracture after calcaneal fractures. These injuries are significant because of severity ofthe complications and long-term disability which include AVN of talus body, non-union,malunion, skin complications and arthritis. Only 5 cases of talus neck fracture withbimalleolar fracture seems have been reported previously in literature. Despite highincidence of osteonecrosis of talus in Hawkins type 3 talar neck fracture none of thesecases developed this complication possible explanation being preservation ofextraosseous vascular supply of talus that accompanies the deltoid and talofibularligamentous complexes.

INTRODUCTIONOnly 2% of all lower extremity injuries and 5%-

7% of foot injuries involve fracture of talus2. Talus issecond most commonly fractured tarsal bone aftercalcaneus3. Fracture and dislocations of talus areinfrequently encountered injuries; but are challenginginjuries. So also, scarce evidence is available in theliterature on these fractures and its management.Overall talus neck fracture account for 50% of theseinjuries. Many controversies surround the treatment oftalus neck fracture which reflects the difficulty ofassessme nt, surgical approach, fixation method andfrequency of post-op complications3

Management of fracture talus depends entirelyupon whether or not fracture is displaced and sothorough assessment is essential in its management.Also, talus is unique in having no muscular attachment;60 % of its surface is covered by articular cartilage andis an integral component of the ankle joint and has beenwell known for its precarious blood supply. Outcomemay be poor with disability due to non-union,development of avascular necrosis and osteoarthritis.Talus neck fracture are commonly the result of hyper-dorsiflexion injuries and are often secondary to highenergy trauma, often associated with other injuries andcommonly present with foot and ankle swelling anddeformity. Anderson et al described the “Aviatorsastragalus” which were talar neck fractures commonlyseen in pilots during the World War 1 as a result of hyperdorsiflexion injury at the time of landing. Coltart et al,

reviewed 25,000 fractures sustained during World WarII and found 228 talar fractures, 106were classified astalar neck. They reported osteonecrosis rate of 35%with subtalar dislocation and 95% with ankle andsubtalar dislocation.4

The appropriate diagnosis and treatment of thesefractures play an important role in the patient’s outcome.Treatment has evolved slowly throughout the years,from closed treatment to open reduction and internalfixation (ORIF)4

The option of closed reduction versus ORIF isdependent upon the degree of injury, surgeonexperience, and preference. The frequent incidence ofserious complications of skin dehiscence, non-union,osteonecrosis, neurovascular injuries, pain, stiffnessand post traumatic arthritis of the subtalar and theankle joint, leads to high risk of unsatisfactory results.Still, the talus fracture remain among the mostinteresting and difficult injuries in orthopaedic trauma2,4.

CASE REPORT:Male patient aged 27 who had history of fall from

5 feet height, sustained left ankle injury, came with painand deformity of left ankle. On examination left ankledeformity found, without external wounds and distalneurovascular deficits. X ray shows Vertical fractureof medial malleolus and oblique fracture of lateralmalleolus with talus neck fracture with dislocation ofankle and subtalar joint. Since its supination adduction

TRAUMA


type of ankle injury; Immediate closed reduction doneby traction and exaggeration of the deformity followedby pronation and abduction. Reduction done found to beunstable hence temporary BK splint applied.

Figure 1: AP and Lateral X rays at the time ofpresentation

Figure 2: AP and lateral X rays after emergencyclosed reduction

Patient was taken for surgery after 19 hours of injuryfor ORIF with cannulated screws. Through Antero-medial and antero-lateral approaches fracture siteexposed and reduced fracture with k wires as joystickto maintain length and alignment. Provisionally fixedwith k wires, definitive fixation by partial threadedcannulated screws. Lateral incision taken for lateralmalleolus fracture fixed with partial threaded cannulatedscrew. For medial malleolus Antero-medial incisionextended proximally and fixed with 2 partial threadedcannulated screws perpendicular to fracture.

Figure 3: Intra operative pictures reduction of fracture

Figure 4: Intra operative pictures following fixation

Figure 5: AP and Lateral X rays of immediate post op

Post operatively patient was on below knee slab for4 weeks, Range of motion exercises of ankle from 5thweek onwards with Non weight bearing walking. Fullweight bearing walking started on 3th month when uniontalus neck fracture confirmed by radiologic examination.

Figure 6: 1 month post op X rays

Figure 7: 1 year post op X rays


Figure 8: Hawkins sign at 6th week

RESULTSRadiological union of medial and lateral malleoli

confirmed at 2 months and of talus neck fractureconfirmed at 3rd month. Hawkins sign was evident on6th week. On 1 year follow up no evidence AVN oftalus. Dorsiflexion of 20 degrees, plantar flexion of 30degrees and 5 degrees of inversion eversion movementsat subtalar joint. Patient was walking comfortablywithout pain and he has returned to his previousoccupation. AOFA score was 92 % excellent functionaloutcome.

DISCUSSIONA case reported here is very rare case. In

literature Only 5 cases has been reported. Mechanismof injury: Combined fracture of the ankle and talus is anuncommon fracture pattern. The only other report of thistype of fracture in the literature was published byMontane I, Zych GA1. The accepted mechanism forisolated talus neck fracture is hyperdorsiflexion of ankle.

Forced supination of the foot can also create atalar neck fracture5. Based on the work by Lauge-Hansen8 the classic description of a supination-adduction injury is a vertical split fracture of the medialmalleolus with a fracture below the level of thesyndesmosis. The supination adduction mechanismdescribed by Lauge-Hansen involved two stages. Thefirst stage begins with failure of the lateral malleolus orlateral ligaments. The second stage is a vertical fractureof the medial malleolus, which may also involve someimpaction of the joint surface on the medial aspect of thetibial plafond8. We propose that this fracture results ascombination of supination-adduction injury along withhyperdorsiflexion.

Therefore, this injury occurs through a supination-adduction-hyperdorsiflexion force.Routine radiographsof the ankle, consisting of antero-posterior, mortise, and

lateral plain radiographs, are used to identify fracturesand displacement of the talar neck. The special obliqueview of the talar neck described by Canale and Kellyprovides the best evaluation of talar neck angulation andshortening, which is not easily appreciated on routineradiographs6. This radiograph is made by placing theankle into maximum equinus and pronating the foot 15°while the x-ray tube is angled 75° from the horizontalplane. Preoperatively, CT scans are useful forassessing comminution and displacement of thefractures, as well as providing accurate images of theankle, subtalar, and transverse tarsal joints.

Figure 9: Canale’s view

It remains controversial whether talar neckfractures require emergent treatment. The time ofdefinitive fixation always depends on multiplefactors, including fracture comminution, soft tissueconditions, available resources, surgeon experience andcomfort level, and medical status of the patient. Inseveral clinical studies, the timing of internal fixation didnot have a significant effect on the rate of avascularnecrosis or the functional outcome6,9.

Based on this presumed mechanism of failure,we planned our choice of fixation. The patient presentedwith a vertical fracture through the medial malleolus;therefore, this fracture pattern may be treated with twotransverse lag screws or an anti-glide plate placed atthe apex of the fracture with the possible addition of lagscrews across the fracture through the distal holes ofthe plate or in combination of transverse lag screwswith an anti-glide plate or to insert screws directedproximally from the tip of the medial malleolus7.Astudyin 2008 compared two screws to a plate and theinvestigators found the plate construct had asignificant mechanical advantage compared to the twoscrews. In the other case report of a bimalleolar anklefracture with a talar body fracture, the investigatorschose to treat the vertical medial malleolus fracture withone screw inserted at the tip of the medial malleolus


directed proximally and neutralization plate on the distalfibula10.

Most surgeons recommend the use of dualsurgical approaches, anteromedial and anterolateral, toallow accurate visualization and anatomic reduction oftalar neck fractures6. The anteromedial approachbegins at the anterior border of the medial malleolus andextends toward the navicular tuberosity, just betweenthe anterior tibial and posterior tibial tendons. Laterally,the incision begins at the Chaput tubercle on the tibiaand extends toward the bases of the third and fourthmetatarsals. It is important to carefully preserve anyremaining talar blood supply, regardless of theapproaches.The goal of talar neck fracture treatment isanatomic reduction of both the neck and subtalar joint,because even minimal residual displacement canadversely affect subtalar joint mechanics6.Misalignment of the talar neck after surgical repair canredistribute the load among the posterior, middle, andanterior facets of the subtalar joints, which can changethe joint biomechanics, cause arthritis, and impairfunction11. It is important to avoid reducing the talarneck fragment in supination, pronation, or axialmalalignment because rotational alignment is verydifficult to judge, dual approaches are usually required.Provisional K-wires may be placed in the talar body andtalar head fragment to serve as a joystick to correct thedisplacement and deformity. This technique avoids theuse of a pointed reduction clamp that may require alarger exposure and cause more vascular compromise

To achieve stable internal fixation and decreasethe rate of malunion, at least 2 screws are required.Numerous types of screws have been described fortalar neck fracture fixation, but titanium screws havethe advantage of compatibility with MRI, allowing earlydetection of osteonecrosis. Bioabsorbable screws havesome theoretical advantages, in that they can be placedthrough the articular surface and resorb over time6.

Most authors12,6 prefer to place screws fromanterior to posterior because the fracture site is routinelyexposed from an anterior approach. However, Swansonet al 14 compared the biomechanical strengths of variousfixation methods in a transverse, noncomminuted talarneck fracture model, and concluded that posterior-to-anterior screw fixation was stronger13. Posterior-to-anterior screw fixation has potential disadvantages,including requiring an additional posterior approach withpotential injury to the peroneal artery and its branchesand screw head prominence that can limit ankle plantarflexion. Furthermore, if a posteroanterior screw issituated in the lower half of the head, the shaft of thescrew protrudes into the roof of the sinus or canal tarsi,and can injure the canal tarsi artery6. Attiah et al15

studied different screw configurations in a comminutedtalar neck fracture model. They compared 3anteroposterior screws, 2 cannulated posteroanteriorscrews, 1 screw from anterior to posterior, and amedially applied blade plate. They concluded that theanteroposterior screws had approximately 20% loweryield point and stiffness compared to theposteroanterior screws or blade plate techniques, butthis difference was not statistically significant.

Lag screws are typically used to compress talarneck fractures to withstand early motion which, isbeneficial for ankle and subtalar joint function.However, when there is comminution of the talar neck,especially the medial column the use of a lag screwmaybe contraindicated, as it will cause deformity andmalunion. Transfixion screws are used to avoidcompression and maintain the correct length of thetalus 6. Bone grafting is occasionally needed to replaceareas of impaction defects to restore the neck length.

For comminuted talar neck fractures, manyauthors have advocated plate fixation with or withoutneutralization screw fixation 6,16. By providing a solidbuttress as a bridging strut, plates can be placed on themost comminuted column of the talus, either medial,lateral, or bilateral columns. Plate sizes used range from2 to 2.7 mm. Plates not only provide longitudinalstructural support, but also prevent supination orpronation of the distal fragment. Charlson et al17.compared posteroanterior screw fixation and platefixation incomminuted talar neck fractures, and foundthat while plate fixation may offer substantialadvantages in the ability to control the anatomicalignment, it does not provide any biomechanicaladvantage compared with screw fixation.Intraoperative fluoroscopy is a valuable tool to assessthe reduction accuracy and implant position.

Avascular necrosis of the talar body, resultingfrom interruption of the precarious vascular supply tothe talus, is the most dreaded late complication aftertalar neck fractures. The risk of developing avascularnecrosis in a Hawkins type I fracture is only 0% to 15%,since only the blood supply entering through the neck isdisrupted. Hawkins type II fractures have a 20% to 50%risk of avascular necrosis, with the artery of the tarsalcanal and the dorsal blood supply from the neck beingdisrupted. Type III and IV fractures have a 69% to 100%risk of avascular necrosis, with all 3 main sources ofblood supply damaged6. Greater displacement,comminution, and open fractures could increase thelikelihood of developing avascular necrosis. Whethercollapse of the talar dome is partial or full, thesubsequent degenerative changes lead to pain anddisability in both the ankle and subtalar joints, along with


shortening of the affected leg6.Due to the high incidence of osteonecrosis with

talar neck fractures, the patient was closely monitoredfor the presence of a Hawkin’s sign on follow-upradiographs during the postoperative follow up. Theradiolucent band results from an increase in bonereabsorption relative to bone formation, and it manifestswith active hyperemia of the bone. Therefore, for thislinear subchondral area of hyperlucency to be seen, thebone must have a preserved blood supply Hawkins signwas evident on 6th week postoperative radiographs.The patient in this case presented with Hawkin’s type 3talus neck fracture with bimalleolar fracture andpostoperatively had a positive Hawkin’s sign; we canmost likely conclude that he had very minimal disruptionto the blood supply of the talus. Based on prior reportsof talus fractures associated with malleolar fractures,the incidence of osteonecrosis of the talus appears to belower than other types of talus fractures probablybecause the medial and lateral soft tissue attachmentsremain intact on the talus1,7.

At the 3 month follow-up patient has achievedcomplete bony union of his fractures and has progressedto full weight bearing. The patient continued to do wellpostoperatively. Radiographs at one year showed noevidence of talar osteonecrosis. Continued regularfollow-up in this patient is required to monitor for theprogression of his post-traumatic arthritis.

CONCLUSIONTalar neck fractures have been associated with a

high incidence of complications, including osteonecrosis,infection, skin necrosis, malunion, nonunion, andposttraumatic arthritis. The most common mechanismfor isolated talus neck fracture is Hyperdorsiflexionforce at foot. Forced supination can also result in talusneck fracture. Based on our case report likelymechanism for talus neck and ankle facture includescombination of supination- adduction andhyperdorsiflexion.

It appears that a Hawkins type 3 fractureassociated with bimalleolar fracture is accompanied bysignificantly lower incidence of osteonecrosis of talus.This could be due to preservation of extraosseousvascular supply of talus that accompanies the deltoidand talofibular ligamentous complexes.

