The Functional Outcome of Fixation of Trimalleolar Fracture, through Fixation of Lateral Malleolus by Plating, Medial Malleolus by Tension Band Wiring and Percutaneous Screw Fixation of Posterior Malleolus: A Prospective Study

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 30-32|  D C Srivastava, Sachin Yadav, Ankur Singh, Alok Gupta


Authors:  D C Srivastava [1], Sachin Yadav [1], Ankur Singh [1], Alok Gupta [1]

[1] Department of Orthopaedics, M L N Medical College Allahabad, UP, India

Address of Correspondence
Dr. Dinesh Chandra Srivastava
Department of Orthopaedics, M L N Medical College Allahabad, UP, India.
Email: srivastavadc1@rediffmail.com


Abstact

Background: Ankle injuries gain importance because body weight is transmitted through it and locomotion depends upon the stability of this joint. Trimalleolar fractures are one of the most complex fracture around ankle. As with all intra articular fractures, Trimalleolar fractures necessitate reduction and stable internal fixation. The purpose of this study is to assess the functional outcome and results of surgical treatment of Trimalleolar fractures by specific modalities. to attain a proper anatomical alignment and stability of ankle joint and further applying a syndesmotic screw if needed.
Material And Methods: A Prospective review was conducted for 20 patients with trimalleolar fracture. Open reduction and internal fixation was done with specific modalities. Patients were evaluated with functional scoring by Biard and Jackson. The functional outcome of ORIF and advantages of the procedures were recorded.
Results: In the present study of 20 patients with ankle fractures treated by open reduction and internal fixation. Excellent results were achieved in 13 (65%) patients, good in 5 (25%), fair in 1 (5%) and poor in 1 (5%) patient. Excellent results were observed in all isolated lateral malleolar and bimalleoluar fractures. Two (14%) patient of with trimalleolar fracture had poor to fair results. The patient with poor result had mild pain with activities of daily living, diminution in the abilities to run and to do work, reduced motion of ankle and narrowing of joint space.
Conclusion: This fracture pattern was classified under Lauge-Hansens on basis of different injury mechanisms, and were treated according to it. After anatomic reduction and stable fixation through the specific operative approach ans methods, the short-term outcome was good and complications were reduced to minimum.
Keywords: Trimalleolar fracture, plating, tension band wiring


Introduction
Sir Robert Jones said “Ankle is the most injured joint of the body but the least well treated[1]. As with all intra articular fractures, Trimalleolar fractures necessitate reduction and stable internal fixation [2,3,4]. Ankle fracture is one of the most common lower limb fractures [5] for they account for 9% of all fractures representing a significant portion of the trauma workload [6]. Ankle fractures usually affect young men and older women, however, below the age of 50 [7]; ankle fractures are the commonest in men. Two commonly used classification systems for ankle fractures include the Danis Weber AO classification and the Lauge-Hansen classification. There are several different methods of ankle fracture fixation, however the goal of treatment remains a stable anatomic reduction of talus in the ankle mortise and correction of the fibula length as a 1 mm lateral shift of the talus in the ankle mortise reduces the contact area by 42%, and displacement (or shortening) of the fibula more than 2 mm will lead to significant increases in joint contact pressures. Further research both biomechanically and clinically needs to be undertaken in order to clarify a preferable choice of fixation.
Many of the fractures which are stable are reduced by conservative treatment and have given good result. The other unstable displaced and open fractures require open reduction internal fixation. The superiority of ORIF over closed treatment have been thoroughly demonstrated in literature3. However all studies have not obtained good results in cases of Trimalleolar fractures.
The purpose of this study is to assess the functional outcome and results of surgical treatment of Trimalleolar fractures by specific modalities of tension band wiring of medial malleoli, plating of lateral malleoli, and screw fixation of posterior malleoli , to attain a proper anatomical alignment and stability of ankle joint and further applying a syndesmotic screw if needed.

Material And Methods:
20 Patients with fresh trimalleolar fractures who attended SRN Hospital, Allahabad from August 2014 to July 2015 were included in study. As soon as the patients were brought to the casualty a complete survey was carried out to rule out significant injuries. Then the patients radiograph’s were taken, both anteroposterior and lateral views of the ankle joints. On admission to the ward detailed history was taken relating to the age, sex, occupation, address, mode of injury past and associated medical illness. Patients general condition was assessed and then they were put through a thorough clinical examination. Patients with active infection at site of injury were excluded from the study. Post operation, assessment was done at 6 weeks, 12 weeks and 6 months according to Biard and Jacksons functional scoring [4].

Operative methods:
There are several different methods of ankle fracture fixation, however the goal of treatment remains a stable anatomic reduction of talus in the ankle mortise and correction of the fibula length as a 1mm lateral shift of the talus in the ankle mortise reduces the contact area by 42% [3], and displacement (or shortening) of the fibula more than 2 mm will lead to significant increases in joint contact pressures.
The choice of fixing the medial or lateral side8 first may be guided by the surgeon’s preference, but the ankle joint in these fractures is often very unstable. The stability is dramatically improved once the medial fracture is fixed (if present), therefore if our study we have followed the following sequence:
1. The medial fracture is fixed
2. The fibular shaft is brought out to length and fixed
3. The Volkmann’s fragment(posterior mallelous) is reduced and fixed
4. The integrity of the syndesmosis is restored
Medial malleolus was fixed using tension band fixation which is bio mechanically a strong construct using a long medial incision [9]. For Lateral malleolus lateral incision was used length of fibula was maintained and is best fixed with a one-third semitubular plate placed over the lateral surface of the fibula and bent and twisted [9]. After Fibula has been fixed we will look for syndesmotic stability. Various maneuvers are done on able to try to separate the fibula from the tibia. Instability was fixed by Use a 4.5mm cortical screw inserted through the fibula into the tibia 2 to 3 cm above and parallel to the ankle joint. Posterior malleolus was fixed only if it constituted 25% or more of the articular surface. it is fixed with one or two 4-mm cancellous screws with a small stab incision in a anteroposterior direction or a posteroanterior direction, fixing it percutaneously [9].

Results:
In the present study of 20 patients with ankle fractures treated by open reduction and internal fixation. Excellent results were achieved in 13 (65%) patients, good in 5 (25%), fair in 1 (5%) and poor in 1 (5%) patient. Excellent results were observed in all isolated lateral malleolar and bimalleoluar fractures. Two (14%) patient with trimalleolar fracture had poor to fair results. The patient with poor result had mild pain with activities of daily living, diminution in the abilities to run and to do work, reduced motion of ankle and narrowing of joint space.

Figure 1: Preoperative (a), intraoperative (b) and post-operative (c) pictures of one of the case in our series

Figure 1: Preoperative (a), intraoperative (b) and post-operative (c) pictures of one of the case in our series

Figure 2: Patient showing good Plantar flexion (a), dorsiflexion (b) and is able to squat well (c) at final follow up

Figure 2: Patient showing good Plantar flexion (a), dorsiflexion (b) and is able to squat well (c) at final follow up

Discussion:
Increased knowledge about the normal and post traumatic anatomy and function of the ankle joint has lead to demands for exact reduction and rigid fixation of the trimalleolar fractures. Prompt operative treatment of displaced ankle fractures decreases morbidity and improves functional outcome [10,11,12]
The treatment of trimalleolar fractures with accurate open reduction and stable internal fixation using AO method and principles was found to give a high percentage of excellent and good results [2]. This study supports these conclusions.
Although the scoring of Baird and Jackson has proven to be strict allowing only very small fluctuation from normal about 65% patients in this series achieved excellent results by that scoring system and 25% patients achieved good results and also had anatomical reduction of all the malleoli as well as anatomical reduction of talus radiologically. It is seen that the percutaneous fixation of posterior malleolus reduces the chances of skin necrosis as compared to the single postero-lateral incision for posterior as well as lateral malleolus. This percutaneous fixation reduces soft tissue trauma and postero-lateral complex of vessels is less hampered which resulted in reduced AVN of talus as a late complication.
In our study it was seen that better biomechanical stability of ankle was also related to fixation of diastasis only after fixation of posterior malleolus. After fixation of diastasis Per operative medial and lateral stability were checked under C-arm with the help of lateral and medial stress tests. Per operative checking of congruency of talus with both malleolus by C-arm produces the maximum contact weight bearing surface of ankle joint. While walking it is useful in providing excellent gait biomechanic in the long run.
Anatomical fixation of fibula by moulded plate not only maintains fibula length but is also paramount for lateral stability. It is also important for maintaining congruency of medial part of fibula to talus.
The chances of non-union in medial malleolus were reduced to minimum by taking care of periosteal interposition during its fixation and use of tension band principle by AO.It is also concluded that anatomical relation of malleoli is maintained with talus when ankle diastasis is fixed in neutral position because in dorsiflexion fibula is pushed back and it disturbs its congruency with talus.


References

1. Shelton Marvin L. Complication of fractures and dislocation of the ankle. In: Complications in orthopaedic surgery, Chapter 23, 3rd edn., Vol.I, edt. EPPS, Charles H, Philadelphia : J.B. Lippincott Company, 1994; 595-648pp.
2. Beris AE, Kabbani KT, Xenakis TA, Mitsionis G, Soucacos PK, Soucacos PN. Surgical treatment of malleolar fractures – a review of 144 patients. Clin Orthop Related Research, 1997 Aug; 341: 90-98.
3. Weber MJ. Ankle fractures and dislocations. In : Operative Orthopaedics, Chapter-50, 2nd edn., Vol.3, Ed. Chapman MW, Madison M. Philadelphia : J.B. Lippincott Company, 1993; 731-748pp.
4. Baird RA and Jackson ST. Fracture of the distal part of fibula with associated disruption of the deltoid ligament. J Bone Joint Surg, 1987; 69A: 1346-52.
5. Lash, N., Horne, G., Fielden, J. and Devane, P. (2002) Ankle Fractures: Functional and Lifestyle Outcomes at 2 Years. ANZ Journal of Surgery, 72, 724-730.
6. Court-Brown, C.M. and Caesar, B. (2006) Epidemiology of Adult Fractures: A Review. Injury, 37, 691-697.http:// dx.doi.org/ 10.1016/ j.injury. 2006.04. 130
7. Bugler, K.E., White, T.O. and Thordarson, D.B. (2012) Focus on Ankle Fractures. The Journal of Bone and Joint Surgery, 94, 1107-1112.
8. https:// www2.aofoundation.org/ wps/ portal/ surgery? showPage=redfix&bone= Tibia&segment= Malleoli&classification= 44-C1&treatment= &method= Open%20 reduction%20 internal%20 fixation& implantstype= &approach= &redfix_url= 1423753381492& Language=en
9. Desouza LJ. Fractures and dislocations about the ankle. In: Fractures and dislocations, Chapter-30, Vol.II, edt. Gustilo RB, Kyle RF, Templeman D, St. Louis : Mosby Year book Inc., 1993, 997-1043pp.
10. Lindsojo U. Operative treatment of ankle fracture – dislocations. Clin Orthop, 1985; 199: 28-38.
11. Muller ME, Allgower M, Scheider R, Willenegger H. Manual of internal fixation: techniques recommended by the AO-group, 3rd edn, New York: Springer- Verlag, 1991.
12. Burwell HN and Charnley AD. The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. J Bone Joint Surg, 1965; 47B: 634-660.

How to Cite this Article: Srivastava DC, Yadav S, Singh A, Gupta A. The Functional Outcome of Fixation of Trimalleolar Fracture, through Fixation of Lateral Malleolus by Plating, Medial Malleolus by Tension Band Wiring and Percutaneous Screw Fixation of Posterior Malleolus: A Prospective Study. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):30-32 .


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A Prospective Study of 9 Cases of Neglected Posterior Dislocation of Elbow Treated by Open Reduction and V-Y Tricepsplasty of Speed

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 26-29| Saurabh Agarwal ,  Ranjeet Kumar Patel


Authors: Saurabh Agarwal[1],  Ranjeet Kumar Patel[1 ]

[1] Department Orthopaedics M.L.B. Medical College, Jhansi

Address of Correspondence:

Dr. Ranjeet Kumar Patel
Department of Orthopaedics, MLB Medical College, Jhansi, UP
Email: ranjeet05gsvm@gmail.com


Abstact

Aim: Neglected dislocations are common in developing country like ours. These injuries are challenging for surgeons because negligence results into soft tissue contractures and joint cavity is filled with fibrous tissue. We want to share this prospective study based on 9 cases of neglected posterior dislocation of elbow treated by open and V-Y tricepsplasty.
Method: Pain, stiffness of joint and functional impairment were the main indication for surgery. We treated 9 patients (5 men ,4 women ) with mean age of patient was 34.5 ( range 28 years to 42 years); mean time since injury was 9 weeks (range 4 to 14 weeks).
Results: The average follow-up was 12 month (range 6 to 18 months). The mean arc of flexion was 109 ( range 75 to 125 degree) and the mean arc of supination and pronation was 152 ( range 130-10 degree). The average Mayo elbow performance index was 83 ( range 95 to 60) with 5 excellent, 2 good and 2 poor results. Complication was wound dehiscence in 2 cases.
Conclusion: Open reduction, V-Y tricepsplasty followed by supervised physiotherapy is effective in restoring the functional range of motion, stable and painless joint in neglected dislocation of elbow.
Keywords: Neglected, dislocations, elbow.


Introduction
Neglected dislocations are common in developing country like ours [1]. It should be considered emergency situation and set into place as soon as possible by trauma specialist. Each joint in body can be dislocated however there are common sites where most dislocation occur. The most commonly dislocated the shoulder joint and elbow joint. Posterior elbow dislocation accounts 90% of all elbow dislocation.
In India, there is often a delay of some months in coming to orthopedic hospital for treatment because of ignorance, poverty and non availability of medical aid, the rural patient still seek indigenous treatment with consequent neglect and mismanagement of their injuries. These people have faith in village doctor. Almost every village has a bone setter. Even in big cities there are unqualified bonesetter .However the popularity and the number of the quacks is fast decreasing.
Patient comes to hospital mainly for pain relief, stiffness of joint and functional impairment. There are various treatment options for neglected posterior dislocation of elbow: closed reduction, open reduction, excisional arthroplasty, interpositional or replacement arthroplasty and arthrodesis.
The aims of this study was to assess the functional outcome after correction.

