Obituary

  Dr. KP Srivastava was born at Gorakhpur on 5th April, 1935. He did his MBBS & MS (Gen Surgery) from SN Medical College, Agra. His interest in Orthopaedics & Trauma Care took him to GSVM medical College, Kanpur where he completed his MS (Ortho) under the legendary Prof. AK Gupta. He joined the deptt. Of Orthopaedics SN Medical College, Agra as a lecturer in 1968 He rose to become Prof. & HOD in Orthopaedics in 1983 and later Prof. Emeritus. He was one of the visionary orthopaedician and was instrumental in the formation of IOA as a Separate entity from ASI. At his initiation, UP Chapter of IOA was formed in 1977 and Agra Orthopaedic Society in 1979 which happens to be one of the first city chapter in North India. He served UPOA as treasurer, secretary for six years and as President in 1986He was President of AOS from 1983 to 1997 and was elected to the post of President of IOA in 1997. He recd. J&J Fellowship in 1972, AA Mehta Gold Medal in 1978, Foreign Fellowship Award to USA in 1989 and FNAMS in 1990. He was the proud recipient of Dr. BC Roy National Award in 1991 as an eminent teacher. He was conferred UP Rattan by His Excellency the Governor of UP in 2001. He started the Journal of Bone & Joint Diseases, an official publication of UPOA. IOA has best Poster Presentation Medal in his name . UP Orthopaedic Association has an Oration in his name, which is delivered by the past President of IOA and the best Ortho Club of the State Trophy in his name.

He was born on 15th June, 1940. He passed his MBBS in year 1958 from KGMC, Lucknow and Diploma in Orthopaedics from MLN Medical College, Allahabad in year 1969. He worked as medical officer in cantonment hospital, Allahabad from year 1965 to year 2000. He was running a clinic in the name Meetu Clinic at Allahabad. He was past president of Allahabad Ortrhopaedic Society. He was receipient of life time achievement award in year 2010. Dr Gokul Mohan Gopal left for his heavenly abode on 16th Feb, 2017.

Dr S D Mishra, a sport loving person, was born on 25.12.1939. He completed his MBBS in 1969 and D.Orth in 1985 both from MLN Medical College, Allahabad. He joine provincial medical service in year 1974 and retired as joint director in year 2000. He won many gold medals in Allahabad medical Association annual athletics. He was past president of Allahabad orthopaedic society. In a traggic roadside accident he expired on 30th Sep, 2015.

 

Dr Krishna Kumar Gupta, born on 3rd June, 1950, completed his MBBS from MLN Medical College, Allahabad in year 1974. He also comleted his D.Orth. from same institution. He was doing private practice at Allahabad. He was Vice President of Indian Orthopaedic Association from year 2001 to 2002. He left his heavenly abode on 3rd Oct, 2016.


 

 

Nonsecretory Multiple Myeloma: An Unusual Variant of Multiple Myeloma

Vol 32 | Issue 2 | July – Sep 2017 | page:51-53 | Mohammad Jesan Khan, Abdul Qayyum Khan, Mohammad Khalid Anwar Sherwani, Rana Sherwani


Authors: Mohammad Jesan Khan [1], Abdul Qayyum Khan [1], Mohammad Khalid Anwar Sherwani [1], Rana Sherwani [2].

[1]Department of Orthopaedic Surgery, JNMC, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
[2]Department of Pathology, JNMC, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.

Address of Correspondence

Dr. Mohammad Jesan Khan,
Department of Orthopaedic Surgery, JNMC, Aligarh Muslim University,
Aligarh – 202 002, Uttar Pradesh,
E-mail: mzkhan2k1@gmail.com


Abstract

Introduction: Multiple myeloma is characterised by malignant transfomation of plasma cells which is diagnosed by detecting abnormal paraprotein in blood and urine. However 1% to 5% of cases may not reveal any protein in blood and urine. Such cases are known as non secterory multiple myeloma. Skeletal survey of such cases usually reveals multiple osteolytic lesions which could be present in other pathologic conditions of bone. Hence diagnosis become challenging. Here we report a case of 65 year old female of non secretory multiple myeloma who had put us in great diagnostic perplexity in making final diagnosis.
Keywords: Multiple myeloma, nonsecretory multiple myeloma, pathological fracture.


How to Cite this Article: Khan MJ, Khan AQ, Sherwani MKA, Sherwani R. Nonsecretory Multiple Myeloma: An Unusual Variant of Multiple Myeloma.
Journal of Bone and Joint Diseases July-Sep 2017;32(2):51-53.


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Isolated Volar Dislocation of Distal Radio-ulnar Joint: A Case Report

Vol 32 | Issue 2 | July – Sep 2017 | page:48-50 | Vivek Mittal, Archana Agarwal, Gaurav Deshwar, Danish Altaf.


Authors: Vivek Mittal [1], Archana Agarwal [1], Gaurav Deshwar [2], Danish Altaf [3].

[1] Department of Orthopaedics, S.N. Medical College, Agra, Uttar Pradesh, India
[2] Department of Orthopaedics, S.M.S. Medical College, Jaipur, Rajasthan, India
[3] Department of Orthopaedics, Teerthanker Mahaveer Medical College and Research Center, Moradabad, Uttar Pradesh, India.

Address of Correspondence

Dr. Gaurav Deshwar,
Department of Orthopaedics, S.N. Medical College, Agra,
Uttar Pradesh, India.
E-mail: gauravdeshwar@gmail.com


Abstract

Introduction: Any dislocation of distal radio-ulnar joint is a rare injury especially when it is not associated with any fractures. A detailed history, careful physical examination, proper radiographic imaging along with a high index of suspicion is required to diagnose these injuries.
Case Report: We report a case of 40-year-old women, who sustained an acute volar dislocation of the distal radio-ulnar joint. Dislocation was reduced under general anesthesia followed by above elbow plaster of Paris (POP) slab.
Conclusion: Most of the case report reported in literature are managed same as our treatment by closed reduction and above elbow POP slab. Only a few case reports have described the management of these volar dislocations with open reduction and repair in the past 60 years.
Keywords: Distal radio-ulnar joint, acute isolated dislocation, volar, close reduction.


Introduction

Dislocation of distal radioulnar joint (DRUJ) is usually associated with distal radius fractures [1]. However, isolated dislocations of the DRUJ are quite uncommon. There is little number of case reports or case series in relevant literature [2-7]. Isolated dislocations of DRUJ can be easily missed due to lack of evident clinical deformity and the difficulties in assessment of faulty positioned wrist radiographs at emergency department [8]. In delayed cases, complex surgical procedures are needed for reconstruction and possible loss of wrist function may occur [4]. Therefore, it is important to recognize these rare injuries at initial admission. Herein, a case of DRUJ dislocation associated is presented, and radiologic diagnosis, clinical findings and treatment methods are discussed.

Case Report
A women aged 40 year with h/o fall on ground heavily on her right hand with twisting her forearm, came to the hospital with wrist pain, which was increasing in any attempt to rotate the forearm. Movement at radio-carpal joint and elbow joint(flexion-extension) was normal. On examination forearm is locked in supination and any attempt to pronate the forearm is painful, depression over wrist at posterior ulnar side is there. Neurovascular examination was normal. Anteroposterior and lateral radiograph of the wrist showed anterior- radialward displacement of the distal part of the ulna, confirming the isolated volar dislocation of distal radio-ulnar joint.

Figure 1. (a) Anteroposterior and (b) lateral direct radiographs of the wrist. (Pre-reduction X-ray)

Dislocation was reduced under general anaesthesia by traction and direct pressure over volar aspect of ulnar styloid process while forearm is pronated.Joint was reduced and stabilized in this position. Above elbow POP slab was applied with forearm pronated for six weeks. Reduction was confirmed with both anteroposterior and lateral radiograph.

Figure 2. (a) Anteroposterior and (b) lateral direct radiographs of the wrist. (Post-reduction X-ray)

Plaster was removed after six weeks and patient was referred to physiotherapist. At the final follow-up 3 months after the initial injury,movements were checked, there was no instability and full movement was there at inferior radio-ulnar joint.

Discussion

Almost half of distal radio-ulnar joint dislocations are failure to recognize at initial admission to emergency department [9]. Reasons are lack of clinically significant physical findings, difficulty in obtaining true The distal radio-ulnar joint dislocations are divided into two subtypes according to direction of ulnar displacement, volar and dorsal DRUJ dislocations [2]. In volar (anterior), terminal arch of supination lost lateral radiographs of wrist and decision making using unstandardized radiographs lead to misdiagnosis. High index of suspicion is necessary to recognize these rare injuries. whereas limitation of supination is seen with dorsal dislocation [2]. On anteroposterior wrist radiograph, an ulnar styloid overlapping with radius and bigger ulnar head suggest volar dislocation. On the contrary radioulnar separation and a smaller head suggest dorsal dislocation. On standard lateral wrist radiograph, ulna superimposed with radius and aligns with 3rd metacarpal base together with capitate and lunate bones [6]. Any deviation with this alignment suggests dislocation of DRUJ. Obtaining a truelateral radiograph is difficult due to painful extremity. Computed tomography is an alternative modality to confirm the diagnosis [10]. Initially closed reduction attempted in DRUJ dislocations, followed by immobilization of the wrist for 4-6 weeks. Recurrent dislocations are common after closed reduction alone; stabilization with percutaneous pinning should be done in case of residual instability during post reduction examination. In patients in whom closed reduction failed, open reduction and TFCC repair are required [8]. If DRUJ dislocation is timely recognize and treated properly, prognosis is excellent. As a conclusion, isolated DRUJ dislocations are rare injuries. Early recognition of these injuries necessitates detailed physical examination, properly taken radiographs and high index of suspicion.


References

1. Buterbaugh GA, Palmer AK. Fractures and dislocations of the distal radioulnar joint. Hand Clin. 1988; 4(3):361-75.
2. Dameron TB Jr. Traumatic dislocation of the distal radio-ulnar joint. ClinOrthopRelat Res. 1972;83:55-63.
3. Kumar A, Iqbal MJ. Missed isolated volar dislocation of distal radio-ulnar joint: a case report. J Emerg Med. 1999;17(5):873-5.
4. Quah C, CounsellA, Heasley R, Kocialkowski A. Isolated volar dislocation of the distal radio-ulna joint: A case report and review of the literature. The Internet Journal of Orthopedic Surgery. 2007;(7):2
5. Takami H, Takahashi S, Ando M. Isolated palmar dislocation of the distal radioulnar joint in a football player. Arch Orthop Trauma Surg. 2000;120(10):598-600
6. D. McMurray, K. Muralikuttan. Volar dislocation of the distal radio–ulnar joint without fracture: A case report and literature review. Injury Extra. 2008;39(11):352-55.
7. Wassink S, Lisowski LA, Schutte BG. Traumatic recurrent distal radioulnar joint dislocation: a case report. Strategies Trauma Limb Reconstr. 2009; 24. [Epub ahead of print]
8. Carlsen BT, Dennison DG, Moran SL. Acute dislocations of the distal radioulnar joint and distal ulna fractures. Hand Clin. 2010;26(4):503-16
9. Rainey RK, Pfautsch ML. Traumatic volar dislocation of the distal radioulnar joint. Orthopedics. 1985;8(7):896-900.
10. Mino DE, Palmer AK, Levinsohn EM. Radiography and computerized tomography in the diagnosis of incongruity of the distal radio-ulnar joint. A prospective study. J Bone Joint Surg Am. 1985;67(2):247-52.


How to Cite this Article: Mittal V, Agarwal A, Deshwar G, Altaf D. Isolated Volar Dislocation of Distal Radio-ulnar Joint: A Case Report. Journal of Bone and Joint Diseases Jul-Sep 2017;32(2):48-50.


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Synovial Biopsy: Role in Diagnosis and Management of Unilateral Synovitis Knee

Vol 32 | Issue 2 | July – Sep 2017 | page:43-47 |Chandra Prakash Pal, Amrit Goyal, Brijesh Sharma, Harendra Kumar, Sanjay Singh Rawat, Aditya Prakash


Authors: Chandra Prakash Pal [1], Amrit Goyal [1], Brijesh Sharma [1], Harendra Kumar [1], Sanjay Singh Rawat [1], Aditya Prakash [1]. 

 [1]Department of Orthopaedics, Sarojini Naidu Medical College, Agra, India

Address of Correspondence

Dr. Amrit Goyal,
Department of Orthopaedics, Sarojini Naidu Medical College, Agra,
India.