REFERENCES1. Montane I, Zych GA. An unusual fracture of the talus associatedwith a bimalleolar ankle fracture. A case report and review of theliterature. ClinOrthop Relat Res. 1986 Jul;(208):278-81. Review.PubMed PMID: 3522024.2. Sanders DW. Fracture and dislocations of talus. In Rockwood

and Greens Fracture in adults. 8th edition. Wolters KluwerHealth;2015:2593-4.3. Canale ST, Beaty JH, Campbell operative orthopaedics. EdnInternational. 2012;4(12):4162-3.4. Gawali SR et al. Int J Res Orthop. 2016 Sep;2(3):80-855. Surgery of the foot and ankle.—8th ed. / editors, Michael J.Coughlin, Roger A. Mann, Charles Saltzman.;2007: 2076-21646. Hak D, Lin S. Management of Talar Neck Fractures.ORTHOPEDICS. 1; 32: 715- 721. doi: 10.3928/01477447-20110714-167. Combined Ankle and Talus Fractures. Bulletin of the Hospital forJoint Diseases . 2013, Vol. 71 Issue 2, p161-165. 5p Author(s):Weatherall, Justin; Schwarzkopf, Ran; Sheskier, Steven8. Lauge-Hansen N. Fractures of the Ankle. Combined experimental-surgical and experimental roentgenologic investigations. Arch Surg.1950;60:957-85.9.Vallier HA, Nork SE, Barei DP Benirschke SK, SangeorzanBJ.Talar neck fractures: results and outcomes. J Bone Joint SurgAm.2004;86(8):1616-162410. Verettas DA, Ververidis A, Drosos GI, et al. Talar body fracturecombined with bimalleolar fracture. Arch Orthop Trauma Surg.2008;128:731-4.11. Çolak TK, Çolak Ý, Timurtaº E, Bulut G, Polat MG.Pedobarographic and Radiological Analysis After Treating a TalusNeck Fracture. J Foot Ankle Surg. 2016 Sep 2. pii:S1067-2516(16)30179-X.doi:10.1053/j.jfas.2016.07.017.12. Rammelt S, Zwipp H. Talar neck and body fractures [publishedonline ahead of print April 24, 2008]. Injury. 2009;40(2):120-135.13. 10.Beltran MJ, Mitchell PM, Collinge CA. Posterior to AnteriorlyDirected Screws for Management of Talar Neck Fractures. FootAnkle Int. 2016 Jun 23. pii: 1071100716655434.14. Swanson TV, Bray TJ, Holmes GB Jr. Fractures of the talar neck.A mechanical study of fixation. J Bone Joint Surg Am.1992;74(4):544-551.15. Attiah M, Sanders DW, Valdivia G, et al. Comminuted talar neckfractures: a mechanical comparison of fixation techniques. J OrthopTrauma. 2007; 21(1):47-51.16. Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long-term results of displaced talar neck fractures. Clin Orthop Relat Res.1985; (199):81-87.17. Charlson MD, Parks BG, Weber TG, Guyton GP. Comparison ofplate and screw fixation and screw fixation alone in a comminutedtalar neck fracture model. Foot Ankle Int. 2006; 27(5):340-34318. Milenkovic S, Stanojkovic M. [Hawkins type III fracture:dislocation of the talus and fracture of the medial malleolus treated bydistraction external fixation].Unfallchirurg.2008 Feb;111(2):112-6. German.19. Schulze W, Richter J, Russe O,Ingelfinger P, Muhr G. [Prognostic factors for avascular necrosisfollowing talar fractures]. Z Orthop Ihre Grenzgeb. 2002 Jul-Aug;140(4):428-34. German.20. Chen H, Liu W, Deng L, Song W. The prognostic value of thehawkins sign and diagnostic value of MRI after talar neck fractures.Foot Ankle Int. 2014 Dec;35(12):1255-61. doi:10.1177/1071100714547219. Epub 2014 Aug 12.21. Rammelt S, Zwipp H. Talar neck and body fractures.Injury.2009Feb;40(2):120-35.doi:10.1016 j.injury.2008.01.021.Epub 2008 Apr 24.22. Daniels TR, Smith JW. Talar neck fractures. Foot Ankle.1993May;14(4):225-34.23. Wu K, Zhou Z, Huang J, Lin J, Wang Q, Tao J. Talar NeckFractures Treated Using a Highly Selective Incision: A Case-ControlStudy and Review of the Literature. J Foot Ankle Surg. 2016 May-Jun;55(3):450-5. doi:10.1053/j.jfas.2016.02.002. Epub 2016 Mar 5.


SHORT INTRAMEDULLARY NAIL IN MANAGEMENT OF UNSTABLE

INTERTROCHANTERIC FRACTURES -A PROSPECTIVE STUDY

Dr.Anandsrinivas A.Sowlee, Dr.R.Neelakrishnan, Dr.V.Barathiselvan,Dr.A.T.Shanmuga Raja, Dr.V.Manooj Kumar

Department of Orthopaedics, Rajah Muthiah Medical College & Hospital, Annamalai University

ABSTRACT

Introduction: Intertrochanteric fractures are one of the most common fractures of the hip andhave been recognized since the time of Hippocrates. The incidence of intertrochanteric fractureis rising because of increasing number of senior citizens with osteoporosis and also the increasingnumber of road traffic accidents. For unstable fractures intramedullary has been preferredrecently.

AIM- To assess the outcome of Unstable Intertrochanteric fractures treated withShort Intramedullary Nail.

MATERIALS &METHODS- A prospective study done at the Department of Orthopaedics,Rajah Muthiah Medical College & Hospital, Annamalai University, Chidambaram. Patient withIntertrochanteric fractures were treated with short intramedullary nail(TFN& Short PFN)&Follow up done at regular intervals for a period of 2 years (Aug 2014- Sept 2016).

RESULTS- 50patients with unstable Intertrochanteric fracture were treated with shortintramedullary nail (30 patients with TFN and 20 patients with PFN). Average age of patientswas 65.07 years for patients treated with TFN and 68.50 years for patients treated with PFN.Overall mean time of radiological fracture union was 15 weeks. Mean hospital stay was 13days. Average Modified Harris Hip Score was 88.25 for patients treated with TFN and 89.25for patients treated with PFN.

CONCLUSION-In our study, depending on the fracture pattern the implant was chosen. Whenthe lesser trochanter was not involved trochanteric fixation nail was chosen but when the fractureline extended below the lesser trochanter proximal femoral nail was a better option.

KEY WORDS- Unstable Intertrochanteric fracture, short intramedullary nail, outcome

INTRODUCTIONIntertrochanteric fracturesare one of the most

common fractures of the hip and have been recognizedsince the time of Hippocrates. Aitken suggested thatdegree of osteoporosis in fracture, influences fracturetype1.The incidence of intertrochanteric fracture isrising because of increasing number of senior citizenswith osteoporosis and also the increasing number of roadtraffic accidents. Gallagher et al suggested that, withincrease in the life expectancy, the incidence ofIntertrochanteric fractures has sharply risen among thegeriatric population2 especially in the elderly with

osteoporotic bones, usually due to low-energy traumalike simple falls. In the younger age group, whereUnstable Intertrochanteric fractures are more common,the cause is usually high-energy trauma like road trafficaccidents.Unstable Intertrochanteric fractures are thosewhere there is poor contact between fracturefragments, especially medial and posterior corticaldisplacement, comminution or a fracture pattern suchthat the weight bearing forces tend to displace thefracture further or a reverse oblique type. It isuniversally agreed that the treatment of unstableintertrochanteric fractures is stable internal fixation as


early as possible.Treatment goals for patients withunstable intertrochanteric fractures include earlyrehabilitation, restoration of the anatomic alignment ofthe proximal part of femur and maintenance of thefracture reduction.Stable intertrochanteric fractures arecommonly treated with Dynamic hip screw (DHS)fixation. However, despite many methods, there hasbeen no gold-standard treatment for unstableintertrochanteric fractures. Generally intramedullary nailhas been preferred for unstable fractures.

AIMThe aim of this study is to assess the

functional outcome of unstableintertrochantericfractures treated with short intramedullary nail withtwodifferent length, trochanteric fixation nail (180 mm),proximal femoral nail (250 mm) were used.

MATERIALS AND METHODOLGYA prospective study was conducted, the data for

this study was collected from the patient admitted to RajahMuthiah Medical College and Hospital, AnnamalaiUniversity, Chidambaram, diagnosed to haveIntertrochanteric Femur fracture, were treated surgicallyusing trochanteric fixation nail during the period August2014 to October 2016. The clinical and radiologicaloutcome was assessed and recorded. The ethicalcommittee clearance was obtained from the institution.Inclusion Criteria: 1) Patients with intertrochantericfractures aged 30 years and above, 2) All types ofintertrochanteric fractures(especially those ofosteoporotic & grossly comminuted) treated withintramedullary nail, 3) Both males & females, 4) adequatequality preoperative, immediate postoperative, atleast oneset of adequate quality postoperativeradiographs.Exclusion Criteria: 1) Previous surgery ofthe proximal femur, 2) patients with pathological fracturesother than osteoporosis, 3) Patients managedconservatively for other medical reasons, 4) Ongoingchemotherapy or irradiation treatment due to malignancy,5) Patients who are not able to give consent wereexcluded from the study.If the fracture was not extendingbelow lesser trochanter the patients were treated withTrochanteric fixation nail. If the fracture line extendedbelow lesser trochanter proximal femoral nail was used.

Both the implants were made up of a stainlesssteel 316L type. The system consists of cannulated nail,cannulated hip screws of sizes 8 millimetres and 6.4millimetres and locking bolts (4.9 millimetres). There isa locking mechanism in the upper part of the nail tocontrol the rotation of the hip screw. The proximaldiameter of the nail is thirteen millimetres. The distaldiameter varies from nine to twelve millimetres. All nails

have an anatomical valgus angle of six degrees. Theangle between the nail and hip screws are available in130 and 135 degrees. In the nail, there are two holesdistally one for static and one for dynamic locking. Thelocking bolts have a diameter of 4.9 millimetres. Thelength of nail used in TFN was 180 mm. length of thenail used in PFN was 250 mm.All the patients were puton fracture table and close reduction was done. Whenthe fracture reduction was unacceptable, as determinedby the surgeon, open reduction was done. Thus fracturereduction is the most important step prior to thefixation.Implants were placed and compression of thefracture was performed. Ideally, twoCephalomedullary screws were inserted with one or twodistal screw as deemed by the surgeon.

The tip apex-distance was measured accuratelyprior to the placement of the Cephalomedullaryscrews.The distance was calculated in both AP &lateral views.The adequacy of reduction of theposteromedial calcar was determined using both APand lateral radiographs5. Initial radiographs wereclassified according the AO system and further sub-classified into unstable fractures (31-A2.2, 31-A2.3, 31-A3.1, 31-A3.2, and 31-A3.3).

Post-operatively early mobilization was begunwithin limits of pain tolerance. Active, assisted and activerange of motion exercises proved to be valuableadjuvant for achieving good range of motion. All patientswere advised partial weight bearing with a walker for aperiod of six to eight weeks. Patients were allowed fullweight bearing after radiological evidence of fractureunion. Radiographs were taken at regular intervals andevaluated for fracture healing alignment, screwbreakage or screw back-out, cut-out, Varus malunioncollapse. Clinical union was defined as a painlessfracture site during full weight bearing. Radiographicunion was defined as bridging trabeculations across thefracture line on two orthogonal views in the absence ofmigration, loosening or breakage of hardware. Caseswere followed up until eighteen months. Functionalassessment of patients was done using Modified HarrisHip Scoring system.

Proximal Femoral nail


T r o c h a n t e r i cFixation nail

RESULTSDuring the period of study a total of 50 cases with

intertrochanteric fracture were received. Twenty caseswere treated with PFN and the remaining thirty caseswere treated with TFN and patients were followed upat three months, six months,twelve& eighteen month’sintervals.

Average age of patients was 65.07 years forpatients treated with TFN and 68.50 years for patientstreated with PFN. Out of the 30 patients treated withTFN, 12 were male and 18 were female with right hipinvolvement in 17 patients and left hip in 13 patients.Out of the 20 patients treated with PFN, 7 weremale and 12 were female with right hip involvementin 10 cases and left hip in 10 cases. Average traumasurgery interval was 8 days (range 2 to 15 days).Among patients treated with TFN closed reduction wasdone in 26 patients whereas 4 patients required openreduction. Among patients treated with PFN, Closedreduction was achieved in 18 patients and openreduction in 2 patients.The average surgical time was67 minutes (range 30 to 95 min). Average blood losswas 165 ml (range 130 to 350ml) Average hospital staywas 15 days (range 13 to 18 days). Partial weightbearing was achieved in mean 5 days (range 3 to 9days). Full weight bearing was achieved after 50 days(41 to 57 days).The Average radiological union was 15weeks (12-18 weeks), Average Modified Harris HipScore was 88.25 for patients treated with TFN and89.25 for patients treated with PFN. The average neckshaft angle was 138 degrees (range 130- 145 degrees).In our series, among patients treated with TFN, threepatients had Varus collapse, one patient had backing outof Cephalomedullary screws due to poor purchase inhead and one patient had significant shortening of 3 cmwho was treated with sole raise shoes. Among patientstreated with PFN two patients had varus collapse andtwo patients had anterior thigh pain which was not seenin patient treated with TFN.

Table 1 Results

TFN PFNNumber 30 20Age 65.07 68.50Sex (Male: Female) 12:18 7:13Side (Right: Left) 17:13 10:10Reduction (Closed : Open) 26:4 18:2Modified Harris Hip Score 88.25 89.50

Type of fracture No. of patients No. of patients(TFN) (PFN)

31-A2.1 6 531-A2.2 12 431-A2.3 8 631-A3.1 2 231-A3.2 1 231-A3.3 1 1

Table 2 Fracture Pattern

Score No. of patients No. of patients(TFN) (PFN)

Excellent(more than 90) 7 6Good (81-90) 18 12Fair (71-80) 5 2Poor (less than 70) 0 0

Table 3 Modified Harris Hip Score

TFN PFN

Post-operative Infection 0 0Varus collapse 3 2Screw backing out(reversemigration) 1 0Significant shortening (> 2cm) 1 0Non union 0 0Sciatic nerve palsy 0 0Anterior thigh pain 0 2

Table 4 Complications


PRE OP X-RAY POST OP X-RAY (treated with TFN)

PRE OP X-RAY POST OP X-RAY (treated with PFN)

DISCUSSIONIntertrochanteric fractures in the elderly pose

certain special problems. In this age group the fractureconfiguration is generally comminuted with presence ofextensive osteoporosis. There is problem with correctand accurate placement of the implant and hold of theimplant. So if the fixation is not stable, prolongedimmobilization may be required to achieve completeunion. On the other hand there is a need for rapidweight bearing and mobilization of this group of patientsas they are generally medically compromised due to ageand associated diseases.

Anthropometric measurements of proximalfemur in Indian population is smaller than westernpopulation. So there appeared a need of design suitablefor Indian Population.

Egol KA, Chang EY, Cvitkovic J, Kummer FJ,Koval KJ2o(2004)did a study on the mismatch of currentintramedullary nails with the anterior bow of the femur.They inferred that Intra-operative complications suchas splintering and fractures are due to oversized implantsthat are manufactured according to western populationparameters. In India, the proximal femoral nail isavailable with a length of 240-250 mm. It crosses themiddiaphysis of the femur. This may give rise to intra-operative femoral shaft fractures and thigh pain,because the implant touches the anterior cortex of thefemur.

Modification of the gamma nail by reducing itsdiameter and length has been performed in the Chinese

population. Hence complications such as splintering andfractures due to oversized implants can be avoided byusing implants designed specifically for the relativelysmall Asian femur.