Patients and Methods
This prospective study is based on 9 cases of neglected elbow dislocation which where more than 3 weeks old treated surgically at M. L. B. Medical College Jhansi from the beginning of January 2014 to the end of December 2015.They included 5 men aged from 31 to 42 years (mean 36.8 years) and 4 women aged 28 to 37 years ( mean 31.8 years) . Right arm involved in 7 cases and left arm in 2 cases. Time from injury to presentation ranged from 4 to 14 weeks( mean 9 weeks). They had various occupation; 3 were farmers , 2 were Labourer and 4 housewives. All patients had initially received treatment with massage and wooden splints from local bonesetters .Pain ,elbow stiffness and functional impairment were the main indications for surgery. All patients presented with posterior elbow dislocation. In old dislocation the olecranon was prominent and the triceps was shortened and tenting on the posterior aspect of the elbow and humerus was prominent anteriorly. Three bony point relationship was disturbed. The elbow were fixed in few degrees of flexion and range of movement was non functional preoperatively ( 5,13). None of patients could flex their elbow beyond 90 degree. Heterotopic ossification was present in 4 cases.
Surgery was performed under brachial block. V-Y tricepsplasty of Speed’ procedure (2)was performed in all cases for open reduction. The patient was positioned lateral decubitus with the elbow flexed at 90 degree on a side arm attached to the table. An electronic pneumatic tourniquet was applied and the posterior approach was used. The ulnar nerve was identified and released .An inverted V- flap of the triceps aponeurosis was prepared in all cases to compensate for the triceps shortening. Any fibrotic tissue, osteophytes and heterotopic ossifications were resected. Reduction was achieved with slow, gentle traction. Full reduction was achieved by gently reducing first the humeroradial dislocation then the humeroulnar dislocation. Once the reduction was achieved olecranohumeral k-wires (2 to 2.5 mm) used to stabilise the elbow at 90 degree. The wound was closed in layers over suction drain. An above elbow pop slab was applied with the elbow at 90 degree flexion. Drain was removed after 2 days, sutures were removed at 2 weeks and k-wire was removed at 3 weeks except in two cases which were infected superficially were removed at 4 weeks. Active movement of elbow was started after 3 weeks.
The Mayo(3) elbow performance index was used to assess the functional outcomes before and after surgery .This index consists of four parts; Pain(with maximum score of 45 points), ulnohumeral motion (20 points),elbow stability(10 points) and ability to perform five functional tasks(25 points).Pain is rated as none(45 points); mild(30 points) if there is no limitation of activity and occasional use of analgesics; moderate(15 points) if there is limitation of activity and regular use of analgesics; severe(o points) if there is constant pain and regular use of analgesics .The stability is graded as stable, mildly unstable or unstable. The functional score is determined on the basis of the patients ability to perform normal activities of daily living .The total score ranges from 5 to 100 points, with higher scores indicating better function. If the total score is between 90 to 100 points, it can be considered excellent; between 75 to 89 points, good; between 60 to 74 points, fair; less than 60 points, poor. The follow -up radiographs were evaluated for articular alignment and post-traumatic orthrosis using the rating scale of Broberg and Morrey (4).No radiographic joint narrowing was defined as grade 0, slight joint narrowing as grade 1,moderate joint space narrowing with minimal osteophytosis as grade 2 and severe degenerative changes with loss of the joint space as grade 3.

Figure 1: Anterior postior and lateral radiograph showing dislocation

Figure 1: Anterior posterior and lateral radiograph showing dislocation

Figure 2: Postoperative Lateral and AP and radiograph

Figure 2: Postoperative Lateral and AP and radiograph

Results
Patients were followed for a mean of 12 months (6 to 18 months) with a minimum of 6 months and maximum of 18 months .Average Mayo elbow performance index was 83 (range 95 to 60) with 5 excellent, 2 good and 2 poor results. Poor result were in 2 patients who had an superficial infection which was treated with appropriate oral antibiotics and proper dressings .7 patients had no pain, 2 had mild pain. Mean pain score was 42 ( range 45 to 30).At the final follow-up no patients had any sign of instability, mean score was 10. 7 achieved a flexion range of 110 to 135 degree , one achieved 90 degree and one achieved 75 degree .The mean arc of flexion was 109 degree( range 75 to 125 degree). The mean arc of supination – pronation was 152 degree ( range 130 to 170 degree). None of the patients complained of instability when performing activities of daily living. Although no significant correlation was noted between the range of movements achieved and the age of dislocation but the range of movement was greater when the patients treated earlier.
All patients had radiographic ulnohumeral and radiocapitellar alignment. At follow-up of 6 to 8 months duration, two patients had evidence of mild joint space narrowing and osteophyte formation (grade 1 orthrosis). Complications included; pin site infection(2) and wound dehiscence(2), managed by oral antibiotics and daily dressing.

Figure 3: Final Follow up radiographs

Figure 3: Final Follow up radiographs

 

Figure 4: Range of movement at final follow up

Figure 4: Range of movement at final follow up

Discussion
Neglected elbow dislocation is a common in developing countries. In our series all the patients were initially treated by local bonesetters by elbow immobilisation in extension resulting in stiffness of joint. The operative technique in our series was V-Y tricepsplasty of Speed. After 3 weeks of trauma, soft tissue contracture develops which causes closed reduction by traction impossible. So most authors recommend closed reduction of elbow upto 3 weeks. Fowles et al [5] in their study found that neglected elbow dislocation of duration 2 months might give good results with conservative therapy. According to some authors final outcome of open reduction of neglected dislocation depends on the age of dislocation. Most authors [3, ,8 13] recommend open reduction for dislocation of 3 months duration and excisional arthroplasty, total elbow arthroplasty or orthrodesis thereafter. In our study we achieved a good results and a good range of movement with open reduction. Most activities of daily living can be performed with a 100 degree flexion and a 100 degree supination – pronation arm; such an elbow was termed ‘useful’ [6]. All our patients were within this range and could perform activities of daily living. Our study is comparable to similar study done by Mehta et al [7] , and Elzohairy [8] .Like most of authors [7,8] we also concluded that a retracted collateral ligament do not need to be repaired to restore elbow stability. Ligament repair has been described by Arafiles [9] using an allograft from the palmaris longus or extensor radialis longus tendons. This method takes longer procedure times and increase the risk of morbidity due to second surgical site. Jupiter and Ring [10] used an articulated external fixator. The advantage of these two techniques are that they provide stability and early mobilisation during the first weeks of post surgery. Duckworth et al [11] recommended the use of hinged external fixator to protect the repair. Hotchkiss [12] also used hinged external fixation to maintain joint reduction to permit motion. The posterior and lateral approaches are used most often in open reduction. Krishnamoorthy [13] advocated lateral approach has the advantage of providing a good exposure of the humeroradial joint and the anterior structures, particularly the coronoid fossa. Disadvantage of this approach is often combined with medial approach resulting in second scar. Like most of authors [7,8] we used posterior approach. In posterior approach there was good exposure of posterior structures that are typically retracted, it also easy to perform ulnar nerve transposition when needed. We used V-Y tricepsplasty described by Speed [2] which was most commonly used. Vangorder [14] also described triceps lengthening technique by using an Achilles tendon or fascialata allograft after the triceps is cut transversely. Most authors [7,8] , however, use the V-Y technique described by Speed to lengthen the triceps.

Conclusion
Neglected dislocation are common in our country. Open reduction, V-Y tricepsplasty followed by supervised physiotherapy is effective in restoring the joint to a painless, stable and functional limb in case of neglected elbow dislocations which present upto 3 months [1] after injury.


References

1. Freeman ııı BL. Old unreduced dislocations. In: Crenshaw AH, editor. Campbell′s operative orthopedics, 9th ed. St. Louis: Mosby; 1998. p. 2673-4.
2. Speed JS. An operation for unreduced posterior dislocations of the elbow. South Med Journal 1925 ;  18 : 193-198
3. MooreyBF, Adams RA. Semiconstrained arthroplasty for the treatment of rheumatiod arthritis of elbow, J Bone Joint surg Am. 1992; 74: 479-90.
4. Broberg MA , Moorrey BF. Results of treatment of fracture-dislocations of the elbow . Clin orthop Relat 1987; R 216: 109-19.
5. Fowles JV ,Kassab MT, Douik M. Unreduced posterior dislocation of elbow in children. J bone joint surg Am 1984;66: 921- 926.
6. Moorrey BF ,Askew LJ, chaoey. A biochemical study of normal functional elbow motion. J bone Joint surg, Am 1981;63:872-7.
7. Mehta S, Sud A, Tiwari A, Kapoor SK. Open reduction for late presenting posterior dislocation of elbow. J orthop surg (Hong-Kong). 2007;15:15-21.
8. Elzohairy MM. Neglected posterior dislocation of the elbow. Injury. 2009;40: 197-200.
9. Arafiles RP. Neglected posterior dislocation of the elbow. A reconstruction operation. J bone joint surg Br 1987;69: 199-202.
10. Jupiter JB, Ring D. Treatment of unreduced elbow dislocations with hinged external fixation. J Bone joint surg Am 2002; 84: 1630-5.
11. Duckworth AD, Ring D, Kulijdian A, McKee MD. Unstable elbow dislocations. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):281-6
12. Hotchkiss R: Hinged elbow external fixators: indications and uses, J Am Acad Orthop Surg 13:503 , 2005.
13. Krishnamoorthy S, Bone K, Wang KP. Treatment of old unreduced dislocation of the elbow. Injury. 1976;8:39-42.
14. G. W. Vangorder, surgical approach in old posterior dislocation of the elbow. J Bone Joint Surg Am, 1932;14:127-43.

How to Cite this Article: Agarwal S , Patel RK. A Prospective Study of 9 Cases of Neglected Posterior Dislocation of Elbow Treated by Open Reduction and V-Y Tricepsplasty of Speed. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):26-29 .


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Anterior Knee Pain in Paratendinous Approach of Tibial Interlocking Nail

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 22-25| Gaurav Menwal, Gyaneshwar Tonk, Amit Kumar Gupta, Pranav Kothiyal, Alok Kumar


Authors: Gaurav Menwal[1], Gyaneshwar Tonk[1], Amit Kumar Gupta[1], Pranav Kothiyal[1], Alok Kumar[1 ]

[1] Department OF Orthopaedics, LLRM Medical College, Meerut

Address of Correspondence:

Dr. Gaurav Menwal
Senior Resident Orthopaedics, LLRM Medical College, Meerut
Email: gauravmintu07@gmail.com


Abstact

Aim: Anterior knee pain has been described as the most common complication after intramedullary nailing of fracture shaft of tibia. Dissection of the patellar tendon and its sheath during transtendinous nailing is thought to be as one of the contributing causes of chronic anterior knee pain. The purpose of this prospective study was to estimate the incidence of anterior knee pain after intramedullary nailing of a tibial shaft fracture with paratendinous incision technique.
Material And Methods: From April 2012 to October 2013 forty patients with closed tibial shaft fractures were admitted and treated in our institution, as 12 patients did not complete their follow up or were lost in follow up, so 28 patients were analyzed finally. For assessment we used visual analogue scales to report the level of anterior knee pain. The scales described by Lysholm and Gillquist and by Tegner et al., were also used to quantitate the functional results. Ethical clearance of the study was taken from the institutional ethical committee.
Results: 8 patients out of 28 (28%) treated with paratendinous nailing technique had persistent anterior knee pain after minimum final follow up of 24 weeks. The Lysholm, Tegner functional scoring systems showed a better significant functional outcome.
Conclusion: A paratendinous approach for nail insertion does not reduce the incidence of chronic anterior knee pain or functional impairment after intramedullary nailing of a tibial shaft fracture. In long term, anterior knee pain seems to disappear from many patients.
Keywords: Tibial shaft fracture, Anterior knee pain, Intramedullary nailing, Transtendinous technique, Paratendinous technique.


Introduction
Intramedullary nailing has been described as the treatment of choice for many displaced tibial shaft fractures in adults [1]. Several complications have been described after IM nailing including infection, compartment syndrome, deep vein thrombosis, thermal necrosis of bone, implant failure, non-union and mal-union of fracture [4].
However one of the commonest complications after tibial nailing is chronic anterior knee pain with incidence as high as 86% [9]. Although most knee pain is mild, it can significantly affect patients quality of life, and can be an important handicap for the patient, affecting his employment and daily/leisure activities [6]. After surgery complaints of anterior knee pain exacerbated by walking, squatting, kneeling and stair climbing are common [8]. However the exact etiology of this complication is still unknown [5]. Some investigators have proposed that a transpatellar tendon approach for nail insertion is associated with a higher prevalence of anterior knee pain than a medial paratendinous approach [3].
The purpose of this prospective study was to evaluate the prevalence of anterior knee pain in patients of various age groups treated with a paratendinous approach for tibial nailing. We have also evaluated the functional outcome of patients after closed intramedullary nailing.

Materials And Methods
This study comprised of 40 patients of displaced tibial shaft fracture treated with an intramedullary locking nail at L.L.R.M medical college, Meerut, between April 2012 and October 2013. Inclusion criteria of the study included patients aged more than 15 years, closed tibia fracture without intra-articular extension definitively treated by intramedullary nailing and absence of any co-morbid illness.
The exclusion criteria of the study were fracture shaft tibia treated with plating or primarily by external fixator followed by intramedullary nail, fractures treated conservatively with casting, patients with history of knee pain not related to intramedullary nailing and patients having other fractures around knee like Patella fracture. All the patients were thoroughly examined including all the injuries apart from the tibial fractures.
Every patient was investigated with blood profile, Antero- posterior and lateral views of X-rays. Following hospitalization a well-padded long leg plaster was given till definitive management by nailing; analgesics and other supportive measures were administered as required. Nailing was done at the earliest opportunity after getting clearance from the anaesthesia department.
All patients were informed of the study procedure, purposes, known risks and all gave written informed consent.
Mode of anaesthesia given to the patient was either general anaesthesia or regional (Spinal) anaesthesia depending on the anaesthetist choice. A medial longitudinal incision was made with care taken not to violate the patellar tendon or its sheath and the patellar tendon was retracted laterally. The entry portal in the bone was made immediately behind the patellar tendon in all patients. Reaming was done after insertion of guide wire.
The nail was inserted after selection of appropriate length. Proximal and distal locking screws were always used, and all nails were countersunk below the cortical bone of the proximal part of the tibia. Postoperatively radiographs were taken and the limb was kept elevated and passive exercises of toes were started immediate post operatively. Active exercises of knee and ankle were started as early as possible
All the patients were strictly followed minimally up to 24 weeks. The interval of follow up was 2 weeks, 6 weeks, 12 weeks and 24 weeks or earlier if required. Serial radiographs were taken to assess the radiological healing and photographic records were taken for final functional outcome. Patients were advised weight bearing between 8-16 weeks postoperatively after clinical and radiological examination of fracture union. The patients who did not come for follow up or were lost during the follow up were not included in the study (12 patients out of 40).
At follow ups patients were asked about the severity of pain and amount of disability. Patients were specifically asked whether they had knee pain. If patients complained of knee pain they were asked to localize the pain. Only pain over the anterior portion of the knee was taken as a positive response for knee pain. If the patients specifically points to pain over fracture site or screw head was not considered as anterior knee pain.
Patients were asked to grade the pain as per VAS scale, a 100mm visual-analogue scale, with 0 denoting no pain and 100 denoting the worst pain that the patient could imagine. In addition functional outcome was also seen using Tegner Lysholm score, a 100 point, validated, reliable and responsive outcome tool for functional assessment of knee. The statistical analysis in this study was carried out using SPSS 15 software for Windows program.