Abstract

Background: Monoarticular synovitis is relatively difficult to diagnose and delay in diagnosis leads to poor outcomes. Long-term occurrence of synovitis can result in degeneration of the joint due to the release of inflammatory cytokines which resulted in increased synthesis of matrix metalloproteinases and decreased expression levels of inhibitors. Tubercular synovitis and early arthritis are difficult to diagnose due to the atypical clinical presentation and lack of specificity in diagnosis.
Materials and Methods: This study was conducted from March 2015 to September 2016, where 50 patients underwent synovial biopsy and biopsy reports were evaluated. 44 patients underwent arthroscopic-assisted synovial biopsy and open biopsy was done in 6 patients. Samples obtained were sent for histopathological examination. The paired t-test was used to compare serial changes in pain intensity using numeric pain rating scale.
Results: Out of 50, 21 (42%) cases were diagnosed as inflammatory synovitis, 9 (18%) cases as tubercular synovitis, 6 (12%) cases of osteoarthritis, and 14 (28%) cases of non-specific chronic synovitis. The mean age of patients was 40.32 years, with 58% of the patients presenting in the range between 36 and 50 years. As a diagnostic aid, the role of synovial biopsy was found to be significant (P < 0.05).
Conclusion: Monoarticular arthritis should be thoroughly investigated rule out infectious or metabolic diseases for their destructive potential to destroy cartilage rapidly. Arthroscopic-assisted synovial biopsy has added advantage as it permits macroscopic evaluation of the synovium, and cartilage inadequacy could also be noted along with serving as therapeutic purposes in some cases.
Keywords: Monoarticular, synovitis, synovial biopsy, numeric pain rating scale.


  INTRODUCTION

Synovitis is the medical term for inflammation of the synovial membrane. The main purpose of this synovium is to provide smooth motion by preventing the bones of the leg from grinding together, when the knee is moved. Knee synovitis occurs when the synovial membrane which lines and lubricates the knee joint, becomes inflamed. This condition is usually painful, particularly when the joint is moved. Common causes of synovitis includes infection (septic arthritis), direct joint trauma, allergic reaction, gout, overuse syndromes, systemic autoimmune inflammatory diseases (Rheumatoid arthritis), osteoarthritis, pigmented villonodular synovitis and idiopathic. Synovitis may occur in association with other systemic diseases like lupus, psoriasis and other conditions.Early diagnosis and timely institution of anti-tubercular treatment (ATT) is crucial as delay leads to irreparable damage to the joint and restriction of joint mobility. Establishing the diagnosis of TB beyond doubt is very important when considering the cost and duration of treatment and the effects of delayed treatment including psychosocial implications1. Even in disease endemic countries, only suspicion and imaging results are not accurate enough to diagnose and treat joint TB. Sensitivity of most tests is very low in joint tuberculosis, as there is dilution of tubercle bacilli in synovial fluid1,2. Conventional microbiological methods like smear and culture have low sensitivity and specificity, especially in synovial TB due to the paucibacillary nature of disease1,3. In addition, the culture of Mycobacterium tuberculosis is time consuming, taking 6–8 weeks for the growth to appear and much longer time for positive growth, especially in paucibacillary cases like joint TB4-6. Common conditions, such as rheumatoid arthritis, rarely cause diagnostic problems as they cause symmetrical joints involvement. Monoarticular synovitis is however difficult to diagnose and often times, routine x-ray and pathological investigations including synovial fluid analysis are unable to give conclusive result.  Synovial biopsy is then helpful in distinguishing between various etiologies such as infective, traumatic or crystal induced7,8. Synovitis is usually a secondary condition, which may also be caused by an injury to the knee joint or cancer (synovial sarcoma). For this reason it is important that suspected cases of synovitis are investigated thoroughly.
Materials and Methods  This prospective study was conducted on patients attending the orthopaedic OPD and emergency department of S.N.Medical College, Agra from March 2015 to September 2016 presenting with pain and swelling of single knee, not responding to NSAIDs. All participants were recruited after taking written informed voluntary consent.A detailed history, examination (General systemic and local examination) along with investigation was carried out before doing procedure.  Patients were selected on the basis of strict inclusion and exclusion criteria’s.Inclusion criteria:- Patients with chief complaint of knee pain and swellingwith synovitis notresponding toNSAIDs for at least 4-6 weeks.- Patient from both sex aged 18-60 years.- Cases where sufficient conservative trial has failed to give result.Exclusion criteria:- Age <18 year and >60year  – Pregnant and Lactating women  – Patient with multiple joint involvements  – Patient with low platelet count (<70,000/cumm)  – Advanced radiological osteoarthritic changes All good clinical practiceguidelines were followed and ethical clearance taken from hospital medical research committee, who approved the study.The initial aim of the evaluation of a patient with joint pain was to localize the source of the joint symptoms (bone or soft tissue) and to determine the type of pathophysiologic process responsible for their presence. Knee aspiration was done and fluid analysis sent for examination, which was found to be equivocal.Patient examined carefully to rule out involvement of any other joint and thorough history taken. Pain graded on scale of 0-10 (Numeric pain rating scale) and if restriction of movement present, then measured. Synovial biopsy results were studied and by interpreting histopathological findings diseases were diagnosed. On average it took 15-18 days for histopathology reports to come. Treatment is started as per standard measures against any causative condition diagnosed. Patients were kept in follow-up and closely monitored. For first two months patients came on every 15 days after which they were followed every month.Pain grading done in follow-up to see improvement of patient and pain intensity compared at follow up of up of 3 months to before treatment.
Figure 1 showing: Necrotising granulomatous inflammation, comprising of caseous necrosis, surrounded by epithelioid cells, histiocytes and lymphocytes. Out of 50 patients, 44 underwent arthroscopic synovial biopsy and remaining 6 underwent open synovial biopsy. Arthroscopic synovial biopsy procedure: After general investigations procedure is planned and all surgeries were done under spinal anaesthesia. Arthroscopic evaluation was performed by a senior arthroscopic consultant of our institution. Patient was laid supine on OT table, after giving spinal anaesthesia and tourniquet applied over respective thigh. Part painted and draped as such, so knee can be flexed and extended during procedure. Standard anteromedial and anterolateral portals were used. Anterolateral portal made during the flexion of knee at 90oand 8mm skin incision made over the lateral joint line and another skin incision of 8mm made over medial joint line for anteromedial port. Arthroscope camera and arthroscope probe inserted through above made ports. Irrigation fluid switched on before switching on the light source to avoid thermal damage. On arthroscopic evaluation, joint was thoroughly inspected through standard portals. Sample for synovial biopsy was taken concentrating on suspected focal areas of pathology in synovium. Biopsy is obtained from different places like suprapatellar pouch, medial and lateral gutter and from patellar margins. After the final biopsy sample is taken, the skin is stitched if needed and covered with sterile wound dressing. Arthroscopic partial or subtotal synovectomy was done if needed.Synovial biopsy material is sent for histopathological examination, after packing it in formalin glass bottle.Patients were regularly followed up clinically, radiologically and with help of laboratory investigations like CRP and ESR. At the end of 3 months CRP levels were found to be nearly normal. Pain intensity was graded at 3 month follow-up using numeric pain rating scale. Pain intensity scores at 3 months follow up were compared with pain intensity scores of pre-treatment.

RESULTS:  Out of the 50 cases we studied of monoarticular joint involvement of knee joint were subjected to synovial biopsy investigations and diagnosis was made on basis of histopathological picture (figure 1 showing typical tubercular histopathological picture: Necrotising granulomatous inflammation, comprising of caseous necrosis, surrounded by epithelioid cells, histiocytes and lymphocytes).Both rheumatoid (n=21,42%) and tubercular (n=9, 18%) were found to be more common compared to other etiologies. Next common etiology observed in our study was chronic non-specific synovitis (n=14,28%). There were 6 cases of osteoarthritis (n=6,12%).- Rheumatoid was found to be most common etiology, with 21 patients (42%) out of 50 patients.- 6 patients (12%) were found to be suffering from osteoarthritis. – 9 patients (18%) were of tubercular arthritis.- The mean age of patient with synovitis knee, who underwent synovial biopsy was 40.32 years.- Maximum numbers of patients were from age group 36-50 years (n=29, 58%).- The period of hospitalization required ranged from 2-3 days and post-operatively, weight bearing and knee movement was allowed as tolerated by patient.No significant complications occurred in all 50 patients post synovial biopsy.- Pain intensity improved during follow up with time as graded according to numeric pain rating scale compared to pre-treatment.- Paired t-test was applied for comparing pain intensity at pre-treatment and at 3 months follow-up which was found <0.05 which is significant.- Diagnosed cases were managed accordingly and responded well to treatment and were monitored during follow-up.

Age wise distribution: Age wise distribution: The youngest patient age was 19 years and oldest patient age was 66 years. 29 patients were in the age group of 36-50 years (Table 1). The average age of patient was 40.32 years. Table-1: Age wise distribution:  

Incidence of different diseases as assessed by synovial biopsy: Among the 50 patients, 21 patients were diagnosed with rheumatoid arthritis, 9 patients with tubercular arthritis, 6 patients of osteoarthritis and 14 patients of non-specific chronic synovitis (Table 2).
Table-2: Incidence of different diseases as assessed by synovial biopsy  

DISCUSSION
Inflammatory synovitis of the knee is one of the commonest clinical presentations in day to day orthopaedic clinical practice. The aetiology remains unclear in many cases. Routine laboratory and radiological investigations in monoarticular joint lesion are often equivocal. Diagnosis of arthritis is often made clinically and treatment is given empirically, due to which results are sometimes disappointing for both patients and doctors. In our study synovial biopsy was performed in 50 patients to obtain a sample of the tissue directly under vision from the suspected site of pathology. Synovial tissue was obtained arthroscopic assisted in44 patients and by open biopsy in 6patients. In our study male to female (29+21=50) ratios were 1.38:1. According toaetiology it was 3.2:1 in rheumatoid synovitis, 7:1 in tuberculous synovitis and 4:7 in chronic non-specific synovitis. The average age of patients was 40.32years. Youngest patient in this study was 19 years of age and oldest was 66. Maximum cases of unilateral synovitis were found in 4th and 5th decades. The maximum number of synovitis occurred in the age group of 36-50 years, 30 patients (60%). In G Raghunandanet al9 study there were 25 males and 15 females with male: female ratio of 5:3. Histological examination by synovial biopsy was found to be of significant diagnostic value. It was helpful in confirming the diagnosis of the underlying pathology after clinical evaluation in 36 cases (72%) including rheumatoid arthritis, tubercular arthritis and osteoarthritis. In remaining 14 cases, no specific pathology was found on histopathology and they were declared as chronic non-specific synovitis. In cases where clinical diagnosis was non-specific, histological examination of synovial biopsy helped in reaching the final diagnosis. In our study most common etiology was found to be rheumatoid followed by cases of non-specific chronic synovitis. Rheumatoid arthritis was found in 21 patients (42%) out of 50 patients. In onissinghal et al10 study rheumatoid arthritis was found in 11 patients (22%) out of 50 patients. In Chen GQ et al17 study 39(52.9%) cases of rheumatoid arthritis were found out of total 71 patients. In G Raghunandanet al9 study 5(12.5%) cases were diagnosed with rheumatoid arthritis. In Sundararajan S R et al11 study 7(20.58%) cases were diagnosed with rheumatoid arthritis out of total 34 patients. In VijayP.M et al12 study rheumatoid arthritis was found in 4 patients (4.8%). Early diagnosis of rheumatoid arthritis with help of histopathology, helps in improving prognosis of disease. There is evidence that the very early introduction of disease modifying therapy inhibit progressive structural damage maximally. Clinician exploiting this “window of opportunity” therefore requires very early indicators of the diagnosis and outcome in patients who present with an undifferentiated inflammatory arthritis13. Serial synovial biopsies in open therapeutic studies and in randomized clinical trials showed that the immunohistological features of RA and other arthropathies changes after treatment with DMARDs (Disease modifying anti rheumatic drugs). It has been established that DMARDs therapy reduces the rate of progressive joint damage more effectively when introduced within 6 months of the onset of symptoms. It is now standard practice to introduce conventional DMARDs such as methotrexate, and even targeted biological therapies, as first line treatment in patient with RA. Although there is no diagnostic role in early RA, synovial biopsy and tissue analysis may provide important prognostic information. In our study 9(18%) cases were diagnosed as tubercular arthritis. These were more commonly found in younger population. In our study males were more commonly affected than females with ratio of 7:1. In OnisSinghal et al study tubercular arthritis was found in 13 patients (n=26%) out of 50 patients. In G Raghunandan et al study 6 cases (15%) were of tubercular arthritis out of 40 patients. In Chen GQ et al study 5(6.5%) cases of tuberculosis arthritis were found out of total 71 patients14. In Sundararajan S R et al study 7(20.58%) cases were diagnosed with tubercular arthritis out of total 34 patients. In VijayP.M et al study 15 patients (18.07%) were found of tubercular arthritis. Another study was conducted on 70 cases of tuberculous synovitis by SantM etal15 and was published in 1992. In this study maximum number of cases were found in the age group of 11-30 years (58.58%) with a male preponderance. Knee joint was found to be most commonly (57.12%) affected. Diagnosis of tuberculous synovitis was possible clinically in 75.72% and radiologically in 67.14% of cases only. Such high percentage of tubercular arthritis patients were found, as our country is endemic for tuberculosis. As definitive treatment with anti-tubercular medication is available, diagnosis of early tubercular synovitis is very essential to prevent cartilage damage.Definitive tissue diagnosis and timely treatment helps in achieving excellent results in 3-4 months period16. In our study 14 cases were diagnosed as chronic non-specific synovitis, out of 50 patients. In OnisSinghal et al study chronic non-specific synovitis was found in 10 patients out of 50 patients (20%). In G Raghunandan et al study 25 cases (62.5%) were of chronic non-specific synovitis out of 40 patients. In Chen GQ et al study 3(4.054%) cases of unknown causes were found out of total 71 patients. In Vijay P.M et al study 59 patients (83.099%) were found of chronic non-specific synovitis. In Sundararajan S R et al study 9(26.47%) cases were diagnosed with chronic non-specific synovitis out of total 34 patients.Chronic non-specific synovitis is also known as monoarthritis of unknown origin. 80% of these can go into complete remission over a period of two years with just conservative treatment.This high occurrence of cases of chronic non-specific synovitis in our study may represent an early stage of rheumatoid arthritis, in which the disease is still in the stage of evolution without a fully developed picture of rheumatoid arthritis, some patients may be due to early osteoarthritis not fulfilling histopathological and radiological features for its diagnosis. If these patients are closely followed up and repeat biopsies are carried out in due course, they may help with specific diagnostic features or patients may have self-limited disease or may undergo complete therapeutic remission. In our study 6 cases (12%) were diagnosed as osteoarthritis, out of 50 patients. Apart from these four diseases diagnosed in our study, synovial biopsy also helps in diagnosis of other diseases like Pigmented villonodular synovitis, septic arthritis, gouty arthritis, sarcoidosis, osteochondromatosis, haemochromatosis, amyloidosis, seronegativespodyloarthropathy and any synovial carcinoma. Arthroscopy is an excellent tool for visualizing and evaluating the condition of the synovium macroscopically and the suspected areas of increased activity were chosen for biopsy. In study by Latosiewicz et al 82 patients underwent arthroscopic synovial biopsy in the course of treatment for chronic knee synovitis. It concluded that arthroscopic synovial biopsy increases diagnostic potential in the synovitis of unclear etiology. In arthroscopic synovial biopsy gross examination gives added advantage in making a diagnosis, like visualizing subchondral bone defect. It has added advantage of performing therapeutic procedures along with biopsy at same time and knee joint lavage could be done during biopsy. Arthroscopic partial or subtotal synovectomy may be done if needed. Arthroscopic synovial biopsy was also better in terms of post biopsy recovery as incision was only made for port entry compared to open biopsy. Results of histopathology arrived in 15-18 days. Arthroscopic findings can alter or add to the treatment plan which includes surgical tissue resection or medical treatment like disease modifying anti-rheumatic drugs to the current treatment. In our study despite thorough arthroscopic and microscopic evaluation, we were not able to accurately diagnose in 28% of patients, which were finally diagnosed as chronic non-specific synovitis. In conclusion, the present case series demonstrates that synovial biopsy can be cost-effective diagnostic tools with therapeutic consequences.This is especially so when the differential diagnosis consists of a disease with characteristic histological hallmarks. Synovial biopsy is useful and cost-effective in mono-articular synovitis cases,especially where advanced radiological facilities like MRI are not available to general population.In terms of diagnostic accuracy, histopathology was found to be the most economical, accurate and time saving method.