The TFN was designed for the Asian populationkeeping all these considerations in mind. Currently, thereis only one study reported till date, of the TFN fortreating intertrochanteric fractures in Asians. Currentlythere is only one study with TFN.Gadegone WM,Salphale YS21 (April 2010) reviewed outcomes of 100Asian patients who underwent trochanteric femoralnailing for stable and unstable intertrochantericfractures. They concluded, that trochanteric fixation nailis a superior implant for stable and unstableintertrochanteric fractures in terms of operating time,surgical exposure, blood loss, and complications,especially for patients with relatively small femur.

Outcomes of treatment of intertrochantericfractures depends on quality of bone, age of patient,general health, trauma surgery interval, and adequacyof treatment, comorbidities and stability offixation9,10,11.

TFN& PFN acts as a buttress to preventmedialisation of the shaft and provides more efficientload transfer16. It is designed to provide linearintraoperative compression of head neck segment toshaft along with rotational stability which minimizesneck malunions, resulting in negligible complicationrate17. It has been proved to be a superior implantcompared to previous implants for stable and unstableintertrochanteric fractures in terms of operating time,surgical exposure, blood loss, and complication rates.18TFN reduces stress concentration at the tip and thesmaller distal diameter may prevent femoral shaftfractures19. But the drawback was that when thefracture extended below the lesser trochanter PFNprovided more stability than TFN.

When the fracture line was extending belowlesser trochanter or when the lesser trochanter waspresent as a third fragment, the fracture was fixed withproximal femoral nail. But when the fracture was notinvolving lesser trochanter, the fracture was fixed withtrochanteric fixation nail.

Since the trochanteric fixation nail is shorter inlength than proximal femoral nail there was no need forintraoperative reaming and the incidence of anteriorthigh pain was not seen but as the nail was shorter it didnot give enough stability when the fracture wasextending below lesser trochanter. Till now there are nostudies involving comparison between TFN and PFN.

CONCLUSIONFor unstable intertrochanteric fractures fixation is must.


Fracture reduction is the key step of the surgery.Intramedullary nailing has shown to be effective inproviding early mobilisation and weight bearing. Whenthe fracture does not involve the lesser trochanter TFNis as effective as PFN but when the fracture isextending below the lesser trochanter or the lessertrochanter is present as a separate fragment, the moreideal choice of implant is proximal femoral nail which islonger than trochanteric fixation nail. Since there are noprevious studies comparing the outcome of TFN withshort PFN. Still further studies with larger population isdeemed necessary to say the efficacy.

REFERENCES1. Koval KJ, Aharonoff GB, Rokito AS, et al. Patientswithfemoral neck and intertrochanteric fractures. Are they thesame? ClinOrthopRelat Res.1996; 330:166-172.2. Grisso JA, Kelsey JI, Strom BL, and Chio GY. Risk factors for fallsas a cause of hip fractures in women. New England journal ofmedicine. 1991; 324:1326-1331.3. Meislin RJ, Zuckerman JD, Kummer FJ, et al. A biomechanicalevaluation of the gamma nail. J Bone Joint Surg.1998; 70-A: 2394. Anchal Kumar. Femoral neck geometry and rationale ofplacement of the proximal femoral nail and its relation with fracturerisk in the Indian population review of 120 cases. 2010: GulmoharHospital, Ranchi.5. Fracture and dislocation compendium. Orthopaedic traumaassociation committee for coding and classification. J OrthopTrauma 1996;10(Suppl. 1):1—154. v—ix.6. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The valueof the tip-apex distance in predicting failure of fixation ofperitrochanteric fractures of the hip. J Bone Joint Surg Am1995;77:1058—64.7. Pervez H, Parker MJ, Vowler S. Prediction of fixation failure aftersliding hip screw fixation. Injury 2004;35:994—8.8. Yoshimine F, Latta LL, Milne EL. Sliding characteristics ofcompression hip screws in the intertrochanteric fracture: a clinicalstudy. J Orthop Trauma 1993;7:348—53.

9. Kyle RF, Gustilo RB, Premer PF. Analysis of Six hundredand Twenty–two intertrochanteric Hip Fractures. J. Bone JointSurg. 1979 March; 61-A: 216-21.10. Dahl E. Mortality and life expectancy after hip fractures.ActaOrthop Scand. 1980 Feb; 51(1)163-70.11. Kaufer H. Mechanics of the treatment of hip injuries.ClinOrthopRelat Res. 1980 Jan- Feb;146:53–61.12. Grisso JA, Kelsey JI, Strom BL, and Chio GY. Risk factors forfalls as a cause of hip fractures in women. New England journal ofmedicine. 1991; 324:1326-1331.13. Ender J, Simon-Weidner R. DieFixierung der trochanteren Bruchemitr undene lastischen Condylennageln. Actachir Austriaca 1970; l: 40-42.14. Cleas H, Broos P, Stappaerts K. Pertrochanteric Fractures inElderly patient Treatmentwith Ender’s nail, bladeplate or endoprosthesis? Injury. 1985;16(4):261-64.15. Heyse-Moore G.H, MacEachen AC, and Jameson Evans DC.Treatment of trochanteric fractures of the femur. J Bone Joint Surg.1983; 65-B: 262-267.16. Morihara T, Arai Y,Tokugawa S, Fujita S, Chatani K, Kubo T.Proximal femoral nail fortreatment of trochanteric femoral fractures. Journal ofOrthopaedic Surgery 2007;15(3):273-7.17. Ruecker AH, Rupprecht M, Gruber M, Gebauer M, Barvencik F,Briem D, Rueger JM: The treatment of intertrochanteric fractures:results using anintramedullary nail with integratedcephalocervicalscrews and linear compression. J OrthopTrauma. 2009;23(1):22-30.18. Gill JB, Jensen L, Chin PC, Rafiei P,Reddy K, Schutt RC Jr : Intertrochanteric hip fractures treated withthe trochanteric fixation nail and sliding hip screw. J SurgOrthopAdv. 2007; 16(2):62-6.19. Bienkowski P, Reindl R, Berry GK, Iakoub E, HarveyEJ: A newintramedullary nail device for the treatment ofintertrochanteric hipfractures: Perioperative experience.J Trauma. 2006; 61(6):1458-62.20. Egol KA, Chang EY, Cvitkovic J, Kummer FJ, Koval KJ.Mismatch of current intramedullary nails with the anterior bow of thefemur. J OrthopTrauma 2004;18:410–5.21. Gadegone WM, Salphale YS. Short Proximal Femoral NailFixation for trochantericFractures J OrthopSurg( Hong Kong). 2010 Apr;18(1):39-44.


RETROSPECTIVE ANALYSIS OF OUTCOME OF HOFFA

FRACTURE, SURGICALLY TREATED BY CANCELLOUS SCREWS

AND CANCELLOUS SCREW WITH BUTTRESS PLATE

Dr.Arunraj SGanga hospital, Coimbatore

ABSTRACTPURPOSE: Hoffa fractures have better outcome when treated surgically and can befixed with different implants. Purpose of this study was to compare the clinico-radiological outcome of Hoffa fracture, treated using cancellous screws and cancellousscrew with one- third semi-tubular plate.METHODS:41 patients from January 2014 – August 2015 with average age of 42.2years (21- 64) including 38 males and 3 females.Divided into two groups based on thesurgical implant fixation, 14 patients with cancellous screw (Group I) and 27 patientswith cancellous screw and buttress plate (Group II). Data analysis made using FisherExact p value.Average follow up for 15 months with subjective functional assessmentand radiographic assessment. RESULTS: In groups I and II, mean TL score was 82.64and 90.2 and mean knee flexion was 99.28° and 112.4° respectively, showing nosignificant functional difference ( P =0.126).Among all patients, 56 % had excellent and 20% had good, 12% had fair and12% had poor outcome. Average degree of knee flexion was 107.8° with TLscore 87.6. Radio logically all patients in both groups showed good union except onemal-union and non-union in group I and II respectively. Overall we had fivecomplications; two cases had knee stiffness and infection, mal-union and non-unionin each case.CONCLUSION:Though no statistically significant difference in functional outcomebetween two groups. Patients in group II had higher range of knee flexion and betterdaily activity.KEY WORDS:Hoffa fracture, Cancellous screws, Cancellous screw with one-thirdsemi- tubular plate.

INTRODUCTIONIsolated coronal plane Hoffa fractures of the

femoral condyle was first mentioned by Friedrich Buschin 18691, it was later named after Albert Hoffa2 in1904.It is an intra-articular fracture in a majorweight-bearing joint, at risk of displacement ifunrecognised. The lateral condyle is more commonlyinjured3 than the medial condyle because ofPhysiologic genu valgum which puts greatercompressive stresses on the lateral side. Frontal impacton a flexed knee is more likely to involve the outeraspect resulting in shearing force on the posterior part oflateral femoral condyle. Treating Hoffa fractures is stilla great challenge. Reduction is even more difficult when

it is communited. This fracture pattern reflects a highenergy mechanism of trauma and needs perfectanatomical reduction and stable fixation followingregular physiotherapy to prevent the complicationslike malunion, non union, soft tissue adhesions andcontracture , implant failure. Though different implantswere available to fix the Hoffa fractures and studiedtheir functional outcome. To the best of our knowledge,there have been no studies published comparing the twodifferent implants. The purpose of this study was tocompare the clinic-radiological outcome of Hoffafracture, surgically treated by cancellous screw andcancellous screw with buttress plating.


MATERIALS AND METHODS

Forty one patients with Hoffa fractures ( Letenneur typeI – 9n, II -1n, III – 31n) from January 2014 to August2015 were analysed retrospectively included. Hoffafracture associated with Patella or Supra condylarfemur or tibial plateau fractures,Simple/ CompoundGrade I, II & III fractures were included and pelvic,pathological fracture and associated with polytrauma,compartment syndrome and severe osteo-arthritis kneewere excluded.These 41 patients (38 men,3 women)had mean age of 42.2 years( 21 to 64). Patients weredivided into 2 groups, Group I Hoffa patients were fixedwith cancellous screw alone and Group II were fixedwith cancellous screw with one-third semi-tubularplate. Implant choice was determined by surgeonintra-operatively based on bone stock, bone quality,reduction stability and implant capacity. Patients wereoperated under spinal anaesthesia, using swash bucklerapproach. The vastus lateralis was retracted laterallyafter lifting it up from the lateral femoral side. The restof the extensor mechanism along with the patella wasretracted medially for unobstructed visualization of bothfemoral condyles. On exposing the knee, a tangentialfracture involving the femoral condyles was noted. Thenthe fractured segment was reduced to anatomicalposition and fixed temporally using 2 or 2.5 mm K-wires.However, reduction was achieved and 6.5 mm partialthreaded cannulated cancellous screws or 4 mmcancellous screw or Herbert screw used passed from

anterior to posterior direction through the non-articularpart under fluoroscopy control in addition one-third semitubular plate were used,if communition was present.Data collected were entered into Excel sheet andstatistical analysis made by applying student t Test todetect differences in functional outcome. The resultswere graded clinically using Tegner Lysholm scoreand radiologically assessed for perfect articularscurface reduction, implant stability, bony union and latecollapse. Post-operatively, Static Quadricepsstrengthening exercise and active ankle and toemovements were started on first post operative day andpassive mobilization of knee (continous passive motion)with non weight bearing walking with walker wasstarted on second post operative day. Activekneemobilization was started after sutures removed.Patients were allowed partial weight bearing crutchwalking after 6 week and full weight bearing walkingafter 3 months.Follow-up: Average follow-up regimen of clinical andradiological review was done for 15 months on average(6 to 24 months). All radiographs were evaluated forcongruent articular reduction in the immediate postoperative x-ray and re-evaluated after 6 months for anylate collapse (to check the implantstability),complications including non-union, malunion,avascular necrosis and failure of implants orosteoarthritis. Clinically,active knee flexion wasmeasured using goniometer. Instability, pain, swelling,limp, stair-climbing,locking,squatting were recorded.Functional evaluation was assessed after 6 monthsusing Tegner Lysholm score grading excellent (100 –90),good (89 – 84),fair (83 – 65),poor (<64).

RESULTSFunctional outcome:TABLE 1: COMPARATIVE FUNCTIONALOUTCOME BASED ON TEGNER LYSHOLMSCORE


Table 1 shows, on comparing the two groups based onthe Tegner Lysholm score, we found excellent outcomein 6 (42.8%),good in 5 (35.7%), fair in 1 (7.14%) andpoor in 3 (21.4%) in group I (n=14), when compared to17 (62.9%) excellent,3 (11.11%) good, 4 (14.8%) fairand 2 (7.4%) poor in group II (n=27). Average scoreof Functional outcome is assessed as per TegnerLysholm criteria was 87.6, with maximum score of 100and minimum of 35 in which 82.64 ± 16.85* (Mean ±

S.D) of TG score present in group I and 90.2 ± 13.76*(Mean ± S.D) in group II. But this difference was notstatistically significant (P = 0.126). Average degree ofknee flexion was 107.8*, with maximum knee flexion of135* and minimum of 40* of which 99.28* ± 23.76*(Mean ± S.D) of knee flexion present in group I and112.40* ± 14.43* (Mean ± S.D) in group II. Thisdifference was statistically significant (P = 0.034).

Table 2 shows, the patients in group II had kneeflexion of about > 120° in 10 patients whereas 4 patientsin group I, also 3 patients in group I had <90° and nopatients in group II. On comparing pain, group I and IIhad slight pain in 28% and 22% , severe pain in everysteps in 1 patient and no patients respectively. Instabilitywas seen in one patient in each group. Comparing stair-climbing and locking, limitations were present almostequally between them.

Radiological Outcome: On assessing theimmediate post operative x-ray for congruent articularreduction, we found only 8/14 (57%) and 17/27 (63%)had perfect reduction in group I and II respectively. Alsolooked for the stability of implants in the immediate and6 months follow up x-rays, (whether the implants werecorrectly placed, adequate length and number ofimplants were used ),showing all patients in both thegroups had stable fixation except for one patient in eachgroup. On assessing the union in follow-up x-rays, wefound good union in all patients in both groups except thesame patient in each group, diagnosing mal-union andnon-union in group I and II respectively. Also found latecollapse of fracture fragments in 2 out of 8 and 3 out of

17 immediate congruent fixation in group I and group IIrespectively .Complications: None of the patients experienced anintra operative complication and no implant failure oravascular necrosis occurred in this series. Overall, inthis group of 41 patients, 5 patients (12%) hadcomplications :

• 1 Mal union • 1 Non union• 2 Knee stiffness • 1 Infection

Pre –operative X-ray of Hoffa fracture;


Immediate post-operative X-ray of cancellous screwwith 1/3rd semi-tubular plate;

8 months follow-up

Patient with excellent knee flexion

DISCUSSIONIsolated Hoffa fractures of the femoral condyle

represents 0.65% of all femoral fractures3.Increasedincidence of this fractures can be attributed toincreasing number of high velocity injuries in our society.With the increase in high velocity injuries, the fracturepattern also shows severe comminution or associatedfractures like supra-condylar femur fracture. Non-operative treatment can result in stiffness and poor jointfunction 4. Ideal treatment for Hoffa fractures shouldresult in proper reduction of articular surface, withnormal range of knee movements. According to Nork etal5 association of Hoffa fracture with supra and inter-condylar femur fracture was found to be 38% and in our

study, it was 43.75%. Unicondylar fractures arefrequently displaced and unstable because of the initialtrauma force, the muscle contraction, in particular, thegastrocnemius and popliteus muscles which can rotateand move the condylar fragments. Hence implantsshould ensure the fracture stable fixation withoutimpairing joint movments.