Results
From out of 28 patients of fracture shaft tibia included in our study, there were 21 men (75%) and 7 women (25%) with a mean age 34.60 years with the youngest being 16 years old and the oldest being 60 years old. In the 28 patients of our study, 12 (43%) had right limb involved, 14 (50%) had their left limb involved; whereas 2(7%) of patients had a bilateral injury. In our study the mechanism of injury was road traffic accident in 20(71%) patients, fall from height in 7(25%) patients; whereas 1(4%) patients had assault as a mode of injury.
Fractures in the middle 1/3 of the shaft of tibia were the commonest consisting 18(64%) out of 28 cases. Involvement of lower 1/3 was in 7(25%) cases and 3 cases were in upper 1/3(11%). In our study no segmental fractures were found. The majority patients had short oblique fractures, 16 (57%) with a variety of comminution followed by transverse fractures 12(42%). Out of the 28 patients, 10 patients (36%) were treated within 48 hrs of sustaining trauma. 9 patients (32%) were treated within 4 days of sustaining trauma. This delay was mainly because of gross swelling of the operated part. 9 patients (32%) were operated within 7 days of sustaining trauma. The delay in this group was mostly because of associated injuries and delay in anaesthesia fitness.
At the time of final follow up of 24 weeks, 8 patients out of 28(28%), in which paratendinous technique was used, had persistent anterior knee pain. It was seen that at the follow ups of 2nd, 6th, 12th weeks, all the patients showed almost similar results in term of median, minimum and maximum values. Further, it was also noted that as the duration of follow up increases, median analogue score decreases with a minimum of 0 and maximum of 10. P-values at various follow ups were also statistically not significant (Table 1). Among those who even after 24 weeks had pain, the pain was worst on kneeling, squatting and after long term sitting. The above noted prevalence of anterior knee pain is the same as that reported intranstendinous approach [4,5,7]. With the numbers available, we could not find any association between the entry incision and anterior knee pain.
On evaluation of final functional outcome scores at 24 weeks, 9 patients (32%) had excellent results, 5 patients (18%) had good results and 14 patients (50%) had fair results. In our study patients, patients who had anterior knee pain at follow up had lower functional scores than those who never had knee pain or those whose knee pain has disappeared over time.

 

Table 1: Comparision of VAS Score over period of time

Table 1: Comparision of VAS Score over period of time

Table 2: Comparision of LKS Score over period of time

Table 2: Comparision of LKS Score over period of time

Discussion
As with other various treatment modalities, intramedullary nailing also has its pearls and pitfalls. Of which, chronic anterior knee pain is one of the most frequently reported complication of closed nailing. The source of anterior knee pain is multifactorial. Some investigators have proposed that a transpatellar tendon approach for nail insertion is associated with a higher prevalence of knee pain than a medial paratendinous approach.
In a retrospective study in which the nail was inserted via a paratendinous incision in 65 fractures and via a tendon splitting incision in 36 fractures, Keating et al (1997) [8] reported that insertion of an intramedullary nail paratendinously resulted in an incidence of knee pain of 50%, whereas this incidence in the tendon splitting incision group was 77%. This difference was significant (p<0.01). They thus recommended a parapatellar tendon incision for nail insertion [8]. Toivanen et al (2002) undertook a prospective randomized study of 56 patients with tibial shaft fracture requiring intramedullary nailing. At the time of the 8 year follow up, 4(29%) of the 14 patients treated with the transtendinous approach and 4(29%) of the patients treated with the paratendinous approach reported anterior knee pain, assessed with the visual analogue scale. They thus concluded that it was not possible to reduce the anterior knee pain by using a paratendinous approach rather than a transtendinous approach [10]. In our final follow up of six months 18 (65%) patients were painless and only 10 (35%) patients had chronic anterior knee pain. 8 patients out of 28(28%) treated with paratendinous nailing approach, had persistent anterior knee pain after final follow up of 24 weeks, while it was subsided in rest of the patients during this study.
There are many other factors than the surgical approach that may cause anterior knee pain after intramedullary nailing of a tibial shaft fracture. Possible causes include iatrogenic/injury related intra-articular damage, nail prominence, violation of patella tendon or damage to the infra patellar nerve.
Hernigou and Cohen (2000) investigated 12 pairs of cadaver knees after intramedullary nailing of the tibia. The intra-articular structures particularly at risk for damage during tibial nailing are medial meniscus, the lateral tibial plateau, and the transverse ligament. They also retrospectively analyzed 30 patients radiologically who had undergone tibial nailing and recorded unrecognized articular penetration and damage during surgery in 4patients [7].
In our study, 10 patients (35%) had persistent anterior knee pain after 24 weeks of follow up, of which 7(70%) were male and 3(30%) were females. Maximum patients having persistent knee pain were in the age group of 20-45 years. In their study Keating et al (1997) reported that the incidence of anterior knee pain is more common among younger than older patients [7]. This may be due to the more sedentary lifestyle of the elderly patients.
Keating et al and Toivanen et al [8] found no association between nail protrusion and anterior knee pain. In our study it is also seen that difference in the limb length and nail size do not differ significantly in the patients having knee pain as compared to those who do not have knee pain. Bleakney et al (2002) measured quadriceps musculature and atrophy using high-resolution real time ultrasonography (HRRTU) in 13 skeletally mature male patients with an isolated unilateral diaphyseal fracture of the femur or the tibia.2,3 They found clear differences in quadriceps morphology in the nailed and unnailed limb [9]. Patients who had anterior knee pain at final follow up had lower functional scores than those who never had knee pain or those whose knee pain has disappeared over time. Overall 43% excellent to good results and 57% fair results functionally are seen in this study. This also suggest that closed intramedullary nailing is an optimum treatment for tibial diaphyseal fractures.
We conclude that there is no co-relation of approach, either transtendinous or paratendinous with respect to anterior knee pain. There are many factors other than the surgical approach that may cause anterior knee pain after intramedullary nailing and additional studies to assess the role of these other factors in chronic anterior knee pain are warranted.
Although our data showed no differences between the groups, the groups were relatively small to accept this null hypothesis with full confidence and a longer study will establish the final results.


References

1. Alho A, Benterud JG, Hogevold HE, Ekeland A and Stromsoe K. Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures. Clin Orthop; 1992; 277: 243–250.
2. Bhandari M, Guyatt GH, Tornetta P III, Swiontkowski MF, Hanson B, Sprague S, Syed A and Schemitsch EH. Current practice in the intramedullary nailing of tibial shaft fractures: an international survey. J Trauma; 2002: 53:725–732.
3. Bleaky R, Maffuli N. Ultrasound changes to intramuscular architecture of the quadriceps following intramedullary nailing. J sports Med Phys Fit: 2002; 42: 120-125.
4. Bohnsack M, Wilharm A, Hurschler C, Ruhmann O, Stukenborg-Colsman C and Wirth CJ. Biomechanical and kinematic influences of a total infrapatellar fat pad resection on the knee. Am J Sports Med; 2004: 32: 1873–1880.
5. Court-Brown CM, Gustilo T, and Shaw AD. Knee pain after intramedullary tibial nailing: Its incidence, etiology and outcome. J Orthop Trauma; 1997, 11: 103–105.
6. Devitt TA, Coughlan KA, Ward T, McCormack D, Mulcahy D, Felle P, and McElwain JP. Patellofemoral contact forces and pressures during intramedullary tibial nailing. Int Orthop; 1998, 22: 92–96.
7. Hernigou P and Cohen D. Proximal entry for ontramedullary nailing of the tibia. The risk of unrecognised articular damage. J Bone Joint Surg; 2000, 82-B: 33–41.
8. Keating JF, Orfaly R, and O’Brien PJ. Knee pain after tibial nailing. J Orthop Trauma, 1997; 11: 10–13.
9. Nyland J, Bealle DP, Kaufer H, and Johnson DL. Long-term quadriceps femoris functional deficits following intramedullary nailing of isolated tibial fractures. Int Orthop; 2001, 24: 342–346.
10. Toivanen JAK, Väistö O, Kannus P, Latvala K, Honkonen S, and Järvinen M. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques. J Bone Joint Surg; 2002: 84-A: 580–585.

How to Cite this Article: Menwal G, Tonk G, Gupta AK, Kothiyal P, Kumar A. Anterior Knee Pain in Paratendinous Approach of Tibial Interlocking Nail. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):22-25 .


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Vitamin D Supplementation in Orthopaedic Patients – An Indian Perspective

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 33-37 | Chandra Prakash Pal, Vivek Mittal, Karuna Shankar Dinkar, Pawan Kumar, Ravi Mehrotra, Gaurav Deshwar


Authors: Chandra Prakash Pal [1], Vivek Mittal [1], Karuna Shankar Dinkar [1], Pawan Kumar [1], Ravi Mehrotra  [1], Gaurav Deshwar [1]

[1] Department Of Orthopaedics, S.N. Medical College , Agra, India

Address of Correspondence:

Dr. Pawan Kumar
Department of Orthopaedics, S N Medical College, Agra
Email: pawangangwar61@gmail.com


Abstract

Aim: Assessment of vitamin D role in vitamin D deficient adult Indian patients with orthopaedic complains
Material And Methods: This prospective study was conducted in department of orthopaedics in SN medical college Agra. 800 patients from both sex between 20 to 80 years were included in this study. These 800 patients were divided in two groups, group A of 400 patients was supplemented by 60000 IU/week orally active vitamin D for 3 months, while group B of 400 patients was supplemented by placebo for 3 months. Each patients was assessed clinically after 15 days and serum markers including 25(OH)D, total calcium, inorganic phosphate, intact parathyroid hormone(PTH-i), alkaline phosphates and 1,25(OH)2D were reassessed after 3 months .
Results: After 3 month of vitamin D supplementation parathyroid hormone (i-PTH) level decreased to 33.7 pg/ml from 41.2 in group A, while in placebo supplemented patients (group B), it remains 39.7pg/ml. insignificant difference (p<.3343) between two groups became significant (p<.0001), which shows parathyroid hormone decreased abruptly when vitamin D was supplemented adequately). Patients who were presented with pain in their hip region and later looser zone was identified in their x-rays. They are again assessed radiologically after 3months of vitamin D supplementation, their x-rays shows signs of healing on the site of looser zone.
Conclusion: Vitamin D is responsible for various neuro-muscular abnormalities like pain in multiple joints, muscle weakness( proximal muscles mostly involved) leads to imbalance and difficulty in walking and these signs and symptoms are directly related with serum 25(OH)D. After 60000 IU/week vitamin D supplementation in vitamin D deficient patients, 25(OH)D was elevated at significant level and all complains due to deficiency were subsided gradually.
Key Words: 25(OH)D, 60000IU/week vitamin D, visual analogue scale, looser zone


Introduction
Major role of vitamin D in humans is to increase the absorption of calcium and phosphate for mineralization of the skeleton. In adults with vitamin D deficiency, the newly formed bone matrix (the osteoid) is not mineralized, causing osteomalacia [1]. vitamin D synthesis takes place in the skin under the effect of sunlight. The India is situated between 8.4° N and 37.6° N latitude and has adequate sun exposure throughout the year. Despite this fact, there is widespread prevalence of hypovitaminosis D that may have an adverse impact on bone health [3–7]. Avoidance of sunlight, cultural and clothing practices, and skin pigment are factors contributing to vitamin D deficiency. Increasing urbanization that results in poor outdoor activity and greater pollution may further aggravate the problem [2-6]. Severe vitamin D deficiency results in clinically apparent metabolic bone disease, i.e., rickets and osteomalacia. Subclinical vitamin D deficiency or insufficiency can result in decrease in overall bone mass and, therefore, an increased risk of osteoporosis [3, 10]. Adequate replacement with vitamin D can increase the bone mass and decrease the risk of fractures [11].
Adequate dose and duration of vitamin D intake for the general population remains a subject of controversy. Experts now feel that 25-hydroxyvitamin D level of 30 ng/ml is required for maintaining optimal skeletal health [12]. The recommended doses of vitamin D (200–400 IU/day) intake are grossly inadequate to bring such low 25(OH)D levels to the desired levels [9–13]. This study was, therefore, undertaken to assess the efficacy and safety of cholecalciferol supplementation administered orally 60,000 IU/week for 3 months. This dose was chosen because this preparation is commonly and easily available in India, and the dose seems to be in agreement with the current suggestions available on vitamin D supplementation in the literature [10]. According to present studies, a dose as high as 10,000 IU/day is likely to pose no risk of adverse effects [14].