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16. Cai D, Chen Y, Rong L. Arthroscopy in diagnosis and treatment of tuberculous synovitis. ZhonghuaJie He He Hu Xi ZaZhi. 1998 May; 21(5):276-7.
17. Chen GQ, Zhang HW, Li ZF,Guo DM, Yu YT. Significance of arthroscopy in the diagnosis of unilateral knee arthritis. Zhonghua Yi XueZaZhi. 2010 Jun15; 90(23):1615-7.


How to Cite this Article: Pal CP, Goyal A, Sharma B, Kumar H, Rawat SS, Prakash A. Synovial Biopsy: Role in Diagnosis and Management of Unilateral Synovitis Knee. Journal of Bone and Joint Diseases. July-Sep 2017;32(2):43-47.


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Rush Nail in the Management of Distal One-third Fibular Fracture in Both Bone Fractured Legs: A Clinical Study

Vol 32 | Issue 2 | July – Sep 2017 | page:32-36 | Rizwan Khan, Javed Jameel, Sandeep Kumar, Ammar Aslam, Gaurav Chahal, Shishir Rastogi.


Authors: Rizwan Khan [1], Javed Jameel [1], Sandeep Kumar [1], Ammar Aslam [1], Gaurav Chahal [1], Shishir Rastogi [1].

[1] Hamdard Institute of Medical Sciences and Research, New Delhi, India.

Address of Correspondence

Javed Jameel,
Hamdard Institute of Medical Sciences and Research,
New Delhi, India.
E-mail: drjavedjameel@gmail.com


Abstract

Background: Aim of this study is to evaluate the results of percutaneous rush pin fixation in distal third fibula in both bone fractured legs.
Materials and Methods: Forty patients were treated from emergency and outpatient department, having closed fracture of the distal third fibula in both bone fractured legs.
Results: Out of 40 patients, 35 patients underwent union in 3-4 months. Touch-down weight bearing was started on 2nd post-operative day. Complications were found in five patients who had delayed union in three and soft-tissue infection at the nail entry point in two patients.
Conclusions: Fixation using rush nail in distal third fibular fracture is a safe and effective method of surgery that could be performed in patients with compromised soft-tissue condition and showed sufficient stability after fixation.
Key words: Fibular fracture, percutaneous, rush pin, both bone fractures.


Introduction

Fractures of distal tibia are almost always accompanied with a fibular fracture the fixation of which is always a matter of debate1. Plate fixation is the most frequent technique used for stabilization of fibula but percutaneous techniques (pins, screw fixation) have also been proposed2. Plate fixation of these fractures is challenging owing to wound infection, mechanical failures & symptoms related to metalwork which are more frequent in elderly and patients of diabetes & neuropathy. Considering these complication rush nail seems to be a better alternative as it offers a stable fixation with minimal surgical exposure and less prominent metal work.
Materials and Method: 40 Patients Were Selected Which Had closed fractures of both bone leg with fibula fracture at distal one third. A written informed consent was obtained from all the patients; they were explained about treatment plan, cost of operation, and hospital stay after surgery, and complications of anesthesia. They were followed-up after surgery, were clinically and radiologically assessed for fracture healing, joint movements, and implant failure.In majority of the patients close rush nailing of fibula was performed within 24-48 hrs after the injury. Fracture of leg were evaluated using plain radiographs in anteroposterior (A-P) and lateral. The fractures were classified using the AO/OTA classification systems.
Inclusion criteria: Age 18-60 yrs, all both bone leg fracture with distal one third fibula
Exclusion criteria: Age <18, compound grade 111 b fibula fracture, pathological fracture
Surgical technique
The patient was placed in supine position with a bump underneath the ipsilateral hip to prevent the usual external rotation of the limb and to give access to the lateral side of the ankle. The entire limb was prepared and draped. The starting point for the rush nail was the distal tip of the fibula. A small (approximately 2 cm) longitudinal incision was made approximately 2-3 cm distal to the tip of the fibula; it should be distal enough to allow the drill bit to drill in line with the fibular shaft. A sharp elevator cleared the soft tissue at the tip of the fibula to create a “landing zone” for the drill bit. With the help of an image intensifier, a 3.5 mm bit was used to drill an opening hole in the distal fibula. It is essential to drill in line with the diaphysis of the fibula on both A-P and lateral images to facilitate passage of the rush nail. After the opening hole was made, a long 2.5 mm drill bit was used to “ream” the distal fibula to approximately 5-6 cm. A soft-tissue sleeve for the 2.5 mm drill bit was inserted into the previously drilled starting hole. A 2.4 mm rush nail was locked securely onto the T-handle chuck. Tip of the nail was bend 10 degree approx that helped in reduction and the passing of nail .The nail was then placed into the starting hole distally and advanced proximally with controlled mallet strikes on the chuck. Rush nail can be controlled with a T-handle chuck, “choking up” on the nail and resetting the chuck farther back as the nail is advanced into the fibula. There should be minimal resistance with nail insertion, and the T-handle should be rotated in 45± motions while the mallet is used. At the fracture site, the nail was advanced across the fracture and into the proximal fragment medullary canal. A closed reduction technique, such as axial traction or blunt manipulation of the fracture fragments, can be used to pass the rush nail. The nail was advanced 5-10 cm into the fibular medullary canal in the proximal fragment. The distal end of the bend nail was then impacted into the lateral malleolus. The wound was then irrigated and closed with nylon sutures. For tibia conventional intermedullary interlocking nailing done. Rehabilitation such as touch down weight bearing was started on 2 nd postoperative day and sutures were removed on 14 th postoperative day. These patients were assessed clinically and radiologically for union timing at 6 months following surgery. 

Results
5 patients out of 40 complained postoperative ankle pain, which was spontaneously resolved in 2 weeks. There were 3, delayed unions which were treated by platelet rich plasma and bone marrow injection. In our study two patients had soft tissue infection at the point of entry of nail that was managed by antibiotics. No rotational instability was seen in any patients postoperatively. Patients were followed-up at 1,2, 3 and 6 months till one year  respectively. No cases of degenerative arthritis were noted in patients. The patients were evaluated by American foot and ankle score in which  35 patients had score above 90 and 5 were above 80, (Table 1).