Though there were many implants available, stillthere was a paucity of data recommending what implantwill be the ideal and among the implants which g ivesbetter functional outcome. When hoffa fractures wasfixed, atleast 2 screws must needed to provide stablefixation and to prevent the rotation of fragments.Though Jarit et al6 found that Lag screws placedposterior to anterior provided more stable fixation thanantero- posteriorly placed screws and Ashok gavaskaret al8 fixed Hoffa fractures with cancellous screw inAP/PA directions , we placed antero-posterior screw asmost surgeons routinely used to fix the Hoffa fragment.In case of comminution, in additional buttress plating isessential because of the orientation of the fracture lineitself, which creates a sliding plane favouring upwardcondylar movement. Stable fixation, although difficult toobtain in the soft or even osteoporotic knee joint, isneeded to permit early motion and to prevent kneestiffness.

Lin7 et al studied on 11 patients of Hoffa fracturetreated with 6.5mm cannulated lag screw with lateralsupporting plate, concluding 7 patients had excellentresults,3 had Good results and one patient had poorresult, when treated on letenneur type I and III. In ourstudy, 19 patients of Hoffa fracture type III were treatedwith cancellous screw with lateral buttress plating,concluding 13 (69.4%) patients had excellent results,2(10.2%) patients had good results, 2 (10.2%) had fairresults and 2(10.2%) had poor results.

Ashok gavaskar et al8 studied on 18 hoffafractures fixed with cancellous screw in AP/PAdirections concluding complications like Stiffness andpain in 1 patient, collateral laxity in 2 patients andprogression of arthritis in 1 patient. In my study,complications shows 2 patients shows knee stiffness and2 patients shows instability.

Tetsunaga9 et al studied on 5 patients with Hoffafractures treated with one third semi-tubular plate andlocking compression plate, concluding all 5 patientshad excellent results with mean knee flexion of 121°,also presented with no complications. In our study 27patients were treated with one third semi-tubular plate,among which 17(62.9%) patients had excellent resultswith mean knee flexion of 112.40° and mean TG scoreof 90.2

Following surgery, the functional outcome was


assessed by Tegner Lysholm score. On comparing thefunctional results between group I and II, no statisticaldifference was seen, but still on analysing thecomplications between them, patients in group II hadlesser complications and doing better daily activitiesin knee flexion, pain, swelling, instability comparingthe patients in group I

On analysing the both groups radiologically,though 8/14 and 17/27 patients in group I and IIrespectively, had congruent reduction immediately aftersurgery, 25% (2/8) of late collapse was seen in group Icompared to 17% (3/17) of patients in group II. Allpatients had good union and stable fixation except forone patient in each group. This was due to both improperarticular surface reduction and unstable fixation ie.,inadequate lengthof screw was used to hold the Hoffafragment that leads to late collapse thereby leading to

Mal union and Non union in group I and IIrespectively.

The distal end of femur has minimal soft tissueattachment in the posterior aspect; so, if such fracturesare not adequately fixed, it may lead to complicationslike non- union and avascular necrosis10-11. Letenneuret al12 classified fractures based on the integrity of soft-tissue attachments in an attempt to predict theoccurrence of avascular necr osis (AVN). Types I andIII have residual soft-tissue attachments, whilst type IIfractures are more posterior and have minimal or noattached soft tissues. They proposed higher rates ofAVN in type II fractures, but it has not been translatedin clinical studies. In our study, although only one patientwas in Type II, didn’t developed AVN. The absence ofAVN in the current series refutes it further but thesample size is small and the follow-up period is short.Overall in this study, no implant failure and avascularnecrosis was seen but one case of non union and malunion was seen.Also we had 2 cases of stiff knee whichwas found associated with supra condylar femurfracture.

CONCLUSIONOn analysing the Hoffa fracture fixation radio

logically between cancellous screw and cancellousscrew with buttress plating, we found that whatever thetype of fixations, Primary congruent anatomicalreduction of articular surface seems to be the mostimportant prime factor. Secondly, Stable implant fixationis also equally important to be considered to prevent late

collapse, and found that fractures fixed with cancellousscrew and buttress plating provides better stabilitythan cancellous screws alone. On analysing thefunctional outcome, on the basis of Tegner Lysholmscore and range of Knee flexion, patients treated withcancellous screw and buttress plating were found betterin carrying out their daily activities without muchdifficulties and complications, though there was nostatistically significant difference between them.RECOMMENDATIONS

We recommend to fix the Hoffa fracture withCancellous screw with buttress plate in case ofcomminution of bone was present, to achieve betterfunctional outcome. However, Randomized ControlStudy was needed, to evaluate the superiority betweenthe cancellous screw and cancellous screw withbuttress plate.

REFERENCE1 Heuschen UA, Göhring U, Meeder PJ. Bilateral Hoffa fracture:a rarity. Aktuelle Traumatol 1994;24:83–86 (in German).2. Hoffa A. Lehrbruch der frakturen und luxationen. Fourth ed.Stuttgart: Ferdinand Enke- Verlag, 1904.3. Manfredini M, Gildone A, Ferrante R, Bernasconi S, Massari L.Unicondylar femoral fractures: therapeutic strategy and long-termresults: a review of 23 patients. Acta Orthop Belg 2001;67:132–138.4. McDonough PW, Bernstein RM. Nonunion of a Hoffa fracture in achild. J Orthop Trauma 2000;14:519–215. Nork SE, Segina DN, Aflatoon K, et al. The association betweensupracondylar intercondylar distal femoral fractures and coronalplane fractures. J Bone Joint Surg [Am]2005;87-A:564–569.6.Jarit GJ, Kummer FJ, Gibber MJ, et al. A mechanical evaluation oftwo fixation methods using cancellous screws for coronal fracturesof the lateral condyle of the distal femur (OTA type 33B) [J]. J OrthopTrauma 2006;20 (4)273-6.7. Lin T, Yang S, Xiao B, Fu D;Cannulated lag screw combined withlateral supporting plate for treatment of Hoffa fracture of Letenneurtype I and type III;Chinese journal of reparative and reconstructivesurgery. 2013 Sep;27(9):1050-3.8. Ashok S. Gavaskar et al: Operative management of Hoffafractures—A prospective review of 18 patients. Injury, Int. J. CareInjured 42 (2011) 1495–1498.9. Tomonori Tetsunaga et al; Posterior buttress plate with lockingcompression plate for Hoffa fracture. J Orthop Sci. 2013 sep;18(5):798-802.10.Zeebregts CJ, Zimmerman KW, ten Duis HJ. Operativetreatment of a unilateral bicondylar fracture of the femur. Acta ChirBelg. 2000;100(3):104–6. [PubMed: 11280171]11.Papadopoulos AX, Panagopoulos A, Karageorgos A, TyllianakisM. Operative Treatment of Unilateral Bicondylar Hoffa Fractures. JOrthop Trauma. 2004;18(2):119–22.12. Letenneur J, Labour PE, Rogez LM, Lignon J, Bainvel JV.Fractures de Hoffa: a propos de 20 observations. Ann Chir1978;32:213–9.


FUNCTIONAL OUTCOME ANALYSIS OF SACROLIAC JOINT

FRACTURE DISLOCATION (CRESECNT FRACTURE)

Dr.Mohan Kumar S, Prof N Deen Muhammad Ismail.

Institute of Orthopaedics & Traumatology, Madras Medical College & RGGGH, Chennai.

IntroductionWhen the posterior pelvic disruption passes

through the lower portion of the sacroiliac joint andexits through the ilium, this is known as a “crescentfracture.” The fragment which contain PosteriorSuperior Iliac Spine and Posterior Inferior Iliac Spine iscalled crescent fragment.

A portion of the iliac wing remains attached to thesacrum by means of the sacro-iliac ligaments. The pieceof bone fractured from the iliac wing resembles acrescentic moon, hence the term.Three types of crescentfractures are type I anterior ,type II middle ,type IIIposterior. Most common type is II which need sacroiliac screw fixation definitely .In type I most of thefragment is attached to sacro iliac ligaments and type IIIonly posterior fragment is avulsed.

The most common mechanism of injury is lateralcompression, resulting in the wing being impingedagainst the dense sacral bone.

These fractures are rotationally unstable,and are classified as lateral compression type II inthe Young–Burgess classification system

Traditionally, these fractures have been stabilizedwith open reduction and internal fixation. They can beapproached anteriorly, via an iliac fossa approach, orposteriorly, by elevating the gluteus maximus to exposethe posterior ilium.

These open approaches are beneficial in that theyallow direct manipulation of bone fragments.Reports ofopen reduction and internal fixation of crescent fractureshave shown uniformly good results. But, as withother open procedures, open reduction of crescentfractures carries a moderate risk of softtissuecomplication. Due to the risk, percutaneous methodshave been attempted for this injury pattern. The injurymechanism is often a lateral compression, which resultsin internal rotation of the hemipelvis. External rotationand abduction of the hip often serve to correct thedeformity in percutaneous fixation.

METHODSThis is a Prospective study done at Institute ofOrthopaedics and Traumatology,Rajiv Gandhi

Government General Hospital, Chennai, in 15 patientsfrom 2014 -2016.

INCLUSION CRITERIAPelvis fractures with Sacro-iliac joint fracture

disruption

EXCLUSION CRITERIA1. Paediatric population2. Associated acetabulum fractures3. Pathological fractures

Pre Operative EvaluationIn acute presentation of patients with pelvic ringdisruption, ATLS protocol was followed. All stabilisedpatients were subjected to the following

Detailed clinical examination Complete haemogram Renal function tests Radiographs of the Pelvis (Antero-posterior, Inletand Outlet views). CT pelvis with 3D reconstruction? CT abdomen/CECT KUB with cystogram /CT study forassociated injuries

In all patients open reduction and internal fixationwere done anteriorly, two or three holed reconstructionplate with 3.5mm cortical screws used.

POSTOPERATIVE PROTOCOL1) Nil per oral until bowel sounds and passing of flatus2) Drain was removed on the 2ndpost operative day withcollection being less than 20 ml for a period of 8 hours.Post operatively intravenous antibiotic for5days and oral antibiotic for another 7 days.3) All patients were treated with prophylactic lowmolecular weight heparin postoperatively for twoweeks and aspirin for 6 weeks. High risk patient wastreated with 3 months of aspirin .4) Suture removal done on 12thpost operative day5) Oral diet started only after flatus is passed andbowel sounds returned.


Postoperative bowel regime should be aggressive and itshould be a part of post operative protocol.6) Patient was mobilised from bed to chair usinguninjured leg as a pivot on the1st post operative.7) Touchdown weight bearing for 10 to 12 weeks8) Aid free ambulation after 12 weeks.9) Progressive return to full activity usually began after6 months.10) Avoid of sitting crossed leg upto 3 months to reducestrain in sacroiliac joint.

FOLLOW UPPatients were followed at 4 weeks, 12 weeks and at 6months. At each visit patient is subjected to thefollowing,1) Local tenderness of the sacroiliac joint . Tendernesson external rotation after 12 weeks2) Clinical examination includes gait, trendelenbergtest, sacral /pubic3) tenderness, strength of lower limb musclegroupFunctional ability of the patient (history)4) Assessment of implants (radiographs) for:a) Loosening b) Infection c) Failure5) Radiographic assessment i) -AP viewii) -Inlet view iii) -Outlet view6) CT of SI joint

Scoring-was based on Majeed Functional outcomescoring system based onSitting Standing Walking Sexual intercourse Work Pain Gait pattern

Functional outcome grading Points

Excellent >85

Good 70-84

Fair 55-69

Poor <55

RESULTSIn our study among 15 patients , 13 are male and2

are female,For 12 patients mechanism of Injury was byRTA, remaining 3, it was fall from height.In our study allpatients had definitive fixation within 3 weeks of

admission all of them show excellent Majeed functionaloutcome score (MFOS) except 2 patients who hadassociated other long bone fractures. The mean scorewas found to be 89.The result is not significant at p<0.05due to small sample.

The incidence of deep vein thrombosis in unstablesacroiliac joint disruptions was 10-80% in various studies.We used thromboprophylaxis in patients who underwentopen reduction and internal fixation thorough anteriorapproach. We didn’t have any deep vein thrombosis asa complication in our study.

Majeed outcome scoring system has theadvantage of including sexual function analysis whichis psychologically important factor which is notincluded in other scoring systems. The functionaloutcome of these patients are analyse with Majeedoutcome scoring system which include pain, sitting,standing, sexual intercourse, walking and radiologicalanalysis.

CONCLUSIONPelvic ring injuries with crescent fractures are

better managed in tertiary care centre. Haemodynamicresuscitation measures and efficacy in initial evaluationand temporary stabilisation procedures are lifesaving innature.We concluded that experienced and well equippedorthopaedic unit is an absolute necessity in ensuring notonly a good functional outcome but also save the life ofpatients on initial presentation.Definitive skeletal stabilisation done less than 3 weekshave given excellent MFOS in our study.

REFERENCES1) Adams JE 2003 Jul;17(6):406-10.J orthop trauma Pelvic traumain rapidly fatal motor vehicle accidents.2) Cydulka RK, Parreira JG et al 2000;31:677-682. The role ofassociated injuries on outcome of blunt trauma patients sustainingpelvic fractures. Injury.3) Hesp WL, van der Werken C, Keunen RW, Goris RJ. Unstablefractures and dislocations of the pelvic ring:results of treatmentinrelation to the severity of injury. Neth J Surg. 1985; 37:l48-524) Pennal George, Marvin Tile. Pelvic disruption assessment andclassification. Clinical Orthopaedics and Related Research.1980;151:12-21.5) Majeed Grading the outcome of pelvic fractures. Journal of Boneand Joint surgery, British. 1989; 71-B(2):304-306.6) Pennal George, Marvin Tile. Pelvic disruption assessment andclassification. Clinical Orthopaedics and Related Research.1980;151:12-21.


NEGLECTED POSTERIOR DISLOCATION OF SHOULDER TREATED

WITH SUBSCAPULARIS TENDON TRANSFER - A CASE REPORT

Prof. Dr.R.Sivakumar, Dr.Prahalad Kumar Singhi, Prof.Dr.M.Chidambaram,Dr. Somasekar, Dr. Sudeep

Preethi Hospital, Madurai

INTRODUCTIONPosterior shoulder dislocations represent 2%-5%

(1-4) of all shoulder dislocations; 60-79% (1) are missedIn 1955 McLaughlin (1) recognized that clinical

and radiological evidence of lesion is always present butusually escapes notice unless deduced. Complexity ofinjury, failure to notice and its rarity results in significantmorbidity.