Materials and Methods
This prospective study was conducted on patients attending the orthopaedic OPD and emergency department of S.N. medical college, Agra from November 2013 to October 2015. 800 patients from both sex between 20 to 80 years were included in this study. All participants were recruited after taking written informed voluntary consent. The study subjects were recruited after a careful history, general and systemic physical examination. The questionnaire recorded information on age, co-morbidity status(such as diabetes mellitus, hypertension and Ischemic heart disease) and medication use including oral vitamin D supplementation.
Nutritional status was assessed by estimating the average composition of the daily diet in terms of energy, carbohydrate, protein, fat, calcium, and phytate (phytin-P) by use of a semi-quantitative food-frequency questionnaire and published data on the nutrient composition of Indian food.
Direct sunlight exposure was assessed by documenting average duration of exposure and percentage of the surface area of the body exposed daily. The average duration of cloud free sunshine during the years of study (2013-15) was 7.4 h/day in winter months (October to March) and 9.5 h/day in summer (April to September), according to the data provided by the Meteorology Department of U.P. Patients were selected on the basis of strict inclusion and exclusion criteria’s-
Inclusion Crieteria
1. Orthopaedic patients from both sex from age group 20 yrs to 80 yrs coming to orthopedic OPD and emergency department.
2. Subjects with any signs and symptoms of musculoskeletal problems including bone and joint pain, fracture and acute soft tissue injury, degenerative joint disease, metabolic bone, proximal myopathy disease etc.
Exclusion crieteria
1. Age <20 yrs and > 80 years.
2. Pregnant and lactating women
3. Drugs that can affect bone mineral metabolism, glucocorticoids, antitubercular therapy, antiepileptics, levothyroxine, hormone replacement therapy, biophosphonates, teriparatide etc.
4. Patient with history of surgery, hospitalization, or major medical illness within the past one year.
5. Diabetes mellitus patient, cancer patient, hepatic, renal, dermatological disorders and alcoholic persons.
6. Person taking vitamins and mineral supplementation since last 6 months.
Serum 25(OH)D concentrations will be estimated by using a radioimmunoassay. Serum marker measured included total calcium (Ca), inorganic phosphate, intact parathyroid hormone (PTH-i), alkaline phosphates and 1,25(OH)2D. Intact PTH was determined by a two site binding immunoradiometric assay. The normal values, standardized in our laboratory, are as follows: serum calcium 8.5–10.5 mg/dl, serum phosphorus 2.5–4.5 mg/dl; serum alkaline phosphatase 6–15 KAU/dl. Serum 25-hydroxyvitamin D3 (reference range 9–37.6 ng/ml) and serum intact PTH (13–54 ng/L). The subjects were classified as vitamin D-deficient, insufficient or sufficient on the basis of 25(OH)D concentrations of <20ng/mL, 21-29ng/ml and 30-100 ng/mL respectively, according to recent consensus [to convert to nmol/L, multiply by 2. 800 patients were divided in two groups, group A of 400 patients was supplemented by 60000 IU/week orally active vitamin D and 1000 mg calcium in two devided doses daily for 3 months, while group B of 400 patients was supplemented by placebo for 3 months. Each patients was assessed clinically after 15 days and serum markers including 25(OH)D, total calcium, inorganic phosphate, intact parathyroid hormone(PTH-i), alkaline phosphates and 1,25(OH)2D were reassessed after 3 months .
Statistical analysis – The data was categorised either in n (%) and means ± SD. Paired t test was used to compare changes in biochemical parameters before and after supplementation in group A and group B.. A p-value of < 0.05 was taken to be statistically significant.

 

Table 1

Table 1: Sex wise distribution: Females are more vitamin D deficient than males because of more indoor activity, more illiterate and due to post menopausal effect

                                                                                                 

Table 2

Table 2: Biochemical parameters in vitamin D deficient and insufficient patients as compare to vitamin D sufficient individual.

                                                                                                

Table 3

Table 3: Parameters after 3 month of 60000IU/week vitamin D and placebo supplementation

                                                                                                

Table 4

Table 4: Changes in visual analogue scale after 3 month of vitamin D supplementation.

                                                                                                

Results
Out of 800 patients included in our study, 264(33%) were males and 536(67%) female, among which patients 729 (90.2%) had vitamin D level <20 ng/ml, named as vitamin D deficient and 71 patients (9.8%) had vitamin D 21-29 ng/ml, called vitamin D insufficient. Initially there was no significant difference ( p<.1506) in 25(OH) D in group A and group B, but after 3 month of vitamin D ( in group A) and placebo ( in group B) supplementation the difference was significant (p<.0001), which shows significant increment in 25(OH)D level after 60000 IU/week vitamin D supplementation for 3 months. After 3 month of vitamin D supplementation parathyroid hormone (i-PTH) level decreased to 33.7 pg/ml from 41.2 in group A, while in placebo supplemented patients (group B), it remains 39.7pg/ml. insignificant difference (p<.3343) between two groups became significant (p<.0001), which shows parathyroid hormone decreased abruptly when vitamin D was supplemented adequately. Calcium was also elevated in vitamin D supplemented group ( group A) up to the significant level, while group B (placebo supplemented group) patient were remained calcium deficient . The difference between these two groups became significant( p<.0005 from p<.2676). There was no significant difference in phosphorus in group A and group B patients ( p<.2770), after vitamin D supplementation this difference became significant ( p< .0001) , that shows rise in phosphorous values in supplemented group while no change in placebo supplemented group.
After vitamin D supplementation alkaline phosphatase was decreased and difference between two groups became significant (p-value changes into .0001 from .0775). Patients who were presented with pain in their hip region and later looser zone was identified in their x-rays. They are again assessed radiologically after 3months of vitamin D supplementation, their x-rays shows signs of healing on the site of looser zone. Complain of their pain was also subsided gradually. After supplementation of 60000IU/week vitamin D, changes in visual analogue scale at the end of 2nd, 4th, 6th, 8th, 10th and 12th week in vitamin D supplemented group was 78, 45, 35, 30, 20, 15 respectively while in placebo group it was 82, 80, 78, 70, 70 respectively.

Figure 1: Looser zone in 32 years female

Figure 1: Looser zone in 32 years female

Figure 2: Looser zone healing after 3 months vitamin D ( 60000IU/week) supplementation

Figure 2: Looser zone healing after 3 months vitamin D ( 60000IU/week) supplementation

Discussion
This study was conducted on 800 patients coming to OPD and Emergency in department of orthopaedics of S.N. Medical College to evaluate the role of vitamin D supplementation in vitamin D deficient adult Indian orthopaedic population. Indians obtained most of their vitamin D through adequate sun exposure, however, darker skin pigmentation and the changes. Which have accompanied India’s modernization, including increased hours spent working indoors and pollution, limit sun exposure for many. The “adequacy of exposure to sunlight of an individual’s bare skin” required to synthesize vitamin D is grossly ill understood. Darker skin has high melanin content which acts as a natural sunscreen. Therefore, darker skin produces a significantly lesser amount of vitamin D when compared with the individuals with fairer skin, such as Caucasians. Thus, for Indian skin tone, minimum “direct sun exposure” required daily is more than 45 min to bare face, arms and legs to sun’s UV rays (wavelength 290–310 nm).
Inadequate sun exposure results in reduced vitamin D synthesis and ultimately poor vitamin D status if not compensated by dietary intake. Dietary vitamin D intake is very low in India because of low consumption of vitamin D rich foods absence of fortification and low use of supplements. Females are more prone to vitamin D deficiency as compare to men. As in our study out of 800 patients 536(67%) are females because most of women in India are house bound, living in crowded localities and with covered-up style of clothing and purdah and thus, deprived, of sun exposure, are at the highest risk of developing vitamin D deficiency.
In our study most of vitamin D deficients are in 60-80 years of age (47%) group, older people are prone to develop vitamin D deficiency because of various risk factors: decreased dietary intake, diminished sunlight exposure, reduced skin thickness, impaired intestinal absorption, and impaired hydroxylation in the liver and kidneys.
Dose of vitamin D for treating complications related with vitamin D deficiency are not fixed, many societies and studies suggest various regimens with different doses but in most of studies 50,000 IU/ week for 6-8 weeks is optimal dose for deficiency correction, as in 1998 Malabanan et al reported that ergocalciferol in a dosage of 50,000 IU once a week for 8 was an effective regimen to improve vitamin D status and decrease PTH levels in patients managed in an osteoporosis. In our study we found that after 3 month of 60,000 IU/week vitamin D supplementation, there is significant (p<.0001) rise in 25(OH) D, which shows repletion of vitamin D pool in body. Similar relation was found by Close et al. (2013), they examined young, United Kingdom based athletes (n = 30), and examined the effects that vitamin D supplementation (20–40,000 IU/week for 12 weeks) had on muscle performance (1-RM bench press, leg press and vertical jump height). Subjects were assigned to a placebo, 20,000 IU/week or 40,000 IU/week of vitamin D for 12 weeks. Muscle performance and 25(OH)D was measured at six and 12 weeks, revealing that six weeks of supplementation was enough to correct vitamin D deficiency, however, it was not enough to obtain optimal vitamin D levels >40 ng/mL. serum 25(OH)D levels significantly increased over this time, from an average of 20.43 ng/mL to 31.65–39.26 ng/mL. In our study we found that pain due to loosers zone was gradually decreased after vitamin supplementation. Evidence of healing was also identified radiologically, similar association was found by Abderhaman Ghazali, Patrice Fardellone, André Pruna et al. (1999), they found that looser’s zones (always associated with subperiosteal resorption) did not occur with plasma 25(OH)D of more than 40 nmol/liter, and subperiosteal resorption did not occur with plasma 25OHD of more than 100 nmol/liter., due to vitamin D deficiency most our patients were presented with musculoskelton and joint pain, we assessed response of vitamin D in these patients on the basis of visual analogue scale. We divided scale 0-100 and response of vitamin D was assessed every second week. Patients who was supplemented with vitamin D shows gradually decreased values on visual analogue scale, while in placebo group value was not changed.
Conclusion
Worldwide, vitamin D is predominantly obtained through exposure to UVB radiation in the form of sunlight and cutaneous vitamin D production. Latitude, cultural dress habits, season, sun avoidance, and sunscreen protection can all limit vitamin D production. Gastrointestinal, hepatic, and renal disease may be related to low vitamin D levels, but hypovitaminosis D most commonly results from inadequate intake. As by previous study and researches, vitamin D is responsible for various neuro-muscular abnormalities like pain in multiple joints, muscle weakness( proximal muscles mostly involved) leads to imbalance and difficulty in walking and these signs and symptoms are directly related with serum 25(OH)D. This study demonstrates that vitamin D supplementation has clinically beneficial effects on neuromuscular function in adults. After 60000 IU/week vitamin D supplementation in vitamin D deficient patients, 25(OH)D was elevated at significant level. Patients who was presenting with pain in their hip region during climbing stairs, rising up from stairs , these patients after 60000 IU/week supplementation shows positive response, their complains gradually decreases. While in placebo group their was no change in their complains.


References

1. Holick MF, Garabedian M. Vitamin D. In: Favus JM, editor. Primer on the metabolic bone diseases and disorders of mineral metabolism. 6. Washington: ASBMR; 2006. pp. 106–114.
2. Arya V, Bhambri R, Godbole MM, Mithal A. Vitamin D status and its relationship with bone mineral density in healthy Asian Indians. Osteoporos Int. 2004 Jan;15(1):56-61..
3. Sachan A, Gupta R, Das V, Agarwal A, Awasthi PK, Bhatia V. High prevalence of vitamin D deficiency among pregnant women and their newborns in northern India. Am J Clin Nutr. 2005 May;81(5):1060-4
4. Puri S, Marwaha RK, Agarwal N, Tandon N, Agarwal R, Grewal K, Reddy DH, Singh S. Vitamin D status of apparently healthy schoolgirls from two different socioeconomic strata in Delhi: relation to nutrition and lifestyle. Br J Nutr. 2008 Apr;99(4):876-82.
5. Harinarayan CV, Ramalakshmi T, Prasad UV, Sudhakar D, Srinivasarao PV, Sarma KV, Kumar EG. High prevalence of low dietary calcium, high phytate consumption, and vitamin D deficiency in healthy south Indians. Am J Clin Nutr. 2007
Apr;85(4):1062-7
6. Harinarayan CV. Prevalence of vitamin D insufficiency in postmenopausal south Indian women. Osteoporos Int. 2005 Apr;16(4):397-402.
7. Agarwal KS, Mughal MZ, Upadhyay P, Berry JL, Mawer EB, Puliyel JM. The impact of atmospheric pollution on vitamin D status of infants and toddlers in Delhi, India. Arch Dis Child. 2002 Aug;87(2):111-3.
8. Bischoff-Ferrari HA, Dietrich T, Orav EJ, Dawson-Hughes B. Positive association between 25-hydroxy vitamin D levels and bone mineral density: a population-based study of younger and older adults. Am J Med. 2004 May 1;116(9):634-9
9. Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial. BMJ. 2003 Mar 1;326(7387):469.
10. Heaney RP, Davies KM, Chen TC, Holick MF, Barger-Lux MJ. Human serum 25-hydroxycholecalciferol response to extended oral dosing with cholecalciferol. Am J Clin Nutr. 2003 Jan;77(1):204-10. Erratum in: Am J Clin Nutr. 2003 Nov;78(5):1047.
11.Norman AW, Bouillon R, Whiting SJ, Vieth R, Lips P. 13th Workshop consensus for vitamin D nutritional guidelines. J Steroid Biochem Mol Biol. 2007 Mar;103(3-5):204-5..
12. Holick MF. Vitamin D deficiency. N Eng J Med. 2007;357(3):266–281.
13. Whiting SJ, Calvo MS. Dietary recommendations for vitamin D: a critical need for functional end points to establish an estimated average requirement. J Nutr. 2005 Feb;135(2):304-9.
14. Vieth R. Vitamin D toxicity, policy, and science. J Bone Miner Res. 2007 Dec;22 Suppl 2:V64-8.

How to Cite this Article: Pal CP, Mittal V, Dinkar KS, Kumar P, Kumar P, Mehrotra R, Deshwar G. Vitamin D Supplementation in Orthopaedic Patients – An Indian  Perspective. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):33-37 .

Dr CP Pal

Dr CP Pal


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Comparative Evaluation of Clinical and Functional Outcome of Open Surgical Versus Percutaneous Repair of Acute Tendo Achilles Rupture

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 17-21 | Sachin Yadav, D. C. Srivastava , Siddhartha Sagar , Ankur Singh


Authors: Sachin Yadav [1] , D. C. Srivastava [1] , Siddhartha Sagar [1] , Ankur Singh [1]

[1] Department of Orthopaedics, M L N Medical College Allahabad, UP, India

Address of Correspondence:

Dr. Dinesh Chandra Srivastava
Department of Orthopaedics, M L N Medical College Allahabad, UP, India.
Email: srivastavadc1@rediffmail.com


Abstact

Aim: 1.To evaluate the results 1 year after the management of Achilles tendon rupture, using standardized, validated assessment methods for symptoms and function in patients treated open surgical repair versus percutaneous surgical repair.
2. To evaluate the recovery of function 1 year after injury and to study how function relates to patient-reported outcomes, with regard to lower limb function, as well as general health and quality of life.
Material and Method: This was an Prospective Cohort study of 30 patients of acute ruptured Tendo Achilles who were treated with open surgical repair and percutaneous repair. Patients were randomly allocated into the two treatment group (group 1 patients were managed by open repair and group 2 patients were managed by percutaneous repair) according to their order of presentation (one by one). Cases were taken up according to inclusion and exclusion criteria. All patients underwent a rehabilitation program. Cases were followed and evaluated at 3 weeks, 6 weeks, 12 weeks, 6 month and 1 year interval. The results were evaluated clinically and functionally by Leppilahti scoring method.
Results: All the patients were followed up at 3 weeks, 6 weeks, 12 weeks, 6 months and 1year interval. Mean time to return to work was 6 months in patients who underwent open surgical repair versus 4 months in patients who underwent percutaneous repair of acute ruptured Tendo Achilles. Lippelahti scores were excellent in 53.34% of open repair and 93% of percutaneous repair, good in 33.33% of open repair and 6.67% of percutaneous repair. Complications were significantly lower in percutaneous group.
Conclusion: . Percutaneous repair provides function similar to that achieved with open repair, with a better cosmetic appearance, a lower rate of wound complications and is also cost effective.
Keywords: percutaneous repair, tendoachilis tendon tear, functional outcome


Introduction

Introduction
The incidence of Achilles tendon rupture appears to be rising and approximately 75% of all ruptures occur during sporting activities [1]. Today, an Achilles tendon rupture is treated surgically, using either the standard open technique or the percutaneous technique, or non-surgically, with different mobilization alternatives. There is a wide variation of immobilization methods after both surgical and non-surgical treatment, including a cast and functional brace with or without weight-bearing and range-of-motion training. The main focus in the literature has been to compare the outcome of different treatment options in terms of re-rupture and surgical complications. A large number of medical reports and meta-analyses have been published in the field of Achilles tendon rupture, but there is still a lack of consensus on the best management. The aim of the present study is to evaluate the surgical treatment comparing the results obtained with Open and Percutaneous repair of acute rupture of Tendo Achilles.