Discussion

Distal tibial fractures occur in about 38% of all tibial fractures and in about 78% of these fractures there is a concomitant distal fibula fracture3 . There are different modalities of fixation of fibular fracture viz plate osteosynthesis2, cannulated cancellous screw and Rush nail1. However there is no clear cut consensus in literature on the fixation of fibular fracture in  combined distal tibia and fibula both bone leg , there exists a debate among surgeons as to whether or not fibular fixation is required as an adjuvant to IM nailing of tibia3. Plate osteosynthesis for fractures of the distal tibia is often associated with delayed healing, infection, and hardware problems4,5.In our study 3 cases of delayed healing, 1 case of infection and 1 case of hardware problem was seen. In cases of fibular fixation in fracture both bone lower leg there is less varus or valgus angulation, less rotational deformity and faster union time6. In our study foot and ankle score for  35 patient was above 90, remaining 5 also had good AOFAS SCORE above 80. For distal tibia fractures that also have a fibula fracture, plating of the fibula fracture before nailing of the tibia can help provide alignment and length3. This is particularly useful for simple fibular fracture patterns and very distal tibial fracture patterns. When nailing for a combined distal tibia and fibula fracture, the distal end of nail must anchor in the physeal scar adjacent to the subchondral bone to reduce toggling of narrower nail inside a wider metaphyseal medullary canal which will prevent the nail to deviate mediolaterally and prevent malunion. Care should be taken to reduce the fibula as malreduction of the fibula will prevent accurate reduction of the tibia. After the fibula is plated, care should be taken to make sure the tibia is not malaligned in varus as the fibular plating will keep the tibia out to length laterally, but will typically not prevent varus collapse. Study by Asloum et al concluded that Dilemma of the fibular fixation: Fibula fixation is controversial. If the fibular fixation is fixed with plating, it prevents collapse of the comminuted metaphyseal area or gap, resulting in nonunion or malunion with deformity of tibia. If the fibular fracture is not fixed, the ankle mortise may not be congruous, because if not fixed lateral malleolus may get displaced. If the fibula is fixed, bone grafting is mandatory if there is comminuted or gap/bone loss2. Lambert demonstrated that the fibula has weight bearing function, carrying 1/6 of the load applied to the knee joint7. Prior studies have suggested fibular fixation may influence outcomes of distal tibial fractures favourably but significant complications have also been reported with this adjunctive stabilisation. High-energy fractures of the distal tibia are associated with a high incidence of soft tissue trauma compromising the soft tissue envelope. So ORIF of the fibula has also shown an increased rate of wound complications7. In addition, the incidence of fibular nonunions was 9% with fibular fixation possibly from further devascularisation on open surgical approach in contrast to zero without fibular fixation8. There are very few studies on intramedullary fibular nailing. The main criticism of this system is that it is not rigid enough. However, the notion of an interlocking nailing system cannot be compared to simple percutaneous nailing systems. The series evaluating the latter report the benefits of the percutaneous approach, but functional results vary9. The idea of nailing was first introduced in 1999–2000 with the ANK® nail. Kara et al. and Kabukcuoglu et al. used this nailing system for lateral malleolar fractures associated with syndesmotic injury, and they reported good results and no complications2. The fibula nail provides a relatively easy technique for treating displaced fracture both bone leg involving distal one third fibula fractures. We found a high success rate with its use as depicted by foot and ankle score in our study. AOFAS was more than 90 in 35 patient & more than 80 in remaining 5 patient which is good standard. This technique affords the opportunity to provide fixation through a minimal approach with a limited incision, which decreases the chances of wound infection1. Further, the intra-medullary fixation eliminates the need for hardware removal from the lateral malleolus due to prominent metal work as compared with conventional technique of plating . In a study by Singh et al 25 patients  underwent intramedullary interlocking nailing for fractures of the distal third of the tibia and  rush nail for fractures of the distal third of the fibula1.The mean time to union was 16 weeks. Sixteen patients underwent dynamisation at 12 weeks leading to union of fracture . Two patients had angular malalignment within acceptable limits, but none had rotational malalignment. No patient had shortening, hardware breakdown, or deep-seated infection, only 1 patient had superficial infection of lateral malleolar incision but it was managed well with oral antibiotics and dressing1. In our case 40 patient went for rush nail fibula . All 40 patient fracture united with no rotational malalignment seen. 35 patients had excellent AOFAS score of more than 90. 5 patients had AOFAS good score more than 80 out of which 3 had delayed union  & 2 patient had nail insertion infection. But in none patient there was non union. Alignment was acceptable in all. Distal fractures are prone to malalignment because the metaphysis is much wider than the diameter of the nail and care must be taken to avoid malunion as this may lead to a worse functional outcome3. The keys to avoiding malalignment distally are ensuring the guidewire is placed centrally on both the AP and lateral images (the ―center-center position‖) and keeping the fracture well aligned during reaming and nail insertion. In a study by Khuntia et al \the role of fibular fixation in the treatment of distal third tibial fractures was evaluated10. 40 patients with concomitant fractures of tibia and ipsilateral fibula at distal third level were included in this study during a 48 month period. Patients were randomized in two groups: patients with fibular fixation (group I) and without fibular fixation (group II). The patients were followed up for at least 1 year follow up postoperatively. Johner And Wruh’s Criteria was used for evaluation of functional outcome. Excellent and good results were seen in majority of the patients (85%) in group I as compared to group II (65%). Infection was seen in one patient in group I and two in group II with Gustillo-Anderson II injuries. Majority of patients of both groups union occurred at 16 to 17 weeks of post operative with Average time of union came out to be 16.6 weeks in non-fixing group and 17.85 weeks in fixing group. Most patients about 60% of non-fixing group showed some variety of deformity of valgus/varus and antiversion/recurvation in post union x-ray and some were in unacceptable range. 20% patients of fixation group showed deformity but in acceptable range. We observed unacceptable shortening in 3 patients of non fibula fixation group and acceptable shortening in 5 patients of fibula fixation group. There were 2 patients having non union one in each group. Four patients were infected with two from each group include both superficial and deep infection Knee movement was full in 90% of cases. In three patients there was restriction of 10°-15° of flexion with no extension lag. Ankle movement was full in 80% cases. In 3 out of 8 patients; ankle movement was restricted by 25% in dorsiflexion Johner And Wruh’s Criteria was used for evaluation of functional outcome. Excellent and good results were seen in majority of the patients (85%) in fixation group as compared to non fixation group about 65% and very less number in fair and poor result in fixation group as compared to non-fixation group10. Potential advantages of fibular fixation include mechanical stability, assisting in reduction & restoring the length and alignment of the tibia. While such a construct cannot control rotation, it can preserve length as well as prevent varus and valgus displacement. In our study, all the fibular fractures were fixed with rush rods and did not see any rotational instability. Thus we conclude that in extraarticular fractures of distal tibia with concurrent distal fibular fractures it is advisable to fix the fibular fractures with an intramedullary rush nail rather than a plate for the reasons cited above along with intramedullary interlocking nail for tibia. Usage  of  rush  nails  for  fixation  lower  fibula  fractures  is  having  added advantage  of  small  skin  incision  hence  less  chances  of  local  infection, dynamization  was  more  effectively  achieved,  less  chances  of  rotational instability  in  presence  of  distal  locking  of  tibia,  and  more  important  in present era is reduction of cost of surgery over all1.

Clinical relevance
The fibula nail is probably the ideal choice for fixing distal one third fibula fracture in both bone leg especially with overlying skin conditions, or other immunocompromised  states such as diabetes in which there are higher infection rates with traditional plating techniques. We found a low complication rate and little difficulty with its use intra-operatively. Intramedullary nailing is a percutaneous mini-invasive technique that provides stable fixation and reduces the risk of wound complications. The main limitation is in the treatment of comminuted fractures


References

1. Singh N, Anjum R, Chib M S. A prospective study on intramedullary nailing for both tibia and fibula in distal both bone leg fractures. International Journal of Advanced Research 2015:3;47-49
2. Asloum Y, Bedin B, Roger T, Charissoux Jl, Arnaud J P, Mabit C. Internal Fixation Of The Fibula In Ankle Fractures. A Prospective, Randomized And Comparative Study: plating versus nailing. Orthop traumatol surg res 2014;100:255-9
3. Bucholz R, Heckman J, Court-Brown C. Rockwood and Green’s fractures in adults. 8th ed
4. Tanna DD. Interlocking nailing. 2nd ed. New Delhi: Jaypee Publishers; 2004.
5. Olerud S, Karlstrom G. Tibial fractures treated by AO compression osteosynthesis. Experiences from a five year material. Acta Orthop Scand Suppl 1972;140:1–104.
6. Krishna C, Mondal J. Fracture fixation of both bone lower third leg using minimally invasive plate osteosynthesis technique – is fixation of fibula necessary.International Surgery Journal. 2016 May;3(2):589-594
7. Lambert KL (1971) The weight-bearing function of the fibula.A strain gauge study. J Bone Joint Surg Am 53:507–513
8. Williams TM, Marsh JL, Nepola JV et al (1998) External fixation of tibial plafond fractures: is routine plating of the fibula necessary? J Orthop Trauma 12:16–20
9. Morin PM, Reindl R, Harvey EJ, Beckman L, Steffen T. Fibular fixation as an adjuvant to tibial intramedullary nailing in the treatment of combined distal third tibia and fibula fractures: a biomechanical investigation. Can J Surg 2008;51:45–50
10. Khuntia S,Sahu A, Mall P, Mishra A, Panda S, Sahu S, Mohapatra S, Dash A, Biswas M. Managements of Distal Third Both Bone Leg Fractures By Tibia Interlocking – is Fibular Fixation Mandatory? IOSR Journal of Dental and Medical Sciences 2017;16:36-39


How to Cite this Article: Khan R, Jameel J, Kumar S, Aslam A, Chahal G, Rastogi S. Rush Nail in the Management of Distal One-third Fibular Fracture in Both Bone Fractured Legs: A Clinical Study. Journal of Bone and Joint Diseases. Jul-Sep 2017;32(2):32-36.

 


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Evaluation of the Functional Outcome and Complications of Intramedullary Nailing Through Medial Anterograde Technique in Displaced Midclavicular Fractures

Vol 32 | Issue 2 | July – Sep 2017 | page:28-31 | Vipul Agarwal, Chandra Prakash Pal, Amit Singh, Asif Hussain, Rajat Kapoor.


Authors: Vipul Agarwal [1], Chandra Prakash Pal [1], Amit Singh [1], Asif Hussain [1], Rajat Kapoor [1].

[1]Department of Orthopaedics, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India.

Address of Correspondence

Vipul Agarwal,
Sarojini Naidu Medical College, Agra,
Uttar Pradesh, India.
E-mail: sarinavipul@yahoo.com


Abstract

Aims: The aim of this prospective study was to evaluate the effectiveness and complications of intramedullary nailing in displaced midclavicular fracture through medial anterograde technique. Settings and Design: This was a prospective study.
Methods and Materials: This prospective comparative study was conducted at the tertiary center between October 2013 and September 2015 after being approved by the local ethical committee. Total 19 patients ranging between 18 and 60 years of age included in this study. They were treated by intramedullary nail through medial anterograde technique. Clinical and radiological assessments performed at 3rd week and 6th week and 3rd, 6th, and 12th month postoperatively. Outcomes and complications compared to 1-year follow-up.
Results: Good result achieved regards to functional outcome after fracture union. Although lower blood loss, less duration of hospital stay, and better cosmetic appearance noted in the nailing group done through medial anterograde method. Constant shoulder scores were fairly good after 6 months of follow-up. Infection and revision surgery (nonunion) rates were insignificant in nailing done through medial anterograde method group.
Conclusions: Functional outcome remains fairly good in intramedullary nailing done through medial anterograde technique. Infection and complications were infrequent. Intramedullary nailing done through anterograde method is advantageous concerning better cosmetically appeared scars.
Keywords: Clavicle, intramedullary nailing, anterograde.


How to Cite this Article:  Agarwal V, Pal CP, Singh A, Hussain A, Kapoor R. Evaluation of the Functional Outcome and Complications of Intramedullary Nailing Through Medial Anterograde Technique in Displaced Midclavicular Fractures. Journal of Bone and Joint Diseases. Jul‑Sep2017;32(2):28-31.


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Role of Locked Compression Plate in Osteoporotic Humeral Shaft Nonunions: A Clinical Study

Vol 32 | Issue 2 | July – Sep 2017 | page:24-27 | Javed Jameel, Sandeep Kumar, Rizwan Khan, Shishir Rastogi.


Authors: Javed Jameel [1], Sandeep Kumar [1], Rizwan Khan [1], Shishir Rastogi [1].

[1] Department of Orthopaedics, Hamdard Institute of Medical Science and Research, Jamia Hamdard, New Delhi, India.

Address of Correspondence

Javed Jameel,
Hamdard Institute of Medical Science and Research, Jamia Hamdard,
New Delhi, India.
E-mail: drrizwan85@gmail.com


Abstract

Background: Osteoporotic humeral shaft nonunion is a challenge to modern implant design because of inadequate screw purchase in the bone. Locked compression plating (LCP) is the answer to this difficult condition. In this prospective study, we have tried to evaluate the role of LCP in management of osteoporotic humeral shaft nonunion in patients above 18 years of age.
Materials and Methods: We treated 14 such cases with mean age of 48 years. Open reduction and fixation with LCP along with cancellous bone grafting were done, and the cases were evaluated clinically and radiologically till union.
Results: All the fracture went on to the satisfactory union after an average of 21 weeks (14-32 weeks). Two patients had delayed union and required bone marrow injections. All the patients after union were able to perform their pre-injury work. Pain and limitation of motion improved remarkably.
Conclusion: LCP is a very effective procedure to achieve union in osteoporotic humeral shaft fractures in adult patients. We propose fixation with LCP as it provides additional stability at fracture site, led to high rate of union, with few complications.
Keywords: Osteoporosis, humeral shaft nonunion, locked compression plating.


Introduction:

Humeral shaft fractures result from direct and indirect violence. Common mechanisms for humeral shaft fractures include fall on the outstretched hand, motor vehicle accidents, and direct load to the arm. Most of these fractures heal by conservative means or by surgical intervention. Few fractures fail to unite by 6 months time and they are labeled as nonunion. Humerus shaft nonunion is invariably associated with osteoporosis which further complicates the fracture. The major technical problem faced by the surgeon is the difficulty in obtaining secure fixation of an implant to osteoporotic bone. There is less cortical and cancellous bone for the screw threads to gain purchase so that the pullout strength of the implant is significantly reduced. Bone mineral density correlates linearly with the holding power of screws.1 The load transmitted at the bone implant interface can often exceed the reduced strain tolerance of osteoporotic bone. This may result in microfracture, resorption of the bone, and loosening of the implant, with secondary failure of fixation Although several surgical methods for the management of humeral shaft nonunion have been examined in the literature such as compression plating with bone grafting2 intramedullary nailing3 Illizarov fixator4,non-vascularised intramedullary fibular graft5 but no single technique has proved its superiority over the other. Very few studies have been published about the use of locking compression plate (LCP) in the management of a nonunion of humeral fractures6,7,8 We conducted a prospective study at our institution to evaluate the clinical and radiographical results of locked compression plate in the treatment of osteoporotic humeral shaft nonunion.

Materials and method
This prospective study was conducted at Jawaharlal Nehru medical College, AMU Aligarh from January 2006-July 2008. The tool for data collection was a predesigned data sheet to collect information on the cases. The questionnaire contained information on age, sex, residence, side involved, co-morbid conditions, mechanism of injury, fracture location, initial treatment of the fracture, time from injury to definitive treatment, definitive treatment, time taken to unite, function and complications. In this study, nonunion was defined as absence of radiographic signs of union and persistent pain on clinical examination six months after injury.