We present a case report of a neglected posteriorshoulder dislocation managed with Subscapularis tendontransfer with review of its classification pathoanatomy,diagnosis and treatment.

CLASSIFICATION:Several classifications have been described.May (6) proposed it as habitual, traumatic and obstetricposterior dislocation or subluxation. Heller andColleagues (8) classified them as subacromial,subglenoid and subspinous posterior dislocation.Detenbeck (2) proposed it as acute, chronic andrecurrent (traumatic and atraumatic)Hawkins and Bell(7) proposed based on impressiondefect present or absence and later modified byRobinson and Aderinto based on the size of the defectand classified it as < 20% , 20 – 45%, > 45%, and simpleor complex when associated with a fracture.

MECHANISM OF INJURY:An axial force applied to the upper extremity in thevulnerable position of adduction, internal rotation, andforward elevation dislocates shoulder posteriorly.Seizureprimarily or secondary to metabolic abnormalities, alcoholor drug withdrawal (5)and electric shock orelectroconvulsive therapy which produces intensecontraction of the Strong Internal rotators overpowersthe weak external rotators

PATHOANATOMY:Shoulder is most mobile ball and socket type joint,

inherent bony anatomy and glenohumeral ligamentsform the static stabilizers and surrounding musculaturesprovides a dynamic stabilization.

During dislocation the anterior capsular structurebecomes tense like a cord and serves as a checkrein toposterior dislocation. It is associated with pl lesion and pathognomonic anterior impression fracture(reverse hill sach).

The significance of impression fracture is ittion point which ends with fracture of anatomical neck.The defect may lead to genohumeralarthritis;direct correlation exists between defect size and jointstability and also to plan the treatment protocol.

DIAGNOSIS:High index of suspicion is very important to diagnose thecondition.H/O convulsive disorder, metabolic disorders, alcohol ordrug abuse and trauma due to electric shock is key. O/Epatient presents with a prominent coracoid, an anteriorglenohumeral void, caused by posterior position of


humeral head and squared off anteriorlateral acromionand overlying of soft tissues.

Limb is held in internal rotation with markedrestriction of external rotation and abduction.

Rowe and Zarins test, inability to supinate theforearm when the arm is forward flexed because of theinternal-rotation deformity

Most often misdiagnosed as frozen shoulder.X-ray evaluation with standard AP, axillary,

velpeau and scapular lateral views are most helpful.Inadequate evaluation is common cause of delay indiagnosis. The light bulb sign, vacant glenoid sign theMoloney’s line(13) analogous to Shenton’s line whichruns along the inferior aspect of glenoid rim and continuesalong the inferomedial aspect of the humeral head andneck. Three dimensional CT scan is of great help indiagnosingand planning the treatment protocol. MRIreveals the characteristic posterior capsulolabral and cuffinjury.

We report a case of neglected posteriordislocation of shoulder joint with the defect size of <25%. Patient presented to us 3 months post injury withpain and restriction of external rotation and abduction.Immediately after injury he was treated conservativelyelsewhere, initial diagnosis was missed on x-rays. Onevaluation unreduced posterior dislocation wasdiagnosed with a reverse hill Sachs lesion of < 25%.Modified McLaughlin procedure was done, openreduction using deltopectoral approach joint wasreduced but was unstable so transfer of upper thirdSubscapularis tendon into the defect secured withethibond through drill hole, stable joint achieved.

He was immobilized in external rotation andabduction splint for three weeks and later mobilized.One year post op patient has regained pain freecomplete ROM and satisfactory mean constant score.

TREATMENT:The determinants like duration of dislocation, size

of humeral head impression fracture, presence offracture, viability of humeral head will determinetreatment protocol Skillful neglect (9) has been advisedin elderly debilitated patients or the one with behavioralor psychiatric disorders.

Take Home Message;High Index of Suspicion, Timely clinical and Radiologicalassessment can avoid misdiagnosis.

REFERENCES1.McLaughlin H. Posterior dislocation of the shoulder.J Bone JointSurg Am 1952;24(3):584–90.2 .Detenbeck LC. Posterior dislocations of the shoulder.J Trauma.1972;12(3):183–92.3.MatsenFAIII, TitelmanRM, Lippitt SB, et al.Glenohumeral instability.In: Rockwood CA Jr,Matsen FA III,WirthMA, et al, editors. Theshoulder, vol. 2. 3rd edition. Philadelphia: Saunders; 2004. p. 655–794.4.Rowe CR. Prognosis in dislocations of the shoulder. J Bone JointSurg Am 1956;38(5):957–77.5.Robinson CM, Aderinto J. Posteriorshoulder dislocations and fracture-dislocations. J Bone Joint SurgAm 2005;87(3):639–50.6.May VR Jr. Posterior dislocation of the shoulder habitual, traumatic,and obstetrical. Orthop Clin North Am 1980;11(2):271–85.7.Hawkins RJ, Belle RM. Posterior instability of the shoulder. InstrCourse Lect 1989;38:211–5.8.Heller KD, Forst J, Forst R, et al. Posterior dislocation of theshoulder: recommendations for a classification Arch Orthop TraumaSurg 1994;113(4):228–31.9.Loebenberg MI, Cuomo F. The treatment of chronic anterior andposterior dislocations of the glenohumeral joint and associatedarticular surface defects.10.Orthop Clin North Am 2000;31(1):23–34. Dorgan JA. Posteriordislocation of the shoulder.Am J Surg 1955;89(4):890–900.11. Gerber C, Lambert SM. Allograft reconstruction of segmentaldefects of the humeral head for the treatment of chronic lockedposterior dislocation of the shoulder. J Bone Joint Surg Am1996;78(3):376–8212.Keppler P, Holz U, Thielemann FW, et al. Locked posteriordislocation of the shoulder: treatment using rotational osteotomy ofthe humerus. J Orthop Trauma 1994;8(4):286–92.13.Traumatic Posterior Glenohumeral Dislocation: Classification,Pathoanatomy, Diagnosis,and Treatment Marc S. Kowalsky, MD,William N. Levine, MD*14.ASPECTS OF CURRENT management posterior dislocation ofthe shoulder, N. Cicak From the University of Zagreb, Croatia JBone Joint Surg [Br] 2004;86-B:324-32.


MANAGEMENT OF LATE INFECTION IN

TOTAL KNEE ARTHROPLASTY – A CASE SERIES

Vidya Sagar U, Ravi Kumar. M, Dhanalakshmi. D and Ramesh. TEDept. of Orthopaedic Surgery, Southern Railway HQ Hospital, Chennai, India.

ARTHROPLASTY

ABSTRACT :

Infection after TKA is devastating to the patient as it is expensive, prolongs thetreatment period and diminishes the final functional outcome. Diagnosis can be difficultand relies on multiple factors such as clinical, imaging and laboratory findings. Treatmentmodalities range from antibiotic suppression with implant in-situ to implant replacementin two stage procedure and rarely amputation with the goal of infection eradication andpain free, functional joint. We are reporting a series of cases of infected TKA, ofwhich, two cases are treated by revision TKA in two stage procedure and one case istreated by open debridement along with polyethylene exchange. No recurrence ofinfection is observed after different periods of follow up for all the three cases.

INTRODUCTIONTotal knee arthroplasty (TKA) is a common

surgery for end-stage knee arthritis that is associatedwith significant improvements in pain and function.Infection is the most challenging complication followingTKA effecting 1-2 % of primary TKAs and3-5 % of revision TKAs1. The percentage of infectioncan be still higher with increasing availability andaccuracy of diagnostic techniques. On the basis of variablecriteria, appropriate plan of treatment to be done witheradication of infection as the initial goal. In this paper,we are reporting a series of three cases of infected TKA.

Case reports: Case 1:An 80 year old male patient presented to our

outpatient department with osteoarthritis of bilateral kneejoints. ROM was 0-1000 at left knee. Patient underwentleft TKA with PS plus implants and patellar resurfacing.Post-operative period was uneventful. Wound healedwell. After 7 months of primary TKA, patient presentedwith knee pain and pus discharge from the scar for aperiod of 10 days. There was local rise of temperatureand tender palpable inguinal lymph nodes. ROMwas reduced. X-ray showed no implant loosening. Total

leucocyte count (15600 cells/mm3), ESR (84mm) andCRP were raised. Pre-operative and intra-operative pusculture showed Staphylococcus aureus, sensitive toClindamycin.

We have done revision TKA in two stageprocedure. In first stage, after implant exit, synovectomy,thorough debridement and irrigation of the joint alongwith implantation of articulating antibiotic spacer usingvancomycin mixed cement were done in the order,followed by 6 weeks of intravenous clindamycin.There was eczema and blackish pigmentation of skinafter spacer implantation. So second stageprocedure wasdone only 5 months of first stage. Infection eradicationwas confirmed by clinical and serological examination.Spacer was removed along with cement. Joint wasirrigated thoroughly and unhealthy tissues were debrided.For revision TKA, rotating hinged prosthesis (Fig. 1) wasused along with antibiotic mixed cement. Intra operatively,lateral femoral condyle fracture occurred. So patient waskept in non- weight bearing walk for six weeks. Patientis followed for 7 months. ROM is 0-120o.Except the progressive skin pigmentation, there are nofeatures of recurrent infection.


Figure 1. Rotating hinged prosthesis in revision TKA toprevent instability in the knee after thorough debridementin infected TKA

Figure 2. Articulating antibiotic spacer after prosthesisremoval in infected primary TKA

Case 2:A 60 year old male patient, presented with left

knee pain and swelling for a period of two days. Heunderwent left TKA two years ago. Past history revealedthat he has undergone multiple surgeries in left kneeperiarticular area (left distal femur ORIF with DCSsixteen years ago, implant exit six years ago andarthroscopic abrasive arthroplasty five years ago). Localexamination revealed signs of acute inflammation andmovements were restricted due to pain. No radiologicalsigns of implant loosening. TKA infection was confirmedwith pus aspiration. Culture report showedStaphylococcus aureus, sensitive to Clindamycin.Revision TKA was done in two stage procedure usingarticulating antibiotic cement spacer in 1st stage and PSplus components with long stems in 2nd stage. Fourmonths interval was given between the stages as theESR was not reduced for long duration.

Case 3:A 66 year old lady, presented with bilateral knee

pain and difficulty in flexion of the knee since 2 yearsand gradually progressive. Examination revealed jointswelling and multiple loose bodies. ROM is 0-70o & 0-90o in left and right knee respectively. Bilateral kneesynovial chondromatosis (Fig. 3) with osteoarthritis wasdiagnosed from x-ray findings and planned for bilateralTKA. TKA was done on both sides with two weeksinterval. Intra-operative tibial plateu bone defects werenoted on both sides and was augmented with a boneblock using a cortical screw.

Figure 3. Synovial chondromatosis: x-ray andintraoperative images

After 3 years, she presented with sudden onset of painin left knee with local rise of temperature. Patient wasdoing well for a period of 3 years with functional ROMin both the joints. CRP, ESR and leucocyte count wereraised. Aspiration showed 25ml of straw coloured fluid,culture report of which showed Staphylococcus hominis.No pus cells were found in microscopy. As we werewaiting for culture report, local inflammation wasdecreased gradually without any antibiotic usage. It couldbe due to the low virulence of the organism, commonlyseen in acute haematogenous infection of previously wellfunctioning TKA. X-ray showed no loosening of theimplant. We have done open debridement withpolyethylene liner exchange. Insall’s Quadriceps snipprocedure was used for patellar eversion as we feltdifficulty in doing so.

DISCUSSIONInfection is a devastating complication in TKA

patients. Current infection rate is 1-2% in primary TKAand 3-5% in revision cases1. This number is increasingwith increased rate of TKAs. Hospital source utilizationis four times that of primary TKA and twice that ofaseptic revision.


Increased infection rates with constrained implantscould be due to increased chances of loosening and so thedebris formation which is conductive to bacteria3. Anatomicalfactors like superficial position of the joint, poor vascularityof the soft tissue covering the anterior aspect of the kneeincrease the complications of wound healing and infection.

Estimated bacterial shedding is 1,000-10,000 organisms/min/person4. Repeated surgeries increase the seeding of bacteriaas well as scar tissue with poor vascularity. Body exhaustsuits, impermeable gowns, shoe covers, double gloving withfrequent change and vertical laminar air flow systems canreduce the intraoperative infection rate.

Infact, there is no effective treatment forvancomycin resistant enterococci. Bactrial adhesion topolymers and metal components via glycoproteins andpili increases the resistance5, where as the productionof glycocalyx increase the virulence of some bacteria byprotection from antibiotics and host defence. Consultationwith infectious disease specialist will be helpful intreatment plan.

For routine cases, prophylactic antibiotics of 24hour duration is adequate6, but 48 hour duration may beneeded if catheters or drains are kept in-situ. There arevariable opinions regarding use of prophylactic antibioticsin cement. Most common indication is septic revisionsurgery. There are concerns about allergic reaction,organism resistance and effects on structural properties7of cement due to antibiotics.

Current definition of prosthetic infection includesa combination of clinical signs and symptoms, histologicanalysis of tissue, and results of cultures. The diagnosisof definite infection is made if evaluation of the kneeestablishes at least one of the following criteria8 :(1) two or more cultures obtained by aspiration or deeptissue specimens obtained at surgery yield the sameorganism,(2) histopathologic evaluation of intra-articular tissuereveals changes in acute inflammation,

(3) gross purulence is observed at the time of surgery, or(4) an actively discharging sinus tract is evidentInfections with MRSA & MRSE are emerging andtreatment success rate is 18%, compared to 89% inmethicillin sensitive organisms. Two stage revision TKAis the viable option in infection with resistant organisms.Prosthetic joint infection with candida or TB is rare.

Sometimes diagnosis of infections will be difficult.Factors such as persistent pain after the surgery,prolonged wound drainage, antibiotic treatment for wound


healing, and knee stiffness despite extensive rehabilitationindicates deep infection. Culture of samples obtainedby sonication of prostheses was more sensitive9especially in those who had received antibiotics within14 days of surgery. PCR can identify the DNA of eventhe dead bacteria with excellent sensitivity10, but thefalse positive tests will be more due to high sensitivity.

IL-6 is a cytokine that returns to baseline in 2-3 days ofsurgery. It has a sensitivity of 100% and specificity of95% in diagnosing infected TKA11. In diagnosticdifficulty, intraoperative evaluation of tissue specimensmay be necessary. Frozen section testing to detectinfection was used with variable accuracy12.