Material And Method
The present study was conducted in department of orthopaedics, MLN Medical College and associated SRN hospital Allahabad from January 2014 to december 2015 in a consecutive series of patients who presented in the Outpatient department(OPD) and in the Emergency department with acute rupture of Tendo Achilles during the period of one year and who satisfied the inclusion criteria. This was an Prospective Cohort study and patients were randomly allocated into the two treatment group (group 1 patients were managed by open repair and group 2 patients were managed by percutaneous repair)according to their order of presentation( one by one).The prospect of treating the problem with conventional open repair or percutaneous repair was offered to the patients who accepted after detailed explanation.
A total of forty patients of Acute TendoAchillies rupture were admitted, out of which 5 patients were unfit for surgery and thirty five patient were managed operatively by percutaneous method or open method of repair. All the operatively managed patient were observed from admission to discharge. Each patient was called upon for follow up at 3 weeks, 6 weeks, 12 weeks, 6 month and 1 year duration but only 30 patients of Acute Tendo Achilles rupture were included in the study who turned up for at least 1 year duration. The cases were evaluated clinically , findings were recorded in the Proforma. The results were evaluated clinically and functionally by Leppilahti scoring method.2
Out of these 30 patients, 15 patients had to under go open repair during the course of study and 15 patients had to undergo percutaneous repair of acute rupture of TendoAchilles.

Technique of percutaneous repair: (Fig 1,2) In the operating room with the patient under spinal or epidural or local anesthesia, and with the extremity prepared as for open surgery, the tendon defect was palpated and small stab wounds were made on each side of the Achilles tendon 2.5 cm proximal to the rupture defect. A small hemostat was used to free the underlying tendon sheath from the subcutaneous tissue; a No. 0 or a No. 1 nonabsorbable suture threaded passed on a straight needle from the lateral stab wound through the body of the tendon and exit in the medial stab wound (Fig., Step 1). With a straight needle on each end of the inserted suture, crisscross the needles within the body of the tendon and the skin was punctured just distal to th site of tendon rupture; the sites of needle puncture was enlarged with a scalpel (Fig., Step 2), the suture was pulled completely through the stab wounds; the suture was snuged within the proximal portion of the ruptured tendon. With the lateral suture now threaded on a curved cutting needle, the suture was passed back through the last stab wound to exit at about the midportion of the distal stump of the ruptured tendon on the lateral side (Fig. Step 3). The hole was enlarged with a scalpel before pulling the suture through. A hemostat was used to free the subcutaneous tissue from the underlying tendon sheath (Fig., Step 4).A straight needle used, passed the lateral suture through the body of the distal stump of the tendon; the puncture wound in the skin was enlarged as before (Fig., Steps 5 and 6).A curved cutting needle was used, passing the suture from this distalmost stab wound on the medial side, and exiting at the middle stab wound on the medial side of the ruptured tendon (Fig., Step 7).With the ankle maintained in equinusposition, tension to the suture was applied in a crisscross manner, and brought the tendon ends together;the sutures were tied in this position, and with a small hemostat, the knot was burried in the depths of the wound (Fig., Steps 8 and 9).The skin was sutured. A sterile dressing to the stab wounds was applied.

Technique of Open repair (Krackow et al.)
With the patient prone, a posteromedial incision was made approximately 10 cm long about 1 cm medial to the tendon and ending proximal to where the shoe counter strikes the heel. Sharp dissection was done through the skin, subcutaneous tissues, and tendon sheath. The tendon sheath was reflected with the subcutaneous tissue to minimize subcutaneous dissection. The ruptured ends of the tendon were approximated with a 2-0 nonabsorbable suture. The repair was checked for stability after the sutures were tied. The peritenon and subcutaneous tissues were closed with 4-0 absorbable sutures. The skin was closed and a sterile dressing and a posterior splint or short-leg cast with the foot in gravity equines was applied.

Figure 1: Technique for percutaneous repair (refer to text for details of the steps)

Figure 1: Technique for percutaneous repair (refer to text for details of the steps)

Figure 2: Technique for percutaneous repair (refer to text for details of the steps)

Figure 2: Technique for percutaneous repair (refer to text for details of the steps)

Post operative care:
Postoperatively above knee Plaster of Paris slab was applied in full planter flexion at ankle joint and ninety degree flexion at knee joint and a pillow kept below the knee joint.
Antibiotic prophylaxis against infection (cefoparazone –sulbactum for 5 days) was given to all patient,
Appropriate analgesia was given according to the degree of the pain.
Wound dressing was done on third and fifth post operative day with full aseptic precautions.
Stitches were removed on post operative day 12 and patients were discharged on above knee slab in 30 degree planter flexion at ankle joint and ninety degree flexion at knee joint with written advice to come for follow up after 3 weeks.
At 3 weeks below knee slab was applied in neutral position at ankle joint, At 6 weeks the slab was removed and Walking orthosis given to the patient. The patient was advised partial weight bearing and physiotherapy (heel lift exercise).
At 9 weeks the walking orthosis was removed and patient was advised to gradually increase weight bearing.

Rehabilitaion was delayed for 2 week post surgery. Physiotherapy protocol as below
0– 3 weeks
1. An above knee slab in 30 degree planter flexion at ankle joint and ninety degree flexion at knee joint was applied.
2. Non-weight bearing for 3 weeks — no push off or toe-touch walking was allowed.
3. Toe curls, toe spreads were advised
3 -6 weeks
1. A below knee slab was applied in neutral position at ankle joint.
2.Toe curls, toe spreads, straight leg raises, knee flexion/extension were advised.
6 – 9 weeks
1. Slab was removed and Walking orthosis was given to the patient.
2. Gradual partial weight bearing was advised.
3. Heel raise exercise advised to patient.
4. Slow increase in the intensity and ranges of isometrics of Achilles within the range of the boot.
5. Slow increase in the passive range of motion and stretch on the Achilles tendon

9– 12 weeks
1. Gradual increase in weight bearing with heel lift as tolerated, gait training
2. Weaning into a regular shoe over a 2-4 week period.
3. Gradual increase in active/resistive exercises of the Achilles (i.e. submaximal isometrics, cautious isotonics.
4. Manual full passive range of motion of the Achilles — nothing forceful
5. Progress to cycling in shoe

3– 6 months
1. Closed chain exercises: controlled squats, lunges, bilateral calf raise (progress to unilateral), toe raises, controlled slow eccentrics vs. body weight.
2. Cycling, VersaClimber, rowing machine, NordicTrack (gradually).
6-9 months
Jogging/running, jumping, and eccentric loading exercises, noncompetitive sporting activities, sports-simulated exercises
9-12 months
Return to physically demanding sport and/or work.

Results
The mean age in year for males was 36.14±9.33 years (27 to 46 year).The mean age in year for females was 38±7.71 years(30 to 46 years). Over all mean age in years was 37.07±8.52 years(29 to 46 year). Out of 30 patients, 21(70%) patients were male and 9(30%) patients were females. In this study the most common mode of injury was sports injury. Out of 30 patients 20 (66.67%) patients sustained tendo Achilles rupture due to sport activity. Remaining 10 patients sustained tendo Achilles rupture due to age related(senile) and corticosteroid injections. In present study 15(50%) out of 30 patients with tendo Achilles rupture presented with in 7 days of injury. Remaining 15 patients(50%) presented at variable interval after 7 days but those presented before 6 weeks of injury.
Patients treated with open method of repair were hospitalized for an average period of 15 days ranging from 12 to 18 days.Patients treated percutaneous method of repair were hospitalised for an average period of 7 days ranging from 5 to 9 days.
In present study cases were followed and evaluated at 3 weeks, 6 weeks, 12 weeks, 6 months and 1 year. The results were evaluated clinically and functionally by Leppilahti scoring method
Leppilahti scoring done at 3 weeks, 6 weeks, 12 weeks 6 months and 1 year follow up. Mean leppilahti score for percutaneous and open repair of ruptured tendo Achilles are mention in table 1.

Table 1: Mean leppilahti score for percutaneous and open repair of ruptured tendo Achilles. Comparative assessment over period of time

Table 1: Mean leppilahti score for percutaneous and open repair of ruptured tendo Achilles. Comparative assessment over period of time

This improvement in mean leppilahti score at 3 weeks, 6 weeks, 12 weeks, 6 months and 1 year follow up was found to be statistically significant at p<0.05 suggesting that the percutaneous method of repair for acute rupture of tendo Achilles is better modality than open repair.

Complications: In this study the rate of complications are more with open repair of tendo Achilles as compare to percutaneous repair (Table 2).

Table 2: Incidence of Complications in each group

Table 2: Incidence of Complications in each group

Two(13.33%) out of fifteen patient developed complications in form of superficial infection and sural nerve injury in percutaneous repair of acute rupture of tendo Achilles whereas eight(53.33%) out of fifteen patients developed complications in form of superficial and deep infection, skin maceration and exposed tendon in open repair of acute rupture of Tendo Achilles. Due to high complication rate in open method of repair as compared to percutaneous repair of acute Tendoachilles rupture average duration of delay in post operative rehabilitation physiotherapy was 2 weeks in open repair.

Discussion

Achilles tendon rupture has been related to a relatively hypovascular area of the tendon to be 2 to 6 cm above the tendon insertion into the calcaneus. The major blood supply of the tendon is through its mesotendon, with the richest supply through the anterior mesentery. With increasing age, this anterior mesenteric supply becomes reduced. Age-dependent changes in collagen cross-linking result in increased stiffness and loss of viscoelasticity, predisposing to injury. Repetitive microtrauma to this area may make it impossible for the reparative process to keep pace, and a degenerative attrition may be responsible for many Achilles tendon ruptures.
The tendon of one athlete is able to withstand greater stress than that of another is related to a variety of factors, including long-term active and passive tendon tension, which results in more efficient collagen cross-linking, producing better viscoelastic properties, and tenocyte viability related to vascular nutrients, genetic factors, and hormonal environment, including growth factors, which have been shown to be important in determining scar characteristics.
Another cause of Achilles tendon rupture is the failure of inhibiting mechanisms at the musculotendinous unit as a result of fatigue, with resultant eccentric overload. The cause of Achilles tendon rupture probably is a combination of a relatively hypovascular area and repetitive microtrauma that causes an inflammatory reparative process that is unable to keep up with the stresses because of decreased vascularity. A mechanical overload completes the rupture.

The decision to treat acute tendo Achilles rupture conservatively or operatively is somewhat controversial.
Indications of conservative treatment are:
1. A gap (between the ruptured end of tendo Achilles) of less than 5 mm with maximum planter flexion
2. A gap of less than 10 mm with foot in neutral position.
3. More than 75% tendon apposition with foot in 20 degree planter flexion.
The rate of rerupture was higher with conservative treatment as compare to perative treatment. Of many studies conducted in this regard, 3 landmark studies Willitis  K et al [5], Wong J et al [4] and Kocher et al [6] were showed that rerupture rate was significantly lower with operative (open surgical) treatment as compare to conservative treatment  but to be associated with higher complication rate related to surgery like skin necrosis, adhesion, infection etc.
To obtain the benefits of operative (open surgical) treatment with minimum complications Ma and Griffith describe the percutaneous repair of acute ruptured tendo achilles. Of the many studies conducted to compare the outcome and complication rate of percutaneous versus open surgical repair of ruptured tendo Achilles, 3 landmark studies Carmont Mr et al [7], Cretnik A et al [9], Lim J et al [3], were showed comparable outcome and less complication rate associated with percutaneous repair as compare to open repair.
In the present scenario most common cause of tendo achilles rupture is sports injury. It usually occurs in 30 to 40 year of age group. The goals of management of Achilles tendon ruptures are to minimize the morbidity of the injury, optimize return to full function, and prevent complications..
Percutaneous repair of acute rupture of tendo Achilles is a good method to achieve the outcomes of open surgical repair with less complication rate.
Limitations of the Study
1. Lack of control/comparison /blinding
2. Short duration of study
3. Small study group

Advantage of percutaneous Repair
1. Less time taking procedure.
2. Short learning curve.
3. Can be done in local anaesthesia as a day care surgery.
4. Less amount of blood loss.
5. Tourniquet is not required.
6. Less complications.
7. Early rehabilitation can be start.
8. More economic.
9. Cosmetic.

 

Conclusion
The results of our study shows that rate of complications associated with open repair of Tendo Achilles were significantly low with Percutaneous repair. We observed more or less similar values of Range of Motion, calf muscle strength(subjective according to Lippelahti score), and single heel raising test between the groups however surgical stress to patients and surgical complications were less with shorter period of recovery in the patients of Percutaneous repair group. Mean time to return to work was longer for patients who had open versus percutaneous repair (6 months versus 4 months) because healing of ruptured Tendo Achilles was faster in Percutaneous repair due to lesser complications and physiotherapy could be implemented earliest. Cosmetic appearance is superior in the group of patients who had a percutaneous treatment.
Percutaneous repair provides function similar to that achieved with open repair, with a better cosmetic appearance, a lower rate of wound complications and is also cost effective.