Inclusion criteria
(a) patients more than 18 years of age
(b) patients with osteoporotic humerus shaft non-union
Exclusion criteria
(a) patients less than 18 years of age
(b) patients with fresh fracture of humerus shaft
(c) patients with infected/pathological humeral shaft fractures

Surgical technique
Treatment consisted of a standard Henry’s anterolateral approach for proximal and middle third humeral fractures while posterior triceps splitting approach for lower third fractures. The radial nerve to be identified and protected for the duration of the procedure. Removal of any preexisting implant followed by freshening of bone ends, reaming of medullary canal, reduction followed by stabilization of fracture by 4.5/5mm locking compression plate and autogenous cancellous bone grafting. A minimum of eight cortices of fixation above and below the fracture site were obtained in most fractures. Postoperatively, anteroposterior and lateral radiographs were done to assess alignment, loosening of devices, and later presence of bridging callus across the nonunion site. Patients were placed in an arm sling primarily for comfort for two weeks. Gentle pendulum and active assisted shoulder and elbow range of motion were started at 2 weeks post surgery followed by strengthening and passive range of motion exercises. Patients were reviewed at 2, 6, 12 and 16 weeks. The primary outcomes measured were time to union, function and complications. Union was determined by radiographic evidence of cortical bone bridging at the nonunion site, stable hardware position on radiographs, as well as absence of pain with manual palpation of the nonunion site. Function was assessed using the Disability of the Arm, Shoulder and Hand (DASH) Score for 30 activities of daily living requiring full shoulder and elbow movement. Score range from 0 (no disability) to 100.

Results
We performed open reduction and internal fixation with locking compression plate and iliac crest bone grafting in osteoporotic humeral shaft nonunions in 14 consecutive patients with mean age of 48 years (range 20–60 years, (Table 1).
There were 10 males and 4 females with an equal number of right and left arm affected (7 each). Mean age was 48 years (range 24-65 years). Delay in presentation ranged from 24 to 76 weeks (mean 35 weeks). The mechanism of injury was road-traffic accident in 7 patients, slipping onto ground in 6 and fall from height in one patient. All patients were in good health before the fracture and were doing their routine work. Fracture types included 10 transverse, three short oblique, and one long oblique. None of the fractures was comminuted. All of the fractures were close. There were six proximal third, three middle-third, and five extra-articular distal-third humeral fractures. All the patients had osteoporosis as assessed by cortical index9 (Cortical index is the combined medial and lateral cortical thickness divided by the total width of the bone at that level). No preop complication like radial nerve palsy was reported prior to management in any of the patients. None of the patients had undergone previous surgery. Nine patients had taken local treatment from quacks, five patients were treated in plaster splints for inadequate period. Preoperatively all the patients complained of limitation of shoulder and elbow motion and were unable to use the affected limb properly. Average preop DASH score was 89 (range 65-95). All the patients were followed for an average 12 months (range 6-18 months). There were two cases of superficial skin infection which healed with a course of antibiotics. There was no radial nerve palsy and hardware loosening. Twelve patients showed evidence of complete healing as defined by radiographic evidence of at least three out of four bridging cortices within 24 weeks of the procedure (range 14-32 weeks)(Figure 1 to 3).Two patients required additional bone marrow injections for delayed union with stable hardware position. Postop mean range of movement was 1290 (range 1000-1500). At final follow-up, the average DASH score was 24 (range 10-30).

Discussion 

Nonunion shaft of humerus was managed successfully by several authors using dynamic compression plates2 however osteoporotic humerus shaft nonunion is difficult to manage because of presence of inadequate purchase of implant. Various methods have been employed to achieve union including double plating10,Plating with nonvascularised intramedullary fibula5 but double plating entail extensive periosteal stripping of humerus and nonvascularised fibula has low healing rate. Intramedullary rush pin with plating11 and structural allograft with BMP-7 and mesenchymal stem cells12 was advocated by few authors. Intramedullary implants has high complication rate including rotator cuff injury and shoulder stiffness. Illizarov external fixators4 has been used by several authors in management of humerus nonunion specially in presence of infection, but they are associated with numerous complications like pin tract infection, risk of neurovascular impalement by wires. Additionally the assembly is quite bulky and has high discomfort rate for the patient. Ring et al used LCP in 24 patients with osteoporotic humerus shaft nonunion and achieved successful union in all the cases6 The average duration of nonunion of 9 months in our series (range: 6-19 months) was comparable to that of Ring et al. who had reported an average duration of 28 months (5‑192 months).The mean age of our patients was 48 years in comparison with the mean age of 72 years in the study by Ring et al. Laboratory studies have also shown that locking plate constructs were superior to unlocked plate and screw constructs in osteoporotic diaphyseal humeral fracture models tested in vitro using cyclical torsional loading13. Within the present series, fourteen patients of humeral shaft nonunion with osteoporosis underwent successful salvage with a standard protocol that included fixation with a Locking compression plate, application of autogeneous bone graft, and optimization of associated patient co-morbidities in the perioperative period. All fourteen patients achieved clinical and radiographic union with good functional result.. The strength of our study is that it was a prospective study that allowed comparison between the functional status in the preoperative and postoperative periods. The drawbacks of the present study are the absence of a control group for comparison with the treatment group.

Clinical relevance
Locked compression plating is a very effective procedure to achieve union in osteoporotic humeral nonunion in adult patients. We propose fixation with locked compression plate and autologous bone grafting as it provides additional stability at fracture site, led to predictable high rate of union, and with fewer complications.


References

1. Thiele OC,Eckhardt C,Linke B,Schneider E, Lill CA. Factors affecting the stability of screws in human cortical osteoporotic bone a cadaver study. The Bone & Joint Journal 2007;89(5):701-5
2. Kumar A, Sadiq SA. Non-union of the humeral shaft treated by internal fixation. Int Orthop 2002;26:214–6.
3. Kui LX Giang WH Yong WY, Xiang WZ. Treatment of nonunions of humeral fractures with interlocking intramedullary nailing. Chinese Journal of Traumatology 2008; 11(6):335-340.
4. Kiran M, Jee R. Ilizarov’s method for treatment of nonunion of diaphyseal fractures of the humerus. Indian J Orthop 2010;44:444‑7.
5. Vidyadhara S, Vamsi K, Rao SK, Gnanadoss JJ, Pandian S. Use of intramedullary fibular strut graft: A novel adjunct to plating in the treatment of osteoporotic humeral shaft nonunion. Int Orthop 2009;33:1009‑14.
6. Ring D, Kloen P, Kadzielski J, Helfet D, Jupiter JB. Locking compression plates for osteoporotic nonunions of the diaphyseal humerus. Clin Orthop Relat Res 2004;425:50‑4.
7. Nadkarni B, Srivastav S, Mittal V, Agarwal S. Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: Review of literature and our experience. J Trauma 2008;65:482‑6.
8. Kumar MN, Ravindranat VP, RavishankarMR, Outcome of locking compression plates in humeral shaft nonunions. Indian J Orthop 2013;47(2):150-5.
9. Bloom RA, Laws JW Humeral cortical thickness as an index of osteoporosis in women, Br. J. Radiol 1970, 43, 522-527
10. Martinez AA, Cuenca J, Herrera A. Two-plate fixation for humeral shaft nonunions Journal of Orthopaedic Surgery 2009;17(2):135-8
11. Sitati FC, Kingori J. Outcome of Management of Humerus Diaphysis Non-union East Cent. Afr. j. surg 2009;14(2): 13-17
12. Murena L, Canton G, Vulcano E, Surace MF, Cherubino P. Treatment of Humeral Shaft Aseptic Nonunions in Elderly Patients With Opposite Structural Allograft, BMP-7, and Mesenchymal Stem Cells. Orthopedics 2014;37(2):201-6
13. Gardner MJ, Griffith MH, Demetrakopoulos D, Brophy RH, Grose A, Helfet DL, et al. Hybrid locked plating of osteoporotic fractures of the humerus. J Bone Joint Surg Am 2006;88:1962‑7.


How to Cite this Article: Jameel J, Kumar S, Khan R, Rastogi S. Role of Locked Compression Plate in Osteoporotic Humeral Shaft Nonunions: A Clinical Study. Journal of Bone and Joint Diseases Jul-Sep 2017;32(2):24-27.

 

 


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Repair of Chronic Tendoachilles Rupture – Bosworth Technique versus Peroneus Brevis Transfer Technique – A Retrospective and Prospective Study

Vol 32 | Issue 2 | July – Sep 2017 | page:17-23 | P Ahmed, Y Usmani, Apoorv Mohan Garg.


Authors: P Ahmed [1], Y Usmani[2], Apoorv Mohan Garg [1].

[1]Department of Orthopaedics, LLRM Medical College, Meerut, Uttar Pradesh, India,
[2]Department of Radio-diagnosis, LLRM Medical College, Meerut, Uttar Pradesh, India.

Address of Correspondence

P-16 Medical College Campus, LLRM Medical College, Meerut, U.P.(PIN-250004)
E-mail: drahmedparvez@yahoo.com


Abstract

Introduction: Chronic rupture of Achilles tendon causes marked functional impairment. The recommended treatment for this is surgery and various techniques have been reported in the literature.
Materials and Methods: From 2008 to 2016, 30 patients (20 men and 10 women) operated with Bosworth Technique (23 patients) or peroneus brevis (PB) tendon transfer (7 patients) were included for the study. At 12-month follow-up, all patients were assessed with regard to post-operative complications, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot score, and ankle range of motion.
Result: AOFAS scores increased from an average 61.57/100 (range, 58-80) pre-operatively to 95.91 (range, 90-98) post-operatively for Bosworth technique. AOFAS scores increased from an average 61.14/100 (range, 58-64) pre-operatively to 96.71 (range, 94-98) post-operatively for PB tendon transfer technique. All patients were able to perform their daily activity unrestrictedly at last follow-up. Two patient experienced wound dehiscence and 1 patient had hypertrophic scar in Bosworth technique while 1 patient experienced wound dehiscence in PB Tendon transfer technique.
Conclusion: Both the techniques have near similar functional outcome and complication rate. However, Bosworth technique has limitations in the form of requirement of the distal stump and imparting of bulky consistency to the tendoachilles which are not present with PB tendon transfer technique. Either of the technique can be used as per the surgeon’s preference and expertise as well as patients profile and choice.
Keywords: Bosworth technique, chronic Achilles tendon rupture, peroneus brevis tendon transfer.


Introduction

The Achilles tendon is the strongest, largest, and thickest tendon in the body,1 yet it is the most frequently ruptured tendon,2 with most ruptures occurring at the watershed area approximately 2 to 6 cm proximal to insertion of the tendon.Achilles tendon ruptures and incidences in general have increased substantially during the last few decades and are most commonly seen in middle aged males, 30-50 years old, who participate intermittently in recreational athletic with 75% of all ruptures occurring during sporting activities1, 2. Ruptures additionally can occur in the older patient, usually in those with underlying tendenosis, and may be asymptomatic or subclinical. They usually do not feel the classical sensation of being kicked or hit in the calf nor hear an audible snap, and ruptures tend to occur during low-energy activities. As such, these ruptures may be more difficult to recognize and may be more frequently missed on initial evaluation. Although there is debate of what may be considered a chronic injury, 4 to 10 weeks have been used by various authors1, 2, since 4 weeks is the earliest time point that has demonstrated histological evidence of chronic healing.Patients initially present with swelling, complaints of weakness, difficulty in climbing up and down stairs, loss of balance, and a tendency to fall forward. Loss of Achilles function leads to loss of plantar flexion strength, weakness, fatigue, limp, inability to run, heel rise and play sports1, 2. There is wasting in calf muscle and often a palpable gap between the ends of the Achilles tendon. In chronic Tendo-Achilles rupture, there is 20% less endurance of the muscle and the treatment becomes more difficult.2 If the tendon is not repaired or immobilized, retraction of the muscle fibers leads to decreased muscle tension until it becomes zero at about 60% of the fibers’ resting length.4   The delay in treatment result from decreased pain after the initial injury, as well as misdiagnosis by the first evaluator, in up to 20-36% of patients.4 These delays in treatment, whether operative or non-operative, can have detrimental effects on the final outcomes. In the management for Chronic Tendoachilles rupture conservative treatment has now been entirely abandoned because of better results and less functional morbidity by operative methods. Moreover, clinical evaluations of non-operative treatment have demonstrated a re-rupture rate of 10–30%. Other drawbacks of non-operative treatment include decreased plantar flexion and decreased endurance when compared to surgically repaired tendons. Moreover, several current studies favour operative repair via open or percutaneous techniques in younger, active patients who wish to return to pre-injury activities. Definitive advantage of surgical repair includes lower Re-rupture rate in surgically repaired Achilles tendon however the complications of operative repair include infection and poor wound healing at the surgical site which is more deliberated. The primary goal of any surgical treatment is to restore the function and strength of the gastrocnemius-soleus complex by recreating the optimal length-tension relationship by many surgical techniques described for the management of neglected Achilles ruptures which include end to end repair of the tendon as in V-Y plasty; gastrocnemius soleus complex “turn-down” of proximal Achilles Tendon tissue described by Bosworth5 and others like Coughlin; local tendon transfer Techniques like that of peroneus brevis (PB)6 or flexor hallucis longus (FHL) tendon or by use of synthetic grafts including carbon fiber composites, polyglycol threads, and polyester mesh. Any of these techniques each with their own pros and cons can be used by the surgeon depending in the patients demand and surgeon’s expertise.