Persistent wound drainage is strongly suggestiveof infection and probably should be treated witharthrotomy, débridement, and irrigation. Management ofdelayed wound healing or marginal skin necrosis bydébridement of necrotic skin and primary wound closureis preferable14. Empirical prolonged antibiotic use shouldnot be done to avoid deep infection or chronic prostheticjoint infection.

Goals of the treatment should be in the order oferadication of infection, alleviation of pain andmaintenance of functional knee15. Before initiationof treatment, consider14 whether infection is superficialor deep, time between arthroplasty and diagnosis, hostfactors that effect the treatment, integrity of extensormechanism, whether implant is loose or well fixed,virulence of pathogen, expectations of the patient andexperience of the surgeon .

Treatment options14 include a. Antibioticsuppressionb. Open debridement with/without poly exchange c.Revision TKA in one/two stage procedured. Arthrodesise. Resection arthroplasty f. Amputation

Success of antibiotic suppression was only 18%and cannot be used unless the patient is unfit forsurgery14,16.

Open débridement can be indicated for infectionin the early postoperative period (type 2) or for acutehematogenous infection (type 3) of a well functioningprosthesis. Criteria14 for this treatment are (1) short

duration of symptoms (less than 2 weeks), (2) susceptiblegram-positive organisms, (3) absence of prolongedpostoperative drainage or a draining sinus tract, and (4)no prosthetic loosening. With open debridement, successrate is 71% in a study where patient selection criteriaare strictly followed, otherwise only 33% success rateis reported17. Success rate is higher with polyethyleneliner exchange as it allows better debridement of posteriorsynovium and eliminates biofilm on polyethylene18.

Re-implantation of new prosthesis is currentlyprimary accepted method of treatment with success rateof 91% in two stage procedure19 and 81% in single stageprocedure20. Contra-indications for re-implantation arepersistent infection, disrupted extensor mechanism andpoor soft tissue over the knee. Optimal duration and routeof antibiotics is not clearly determined, but 4 to 6 weeksof intravenous antibiotics showed good result14. Factorsassociated with successful direct exchange21 are (1)infection by gram-positive organisms, (2) absence ofsinus formation, (3) use of antibiotic-impregnated bonecement for the new prosthesis, and (4) a prolonged 12-week course of antibiotic therapy.

Antibiotic impregnated cement has improvedinfection control22. Gentamycin, vancomycin,tobramycin and cefuroxime are commonly used antibioticsin bone cement23. Recommended doses of antibioticsare 2-5 times higher than that will be used forprophylaxis24.


Static spacer is the molded antibiotic cement placed inthe joint space between the stages of surgery. It preservesthe joint space, stabilises the knee and gives rest to thejoint. But it causes soft tissue erosion, contracture, boneloss and difficulty in secondary exposure25,26.Articulating spacer allows joint motion, lesser scarring,easy surgical exposure, better post operative ROM andfunctions27. Articulating spacer can be metal onpolyethylene or cement on cement. Disadvantageswith articulating spacer are risk of cement fracture,spacer dislocation and problems with wound healing28.

CONCLUSIONDiagnosis of TKA infections remain difficult and

is based on a combination of clinical, serological, imagingand laboratory findings. Ultrasonication of retrievedimplants, in combination with molecular diagnostictechniques improve the diagnostic ability. Two stagerevision TKA utilising antibiotic cement has bettersuccess at infection eradication. Use of an articulatingspacer reduces scarring & bone loss, gives good secondstage exposure and preserves the joint range of motion.

REFERENCES

1. Blom AW, Brown J, Taylor AH, Pattison G, Whitehouse S,Bannister GC.Infection after total knee arthroplasty. J Bone Joint Surg Br 2004;86(5): 688-91.2. Insall & Scott’s ‘Surgery of the Knee’, 3rd ed, chapter 90.3.Johnson D, Bannister G. Outcome of infected arthroplasty of theknee. J Bone Joint Surg Br 1986; 68:289.4. Ritter M. Intraoperative controls for bacterial contamination duringtotal knee replacement. Orthop Clin North Am 1989; 20:49.5.Kendall R, Duncan C, Smith J, et al. Persistence of bacteria onantibiotic loaded acrylic depots. Clin Orthop 1996; 329:273.6. Mauerhan D, Nelson C, Smith D, et al. Prophylaxis against infectionin total joint arthroplasty. J Bone Joint Surg 1994; 76:39.7.Wright T, Sullivan D, Arnoczky S. The effect of antibioticadditions on the fracture properties of bone cements. Acta OrthopScand 1984; 55:414.8. Ghanem E, Parvizi J, Burnett RS, et al. Cell count and differentialof aspirated fluid in the diagnosis of infection at the site of total kneearthroplasty. J Bone Joint Surg Am 2008; 90(8): 1637-43.9. Trampuz A, Piper KE, Jacobson MJ, et al. Sonication of removedhip and knee prostheses for diagnosis of infection. N Engl J Med2007; 357(7): 654-63.

10. McDowell A, Patrick S. Evaluation of nonculture methods for thedetection of prosthetic hip biofilms. Clin Orthop Relat Res 2005; (437):74-82.11. Di Cesare PE, Chang E, Preston CF, Liu CJ. Serum interleukin-6as a marker of periprosthetic infection following total hip and kneearthroplasty. J Bone Joint Surg Am 2005; 87(9): 1921-7.12. Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis ofperiprosthetic infection. J Bone Joint Surg Am 2006; 88(4): 869-82.13. Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB.Infection after total knee arthroplasty: a retrospective study of thetreatment of eighty-one infections. J Bone Joint Surg Am 1999;81:1434–1445.14. Insall & Scott’s ‘Surgery of the Knee’, 5th ed, chapter 128.15. Hanssen AD, Spangehl MJ. Practical applications ofantibioticloaded bone cement for treatment of infected jointreplacements. Clin Orthop Relat Res 2004; (427):79-85.16. Haddad FS, Adejuwon A. The management of infected total kneearthroplasty.Orthopedics 2007; 30(9): 779-80.17. Schoifet SD, Morrey BF. Treatment of infection after total kneearthroplasty by debridement with retention of the components. J BoneJoint Surg Am 1990; 72(9):1383-90.18. Rand JA. Evaluation and management of infected total kneearthroplasty. Semin Arthroplasty 1994; 5(4): 178-82.19. Insall JN,Thompson FM, Brause BD. Two-stage reimplantation for the salvageof infected total knee arthroplasty. J Bone Joint Surg Am 1983; 65(8):1087-98.20. Lombardi AV, Jr, Karnes JM, Berend KR. A motion maintainingantibiotic delivery system. J Arthroplasty 2007; 22(4 Suppl 1): 50-5.21. Silva M, Tharani R, Schmalzried TP. Results of direct exchange ordebridement of the infected total knee arthroplasty. Clin Orthop RelatRes 2002; (404): 125-31.22. Garvin K, Salvati E, Brause B. Role of gentamycin impregnatedcement in totalknee arthroplasty. Orthop Clin North Am 1988; 19:605.23. Niraj V. Kalore, Terence J. Gioe, Jasvinder A. Singh. Diagnosisand management of infected total knee arthroplasty. The Open OrthoJ 2011; 5:86-91.24. Hanssen AD, Spangehl MJ. Practical applications of antibioticloaded bone cement for treatment of infected joint replacements. ClinOrthop Relat Res 2004; (427): 79-85.25. Fehring TK, Odum S, Calton TF, Mason JB. Articulating versusstatic spacers in revision total knee arthroplasty for sepsis. TheRanawat Award. Clin Orthop Relat Res 2000; (380): 9-16.26. Calton TF, Fehring TK, Griffin WL. Bone loss associated with theuse of spacer blocks in infected total knee arthroplasty. Clin OrthopRelat Res 1997; (345): 148-54.27. Jamsen E, Sheng P, Halonen P, et al. Spacer prostheses in twostage revision of infected knee arthroplasty. Int Orthop 2006;30(4):257-61.28. Jacobs C, Christensen CP, Berend ME. Static and mobile antibiotic-impregnated cement spacers for the management of prosthetic jointinfection. J Am Acad Orthop Surg 2009; 17(6):356-68.


MODIFIED ANTERIOR-ONLY REDUCTION AND FIXATION FOR

TRAUMATIC CERVICAL FACET DISLOCATION

(AO TYPE C INJURIES)

Dr Rishi M Kanna, Dr Ajoy P Shetty, Prof S RajasekaranDepartment of Orthopaedics and Spine Surgery, Ganga Hospital Coimbatore

ABSTRACTSurgical reduction of uni and bi-facetal dislocations of the cervical spine (AO Type CInjuries) can be performed by posterior, anterior or combined approaches. Ease ofaccess, low infection rates and less risks of neurological worsening has popularizedanterior approach. However reduction of locked cervical facets can be intricatethrough anterior approach. We analysed the safety, efficacy and outcomes at a minimumone year, of a novel anterior reduction technique for consecutively treated cervicalfacet dislocationsMaterials & Methods:Patients with single level traumatic sub-axial cervical dislocation (n=51) treated bythis modified anterior technique, with a minimum follow-up of one year were studied.The technique involved standard Smith-Robinson approach, discectomy beyond PLL,use of inter-laminar distracter to distract while Caspar pins were used as “joysticks”(either flexion-extension or lateral rotation moments are provided), to reduce thesub-luxed facets. Four patients who had spontaneous reduction and 8 treated byplanned global fusion were excluded.Results39 patients of mean age 49.9 years (M:F- 30:9) were studied. The levels of injuryincluded (C3-4=2, C 4-5=5, C5-6= 20, C6-7= 12). 18 were bi-facetal and 21 were uni-facetal dislocation. One facet was fractured in 17 and both in 5 patients. 30% (n=13)had a concomitant disc prolapse. The neurological status was as follows: 9 ASIA A, 9ASIA C, 13 ASIA D and 8 ASIA E. All the patients were successfully reduced by thistechnique and fixed with anterior locking cervical locking plates. No supplementalposterior surgery was performed. 22 patients with incomplete deficit showed recovery.The mean follow-up was 14.3 months and there was no implant failure except onepatient who had partial loss of the reduction.Conclusion:Patients with traumatic sub-axial cervical dislocation (AO Type C Injuries) can besafely and effectively reduced by this novel anterior technique. Other advantagesinclude minimal blood loss, less risks of infection, shorted fusion zone, good fusionrate and neurological recovery.Keywords: cervical spine; injury; facet; dislocation; anterior; reduction

INTRODUCTIONCervical traumatic facet dislocations (AO Type

C Injuries) are common type of traumatic sub- axialspinal injuries and require reduction, either by closed oropen methods. The management has beencontroversial with some surgeons favoring closedreduction followed by external immobilization or internalfixation [1,2], and others favoring direct surgical

reduction [3,4]. Surgical reduction of uni/bi-facetaldislocations of the cervical spine can be performed byposterior, anterior or combined approaches. Since thefacet subluxation is the major impediment to successfulreduction, posterior reduction techniques have beenpopular but have the disadvantages of risking neurologicaldeterioration in the presence of traumatic prolapse, need

SPINE


for long segment fixation, due to associated fractures ofthe lateral mass, chronic post-operative axial pain andneed for concomitant anterior fusion. Several studieshave shown that the incidence of traumatic cervicaldisc injury and prolapse in patients with cervical facetdislocation can be as high as 40% portending to risks ofneurological injury if reduction is attempted without aprior anterior cervical discectomy [5,6].

Various benefits such as the ease of surgicalaccess, less infection rates and reduced risks ofneurological worsening has enabled surgeons, of late, tofavor anterior techniques of reduction for cervicaldislocation [7]. Standard anterior technique involvesaccess through a Smith Robinson approach, anteriorcervical discectomy and reduction of subluxation by acombination of distraction and reduction enabled byCaspar distractor or an inter-body spreader. However,reduction of locked cervical facets through the anteriorapproach can be difficult and sometimes impossible (Fig1). As described in the literature, the simultaneousapplication of traction and extension maneuver using thesame instrument (Caspar distracter/ inter-laminarspreader) do not allow un-locking of the facets [8].Repeated reduction attempts can be dangerous to theneural tissue and surrounding vascular structures. Hencewe used separate instruments for maneuvering thevertebral body and inter-body distraction, therebyenabling safe and successful reduction. We used thismodified anterior only reduction and fixation techniquein consecutive patients with uni/bifacetal dislocation andthe intra-operative ease, safety, efficacy and the post-operative clinical and radiological outcomes wereanalysed at a minimum of one year.

MATERIAL AND METHODSInstitutional review board approval was sought

for the study. The study was a review of case recordsof patients with single level traumatic sub-axial cervicaldislocation from C3-4 to C6-7 who have been operatedusing this modified reduction technique between January2014 and September 2015, with a minimum follow-upof one year were studied. Patients who were plannedfor 360° fusion (based on indications including multi-levelcervical injury, fused spine, adjacent level spinousprocess fractures, extensive posterior ligamentousdisruption), concomitant fracture of the vertebral body,presentation later than 2 weeks and those who had aspontaneous reduction of the dislocation before applyingthis reduction maneuver were excluded from the study.

All other patients with cervical uni/ bi-facetaldislocations were operated by this technique.

All dislocations were reduced only by opentechnique and no attempts at pre-operative reduction

were attempted. All patients had completeradiographic evaluation including cervical spineradiographs, CT and MRI scan to assess the severity ofthe bony injury, status of facet joints and the extent ofinjury to the disc and posterior ligamentous complex.Surgical technique:

After manual in-line stabilization and endotrachealintubation, the patient was placed in a supine positionwith the neck placed in a head ring and a sand bagplaced between the scapulae. No cervical traction wasapplied. Through a transverse skin incision and standardSmith- Robinson approach, the injured cervical spine wasexposed.

The following steps are useful in the safe andsuccessful execution of the reduction.STEP 1:After identifying the sub-luxed segment, Casparpins were placed on adjacent vertebral bodies parallel tothe vertebral endplates in the cranio-caudal plane andgently distracted. Use of image intensifier helps in theappropriate placement of pins. In the medio-lateral plane,it is essential to place the pins perpendicular to the planeof displacement in uni-facetal subluxation (Fig 2). Forexample, if the right C4-5 joint is dislocated, the C4rotates anteriorly more towards the right side. So theCaspar pin was passed from a left to right direction inthe C4 body. In bi-facetal dislocations, the pins are placedin both the vertebral bodies in the same plane.STEP 2: Anterior cervical discectomy was performedensuring complete decompression beyond the posteriorlongitudinal ligament and till the uncovertebral joints oneither side.STEP 3: Till this stage, the Caspar pin distracters wereused for distraction. The appropriate distraction wasconsidered achieved till the facet joints are seen perchedin the lateral view of image intensifier picture. At thisstage, an inter-body spreader was placed between thevertebral bodies to sustain the distraction.STEP 4: The Caspar distracter was now removed leavingthe Caspar pins in the vertebral body. Now the inter-body spreader acts only as the distracter while theCaspar pins were used as “joy sticks”. The pins weremoved to provide a transverse rotation or flexion-extension moment, depending on the side of facetsubluxation (Fig 3). Use of image intensifier guidance inthe lateral view helps in deciding on the appropriatedistraction force and direction of joy stick maneuverswith the Caspar pins.STEP 5: Once reduction is achieved, the inter-bodyspreader was removed and the interbody space is filledwith either an appropriate sized titanium cage ortricortical iliac crest bone autograft (Fig 4).