References

1. Houshian S, Tscherning T, Riegels-Nielsen P. The epidemiology of Achilles tendon rupture in a Danish county. Injury. 1998;29(9):651-654
2. Leppilahti J, Siira P, Vanharanta H, Orava S. Isokinetic evaluation of calf muscle performance after Achilles rupture repair. Int J Sports Med. 1996;17(8):619-623
3. Lim J, Dalal R, Waseem M. Percutaneous vs. open repair of the ruptured Achilles tendon–a prospective randomized controlled study. Foot Ankle Int. 2001;22(7):559-568.
4. Jason Wong, Victoria Barrass and Nicola Maffulli Quantitative Review of Operative and Nonoperative Management of Achilles Tendon Ruptures Am J sports med 30:565, 2002.
5. Kevin Willits, Annunziato Amendola, Dianne Bryant, et al Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures, A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation J Bone Joint Surg Am, 2010 Dec 01; 92 (17): 2767 -2775 .
6. Mininder S. Kocher , Julius Bishop, Ryan Marshall et al Operative versus Nonoperative Management of Acute Achilles Tendon Rupture Expected-Value Decision Analysis, Am J sports med 30:783, 2002. 11(1):14–19
7. Carmont MR1, Heaver C, Pradhan A, Mei-Dan O, Gravare Silbernagel K. Surgical repair of the ruptured Achilles tendon: the cost-effectiveness of open versus percutaneous repair. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1361-8
8. Cretnik A1, Kosanovic M, Smrkolj V. Percutaneous versus open repair of the ruptured Achilles tendon: a comparative study. Am J Sports Med. 2005 Sep;33(9):1369-79.

How to Cite this Article: Yadav S, Srivastava DC, Sagar S, Singh A. Comparative Evaluation of Clinical and Functional Outcome of Open Surgical Versus Percutaneous Repair of Acute Tendo Achilles Rupture. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):17-21 .


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Assessment of Results of Internal Fixation and External Fixation in Fracture Lower Third Tibia

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 12-16 | Chandra Prakash Pal, Brijesh Sharma, Vipul Aggrawal, Pawan Kumar, Danish Altaf, Ravi Mehrotra


Authors: Chandra Prakash Pal [1], Brijesh Sharma [1], Vipul Aggrawal [1], Pawan Kumar [1], Danish Altaf [1], Ravi Mehrotra  [1]

[1] Department Of Orthopaedics, S.N. Medical College , Agra, India

Address of Correspondence:

Dr. Danish Altaf
Department Of Orthopaedics, S.N. Medical College , Agra, India
Email: drdanish.altaf@gmail.com


Abstract

Aim: Assessments of result of internal fixation and external fixation in fracture lower third tibia.
Material and Method:-This prospective study was conducted in department of S.N.Medical College, Agra. Patients were divided into two groups of 30 patients each. Group 1 were treated with external fixation (Rail fixator, normal fixator and ilizarov fixator) and Group 2 was treated with internal fixation (distal tibial LCP and distal tibial interlocking nail). Patients were selected on the basis of strict inclusion and exclusion criteria. After fulfilment of clinical as well as radiological criteria fracture were considered healed . Soft tissue outcome was assessed on basis infection and wound dehiscence. Final functional outcome was assessed by Ovadia and Beals criteria and Johner wruhs criteria for fracture distal tibia.
Result: Mean time of union found in group 1(for normal fixator 14 – 52 weeks, for rail fixator 15-48 weeks and for ilizarov fixator 15 – 48 weeks) and in group 2(distal tibial LCP 19- 41 weeks and distal tibial interlocking nail 16- 36 weeks) .Four patient in group 1 reported as non- union and two patients were reported non union in group 2, infection was found in 8 patients in group 1 and 4 patients in group 2. Second procedure required 4 cases of group 1 and 2 cases of group2.According to Johner -Wruhs criteria for fracture distal tibia result were found to be excellent in 40 % case of group 1 and 63.33 % cases of group 2.and according to Ovadia and Beals criteria subjective result assessment in group 1 was 43.33 % and 66.66% in group 2. Objective result assessment 30% in group 1 and 66.66% in group 2.
Conclusion: both external and internal fixation are found to be effective for lower third tibia fracture however lower rate of infection, union time was faster and better functional outcome found in internal fixation than external fixation.

Keywords: – pilon fracture, distal tibia fracture, locking plate, MIPPO.


Introduction
Lower third metaphyseal fracture of the tibia with or without intra-articular fracture extension in adults is among the most problematic injuries to treat. The most important variables that affect the final clinical result are the type of fracture, associated soft tissue injury, the method of treatment and the quality of the reduction [1, 2]. Conservative treatment of these fractures quite often results in a number of complications including malunion, non-union and ankle stiffness [3, 1, 4]. These fractures are generally not suitable for intramedullary nailing, despite certain reports indicating satisfactory results in some of these fractures [2, 5, and 6]. External fixation can be used as either a temporary or definitive method of treatment, especially in fractures with severe soft tissue injury [7, 8,9,10, 2], but mal-union and delayed union continue to be the main problems with this method of fixation [11, 12]. Conventional plate osteosynthesis with open reduction can further devitalise fragments and lead to higher incidence of non-union, infection and implant failure [13, 14]. Therefore, minimally invasive osteosynthesis, if possible, offers the best possible option as it permits adequate fixation in a biological manner [15, 9, 6].
Treatment of intra-articular fractures of the distal tibia is challenging due to the difficulties they present in achieving anatomical reduction of the articular surface of the ankle joint and the instability that may occur due to ligamentus and soft tissue injury. Numerous methods of treatment for these fractures have been reported, including conservative treatment with cast, open reduction and internal fixation and the combination of different types of external fixators with or without internal fixation [16]. Controversy exists in the literature concerning the way these fractures should be treated .The aim of the present study is to assess the result of internal fixation and external fixation in fracture lower third tibia.

Material and Methods
The proposed study was a hospital based prospective study centred in department of orthopaedics, S.N. Medical College, Agra.
Sample size: 60 patients divided into two group 30 each. Group 1 for external fixation and group 2 for internal fixation. Patient selected according to inclusion and exclusion criteria
All cases presenting to outpatient and emergency department of orthopaedic S.N. Medical College, Agra and fulfilling the below mentioned criteria will be taken up for the study.
Inclusion criteria.
1. Compound lower third tibia fracture.
2. Compound fracture lower third tibia with bone loss.
3. Closed lower third tibia fracture.
4. Age 20 to 70 years.

Exclusion criteria.
1. Pathological fractures.
2. Medically unfit patient.
3. Noncompliant patients.
4. Distal third tibia fracture with intra-articular extension.

Criteria For Internal Fixation:
1. Healthy skin condition at fracture site.
2. Fracture with compound grade I wound.
3. Fracture without massive swelling.
4. Comminuted fracture without compounding.

Criteria For External Fixation:
1. Fracture with compound grade II and III / with bone loss.
2. Infected skin condition at fracture site.
3. Fracture site massive swelling.
4. Comminuted fracture with compounding

In external fixation group
·18 cases done by normal fixator.
·6 cases done by rail fixator.
·6 cases done by ilizarov fixator.

In internal fixation group
· 18 cases done by distal tibial interlocking nail.
·12 cases done by distal tibial LCP plating.

Follow Up: Follow up the patients done at 3 week, 6 weeks then monthly for 6 month then at interval of 3month up to 15 month. Patients are observed clinically and radiologically and final result outcome was calculated by using Criteria for assessments of results (ovadia and beals, 1986) (table no.1) and Johner-wruhs’ criteria for evaluation of final results (table no.2).

Table 1: Criteria for assessment of results (ovadia and beals); Objective and subjective resultsTable 1: Criteria for assessment of results (ovadia and beals); Objective and subjective results

Results:
In this study 38(63.33%) patient were male and 22 female (36.66%) with mean age of patients 31 – 40 years (38.33%), most of the patients were lower socio economic status. In our study 39 fracture were right and 21 fractures were of left side with most common mode of injury was road traffic accident 28 patient (46.66%). Of all the fractures 24 were extra-articular type, 20 were partial-articular type and 16 intra-articular types. There were 28 compound fractures of which 5 fractures were grade I, 7 fractures were grade II and 16 fractures were grade III According to Gustilo-Anderson classification. The mean time of partial weight bearing in fractures of distal tibia treated by normal fixator (12-14 weeks), rail fixator (3-4 weeks), ilizarov fixator (3-4 weeks) ,distal tibial interlocking nail(7.6 weeks) and distal tibial LCP(9.5 weeks).

Table no 2: Johner-Wruhs' Criteria for Evaluation of Final Results

Table no 2: Johner-Wruhs’ Criteria for Evaluation of Final Results

The mean time of full weight bearing in fractures of distal tibia treated by normal fixator (16-18 weeks), rail fixator (5-6 weeks), ilizarov fixator (5-6 weeks) ,distal tibial interlocking nail (14.25 weeks) and distal tibial LCP(17.32 weeks).
Mean time of union in fracture distal tibia treated by distal tibial interlocking nail (23.45 weeks), treated by rail fixator was 32.5 weeks, and treated by ilizarov fixator was 30.5 weeks and treated by normal fixator was 34 weeks.
According to Ovadia and Beal criteria 1986,
In subjective result assessment in internal fixation 66.66% excellent results and in external fixation 43.33% excellent results and In objective result assessment in internal fixation 66.66% excellent results and in external fixation 30.00% excellent results. According Johner-Wruhs criteria in internal fixation 63.33% excellent results and in external fixation 40.00% excellent results. Second procedure was required in 6 case of non union in which two case of normal fixator non union with implant breakage were treated by distal tibial nailing, two cases of normal fixator with non union without implant breakage were treated by distal tibial interlocking nailing and early dynamization. One case of distal tibial interlocking nail implant breakage with non-union were treated by exchange nailing and one case distal tibial LCP implant breakage with non union was treated by plating with bone grafting.

Figure 1: Distal Tibail Interlocking Nailing a- preoperative radiograph, b-postoperative radiograph and c- 15 months follow up radiograph

Figure 1: Distal Tibail Interlocking Nailing a- preoperative radiograph, b-postoperative radiograph and c- 15 months follow up radiograph

 

Figure 2: Distal Tibial LCP Plating a- preoperative radiograph, b-postoperative radiograph and c- 9 months follow up radiograph

Figure 2: Distal Tibial LCP Plating a- preoperative radiograph, b-postoperative radiograph and c- 9 months follow up radiograph

Discussion
There were total 38 male patients (63.33%) and 22 female patients (36.66%) in this study showing male preponderance because of travelling and Working (Court-Brown CM et al, 1995) [17].The mean age of Fracture was Commonest in age group of 31 – 40 year (38.33%) as most active group of society. The most common mode of injury was road traffic Accident 28 patient (46.66%) followed by 15 (25.00%) fractures were fall from Height. This is similar to previous study Conducted by Siddhartha et al 2014 [18], Aso Mohammed et al 2008 [19], Janssen et al 2007 [20], Vallier et al 2008 [21], Im GI et al 2005 [22] and Guo JJ et al 2010) [23].
Mean time of partial weight bearing and full weight bearing in distal tibial LCP was 9.5 weeks and 17.30 weeks. Which was longer than previous study by N Mahajan [24] (2011) shows partial weight bearing and full weight bearing at an mean time period of 6 and 12 weeks respectively.
Mean time of partial weight bearing and full weight bearing in Distal tibial interlocking nail was 7.6 weeks and 14.25 weeks respectively which was similar to previous study by Obulapathy D and Suresh Reddy .S 2015 [25] in which partial weight bearing was 6.8weeks and full weight bearing was 13.6 weeks. Mean time of partial weight bearing and full weight bearing in rail fixator was 3.5 weeks and 5.5 weeks respectively Mea.n time of partial weight bearing and full weight bearing in ilizarov fixator was 3.5and 5.5 weeks. Mean time of partial weight bearing and full weight bearing in normal fixator was 13.5weeks and 17.5weeks.
Mean time of union in fracture distal tibia treated by distal tibial interlocking nail (23.45 weeks, range 16-36weeks ) which was similar result as done in previous study by Wasudeo Gadegone, Yogesh Salphale , Vijayanand Lokhande 2015 [26] treated by rail fixator was 32.5 weeks(range 15-48 weeks) ,treated by ilizarov fixator was 30.5 weeks(range 15-48weeks) , treated by normal fixator was 34 weeks (range 14-52 weeks) and treated by distal tibial LCP plating 26weeks(range 19-41weeks).

Figure 3: Normal External Fixator a- preoperative radiograph, b-postoperative radiograph and c- 7 months follow up radiograph

Figure 3: Normal External Fixator a- preoperative radiograph, b-postoperative radiograph and c- 7 months follow up radiograph

Figure 4: Rail Fixator a- preoperative radiograph, b-postoperative radiograph and c- 9 months follow up radiograph

Figure 4: Rail Fixator a- preoperative radiograph, b-postoperative radiograph and c- 9 months follow up radiograph

Figure 5: Ilizarov External Fixator a- preoperative radiograph, b,c-postoperative radiograph and d- 10 months follow up radiograph

Figure 5: Ilizarov External Fixator a- preoperative radiograph, b,c-postoperative radiograph and d- 10 months follow up radiograph

According to Ovadia and Beal criteria 1986:In subjective result assessment in internal fixation 66.66% excellent results and in external fixation 43.33% excellent results and In objective result assessment in internal fixation 66.66% excellent results and in external fixation 30.00% excellent results. This result was similar to previous study by Ovadia and Beals 1986 found 55/80 (69%) excellent result in internal fixation and 28/54(43%) excellent result in external fixation.
According Johner-wruhs criteria in internal fixation 63.33% excellent results and in external fixation 40.00% excellent results. Similar results were found in previous study Internal fixation by Obulapathy D and Suresh Reddy .S 2015 Results were excellent in 66.6% and 41.6%, Good in 25% and 33.3%, fair in 8.3% and16.6% of ILN and plating groups respectively and 8.3% Show poor results in plating group.
Conclusion
In the management of fracture distal one third tibia as both internal Fixation and external fixation procedures were found to have merits and demerits, the choice of surgical procedure should be based on individual patient requirements, availability of equipment and Expertise. In this study internal fixation showed favourable Outcome and less complication when compared to external fixation Procedure. Similar results were also found in previous study done by many surgeons and institutes. Hence it may be concluded that from my study and previous held studies that internal fixation is the better Method for treating fracture distal lower third tibia.


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17.Court-Brown CM, Mc Birnie J 1995.The epidemiology of tibial fractures. J Bone Joint Surg Br. May;77(3):417-21
18.Siddhartha Venkata Paluvadi’ Hitesh Lal. Deepak Mittal and Kandarp Vidyarthi,2014. Management of fractures of the distal third tibia by minimally invasive plate osteosynthesis – A prospective series of 50 patients. J Clin Orthop Trauma. sep; 5(3):129-136.
19.Aso Mohammed, Ramaswamy Saravanan, Jason Zammit and Richard King 2008 . Intramedullary tibial nailing in distal third fractures: distal locking screws and fracture
non-union. I nt Orthop. Aug; 32(4):547549
20.Janssen KW, Biert J, Van KA,2007. Treatment of distal tibia fractures: a retrospective outcome analysis of match pairs of patients. Int Orthop;31(5):709-71Johner
21. Vallier HA, Le TT, Bedi A,2008. Radiographic and clinical comparisons of distal tibia fracture (4 to 11 cm proximal to the plafond): plating versus intramedullary nailing. J Orthop Trauma; 22(5):307-11
22.Im GI, Tae SK, 2005. Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma; 59(5):1219-23
23.Guo JJ, Tang N, Yang HL, Tang TS. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br. 2010
Jul;92(7):984-8.
24. Neeraj Mahajan. Minimally Invasive Techniques in Distal Tibial Fractures JK SCIENCE Vol. 10 No. 2, April-June 2008
25. Obulapathy D and Suresh Reddy.S 2015International Journal of Recent Scientific Research Vol. 6, Issue, 6, pp.4918-4920, June, 2015
26. Wasudeo Gadegone, Yogesh Salphale, Vijayanand Lokhande 2015 Surgical Science, 2015; (6) 317-326.