AIMS AND OBJECTIVES
The purpose of this article is to evaluate and compare the clinical and functional outcomes of 30 patients presenting with Chronic tendoachilles rupture who were treated either by Bosworth Technique or Peroneus Brevis Tendon Transfer technique and to determine the advantage disadvantage of each technique over the other. The patients functional outcome were assessed in post operative period by active plantar flexion at the ankle and by the ankle—hind foot scale developed by the American Orthopaedic Foot and Ankle Society (AOFAS Score) 7 and were compared statistically from the active plantar flexion at the ankle  and AOFAS Score taken pre-operatively. Boyden Clinical Score was taken only in post-operative period after patient resume their normal unrestricted activity.

MATERIAL AND METHODS

Patients
The study was conducted at the department of orthopaedics in L.L.R.M. medical college and associated hospital, Meerut during period of 2015-2016. A series of 30 patients (20 men, 10 women) were included for the study. All patients were admitted through OPD and operated with either Bosworth Technique or Peroneus Brevis Tendon transfer from 2008 to 2015 were included and reviewed retrospectively and case operated from 2015 to 2016 were included and followed up prospectively. Patient with associated Severe co morbidities like uncontrolled diabetes, poor skin condition, compound Tendo-Achilles rupture were excluded from the study. MRI of the affected Leg was done on each patient to assess the severity of rupture, partial rupture or complete tear.

Surgical Procedure
BOSWORTH TECHNIQUE5
Anaesthesia was given in the form of spinal anaesthesia/General anaesthesia. The patient was placed prone on the operating table with body supported on bolster one each at just below the level of shoulder supporting the body at the anterior wall of chest and other bolster at the level of level of pubic symphysis. Pneumatic tourniquet was applied to the lower extremity at the thigh. The whole extremity was then painted and draped under aseptic precautions. A posterior longitudinal midline incision, extending from the calcaneus to the proximal one third of the calf was given and the ruptured tendon was exposed. The scar tissue formed between the ends of the ruptured tendon was then excised with sharp dissection. From the median raphe of the gastrocnemius muscle a strip of tendon approx 1.5 cm wide and 17.5 to 22.5 cm long was freed and left attached just proximal to the site of rupture. Strip was then turned distally and passed transversely through the proximal tendon and anchored there with absorbable suture. The strip was then passed distally and then transversely through the distal end of the tendon and passed again through this end from anterior to posterior.While holding the knee at 90 degrees and the ankle in plantar flexion, the fascia strip was drawn tight and anchored with absorbable suture. The strip was then brought proximally and passed transversely throught the proximal end of the tendon, and then was carried distally and sutured on itself. Wound was closed and above knee cast was applied with ankle in maximum equinus.

PERONEUS BREVIS TENDON TRANSFER TECHNIQUE
Anaesthesia was given in the form of spinal anaesthesia/General anaesthesia. The patient was placed prone on the operating table with body supported on bolster one each at just below the level of shoulder supporting the body at the anterior wall of chest and other bolster at the level of level of pubic symphysis. Pneumatic tourniquet was applied to the lower extremity at the thigh. The whole extremity was then painted and draped under aseptic precautions. A posterior longitudinal midline incision, extending from the calcaneus to the proximal one third of the calf was given and the ruptured tendon was exposed. A 2 cm longitudinal incision was then made at the base of 5th metatarsal. Both distal and proximal stump of the ruptured tendon were mobilized by removing peritendinous adhesions and resecting the ruptured tendon back to the healthy tendon. Soft tissue anterior to the soleus and gastroicnemius were realeased to allow max excrusion and minimizing gap between the tendon stumps. The peroneus brevis tendon was then identified and exposed through the incision at the foot and was released from its base after placing a locking suture with absorbable suture. Through the posterior longitudinal midline incision over the Achilles tendon, the deep fascia overlying the peronei muscles was incised identifying the peroneus brevis tendon and withdrawing through the midline incision. The peroneus brevis muscle was then mobilized and a longitudinal tenotomy parallel to the tendon fibres was done in both the tendon stumps. A plane was developed in the distal stump of Achilles tendon and peroneus brevis graft was passed through the tenotomy. It will then be sutured to both sides after putting the ankle in full plantar flexion. Peroneus brevis tendon was then passed beneath into the proximal incision and then from medial to the lateral through transverse tenotomy in proximal stump and then it was secured with absorbable sutures. The peroneus brevis was then sutured back on itself on the lateral side of proximal incision. Wound was closed and above knee cast was applied with ankle in maximum equinus.

POST OPERATIVE CARE
Sutures were removed at 2 weeks and above knee cast with ankle at maximum equines continued till 4 weeks. After 4 weeks cast was changed again and below knee cast with foot gradually brought in plantigrade position was applied for next 2 weeks. At 6-8 weeks, full weight bearing was allowed with the application of removable brace with foot in plantigrade position and gentle range of motion exercises for 20min twice a day were begun along with isometric ankle exercises supplemented with knee strengthening exercise. After 3 months, toe raising exercise with progressive resistance exercises and proprioceptive exercises were started. After 6 months, full unrestricted activity was allowed.

FOLLOW-UP PROTOCOLS
Patients were called for 1st follow up at 15 days for stitch removal. 2nd follow up was at 1 month after surgery when below knee cast was applied bringing the foot in plantigrade position from equines. 3rd follow up was at 2 months after surgery when the cast was removed and physiotheraphy started. 4th follow up was at 3 months after surgery at which first AOFAS score and active plantar flexion is measured for outcome. Subsequent follow ups were then at every 3 months interval till 1 year from surgery at which final AOFAS score and active plantar flexion was measured followed by yearly follow-up.

RESULTS

A series of 30 patients (20 males, 10 females) were included for the study out of which 23 patients (16 males, 7 females) were operated by Bosworth technique for tendon repair while 7 patients (4 males, 3 felmales) were operated by Peroneus brevis tendon transfer technique. Out of 30 patients included in the study 20 patients (66.67%) were male and 10 patients (33.33%) were female thus giving a male to female ratio of 2:1. Age of the patients were between 21 years to 48 years with mean age of 41 years with standard deviation of 6.34. Out of 30 patients included in the study 17 patients (56.67%) had Tendo-Achilles rupture at Right side and 13 patients (43.33%) had rupture at Left side. It was found that minimum follow-up duration of the patients were 12 months while maximum was upto 84 months with the median value of 24 months and interquartile range of 6. Out of the 30 patients in our sample size, 14 (46.67%) had a history of Injection at the Tendo-Achilles and 16 (53.33%) didn’t had a history of injection at Tendo-Achilles. In patients operated with Bosworth Technique, pre-operative active plantar flexion of the patients ranged from 10-40 degrees with median value of 25 degrees and mean active plantar flexion of 22.61. The improvement in active plantar flexion was seen at post-operative period of 12 months with range of 40-50 with median value of 50 and mean active plantar flexion of 49.13 degrees. On comparison it is found to highly statistically significant with P-value less than 0.001. Pre-operative AOFAS score of the patients was from 58-80 with median value of 60 and mean value of 61.57. The improvement in AOFAS score was seen during post-operative period of 12 months which was found to be from 90-98 with median value of 97 and mean value of 95.91. On comparison with pre-op AOFAS Score a significant improvement was seen which was found to be highly statistically significant with P-value less than 0.001. In patients operated with Peroneus Brevis Tendon Transfer technique, pre-operative range of motion of the patients was from 20-40 degrees with median value of 30 degrees and mean active plantar flexion of 28.57. The improvement in active plantar flexion was seen during post-operative period of 12 months with range of 40-50 with median value of 50 and mean active plantar flexion of 50 degrees. On comparison it is found to highly statistically significant with P-value less than 0.001. Pre-operative AOFAS score of the patients was from 58-64 with median value of 62 and mean value of 61.14. The improvement in AOFAS score was seen during post-operative period of 12 months which was found to be from 94-98 with median value of 97 and mean value of 96.71. On comparison with pre-op AOFAS Score a significant improvement was seen which was found to be highly statistically significant with P-value less than 0.001. AOFAS score of the patients at 12 month post-op operated by Bosworth Technique ranged from 90-98 with median value of 97 and mean value of 95.91. AOFAS score of the patients at 12 month post-op operated by Peroneus Brevis Tendon Transfer Technique ranged from 94-98 with median value of 97 and mean value of 96.71. On comparison between AOFAS Scores of subjects at 12th month post-op by Bosworth Technique and AOFAS Scores of subjects at 12th month post-op by Peroneus Brevis Tendon Transfer Technique, it was found to be not statistically significant with P-value more than 0.05. In post-operative functional status of the 30 patients included in over study, as measured by Boyden Score, 29 (96.67%) cases were excellent and 1 (3.33%) cases were good at 12 months after the repair of Chronic Tendo-Achilles rupture. In our study out 30 patients operated for Chronic Tendo-Achilles Rupture, it was found that in 3 patients (10%) problem in wound healing occurred in the form of wound dehiscence out which 2 required reverse sural flap for closure. Only 1 patient (3.33%) had complication of hypertrophic scar over the incision site. No post-operative surgical site infection was found out in any of the 30 case subjects. None of the 30 case subjects neither suffered from re-rupture of the Tendo-Achilles