STEP 6: Suitable size anterior cervical locking plate wasfixed to secure the reduction. A slight convex contour tothe plate provides a three point compression forceholding the reduction in place.The wound is closed over a suction drain. Depending onthe patient’s neurological status, the patient is mobilizedon second day with the support of a cervical collar. Thecollar was discontinued after 6 weeks. No supplementalposterior surgery was performed in any of the patients.The adequacy of reduction was assessed bychecking the alignment of posterior vertebral line andspino-laminar line. Any displacement of the posteriorvertebral line less than2mm and angulation up to 5 degrees were consideredacceptable. Patients’ were followed up periodically withradiographs of the cervical spine and functionaloutcomes based on VAS for neck pain and ASIAneurological scores till one year. Patient’s demographics,radiographicfactors, intra-operative variables and post-operative clinical and radiological outcomes wereanalyzed.

Fig. 1 : Problems in the reduction of cervical facetdislocation by anterior approach. (Schematicrepresentation). a: Normal cervical motion segment, b:Anterior Cervical facetal subluxation, c: Use of inter-body spreader causing distraction but with perchedfacets posteriorly, d: Similarly the use of a Caspar pindistractor alone may impede reduction of the facetdislocation.

Fig. 2 :Placement of Caspar pins parallel to the endplatesin the sagittal plane (a) and perpendicular to the vertebralbody in the axial plane (b) is important for reduction

Fig 3 :The modified reduction technique. The inter-bodyspreader provides the distraction forces while theCaspar pins are used as joy-sticks to reduce thedislocation. Flexion-extension moments are given in thesagittal plane (a) while transverse rotatory moments areprovided in the axial plane (b).

Fig 4 :Steps in the reduction technique. a): Lateral view showing C6-7 uni-facetal subluxation. b,c): Placement of Caspar pins in theappropriate AP (b) and lateral views (c). d): While the distractionis maintained by the inter-body spreader, the Caspar pins aremaneuvered to achieve the reduction. e): Reduction achieved andinter-body spreader has been removed.


This 50 year old male patient presented with traumaticC6-7 bi-facetal dislocation. The AP and lateralradiographs show the subluxation (a,b). The reductionhas been achieved and fixed with anterior fusion withplating (c,d)

RESULTSDuring the study period, 51 patients with uni/

bifacetal dislocation have been treated in our institute.Four patients who had spontaneous reduction of thedislocation after anesthesia and 8 patients treated by pre-operatively planned combined anterior and posteriorfixation during the study period (multi-level cervical injury(n=2), fused spine (n=2), adjacent level spinous processfractures (n=2), extensive posterior ligamentousdisruption (n=2) were excluded. The remaining39 patients whom were treated by this technique formedthe study group.

The mean age of the patients was 49.9 ± 4.5 years(male: female - 30:9). The levels of injury included (C3-4 = 2, C4-5 = 5, C5-6 = 20, C6-7 = 12). Sagittal CTimages showed that 18 patients had bi-facetal dislocation(46%) and 21 were uni-facetal dislocations (54%). Thefacets were intact without a fracture in 17 patients whileone facet was fractured in 17 and both were fracturedin 5 patients. Sagittal T2 MRI sections showed that 13patients had a traumatic disc prolapse (30%). The timeto surgery from injury was as follows: 5 within 24 hours,14 in 48 hours, 5 in 72 hours and 15 in more than 72hours. The longest delay was 10 days in two patients.Eight patients were neurologically intact and 31 haddeficits, which were as follows: 9ASIAA, 9 ASIA C, 13ASIA D. (ASIA-American Spinal Injury Association –ASIA)

All patients were operated by the same surgicalteam. All the patients were successfully reduced by thismethod and no supplemental posterior surgery wasperformed. The disc space was filled with an inter-bodycage in 33 patients, and in 6 patients, tricortical iliac crestgraft was used and the segment was fixed with lockedcervical plating (Fig 5). All patients had adequatereduction as per the assessment criteria for alignment ofposterior vertebral line and spino-laminar line. Onepatient (42 year old male with C6-7 bi-facetal dislocationand ASIA C neurology) had a partial loss of reduction atthe end of 6 weeks but refused revision surgery. Themean blood loss was 165 ± 43 ml and the mean surgicalduration was 124 ± 32 minutes. None of the patients had

a neurological worsening during the reduction. The meanfollow-up was 14.3 months and there was no implantfailure at the final follow-up, except one patient who hadpartial loss of the reduction at the end of six weeks.Four patients with ASIA A neurology died during thefollow- up. All ASIAA patients remained as A, while 5of ASIA C improved to D and 4 improved to E,and allASIA D improved to E. The mean VAS score for neckpain at the end of one year was 2.2 ±1.2.

DISCUSSIONThe present study shows that the modified anterior

reduction technique is a safe and effective method toacquire reduction in cervical facet dislocations. Theability to independently control the subluxated vertebralbodies with the Caspar pins while simultaneous distractionwas applied through inter-body distracter is a keyelement in this technique. Irrespective of the level ofinjury, presence or absence of facet injuries and severityof dislocation, all dislocations treated within 2 weekswere successfully reduced and fixed with this approachand a supplemental posterior fixation was not deemednecessary. At a mean follow-up of 14.3 months, all butone patient had stable maintenance of the reduction.Cervical traumatic facet dislocations (AO Type CInjuries) result from flexion-distraction injuries to thesub-axial cervical spine. These are one of the commoninjuries of the cervical spine and are often associatedwith neurological compromise (9% in our study). Thusearly reduction of the subluxation is advised to providethe best chance for neural recovery. Reduction isachieved either by early or closed reduction methods.Traditionally, these injuries are treated with closedreduction followed by external orthotic immobilization/surgical fusion or by open posterior reduction and fusion.Since the facet injury is the major impediment tosuccessful reduction, posterior reduction techniques havebeen popular.

While the posterior technique is simple with goodresults, few studies have reported the development orworsening of neurological deficit after reductionattributed to the presence of a co-existent disc prolapse[9,10]. Subsequently greater attention was divertedtowards the association between cervical facetdislocation and traumatic disc herniation. Many authorshave suggested that the incidence of this association maybe higher than previously believed and ranges from 0.7%to 42% [11-13]. Rizzolo, et al., showed that the incidenceof disc disruption may be as high as 40% in cases ofunilateral cervical facet dislocation and 80% in cases ofbilateral cervical facet dislocation. In our series, weobserved that 30% of our patients had traumatic discherniation. Magnetic resonance imaging is an effective


tool to identify traumatic disc herniations in associationwith cervical facet dislocations. But MRI still may notpredict the development of disc herniation during posteriorreduction because the disc may be severely disruptedbut not herniated.The second concern about posteriorreduction is the extent of posterior instrumentation. Thepresence of broken facet is an impediment to lateralmass screw fixation and hence there is a need to extendthe instrumentation to adjacent normal segments. In ourstudy, 22 patients had a fractured facet (one facet wasfractured in 17 and both in 5 patients), and if a posteriorreduction and fixation had been performed, 56.4% ofour patients would have had a longer fusion than whathas been done anteriorly. Further posterior surgery hasa higher infection rate compared to anterior cervicalspine surgery as quoted in many studies, especially in atrauma situation [14- 16]. The incidence of postoperativewound infections in anterior cervical discectomy andfusion is 0.1%–1.6% while the incidence of surgical siteinfection after posterior cervical surgery is quoted tobe as high as 18%. Chronic post-operative neck paindue to para-spinal muscle atrophy, higher chances ofpseudoarthrosis, nerve root injury due to misplaced lateralmass screws and the need for concomitant anteriorsurgery after a posterior fixation are other pitfalls ofposterior approach to be considered in patients withcervical facet dislocation.

The potential difficulties perceived with posteriorapproach for cervical dislocation resulted in thedevelopment of anterior techniques of reduction.The advantages of anterior cervical approach beginwith the ease of supine positioning in a patient withunstable spine injury and a safe and bloodless SmithRobinson approach to access the subluxated spine.Ventral decompression enables the cervical disc prolapseto be managed simultaneously thus eliminating the riskof extruded disc fragments encroaching the spinal cordwhile reducing and stabilizing the cervical facetdislocation. Almost always only a single motion segmentis fused and compared to posterior surgery has a lessrate of non-union and post-operative infection.Ordonez et al were one of the first to describe anteriorreduction for facetal subluxation. They reported on 10patients whom were treated by this approach. Theyhad described several reduction measures such asplacing the Caspar pins at approximately a 10 to 20°divergent angle with respect to each other in thesagittal plane to disengage the locked facets. Theyalso suggested other techniques like dorsally directedpressure to the upper vertebral body using manualpressure, use of a curette as a lever arm that forces therostral vertebral body into normal alignment, and use ofinter-body disc spreaders to distract and rotate for

correcting the deformity. In their short series of 10patients, except one patient, all patients had a successfulreduction. Ours is the largest series of facet dislocationsreduced and fixed by an anterior surgical approach.Amajor hurdle in the usage of anterior approach isthe difficulty in reducing the facetal subluxation. Thereduction of the ‘unseen’ locked cervical facets throughthe anterior approach can be difficult and sometimesimpossible. A basic intricacy in the described anteriorreduction techniques is that the simultaneous applicationof traction and extension or rotation maneuver by thedistracters do not allow un-locking of the facets.Repeated attempts at reduction cause injury to vertebralendplates and risks worsening of neurological deficit.Hence there is a need for separate instruments fortraction and maneuvering the vertebral body, therebyenabling safe and successful reduction. In our technique,we performed a thorough anterior discectomy beyondthe PLL. Then distraction was performed using an inter-body spreader while the Caspar pins were used as joysticks to provide appropriate reduction maneuvers. Withthis technique, we were able to achieve reduction in allthe patients completely. There were no complications.None of the patients required a posterior surgery andonly a supplemental cervical collar was provided. Exceptone patient, all other patients had good fusion and noimplant failure was detected during follow-up. Thepatient who had a partial loss of reduction wasasymptomatic and refused further revision surgery.

CONCLUSIONPatients with traumatic sub-axial cervical

dislocation (AO Type C Injuries) can be safely andeffectively reduced by this novel anterior technique. Thetechnique follows the bio-mechanical principles ofdistraction in combination with rotatory moments appliedin the sagittal and axial planes using separate instruments.With advantages like minimal blood loss, less risks ofwound infection and short fusion segments, the techniqueallows effective reduction and stable fixation thusenabling early mobilization and rehabilitation.

REFERENCES1.Alexander EJ Jr, Davis CT Jr, Forsyth HF: Reduction and fusion offracture dislocation of the cervical spine. J Neurosurg 27:588–591,19672.Benzel EC: Traumatic quadriplegia with dislocation and centraldisc herniation. J Spinal Disord 4:497, 19913.Benzel EC, Kesterson L: Posterior cervical interspinouscompression wiring and fusion for mid to low cervical spinal injuries.J Neurosurg 70:893–899, 19894.Berrington NR, van Staden JF, Willers JG, et al: Cervicalintervertebral disc prolapse associated with traumatic facetdislocations. Surg Neurol 40:395–399, 19935. Beyer C, Cabanela M, Berquist TH: Unilateral facetdislocations and fracture- dislocations of the cervical spine. J Bone


Joint Surg (Br) 73:977–981, 19916. Cahill DW, Bellegarrigue R, Ducker TB: Bilateral facet to spinousprocess fusion: a new technique for posterior spinal fusion aftertrauma. Neurosurgery 13:1–4, 19837. Capen D, Garland D, Waters R: Surgical stabilization of thecervical spine. A comparative analysis of anterior and posteriorspine fusions. Clin Orthrop 196:229–237,19858. Caspar W, Barbier DD, Klara PM: Anterior cervical fusion andCaspar plate stabilization for cervical trauma. Neurosurgery25:491–502, 1989 9. Cloward RB: Reduction of traumatic dislocationof the cervical spine with locked facets. Technical note. JNeurosurg 38:527–531, 19739. Cooper PR, Cohen A, Rosiello A, et al: Posterior stabilization ofcervical spine fractures and subluxations using plates and screws.Neurosurgery 23:300–306, 1988

10. Cotler HB, Miller LS, DeLucia FA, et al: Closed reduction ofcervical spine dislocations. Clin Orthop 214:185–199, 198711.de Oliviera JC: Anterior reduction of interlocking facets in thelower cervical spine. Spine 4:195–202, 1979.12. Doran SE, Papadopoulos SM, Ducker TB, et al: Magneticresonance imaging documentation of coexistent traumatic lockedfacets of the cervical spine and disc herniation. J Neurosurg 79:341–345, 199313. Eismont FJ, Arena MJ, Green BA: Extrusion of anintervertebral disc associated with traumatic subluxation ordislocation of cervical facets. Case report. J Bone Joint Surg (Am)73: 1555–1560, 199114. Goffin J, Plets C, Van den Bergh R: Anterior cervical fusionand osteosynthetic stabilization according to Caspar: a prospectivestudy of 41 patients with fractures and/or dislocations of the cervicalspine. Neurosurgery 25:865–871, 1989


AN INNOVATIVE AND NEW PLATE DESIGN PROTOTYPE FOR

CALCANEAL FRACTURES- ORTHODOX METHODOLOGY AIDED

BY ADVANCE TECHNOLOGY

Dr. Thirunarayanan.VAssociate Professor of Orthopaedic Surgery,

Govt. Royapettah Hospital, Chennai, Tamilnadu, India.