How to Cite this Article: Pal CP, Sharma B, Aggrawal V, Kumar P, Altaf D, Mehrotra R. Assessment of Results of Internal Fixation and External Fixation in Fracture Lower Third Tibia. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):12-16 . .

Dr CP Pal

Dr CP Pal


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Orthopaedic device-related Infections in long Bones – The Management Strategies

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 5-11 | Shyam Kumar Saraf, Aditya Malik


Authors: Shyam Kumar Saraf [1],  Aditya Malik [1]

[1] Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi

Address of Correspondence:

Dr. Shyam Kumar Saraf
Department of Orthopaedics, Institute of Medical Sciences, Banaras Hindu University, Varanasi

Email: sksaraf36@hotmail.com


Abstract

Orthopedic device–related infections (ODRIs) present a unique scenario and if often challenging situation to manage This review focuses on etiophatogenesis, classification, diagnosis and management of ODRI. The current literature has been reviewed and the inferences are combined with authors personal experiences to provide practical conclusions that can be used by the readers in clinical practice.
Keywords: Orthopaedic device related infections, management, surgical


Introduction
Orthopedic implants have revolutionized the treatment of bone fractures and non-infectious arthritis. Orthopedic implants have become an essential component of modern medicine. The number of patients requiring implants will continue to grow, as will the risk for orthopedic device–related infections (ODRIs). Despite considerable progress in prevention and management of implant-associated infection, the absolute number of patients with such infections is rising due to the lifelong risk for bacterial seeding on the implant. Infections associated with prosthetic joints are less frequent than aseptic failures, but represent one of the most devastating complications associated with high morbidity and substantial cost. Overall, about 5% of internal fixation devices become infected. The incidence of infection after internal fixation of closed fractures is generally lower (0.5–2%), whereas the incidence may exceed 30% after fixation of open fractures. [1-4]

Pathogenesis
Physiology of biofilm formation is the corner stone for understanding the pathogenesis of orthopedic device-related infections. It involves interaction between microorganisms, the implant and the host. The first and most important step in biofilm formation is the ‘race to the surface’ of the implant between tissue cell integration and bacterial adhesion.[5] On contact, body fluids immediately coat all surfaces with a layer of host material, primarily serum proteins and platelets. Albumin is rapidly deposited on foreign material and prevents nonspecific neutrophil activation and deposition of matrix proteins on the surfaces. Adherence of Staphylococcus aureus to bioprosthetic materials is mediated by adhesins such as – fibronectin, fibrinogen, fibrin, collagen, laminin, vitronectin, thrombospondin, bone sialoprotein, elastin, and the matrix-binding protein. These host proteins promote attachment of S. aureus onto polymeric or metallic surfaces by specific receptors. [6.]Adherence progresses to aggregation of microorganisms on the surface of the foreign body, forming a biofilm. Thus biofilms can be defined as structured communities of bacterial cells enclosed in a self-produced polymeric matrix and adherent to an inert or living surface.
Foreign bodies are devoid of microcirculation, which is crucial for host defense and the delivery of antibiotics. Existence within a biofilm represents a basic survival mechanism by which microbes resist against external and internal environmental factors, such as antimicrobial agents and host immune system [7]. These microorganisms live clustered together in a highly hydrated extracellular matrix attached to some surface. Depletion of metabolic substances or waste product accumulation in biofilms causes microbes to enter a slow growing or stationary state. Within biofilms, microorganisms develop into organized and complex communities with structural and functional heterogeneity resembling multicellular organisms in which water channels serve as a rudimentary circulatory system. Release of cell-to-cell signaling molecules (quorum sensing) allows microorganisms in a biofilm to respond in concert by changing their gene expression involved in biofilm differentiation [8]. Biofilm microorganisms, therefore, are significantly more resistant to killing by growth-dependent antimicrobials than their free-living counterparts. As a result, standard antibiotic therapy typically reverses signs and symptoms caused by planktonic bacteria released from the biofilm but fail to kill bacteria in the biofilm.

Classification of ODRI
Orthopedic device-related infections occur per-operatively by bacterial contamination of the surgical site during surgery or immediately thereafter, by hematogenous microbial spread through blood from a distant focus of infection, or contiguously by direct or lymphatic spread from an adjacent infectious focus or penetrating trauma.
Prosthetic Joint Infections can be classified into three categories based on the duration and timing of appearance of symptoms post surgery.
1. Early Infections – Manifestation of infection at the implant site within 3 months post surgery. It occurs post operatively and is generally caused by virulent organisms like Staphylococcus aureus. There is persisting local pain, erythema, edema, delayed wound healing or dehiscence, hematoma and/or fever.
2. Delayed Infections – Manifestation of infection 3 – 24 months after surgery. Mostly they are due to organisms of low virulence, for example, Coagulase negative staphylococci, Propionibacterium acnes. Persisting or increasing joint pain and early loosening are the hallmarks. Clinical signs of infection maybe lacking and there, the most important differential diagnosis is aseptic failure.
3. Late Infections – Manifestation of infection more than 2 years after surgery. Most such infections result from hematogenous seeding from other foci, such as the skin, respiratory tract, urinary tract and/or dental foci[9,10].
In internal fixation devices, associated infections may again be classified into three categories based on the timing of manifestation symptoms post fixation.
1. Early Infections – Manifesting in less than 2 weeks post fixation. Mainly caused by highly virulent organisms, like Staphyloccus aureus and Gram-negative bacilli.
2. Delayed Infections – Manifesting at 2–10 weeks post fixation.
3. Late Infections – Manifesting beyond 10 weeks post fixation [11].

Diagnosis of Infection
A combination of clinical, laboratory, histopathology, microbiology and imaging studies is required for the diagnosis of infection. Early infection is usually easy to diagnose, as it presents clinically with both systemic and local signs. Systemic signs include fever, malaise, lethargy and loss of appetite. There may be erythema, edema, induration, raised temperature or even frank pus discharge at the operative site. Secretary wet wounds and unsatisfactory wound healing are common presentations. However, in cases of delayed and late infections, a high degree of suspicion is required. Short course of antibiotics may suppress the earlier infection to reappear later. Delayed or chronic infection may present as persistent pain at local site, local signs of inflammation or sinus. We often see sinuses/ discharges from interlock screw/ bolts or persistent discharging sinus in a plated fracture. Unusual delay in fracture healing, loosening of plates and screws should be taken as highly suspicious in favour of infection even if there may not be exterior signs of infection. Many a time patients present with broken/ bent internal fixation implants without any history of trauma. Ununited fractures due to infection should be strongly suspected in such cases. ( Fig.1)

Figure 1: Broken nail, ununited fracture after infection

Figure 1: Broken nail, ununited fracture after infection

Plain X-ray of the operative site may not contribute in the diagnosis in the initial post operative days. Later it may show the osteoporosis around fracture site. The signs of loosening of well fixed plate and screws, reaction around the screws, non union/ delayed union of fracture, sequestrum formation, reaction around the intra medullary nails are the radiological signs of infection. If infection is suspected clinically, even in the absence of radiological signs of infection, it is wiser to explore the wound and send the material for histology and culture and sensitivity.
Blood leukocyte counts and differential counts may show leukocytosis and neutrophilia in acutely acquired infections, however, they are not sufficiently discriminative to predict the presence or absence of infection. Post surgery, C Reactive Protein and ESR is acutely elevated and returns to normal within weeks. Therefore, preoperative and repetitive postoperative measurements are more informative than a single value in the postoperative period. In a prospective case-control study involving 58 patients, elevated serum Interleukin-6 concentration correlated with peri prosthetic infection in patients undergoing re surgery at the site of total hip or knee arthoplasty [12].
Synovial fluid leukocyte count represents a simple, rapid and accurate test for differentiating prosthetic joint-associated infection from aseptic failure. In prosthetic knee infections, synovial fluid leukocyte count of more than 1.7 x 109/l and differential of more than 65% neutrophils has a sensitivity for infection of 94% and 97%, and specificity of 88% and 98%, respectively [13].
Scintigraphy by means of a technetium (Tc99m) scan, gallium citrate (Ga67) scan, or indium (In111)-labeled leukocyte scan may be helpful in the diagnosis of ODRI. However, this approach is expensive, and the accuracy of these methods is still limited. Histopathological examination of the periprosthetic tissue has a sensitivity of more than 80% and a specificity of more than 90% [14]. Acute inflammation has been variably defined to range from at least 1 to 10 neutrophils per high power field. The degree of infiltration with inflammatory cells, however, may vary considerably between specimens from the same patient, even within individual tissue sections. Therefore, areas with the most florid inflammatory changes should be assessed and at least 10 high-power fields should be examined to obtain an average count[15] . Histopathology examination does not identify the causing organism, however, can confirm the presence of infection. Rarely Mycobacterium tuberculosis as the cause of infection has been reported.
Aspiration of synovial fluid and operative site tissue cultures provide the most accurate specimens for detecting the causative microorganism. At least three operative site tissue areas should be sampled for microbiology. If possible, antimicrobial therapy should be discontinued prior to tissue sampling[16]. Peri operative prophylaxis at revision surgery should not be started until after tissue specimens have been collected for culture [17]. If implant material is removed, the device can be cultured in enrichment broth media. The risk of contamination during processing, however, is high and the interpretation of the microbiologic result difficult [18]. New diagnostic approaches include sonication of removed implants to dislodge adherent microorganisms growing in biofilms and the use of molecular techniques to improve diagnostic yield. Explanted implants from 54 patients with aseptic failure and 24 with prosthetic joint infection were sonicated in polyethylene bags, the culture sensitivity of sonicate fluid was superior to that of standard peri-prosthetic tissue (75% versus 54%), whereas the specificity was 87% and 98%, respectively [19].

Treatment strategies
The ultimate goal of a successful therapy is a long term pain-free and functional joint and limb. Eradication of an orthopedic device-related infection is best achieved by a combination of both an appropriate surgical procedure and a prolonged antimicrobial treatment. The traditional procedure is a two-stage exchange of the implant with meticulous removal of all foreign material combined with a finite course of antimicrobial treatment. The result may be suboptimal due to the delayed re-implantation of orthopedic device (typically after more than 6 weeks) [20].
Another option is a lifelong suppressive oral antimicrobial treatment, but this approach usually controls only clinical manifestations and does not eradicate the infection, as the antibiotic kills the planktonic bacteria, but is unable to kill the bacteria lodged in the biofilm associated with the infected implant. In most cases, clinical symptoms recur during or after antibiotic discontinuation [21]. Therefore, it is option suited only when surgery is contraindicated or if the patient refuses surgical intervention. In contrast to prosthetic joint infections, the primary aim in infections associated with fracture fixation is consolidation of the fracture and prevention of subsequent chronic osteomyelitis. There is a trade – off between bony stability and foreign body response. Stability is necessary to eliminate the infection, but organisms remain adherent to the implant and cause persistent infection. If an implant is not necessary to maintain bony stability, it should be removed. Implants needed for stability should be retained until there is bony stability, or they should be replaced by another form of fixation (e.g., removing a plate and replacing it with an external fixator). If infections are not treated aggressively, surgical fixation becomes compromised. It is easier to treat a stable healed fracture with osteomyelitis than an unstable infected non-union. Thus, complete eradication of microorganisms in these infections is not always a mandate, as the colonized device can be removed after the bone is consolidated.

Surgical strategies
Depending on the type and susceptibility of pathogen, duration of symptoms, stability of the implant and the condition of the surrounding soft tissue, the surgical treatment modality may be chosen. The treatment includes debridement with retention of orthopedic device, (Fig.2 & 3) one or two stage exchange, permanent removal of the implant etc. Debridement with retention of implant is a reasonable option for patients if duration of manifestation is less than 3 weeks, the implant is stable and the soft tissue is in good condition, and an agent with activity against biofilm microorganisms is available [22-26]. The one-stage exchange designates the removal and implantation of a new orthopedic device during the same surgical procedure. This approach is recommended if the surrounding soft tissue is in good condition, the infecting pathogen does not belong to the difficult-to-treat microorganisms, and the patient has no severe co-morbidity [27–30]. The two stage exchange includes removal of the implant, with implantation of new device during a later surgical procedure. Typically a short interval until re-implantation (2-4 weeks) and a temporary antimicrobial impregnated bone cement spacer/ beads or an external fixation device is used to secure the limb length. A longer interval (about 8 weeks) is preferred if the microorganism isolated is from the difficult-to-treat category. (eg. MRSA, enterococci or fungi). Permanent removal of device is usually reserved for patients with a high risk of re-infection, in the elderly or when no functional improvement after surgery is expected.

Figure 2: Plating humerus. a) discharging sinuses b) plate retained as construct was stable. C.) fracture united.

Figure 2: Plating humerus. a) discharging sinuses b) plate retained as construct was stable. C.) fracture united.

 

Figure 3: Internal fixation radius and ulna. a) discharging sinuses b) x ray forearm showing signs of infection b) local debridement done however plate retained. c)facture united. D) sinuses healed.

Figure 3: Internal fixation radius and ulna. a) discharging sinuses b) x ray forearm showing signs of infection b) local debridement done however plate retained. c)facture united. D) sinuses healed.

Antibiotic treatment
Intravenous treatment should be typically administered for the initial 2–4 weeks followed by oral therapy to complete the treatment course. In patients with two-stage exchange with a long interval (8 weeks), the aim of antimicrobial therapy is complete elimination of infection in the absence of any foreign material (e.g. antibiotic mixed spacer). Two weeks before re-implantation of the prosthesis, antimicrobial treatment is discontinued in order to get reliable tissue specimens for culture and histopathology at the time of re-implantation. In fracture- fixation devices, the treatment duration is 3 months with device retention, or 6 weeks with removal of all hardware [31,24]. If no antibiotic with efficacy on adherent bacteria is available, treatment with implant retention is generally only suppressive until the implants can definitively be removed. In such cases antibiotics should be continued for at least 2 weeks after removal of all implants to avoid development of chronic osteomyelitis. Many a times prolonged administration of systemic drugs may not be effective, hence the concept of local antibiotic delivery system has come up. The advantage is extremely high level of local antibiotic concentration. This facilitates delivery of antibiotics by diffusion to avascular areas of wound. The resistant organisms start responding to this high concentration. The local antibiotics can be delivered through Non degradable beads – PMMA beads / Spacers ( Fig.4 & 5 )or Bio degradable beads like bone graft, bone graft substitutes, natural polymers, synthetic polymers, composite biomaterials etc.