DISCUSSION

This study was conducted during 2015-16 on 30 patients who presented with Chronic Tendo-Achilles rupture and were treated with either Bosworth Technique of Tendo-achilles repair or by Peroneus Brevis Tendon Transfer technique in the department of orthopaedic surgery of L.L.R.M Medical College and associated S.V.B.P Hospital, Meerut from 2008-2016. In this study the age of the patients were between 21 years to 48 years with mean age of 41 years. Male patients (66.67%) were affected more  than female patients (33.33%) with ratio M:F = 2:1. This can probably be attributed to Sports participation which has undergone an increase in recent decades and therefore there has been subsequent rise in Injuries due to sporting activity. The Achilles tendon has been one of the most common sports-related injuries. Schepsis et al8 observed in 2002 that Tendo-Achilles rupture is observed in men in the fourth to fifth decades of life with male to female injury ratios range from 2:1 to 12:1. Running, sprinting, jumping, and agility activities involving explosive plyometric contractions are usual mechanisms. In this study all of our subjects suffered trauma at their ankle which lead to rupture of Tendo-Achilles which has been consistent with the study conducted by Suchak AA et al9 in 2005. In our study 14 patients (46.67%) had history of corticosteroid injection at their Achilles Tendon while 16 patients (53.33%) had no history of steroid injection. Studies conductied by Maffulli et al10 in 1998 and White et al11 in 2007 implicated Two drugs that have been associated with delayed healing and tendon necrosis which were fluoroquinolone antibiotics and corticosteroids. Fluoroquinolone antibiotics have been observed to weaken the Achilles tendon extracellular matrix, resulting in less tensile tendon strength. Corticosteroids, used to decrease tissue inflammation, also cause collagen to weaken and decrease blood supply to an already avascular structure. The duration of presentation of patient to us with the chronic tendoachilles rupture ranged from 3 months to 36 months. In many patients the initial symptoms after an Achilles tendon rupture diminish quickly. In a study conducted by Christensen et al12 in 1953, out of 57 patients with acute Achilles rupture, 19 of them reported to be painless. Patients with Achilles tendon ruptures frequently are unable to stand on the toes of the involved side, however, active plantarflexion maybe intact due to partial ruptures, recruitment of plantar flexors, and an intact plantaris muscle. The lack of pain and no obvious loss of plantarflexion can be misleading and up to 20-25% of cases the diagnosis is missed initially13,14. The failure to establish the diagnosis at the initial presentation is the most common reason for delayed treatment. Hence, patient is unable to get the required treatment in time and thus showing a wide range of presentation. The follow up duration of our study ranged from minimum 12 months to maximum of 84 months with average duration of follow up being 23.6 months which is consistent with the literature. In our study, out 30 patients who underwent operative intervention for Chronic Tendo-Achilles rupture, 23 of them underwent repair by Bosworth Technique while Peroneus brevis tendon transfer was done on the 7 patients. For patients who underwent repair by Bosworth Technique, We observed that pre-operative functional score AOFAS score of the patients ranged from 58 to 80 with mean AOFAS Score of 61.57. Active plantar flexion of these patients averaged at 22.61o ranging from 10o-40o. For patients who underwent repair by Peroneus Brevis tendon transfer, We observed that pre-operative functional score AOFAS score of the patients ranged from 58 to 64 with mean AOFAS Score of 61.14 and they had range of active plantar flexion from 20o-40o with average flexion of 28.57o in preoperative period. The average AOFAS score of the patients who underwent repair by Bosworth Technique significantly increased to 95.91 with a range from minimum 90 to a maximum of 98. Active plantar flexion of these patients averaged at 49.13o ranging from 40o-50o. The average AOFAS score of patients whose Tendo-Achilles was repaired by Peroneus brevis tendon significantly increased to 96.71 with a range from minimum 94 to a maximum of 98. Active plantar flexion of these patients averaged at 48.57o ranging from 40o-50Out of 30 patients, 5 (16.67%) patients gave a poor score on Boyden scale in pre-operative period to their condition while rest 25 (83.33%) patients had a fair score in Boyden Scale. However in post-operative period, only 1 (3.33%) patient gad a good score on Boyden scale while rest (96.67%) had excellent score on Boyden scale which a significant improvent as compared to previous non-operative state. No intra-operative complication were encountered in any of our cases. Among the post-operative complications, wound dehiscence were found in 3 (10%) of our patients and in 1 (3.33%) patient hypertrophic scar over the incision site was found. Scar hypertrophy was later managed by triamcenolone acetate injection locally with compression bandage. Out of the 3 patients with wound dehiscence in post-operative period, 1 was managed conservatively and healing occurred with daily cleaning and dressing of wound with normal saline and placental extract while other 2 patients where managed by reverse sural flap surgery for their wound. There was no post-operative instability in any of our patients. No post-operative infection was reported in our group. There was no incidence of re-rupture following the procedure in our group. Although wound healing is usually a general complication for most procedures, it is particularly concerning for an Achilles tendon repair. This is because the tendon itself has relatively little soft-tissue coverage and this area of skin has a notoriously poor blood supply. Therefore, any type of wound healing problem can easily end up involving the tendon itself. For most patients, there is approximately a 2-5% chance of a significant wound healing problem. The risk of a wound healing problem increases significantly in smokers and diabetics. In our study 2 patients showed post-op wound dehiscence for which sural flap was done while 1 was healed conservatively with daily dressing by placental extract. Wound detachment and rerupture are well known complications after open surgical treatment of Achilles tendon ruptures. However, open rerupture after surgical treatment of the Achilles tendon occurs much less frequently as compared to conservative treatment. According to a meta-analysis by Bhandari et al15 the rerupture rate with surgical treatment (3.1%) was significantly lower than with nonsurgical treatment (13%). However, there were wide confidence intervals in his included studies. In a meta-analysis by Khan et al16 the rerupture rates were estimated at 3.5% and 12.6% in surgically and nonsurgically treated patients, respectively. García Germán et al17 reported on 2 cases in which they hypothesized that open rerupture may have been related to incomplete closure of the paratenon. Mellor et al18 reported that the rates of wound break down, infection and rerupture after surgical repair were lower when special care was taken to perform a correct separate repair of the paratenon.  Graf et al.19 found that the role of a well vascularized paratenon was of paramount importance in the surgical treatment of a rupture and correct closure could help vascularization and avoid adhesion to superficial layers. We performed a complete suture of the paratenon in all of our cases and we found no rerupture of the tendon although we believe that more cases are needed to comment with certainity about the rerupture rate. Animal studies have shown the importance of mechanical loading in tendon healing. Langberg H et al20 in 1999 and  Olesen JL21 in 2007 have stated in their study that tendon strengthening occurs because exercise leads to anabolic responses of tendons such as increase in the formation of type I collagen in peritendinous tissue, as shown by microdialysis measurements. In 2009, Kjaer M, Langberg H22 et al showed in human models, that mechanical load leads to an increase in collagen synthesis and tendon size. The current AAOS guidelines23 recommend early, protected, postoperative weight-bearing. In our study, all our patients were placed on protected weight bearing as early as within 4 weeks of post-operative period. On comparing the clinical and functional outcome between the Bosworth technique of tendon repair and Peroneus brevis tendon transfer technique, it was not found to be of statistical significance as each of the technique independently provided the near to normal result at 12 months after the surgery. The AOFAS score of 95.91 for the Bosworth technique is only marginally lower than the AOFAS score of 96.71 by the Peroneus brevis tendon transfer technique of tendon repair. As fas as active plantar flexion at the ankle is concerned in the post-operative patients, Bosworth technique(49.13o) fared well although marginally when compared to Peroneus brevis tendon transfer(48.57o). As we all know that plantar flexors are the muscles that push off the ground during walking. Harvesting the plantar flexors results in weakening the push-off phase of walking and is distressing, particularly in young persons24. In cadavers, the failure load was significantly higher in Achilles tendons reconstructed with the peroneus brevis tendon25. After peroneus brevis tendon augmentation, the strength of eversion may be mildly weakened but that of plantar flexion can be maintained26. According to a study conducted by Clarke HD et al27 in 1998, the 2 peroneal muscles contribute only 4% of the work capacity for plantar flexion, but for eversion the peroneus brevis tendon contributes about 28% of the total work strength. Thus, the use of the peroneus brevis tendon may cause a strength deficit in eversion of the ankle but a negligible deficit in planter flexion. Nonetheless, the peroneus longus, which is the major evertor of the hind foot, may take over some of the functions of the peroneus brevis28. Thus, subjective weakness in ankle function after peroneus brevis tendon augmentation is minimal29. This can be cause of slightly less active plantar flexion although insignificant in patient with peroneus brevis tendon transfer. Moreover, it can also be hypothesized that Bosworth technique doesn’t disturb other compartment of the leg. This in theory can cause decrease in movement at the ankle joint due to more dissection around the ankle as well as more involvement of normal functioning tendon for reparative function, which is not done in case of Bosworth technique. Nonetheless, in our patients, ankle movement exercise was performed during rehabilitation as early as 2 months post-operative period and ankle strengthening exercises were started within 3 months post-operative period to reduce the post-operative stiffness of the joint and to achieve near normal range of motion at the ankle.

CONCLUSION

Chronic Achilles tendon ruptures are not uncommon and potentially debilitating. Many surgical treatments are available for reconstruction of a neglected Tendo-Achilles rupture. The choice of management is partly guided by the type of tendon lesion, with most injuries requiring operative management. Many techniques can be used to repair or reconstruct a tendon with a chronic rupture. Most studies have been retrospective and small and have focused on the results of a single technique. There is no concrete data to support one technique over another; hence, there is no “gold standard”. Most agree, however, in order to achieve the optimal functional outcome surgical reconstruction is required. Regardless of the chosen technique, the ultimate goal of surgical treatment is to restore the length tension relationship such that sufficient plantar flexion power is attained. Bosworth technique is a simple, safe and predictable repair with limitation of requirement of distal stump of atleast minimum 2 cm. This technique combines the benefit of operative procedure with reduced rate of re-rupture and non operative procedure by being technically simple and therefore restoring the tendon length and producing excellent functional improvement as shown by marked improvement in post-op AOFAS Score. Moreover, no separate incision is required apart from exposing the Achilles tendon and it does not disturb the anatomy of the adjacent compartments of the leg gives it the edge over other procedures. Peroneus brevis tendon transfer technique is one of the fewest tendon transfer technique with no limitations as of Bosworth Technique and is not associated with any residual morbidity in the foot when compared with FHL or FDL tendon transfer. Theoretical partial loss of eversion of foot is negligible and well compensated by the Peroneus longus. Although this technique does involve violation of two compartments of leg instead of one as in Bosworth technique, final clinical and functional outcome is marginally higher for Peroneus Brevis technique and is not statistically significant. Both the techniques are simple, safe and none of them have a higher complication rate or residual deformity when compared to each other. However, Bosworth technique have some limitations in the form of requirement of distal stump for the repair of Tendo-Achilles and imparting of bulky consistency to the Tendo-Achilles post repair which seldomly gives discomfort to the patient in post-op rehabilitation period. These limitations are not present with Peroneus Brevis Tendon Transfer technique. Both the techniques have near similar functional and clinical outcome and hence either of the technique can be used as per the surgeon’s preference and expertise as well as patients profile and choice after due consideration of procedure of the technique and possible complications and risks associated with either of them. Further study and critical analysis is needed with a larger sample size and a longer follow up.


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How to Cite this Article: Ahmed P, Usmani Y, Garg AM. Repair of Chronic Tendoachilles Rupture – Bosworth Technique versus Peroneus Brevis Transfer Technique – A Retrospective and Prospective Study. Journal of Bone and Joint Diseases. Jul-Sep 2017;32(2):17-23.

 

 


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Comparative Evaluation of Results after Internal Fixation of Fracture Clavicle by Titanium Elastic Nailing System/Plate

Vol 32 | Issue 2 | July – Sep 2017 | page:10-16 | Paras Gupta, Atul Kumar Vishwakarma, D. K. Gupta, Saurabh Agarwal, Neeraj Singh


Authors: Paras Gupta [1], Atul Kumar Vishwakarma [1], D. K. Gupta [1], Saurabh Agarwal [1], Neeraj Singh [2].

[1] Department of Orthopaedics, M.L.B Medical College, Jhansi, Uttar Pradesh, India,
[2] Manobrij Hospital, Lakhimpur, Khiri, Uttar Pradesh, India.

Address of Correspondence

Dr. Paras Gupta,
Department of Orthopaedics, M.L.B Medical College, Jhansi,
Uttar Pradesh, India. Phone: +91-9935914926.
Email: paras12gupta@rediffmail.com


Abstract

Background: Fractures of clavicle are common injuries with incidence of 2.6-8% of all fractures and 44% of all shoulder injuries [1].
Aim: The aim of this study is to compare the results and complications of internal fixation with titanium elastic nailing system (TENS)/plates in displaced fracture midshaft of clavicle.
Materials and Methods: In a prospective study from December 2014 to June 2016, we analyzed 62 patients of displaced fracture midshaft clavicle treated by TENS (31) (Group I) and plate and screws (31) (Group II). Average age in the two groups was Group I (30.22) and Group II (30.34). The majority of the patients were males (65%) in both groups. Mechanism of injury was road traffic accident (67.74%) which was most common others are fall from height and assault. According to Allman classification, all midshaft clavicle are Type I.
Results: No significant difference was found in function and non-union rate in both groups but major complications and union time are more in plate fixation group than TENS group.
Conclusion: Callus formation was early in TENS group, and healing was faster as compare to plate group. TENS is a safe, minimally invasive surgical technique with a lower complication rate, faster return to daily activities, excellent cosmetic and comparable functional results, and can be used as an equally effective alternative to plate fixation in displaced midshaft clavicle fractures.
Keywords: Displaced middle one-third shaft clavicle fractures, titanium elastic nailing system.


Introduction

Fractures of clavicle are common injuries with incidence of 2.6-8 % of all fractures and 44% of all shoulder injuries [1]. Clavicle fractures are more common in males (68%) as compared to females. Left side is involved in 61% of cases. Fracture of clavicle can occur at any site but middle third is commonly involved in 81% of cases [1]. Fractures of clavicle are known since ancient time, earliest description of fracture clavicle is found in Egyptian literature in 3550 BC [2]. Clavicle is short long bone of Skeleton and helps in translation of weight from hand to axial skeleton and provides attachment to the various muscles. Initially the aim of treatment was union of fracture in whatsoever position fracture unites. Many methods of conservative treatment namely triangular sling, cuff and collar sling , three sling method ,figure of eight bandage, figure of eight POP shoulder Spica , clavicular brace, arm shoulder pouch and many others have been described from time to time[7,8,9,10].All these methods did not in volve the reduction of fracture or unable to hold the fracture reduced hence the end results were malunion/nonunion in various cases [7,8]. The malunion resulted in shortening, deformation, disfigurement and poor cosmoses shortening (reduced distance between sternoclavicular joint to the shoulder joint) resulted in biomechanical disadvantage, persistence of pain, limitations of functions and reduction of strength in upper limb in some of these cases. With increasing awareness and demand of the patient and consumer protection court surgeons felt the need for operative intervention and perfect alignment of these fracture to achieve perfect alignment of fragments.Better operative technique; improve metallurgy and availability of image intensifiers made the operative techniques as a method of first choice by more and more surgeons [3,4,11]. Various surgical treatment described are K wire fixation, Austin Moore pins, Knowles pins, Rockwood pin, Intramedullary screw fixation, Steinman pins, External fixator, TENS, Plate and screw.
Materials and methods:The study was conducted in Department of Orthopedics, M.L.B. Medical College and Hospital, Jhansi (U.P.) between December 2014 to June 2016.On 62 cases of displaced fracture midshaft clavicle which were treated by two different modalities of internal fixation. I.e. TENS (n=31) or plate and screws (n=31).