ABSTRACTBackground: Various designs of calcaneal locking plate are available. Mismatch insize and shape of the plates needs cutting and contouring, causing intraoperativedifficulty and softtissue irritation. The aim of our study is to do a morphological studyof calcaneum in indian population and design a new plate prototype.Materials & Methods: Measurements of morphological parameters of calcaneumwere done using CT scans of a 100 calcaneum. Three different mean values for 8parameters were arrived. Based on these measurments an innovative plate designusing CADD was made in three different sizes and tested mechanical propertiesanalysed. By overlap analysis method, plates were matched on calcaneum of 100 patientusing CArm and 50 cadaveric dry bones. Using 3D MAYA software these three sizesof plates and calcaneum was prototyped. Afteran intraoperative overlap analysis on 15 patients, the newly designed plate has beensuccessfully used in 10 patients. Screw holes were positioned in the region of densetrabeculae with sufficient support to the sustentaculum tali and the posterior articularfacet. Manufacturing was done with precision using CNC machines.Results: The small sized plate matched calcaneum of 20 patients, the medium sized54and large sized 26 patients. All dry bones also matched perfectly with one of ourthree sizes, 3D printing prototypes also matched correctly.Conclusions: CT Scan based morphological study, mechanical propertiestesting(ANSYS), overlap analysis in (Dry bones, C arm and live cases),CADD designing,3Dprinting technology, CNC machines were all used in designing this new plateprototype for calcaneum.Keywords: Calcaneal fracture, morphological study, plate design, 3D printing,

INTRODUCTIONCalcaneum is the most commonly injured tarsal

bone. Calcaneal fractures account for approximately2 % of all fractures, with displaced intra-articularfractures comprising 60–75 % of these injuries1.Conservative management of intra-articular calcanealfractures hardly achieve good anatomical reductionleading to mal union of fractures and early developmentof subtalar arthritis. Studies that have comparedconservative treatment vs open reduction and internalfixation showed a better outcome in the latter2,3,4,5,6.Open reduction and internal fixation ofdisplaced intra- articular calcaneal fractures is astandard procedure in many of the institutions now a

days.In India various designs of locking plate are

available for fixation of calcaneal fractures. Theseplates are mostly mismatching in size and needs cuttingand contouring, causing intra operative difficulty. Theoverhanging of plates also causes soft tissue irritation.Moreover mechanical or clinical data are not availablefor most of these implants used.Also the imported platesavailable are designed for western population whosebones are larger than Asians. The aim of our study is toassess morphological characteristics of calcaneum inIndian population and design a new plate prototype forcalcaneal fractures.

RESEARCH ARTICLE


Morphological Parameters of calcaneum aremeasured as shown in( fig 3 and fig 4):

Length of calcaneal axis: The length of the calcanealaxis (LCA): the distance from point G (the midpointbetween C and D) to point E.The length of the anteriorprocess (LAP): the distance between B and C. Theheight of the anterior process (HAP): the distancebetween C and D. The calcaneal tuberosity height: thedistance between F and I

The height of the posterior facet (HPF): theperpendicular distance from point A to the calcanealaxis. The length of the posterior facet (LPF): thedistance between A and BAngle of Gissane: intersection of line AB and line BCInclination angle: The inclination angle was measuredby taking two points 1cm behind the posterior facet.These two points were connected to join the calcanealaxis and the obtuse angle formed was measured.

The morphological parameters of all the calcaneums were measured. The valves of each morphological parameterwere summarized in to minimum, maximum and mean valve with standard deviation. The valves were put in threegroups male, female and average of both (TABLE 1).


Three-dimensional morphological parameters of the normal calcaneus

Total-100 Male - 52 Female - 48

Mean ± SD Min Max Mean ± SD Min Max Mean ± SD Min Max

Length of calcaneal axis 70.1 ± 5.4 54.8 81.6 75.3 ± 3.8 58.1 81.6 65.2± 4.1 54.8 73.

Calcaneal tuberosity height 32.2±2.9 25.6 35.5 34.8± 2.7 29.1 38.5 29.7± 1.8 25.6 33.6

Height of the anterior process 23.4± 3.6 18.4 32.6 26.2±1.6 20.4 32.6 21.4± 1.8 18.4 26.6

Length of the anterior process 21.8±1.8 16.5 24.6 23.1± 2.2 17.1 24.6 19.6±1.2 16.5 22.2

Length of the posterior facet 28.4± 2.4 18.4 31.2 31.1± 1.6 25.1 34.8 25.8 ± 2.1 19.4 28.1

Height of the posterior facet 29.8 ± 2.3 22.8 34.2 33.4 ± 2.2 27.5 36.2 26.3± 1.8 21.8 29.2

Inclination Angle for plate 137 ± 6.3 119 158 140 ± 6.8 125 158 134 ± 6.1 119 146

Plate designingWith the measured valves of various

morphological parameters of calcaneum, three plates ofdifferent sizes were designed in a step wise manner (fig5 to fig 13). The small sized plate based on the meanvalve of female calcaneum, large sized plate was basedon mean valve of male calcaneum and the medium sizeplate was based on the mean valve of all parameters of

both male and female calcaneum. Through three sizesthe entire study group can be covered.

First the desired valves of the length of the plate,height of anterior process, height of calcaneal tuberosityand of length of anterior process were drawn. Then thedesired inclination angle of plate to support posteriorfacet and sustentaculum tali were drawn, along with thelength and height of posterior facet.

With the knowledge of minimum number of screws to be placed in each area, the screws holes were placed in sucha way it lays along the trabecular pattern of calcaneum. Finally these screw holes were joined and a new design ofplate for calcaneum was arrived. Similar steps were followed in designing three different sizes of plate.


Once the shape of the plate was designed, a computer aided design of plate was made using CADD software(fig.14) and was sent to the manufacturer, where after different processing steps, the newly desired designed platewas made.

3D Printing TechnologyUsing 3D printing software called MAYA the threedifferent sizes of calcaneum (small, medium and Large)were exactly designed. The measurements were basedon the CT morphological study of 100 calcaneum fromwhich 3 different means were arrived. The plate designinitially drawn in 2D using CADD was converted into3D format by the same MAYA software. The threeplates were overlapped with the respective sizes ofcalcaneum by 3D images. The screw placements werealso analysed in this 3D software itself and exactdirections of each screw could be visualized in thisvirtual format. After being convinced about the precise

matching of plate, calcaneum and screw placements the3 sizes of plates and plates were printed in 3D printingmachine using fibre material. With these live 3D modelsof plate and calcaneum again matching was checked.The three sizes of plate models matchedwell with thecorresponding sizes of bone models.Asimilar method of3D printing technology alone has been used in designinga plate for distal fibula by Stryker company in Germanyin the year 2013 which was later made available in themarket as the Variax plate. In our study we have usedthis method for reconfirmation of our plate shape andsize along with other orthodox modalities that has beenmentioned in this paper.


Plate manufacturingThe CADD design of the three sizes were fed

into CNC ( computerized numerical control) machinesin a manufacturing unit in Bombay and the plates weremanufactured with precision in 316L stainless steel.Plate features and testing for its mechanical properties:

The plate was designed to suit the anatomicalcharacteristics of lateral surface of calcaneum. Theplates were made of SS316L with the thickness of about1.5mm and 1.8mm. It is a 3.5mm locking calcanealsystem having 10 screw holes. The screw holes are

Ima g e s of 3Dp r i nti n g

placed along the trabacular region of calcaneum with 2screws in anterior process, 2 screws to supportsustanaculum tali, 2 screws to support posterior facet, 4screws in the body. The plate was analyzed for its screwdirection using cadaveric dry bone under c-arm in axialviews. The biomechanical properties were tested by theHead of the Department of Engineering Design in theprestigious Anna University , Guindy Chennai. Metalquality, Bending strength, Flexural strength andTorsional stress were analysed and found to be in thecorrect range standard values.


Overlap analaysis of plate:Overlap analysis of plates was done over 50

cadaveric dry bones of different sizes. Then overlapanalysis of plate over calcaneum of 100 live patientswho underwent different orthopedic procedures wasdone. The plates were placed exteriorly over thecalcaneum and position adjusted under c-arm andchecked for its matching. Intra operative overlap analysisof plate on fractured calcaneum was done in 15 patients.An informed consent was obtained from all patients.

After obtaining ethical approval and informedconsent, by extensile lateral approach for calcaneum,the plate has been used in ten patients with calcanealfractures. Inclusion criteria were: Age 18 to 50 yrs,intraarticular fractures with >2mm displacement, Bohlersangle <20°,Gissane angle >105°,CT - sanders type

ii,iii,iv,fractures < 3 weeks. Exclusion criteria: Age <18and > 50yrs, open and infected fractures, extra- articularfractures, sanders type 1 fractures, fractures > 3weeks,peripheral neurovascular disease, uncontrolled diabetesmellitus, medical contraindications to surgery.

RESULTS:Overlap analysis of plate on calcaneum of 100

patients showed that, the small sized plate matchedcalcaneum of 20 patients, the medium sized plate 54patients, large sized plate 26 patients respectively(fig.15). The dry bones also matched perfectly with ourplate design (fig 16). On Intra operative overlap analysisof plate over fractured calcaneum in 15 patients, smallsized plate matched 4 patients,edium sized platematched 8 patients, large sized plate matched 3 patientsfractured calcaneum exactly.

Of the 10 patients who underwent open reduction andinternal fixation with our newly designed plate,4 patientshad type II and 4patients had type III Sanders calcanealfractures and 2 type IV fractures. In three patient weused small sized plate, in six patients we have usedmedium sized plate and in one patient large sized platewas used (fig.17&fig.18). In all the ten patients, after

achieving reduction of the fracture, plates which exactlymatched the bone was applied without any difficulty andneed for cutting or trimming of plates. The screws wereproviding adequate support to posterior facet withproper purchase in to the sustentaculum tali. Currentlythe patients are within a follow up period of 3months to7 months and are to be evaluated further.


DISCUSSIONThe calcaneum is the largest tarsal bone with a

complex contour and articular facets. In fracture ofcalcaneum restoration of anatomic morphology ofcalcaneum is important to maintain normal function ofhind foot and to ensure stress conduction for weightbearing7, 8,. Conservative management of intra-articularcalcaneal fractures, hardly achieve good anatomicalreduction leading to mal union of fractures and earlydevelopment of subtalar arthritis. Open reduction andinternal fixation of displaced intra- articular calcanealfractures is a standard procedure in many of theinstitutions now a days. Advantages of open reductionand internal fixation are, restoration of normal shape andalignment of hindfoot , restoration of articular facetcongruency, reconstruction of height and width of thecalcaneum, decompression of compartments of foot ,prevention of fracture blisters and its subsequent skincomplications 9. Surgical management provides stablefixation of fracture and allows early return to function &prevention of subtalar arthritis.

A study conducted by Qiang et al showed that,the 3D morphological assessment based on a CT imagepost-processing technique is highly reliable andrepeatable which will be helpful for anatomic reductionof calcaneal fractures and calcaneal malunion10.Thishighly reliable CT 3D morphological assessment ofcalcaneum helped in designing a new plate prototype forIndian population. The calcaneal axial length, whichshortens in intra-articular calcaneal fractures is not onlyhelpful for diagnosis, but also for deciding the size ofaxial screws during surgical procedures10.Forsupporting posterior facet and sustentaculum tali weused an inclination angle for plate which was always 15to 20° higher than that of gissane angle and preventsviolation of subtalar joint by the screws. Theaverage LCA, HPF, LPF and HAP, inclination anglewere larger in male group then female group.

The advantages of our newly designed plate are,it is a cost effective, low profile locking plate where oneof the three sizes will definitely match all the calcaneum.The plate design itself avoids joint penetration of screws,with screws being in denser part of bone providingadequate support to posterior facet and purchase insustentaculam tali. The low profile of plate allows it tobe easily contoured and the chance of soft tissueirritation is very much less.

We say that our newly designed plate is afoolproof system because; the morphologicalmeasurements of calcaneum were done in Indianpopulation by CT three dimensionally. The plate designand pre stress testing were done using software’s. Alloy

testing and axial compressive testing of plate, done byHead of Department of Manufacturing engineering,Anna University, Chennai, Tamil nadu. Overlap analysisof plate on calcaneum of 100 live persons and 50cadaveric dry bones has been done, where one of thethree plates matched all bones. The latest technologicaltool the 3D printing has also been used and a perfectmatching and analysis has been done. Though 3Dprinting technology has entered into the domain oforthopedics they are utilized mainly for customizedneeds only and very minimal studies are available fordesigning standard implants that can be used for theentire population. Ours is one such study and incombination with the conventional and orthodoxmethods it has given a better design and given us moreconvincing evidence to manufacture and also to use it inpatients.

The limitation of our study is that, we have usedour newly designed plate in five patients in a short periodof time and patients are within a follow up period of 3months and patients are to be evaluated using AOFASscore and functional results are to be assessed.Application of plate in large number of patients and longduration of follow up will help in assessing the plateproperties more.

CONCLUSIONCT Scan based morphological studies, physical

testing of plates mechanical properties and, overlapanalysis in (Dry bones, C arm and live cases) are theconventional orthodox method of plate designing. CADDdesigning, ANSYS software based mechanicalproperties testing ,3Dprinting technology and CNCmachines were the recent technological advancements.This combination of Orthodox methods aided byTechnological advancements has made our design aunique, innovative and a new design of calcaneal plate.One of the three sizes of plate definitely matched allcalcaneum in the study. This is a plate for Indianpopulation with proper size fitting and screws in thedenser part of bone providing proper support tosustentaculum tali and posterior facet. This innovativeplate design will be definitely useful in treating patientswith calcaneal fractures without violation of basicprinciples of calcaneal fractures

REFERENCES1.Sanders, R. (2000) Displaced Intra- Articular Fractures of theCalcaneus. The Journal ofBone and Joint Surgery, 82A,225-250.2.Kundel, K., Funk, E., Brutscher, M. and Bickel, R. (1996) CalcanealFractures: Operative versus Non operative Treatment.Journal ofTrauma-Injury Infection & Critical Care, 41, 839-


845.http://dx.doi.org/10.1097/00005373-199611000-000123. Dooley, P., Buckley, R., Tough, S., McCormack, B., Pate, G.,Leighton, R., Petrie, D. and Galpin, B. (2004) Bilateral CalcanealFractures: Operative versus4.Nonoperative Treatment. Foot & Ankle International, 25, 47-52.Barla, J., Buckley, R., McCormack, R., Pate, G., Leighton, R., Petrie, D.and Galpin, R. (2004) Displaced Intraarticular Calcaneal Fractures: Long-Term Outcome in Women. Foot & Ankle International, 25, 853-856.5. Brauer, C.A., Manns, B.J., Ko, M., Donaldson, C. and Buckley, R.(2005) An Economic Evaluation of Operative Compared withNonoperative Management of Displaced Intra- Articular CalcanealFractures. The Journal of Bone andJoint Surgery, 87A, 2741-2749.6.Buckley, R., Tough, S., McCormack, R., Pate, G., Leighton, R., Petrie,D. and Galpin, R. (2002) Operative Compared with Nonoperative

Treatment of Displaced Intra-Articular Calcaneal Fractures: AProspective, Randomized, Controlled Multicenter Trial. Journal of Boneand Joint Surgery, 84, 1733-1744.7.Paley D, Hall H: Intra-articular fractures of the calcaneus. A criticalanalysis of results and prognostic factors. J Bone Joint Surg Am 1993,75:342–354.8.Epstein N, Chandran S, Chou L: Current concepts review: intra-articular fractures of the calcaneus. Foot Ankle Int 2012, 33:79–86.9.Al-Mudhaffar M, Prassad CV, Mofidi A (2000) Wound complicationfollowing operative fixation of calcaneal fractures. Injury 31:461–46410.Qiang et al.: Measurement of three-dimensionalmorphologicalcharacteristics of the calcaneus using CT imagepost-processing.Journal of Foot and Ankle Research 2014 7:19.

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