Figure 4: Gross infection humerus after plating. a) Clinically presenting with gross infection b) infected plating c) plate with diaphyseal sequestrum d) gap after debridement e) PMMA antibiotic spacer f) spacer in gap.

Figure 4: Gross infection humerus after plating. a) Clinically presenting with gross infection b) infected plating c) plate with diaphyseal sequestrum d) gap after debridement e) PMMA antibiotic spacer f) spacer in gap.

 

Figure 5: Infection after Interlock nailing femur. a) Clinically presenting gross infection b) X ray showing nail and infection c) PMMA antibiotic beads after debridement d) radiological union e) wound healed.

Figure 5: Infection after Interlock nailing femur. a) Clinically presenting gross infection b) X ray showing nail and infection c) PMMA antibiotic beads after debridement d) radiological union e) wound healed.

Prevention of infection – The best strategy
As noted from the above discussion, treatment of orthopedic device-related infections is a scenario where many variables play a role in deciding the treatment. The treatment however is difficult and prolonged. Therefore, the best treatment strategy is prevention of infection. Antimicrobial prophylaxis remains the single most effective method of reducing the prevalence of infection after fracture fixation both. In bone surgery, a first- generation or second-generation cephalosporin, such as cefazolin or cefuroxime, is a rational choice. If the patient is allergic to cephalosporins, or in settings with high prevalence of methicillin resistant S. aureus (MRSA), vancomycin or teicoplanin are alternative options [32]. For optimal efficacy of the prophylactic agent, antimicrobial inhibitory concentrations must be achieved in tissue at the time of incision and last during the entire procedure. In an animal study, a short period of prophylactic efficacy of 3 hours has been observed. These animal data have been confirmed in a large retrospective study evaluating the outcome of 2847 surgical wounds [33,34]. When a tourniquet is used, tissue concentrations of the antibiotic are usually insufficient for prevention of surgical site infection when administered 5 min before inflation or later. For internal fixation devices of closed fractures in centers with infection rates of less than 5%, a single dose of intravenous cefuroxime is a reasonable option. In centers with unknown or high infection rates (>5%) and in open fractures grade I and grade II, a 1-day prophylaxis is preferred: intravenous cefuroxime and/or tazobactam-piperacillin maybe be used. In patients with internal fixation of grade III open fractures, pre-emptive therapy with an anti staphylococcal drug such as intravenous amoxicillin/clavulanic acid or cefuroxime for 5–7 days is reasonable. There is little evidence to suggest that newer antimicrobial agents with a broader antimicrobial spectrum are superior to first or second-generation cephalosporins.
Most infections with use of internal fixation devices are exogenous in peri operative period. There is no substitute for meticulous pre operative assessment and observing the rigorous protocol and discipline throughout the peri operative period. Hematogenous seeding of implants may occur during the whole life, although the risk of infection is highest in the first year after implantation. In a cohort study of 40 consecutive episodes of prosthetic knee associated infection, the fraction of hematogenous infections has been estimated at 38% [35]. The most frequent sources of hematogenous infection are infections of the skin and soft tissues, oral cavity, urinary and respiratory tract [36]. They must be tackled accordingly.

Conclusion
The various problems in the management strategies are biofilm formation, bacteria are difficult to culture, the culture & sensitivity is not always reliable, oral and parental antibiotics may not resolve the basic biofilm nidus of infection, the immune response of patient may not be effective, adjoining joints have stiffness and finally the surgeon & patient both become impatient, tired, devoid of resources & their savings. The important factors for consideration in the management are; interval between surgery and clinical presentation of infection, severity of infection, identification of organism and stability at fracture site by the implant. Internal fixation device infection can be classified on the basis of time interval between surgery and clinical manifestations. Infection appearing within 3 weeks is usually as a result of Staph. aureus. Mild superficial infection like stitch abscess can be managed by I V antibiotics, however, in all other cases, it is safer to open the wound, drain abscess if any, debridement of dead necrotic tissue, granulation tissue, sending the material for C/S and wound irrigation. Removal of implant is not necessary at this stage, however, checking the stability of fracture by implant is important. Reinforce the stability if necessary. For deep delayed infection, open the fracture site, debride, irrigate and then local antibiotic beads can be put temporarily. Stabilize fixation if necessary. For mild delayed infection in intra medullary nailing, one can remove intra medullary nail followed by over reaming and thorough lavage of canal. Depending upon the severity, one can reinsert another simple nail of higher diameter or antibiotic coated nail with or without bone grafting. In severe infection, it is safer to remove the nail, ream and putting temporarily antibiotic mixed cement coated intramedullary implant as first stage. Alternatively fracture can be stabilized temporarily by external fixator. In 2nd stage, with control of infection, debride again, ream the canal and put larger size of nail. Treatment of implant-associated infection requires prolonged antimicrobial therapy. The choice of the antimicrobial regimen depends on duration and pathogenesis of infection, stability of the implant, antimicrobial susceptibility of the pathogen, and condition of the surrounding soft tissue.


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How to Cite this Article: Saraf SK, Malik A. Orthopaedic device-related infections in long bones – The management strategies . Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):5-11 .

Dr Shyam K Saraf

Dr Shyam K Saraf


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Points to Note While Submitting to Journal of Bone and Joint Diseases

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 4 | Ashok K Shyam


Authors: Ashok K Shyam [1] [2]

[1] Department Of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, India.
[2] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence:

Dr. Ashok Shyam, Department Of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, India.
Email: drashokshyam@gmail.com


Editorial

Journal of Bone and Joint Diseases (JBJD) is one of the oldest orthopaedic Journal in India as is regularly publishing since last 31 years. JBJD editorial team has decided to keep up with technology and go online with the Journal. With change from print only to online and print, there are major changes in the submission policies of the Journal. Although the format remains standard there are certain points that potential authors should remember while submitting to JBJD in future.
All submissions to JBJD will now be through the online portal ‘Scripture’. Authors have to register with the submission portal which is available on the JBJD website www.jbjdonline.com. After registration, link for new submission will be available on the profile page of the author. Before submitting be sure to keep ready following documents; title page, blinded manuscript with references and figure legends [with no names of author or the institute], tables [on a separate word file], individual figures image files and copy right form. Submit the blinded manuscript file first and then submit the rest of the files as supplementary files. You may embed figures and tables in the blinded manuscript, but please add them as separate supplementary file. It is important to provide good quality images for publication along with detailed figure legend. Each figure should have its own legend which should be in sufficient details so that reader’s do not have to refer back to text to understand the figure details. Please provide the figure legends at the end of the manuscript. Same applies to the tables which should contain detailed legends along with explanation of short forms if they are used. One of the most important points is to refer the table and figures with appropriate numbers at appropriate places in the manuscript. This is most essential with all figures and tables and they should be numbered chronologically as they appear in the manuscript.
Title file is an important document that will identify the names of all authors along with order of the authors. Please provide, first name, middle name and last name of all the authors along with their affiliations in the title page. Provide details of the corresponding authors in the title page along with email and detailed postal address. The institute at which the study was done has to be mentioned in the title page. The title page should be submitted as part of supplementary files on Scripture.
Referencing is one of the most important points that authors should note while submitting. All references have to be in Vancouver format, which means that they should be numbered chronologically as they appear in the manuscript. Please do not include references in the abstract which is a standalone section and is not part of the full manuscript. References have to be mentioned in square brackets at end of sentences, before the full stop.
With these things taken care of grammar remains another important point which authors should take care of. Use a third person language and avoid using ‘I’ or ‘we’ in your manuscript except when absolutely necessary. Please avoid using unnecessary all capitals or capital in the manuscript. Heading and names should be in capital [not all capital] and rest everything is sentence case. Please avoid using capitalisation to highlight points and follow the rules of basic grammar.
These are some basic points in formatting a good scientific article and we recommend all authors to please read the guidelines to authors in details before submitting .


How to Cite this Article: Shyam AK. Points to Note While Submitting to Journal of Bone and Joint Diseases. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):4 .

Dr Ashok Shyam

Dr Ashok Shyam


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Research and Publication – Must Know Tips

Vol 31 | Issue 2 | Aug – Dec 2016 | page: 2-3 | Anil K Jain, Ish Kumar Dhammi.


Authors: Anil K Jain [1], Ish Kumar Dhammi [2]

[1] Director, Professor and Head, University College of Medical Sciences, Delhi–95 India.
[2] Consultant, Guru Teg Bahadur Hospital, Delhi – 95, India.

Address of Correspondence:

Dr. Anil K Jain Department of Orthopaedics, University College of Medical Sciences & Guru Teg Bahadur Hospital, Delhi – 110095 Email:profakjain@gmail.com


Editorial

Medicine has evolved based on sustained scientific research. Medicine is a biological science and biology is never stationary. The biology evolve with time, hence medicine has to evolve by research [1]. India is a second most populous country in the world and about 30% population of India is below the poverty line. India is a land of contrasts inhabiting most affluent to the poorest of the poor [2]. On one hand we have best of the treatment facilities available while on other hand a basic treatment is not available to the masses. The orthopaedic surgeons in India come across large number of low and high velocity trauma, neglected trauma, poor man’s disease such as tuberculosis and other infections, nutritional deficiency diseases. We have vast number of clinical cases in various stages of natural history of disease. Most of the treatment facilities have limited health care budget [2]. The orthopaedic surgeons in our country keep on treating such cases at various stages of natural history, by small modifications/innovations. If any innovation, small or big is evaluated scientifically, this becomes a credible research [3]. The research is nothing but summation of small solutions/innovations evaluated scientifically to make the outcome predictable [3].
The research includes a clinical research and basic science research. Basic research gives us a new and deeper understanding of health, disease and healing whereas clinical research guides us to improve diagnosis and treatment. The basic and clinical researches are two sides of one coin both inseparable [4].
In spite of huge clinical material in India, the articles published by Indian orthopaedic surgeons are very scarce. This is because they are burdened with large number of patients, poor infrastructure to conduct research, less incentives for research and lack of enthusiasm to publish. Further most of the indexed journals are published from developed countries and are less inclined to accept articles on problems of developing countries [5]. We have to provide scientific evidence for treatment to the clinical problems unique to our land. Scientific communications (presentations and publications) are needed for growth of science and to improve the quality of clinical practice.
Any clinician sitting in his hospital/clinic should document all consecutive cases on a computer excel sheet. The identical cases treated in an identical manner over a length of time and evaluated by the same evaluation method every time becomes a credible data. The statistically significant difference in the outcome becomes a conclusion to a research question “whether the reported method has solved the clinical problem or not.
While performing a study the following issues are to be kept in mind. The study should have a clear research question, what is evaluated, how it is evaluated, what is observed, whether observation differences are statistically significant to provide a valid conclusion, which should be the answer to the research question [6]. Any study if published in a journal is available to others practicing far away and beyond human life and a basis for future research.
Before writing, the author should thoroughly go through the instructions to author of that particular journal. Author should follow the style of journal. Introduction should be 25% of manuscript. It should cover current state of knowledge on the subject and lacunae in current knowledge. The introduction should end with the statement as to what is the study with its methodology (research hypothesis).
Materials and Methods section should be very clearly written. It should be written in such a manner that anybody after reading the article can perform study. If one is doing a clinical study, he must include period of study, place of study, design of study, number of patients chosen, inclusion and exclusion criteria, consent of patients, approval from Institutional review board and statistical analysis of data. It should be explicitly clear about the variables chosen, evaluation method adopted and how the data was recorded. If the study is experimental, appropriate consent from animal welfare committee is to be taken as per Helsinki declaration. The details about animal selection, number of animals, selection of variables, tests conducted, observations made must be given.
The results should be analysed after appropriate follow-up. These should be assessed by established criteria. The results should be clear and concise, explained by tables and figures. The patients who have been lost to follow-up and died, should be identified and excluded from overall results.
The discussion should discuss the variation in your study, method of study. The outcome of the study should be discussed in light of articles published in the literature. The limitations of the study are discussed. Lastly conclusion statement should contain answer to the research question.
The abstract should be written at the end. It is most commonly read part of the manuscript [6]. It should stimulate readers to read full paper. The structured abstract, has four parts – Background about study, its aim and research question. Then materials and methods should explain what was done. Results – What was observed or what was found and finally in conclusion what was concluded.
The title should be crisp and informative. The references should be in Vancouver style as per journal’s requirement. In Vancouver style references are cited consecutively in text as they come. The tables should be numbered and quoted in text at appropriate place. There should not be mismatch of data in text and table. The graphs, bar diagrams, histograms are required to highlight some observations which are difficult to understand.
The photographs selected should highlight specific findings. There should be proper legend to each photograph. Only selected photographs should be given, journals are not photo album [6]. At the end of abstract 3-8 key words should be given.
The article then should be read carefully for grammatical correction. Any study, if methodically conducted with clear concise writing will find a place in literature. We conduct almost 1500 thesis/dissertation in India by MS/DNB students. These thesis/dissertations if methodically conducted could contribute significantly to Indian literature and help in improving patient care.
The research is nothing but summations of critically well thought of conclusions about the outcome of treatment we offer to the patients every day and well thought innovations we undertake [6].


References

1. Jain AK. Indian Journal of Orthopaedics dedicated to education, care and research. Indian J Orthop. 2012;46(1):1-3
2. Jain AK. Current state of orthopedic education in India. Indian J Orthop. 2016 Jul;50(4):341-4
3. Jain AK. Cultivate… research an attitude and learning a passion. Indian J Orthop. 2014;48(2):125-6
4. Jain AK. Research in orthopedics: A necessity. Indian J Orthop. 2009;43(4):315-7.
5. Jain AK. Teaching-learning: an integral component of sound patient care. Indian J Orthop. 2008;42(3):239-40
6. Jain AK. Innovations in Orthopaedics: Hypothesis to publication. Indian J Orthop. 2012;46(6):605-7

How to Cite this Article: Jain AK, Dhammi IK. Research and publication – must know tips. Journal of Bone and Joint Diseases  Aug-Dec 2016;31(2):2-3 .

 Dr Anil K. Jain

Dr Anil K. Jain


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