Inclusion Criteria: (a) Age between 16 years to 60years(b) Within 2 weeks of fracture clavicle( c) Displaced fracture of Mid shaft clavicle(d) Shortening > 2 cm(e) Segmental fractures(f)Bilateral clavicle fracture( g) Clavicular fracture associated with other injuries(h) Grade I and II compound fractures.
Exclusion Criteria: (a)Preexisting pathology in shoulderor elbow or both ((b) Scapular malposition and winging on initial examination (c) Floating shoulder (d) Patient who do not give Consent (e) Grade III compound fractures. Patients were clinically examined; first aid was given in the form of, cuff and color sling, analgesics, antacids and was subjected to A-P view, Lardotic view radiograph of full length clavicle to decide the plan of definitive management. If needed CT scan and MRI were also taken. Those requiring  surgery were classified as per Allman classification and investigated for fitness for anesthesia and surgery. The relevant data were recorded in the working proforma. Selected patients were randomly divided in Group I and Group II. Patients of group I were treated by closed/ open reduction &internal fixation by TENS and Group II by open reduction& internal fixation by plate& screws. Patients were followed periodically at 2weeks, 6 weeks, 3, 6 and 12 months. Results were evaluated by Constant scoring system given by Murley (1987) [4,5]

Operative procedure: (a) TENS fixation:-INSTRUMENTS REQUIRED FOR NAILING(a)Set of Titanium elastic nails (1.5 mm, 2 mm,2.5 mm), (b)Awl, (c) Impactor, (d) T- handle.
Procedure
Patients will be placed in supine position on OT table after General Anesthesia. Scrubbing, painting and  draping was done. The insertion point is made approximately 1 cm lateral to the sternoclavicular joint. A one centimeter vertical skin incision is made and a hole is made in the anterior cortex with the help of awl then an TEN inserted (diameter of nail depending on the width of the medullary canal) in the medullary canal of the clavicle with T-handle. With oscillating movements the nail is advanced until it reaches the fracture site. If closed reduction is unsuccessful, an additional skin incision is needed at the level of the fracture site for open reduction of the fragments. Although the clavicle is S shaped, the tip of the TENS is curved which helps the surgeon to pass the elastic nail into distal fragment. After adequate engagement of the distal fragment, the medial end of nail shortened and skin closed over it. The procedure is performed under fluoroscopic guidance. Postoperatively, patients will begiven a arm shoulder pouch, but were encouraged for early shoulder mobilization, starting with ROM exercises from the second day. All patients will review at 2 and 6 weeks, 3, 6, and 12 months after surgery. At each visit, patients will be assesses clinically and radiograph was taken and Functional outcome was assessed by the Constant score of Murlley.

(b) Plate fixation- INSTRUMENTS REQUIRED FOR PLATING (a)Locking Recon Plate/locking anatomical plate (b) Non locking Recon plates (c) Sleeves (d) Drill bit 2.7mm,2.5mm, 3.5mm (e) Tap (f) Depth gauge (f) Locking screw 3.5 mm(g) Cortical screw 3.5 mm (g) Screw drive
Procedure
Patient placed supine/ beach chair position after giving general Anesthesia on OT table, place a sand bag between the medial border of the scapula and the spine.Incision was made transversely just under the fracture site.Supra clavicular nerves will be identified and spared wherever possible.After reduction of fractures, an appropriate size of locking plate was fixed on the antero-superior surface of the bone by appropriate size screw. After reduction recon locking plate was fixed. In oblique or complex fractures,inter fragmentary lag screws were used to achieve compression. The fascia and skin were closed in layers. Pre-op x-ray  Pre-op x-ray  Immediate post-op 3 months post op  12 months post-op Fig. (c) Plate group case 1 Pre op x-ray  Immediate post op 6 months post op  12 months post opFig. (d) Plate group case 2Data extraction and analysis
Included studies were summarised in a data-extraction form, including the following items: type of study, surgery (type of plate fixation or specified method of intramedullary fixation), descriptive data (sample size, missing data, and follow-up), patient characteristics, functional outcome, operation characteristics (amount of blood loss and duration of the surgery) and complications. Functional outcome was defined as shoulder function with the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. The DASH questionnaire is a self administered outcome instrument developed as a measure of self-rated upper extremity disability and symptoms. The Constant score includes an analysis of pain, shoulder motion, strength, and function.Shoulder function was evaluated according to the Constant score, (100-point scoring systems). These scoring systems combine assessments of subjective symptoms and objective findings. In the Constant scoring system[4,5], the overall grading is excellent if the total score ranges from 90 to 100, good for 80–89, fair for 70–79, and poor if the scores are 69 or less (or Difference betweennormal and abnormal side, <11 excellent, 11-20 good, 21-30 fair, >30Poor).Complications were recorded and compared between both groups. Non-union was defined as an unsuccessful healing of the bone after 9 months, clinically manifesting as pain at the fracture site and radiologically as a visible gap between the fracture parts. Deep infection was defined as infection requiring implant removal. Refracture was defined as a fracture of the clavicle within 3 months of implant removal without any history of retrauma.Student’s t-test was used to analyze the difference of means for different parameters. Mean, standard deviation and standard error of mean for the variables were also calculated. The test was referenced for a two-tailed p value, and a 95 % confidence interval was constructed around a sensitivity proportion using a normal approximation method. Statistical analyses were performed using SPSS software. A value of <0.05 was considered statistically significant.
Results: In this study, from December 2014 to June 2016, 62 patients with displaced midshaft clavicle fractures were included as per inclusion criteria and underwent surgical fixation.In the TENS group, closed fracture reduction and internal fixation was done in 27 cases (87.09 %), and open reduction was required in the remaining 4 patients (12.90 %). There was less operative time, less blood loss and lesser length of hospital stay in TENS group.

Table1: OPEN/CLOSED REDUCTION INTERNAL FIXATION

The bone union time was shorter in the TENS group as compare to plating group. Three cases in the plate group and fivecases in the TENSGroup developed superficial infection. But infection was controlled by oral antibiotics in all eight cases. There was two cases in plate group develop deep infection one subsided by i/v antibiotics other need wound wash, but infection was completely controlled. Nonunion occurred in two cases in each groups. No implant failure occurred in both the groups. In plate group three patients having ugly scar after healing. Implant protuberance seen in two patients of plating group. Pin migration seen in two patients of TENS group.

Table2: Comparison of complications of both groups 

Constant score of Murley [4,5] were assessed at every follow-up visit and the 2-month postoperative follow-up visit showed significantly higher Constant scores of 71.35 ± 8.22 in the plating group than in the TENS group (67.03 ± 8.14) (p = 0.01). The final scores at the 12-month follow-up visit showed no significant difference between two groups, as shown in Table -3 (p > 0.05)

Table 3:Final Functional Assessment:


Discussion

The best treatment strategy for displaced midshaft clavicle fractures remains a topic of debate. Conservative management of these fractures results in an approximately 15-20 % nonunion rate [16]. While non-operative management remains the mainstay of treatment for most midshaft clavicle fractures, the indications for surgery may be expanding. Recent studies have showed a poorer outcome in cases of displaced midshaft clavicle fractures that were treated non-operatively [9,49,50] in comparison to surgically treated patients. Initially these fractures were managed conservatively which did not involves the reduction of fracture and is unable to hold the fracture reduced hence the end results was malunion /nonunion/shortening &deformation, which decreases the functional capability of affected upper limb, disfigurement and poor cosmoses [7,8,910]. To overcome above disadvantages of conservative treatment and increasing awareness & demand, by patient’s surgeons considered operative management of these fractures, which involved closed/open reduction of these fractures and internal fixation. Conservative treatment is indicated only in, undisplaced fractures or less demanding patients. Three types of fixation are available for middle-third clavicle fractures: intramedullary devices, plates, and external fixators. Intramedullary fixation can be done by smooth or threaded K- wires[3], Steinman pins, Knowles pins, Hagie pins, Rush pins or cannulated screws [51,52]. Plate fixation can be done with a 3.5-mm dynamic compression plate (DCP), low-contact dynamic compression plates, reconstruction plates or locking compression plates with at least three screws (six cortices) in both the medial and lateral fragment each, and an interfragmentary lag screw whenever the fracture pattern allow it. Plating of displaced mid shaft clavicle fractures is advocated as the preferred fixation method by many authors [4,31]. Biomechanically, plate fixation is superior to intramedullary fixation because it better resists the bending and torsional forces that occur during elevation of the upper extremity above shoulder level [36]. Patients treated with plate fixation can be allowed full range of motion once their soft tissues have healed. Disadvantages of plate fixation include the necessity for increased exposure and soft tissue stripping, increased risk of damage to the supraclavicular nerve, slightly higher infection rates, and the risk of refracture after plate removal [19].open reduction and internal fixation with a 3.5-mm dynamic compression plate  is the standard method in comminuted fracture midshaft clavicle which maintained lenth of clavicle better as compared to TENS fixation, so plate and screw fixation is better implant of choicein comminuted fracture clavicle. In segmental fracture TENS is the treatment of choice.In this study, both methods of fixation were compared in terms of outcomes and complications. Early callus formation and faster healing of fracture was observed in TENS group which were treated by closed or limited exposure technique and fixation of fracture by percutaneous method as compare to plate group where open reduction internal fixation was done. Similar observation about faster healing and union in patients treated by intramedullary nail as compare to plate has also been reported by Wu CC et al 1998 [29], Mueller et al 2008 [34], Hartmann et al (2008) [35] and Liu et al (2010) [38] independently. Some other workers Thyagarajan et al (2009) [25],Shishir et al (2014) [40],Mishra et al(2014) [42],Gao et al(2016) [48],Kadakia(2016) [44],Jain et al(2016) independently reported similar observations of faster union.Fewer complication encountered were superficial infection, deep infection, ugly scar, implant protuberance, pin migration, nonunion. Superficial infection occurred in 5 cases of group I (TENS) at the entry point whereas 3 patients had superficial infection and two patients had deep infection  at site of incision in plating group (group II).None of the cases treated by TENS had any evidence of deep infection at fracture site.Clavicle is the percutaneous bone without muscle coverage hence two patients had protuberance of plate and 3 patients had ugly scar in patients treated with plate whereas  2 patients had pin migration in TENS group. Incidence of nonunion was same in each group.Zeng et al (2015) [43] observed that plate fixation can provide more rigid stabilization than intramedullary pin fixation and may facilitate early mobilization and offer a superior construct for highly comminuted fractures where the bridge plating technique can be implemented. However, this technique may require large incisions and extensive exposure and soft tissue insult which could cause complications such as infection, scarring, and refracture after the removal of the plate. Intramedullary fixation provides an alternative and less invasive technique for the treatment of displaced midshaft clavicular fractures. It has the advantages of obtaining relatively stable fixation that allows axial compression, and preserving the soft tissue envelope, the periosteum and the vascular integrity of the fracture site, which enhances healing. Chen et al observed that TENS fixation allows for earlier relief of shoulder pain and a more cosmetically satisfactory appearance than plate fixation. In addition, the infection rates may be decreased and fracture callus formation enhanced. However, the main complications of intramedullary fixation are superficial infection, hardware migration, skin irritation. In our study complications are more in plating group as compare to TENS group, which is in accordance of available literature, Kadakia et al (2012) [44], Zeng et al (2015) [43], Sharma et al (2016) Y gao et al (2016) [48].Shorter operative time, shorter hospital stay and shorter time of union in patients treated by close reduction internal fixation by TENS as compared to patients treated with open reduction internal fixation by plate and screws has also been observed independently by Wu CC et al(1998) [29], Mueller et al (2008) [34],Hartman et al(2008)[35].At final evaluation the overall result were evaluated using the constant scoring system of Murley. In group II (plate) 29 patients scored less than 11 point as per constant scoring system of Murley and were graded as excellent, 2 patients scored between  11-20 and were graded as good. Whereas 29 excellent, 1 good and 1 poor in TENS group.Though there was early callus formation and faster healing in patients treated by intramedullary fixation but at 1 year post-operative treatment constant score in two group was not significantly different. In our study, functional shoulder scores were significantly higher for the plating group than the TENS group inthe first 2 weeks, but at the 12-month follow-up visit,there was no significant difference observed between the two groups in terms of shoulder scores.


Conclusion

The primary limitation of our study was that it was a small prospective comparative study including a small number of patients and done at a single center. Larger randomized controlled trials are needed to further evaluate outcomes and complications of  plates and TENS in displaced midshaft clavicle fractures. Still, we can conclude from our study that both  plating group and TENS group are equally effective alternatives for surgical fixation of displaced midshaft clavicular fractures. TENS group  have advantages like less soft tissue injury, shorter operating time and hospital stay, less blood loss, more cosmetic satisfaction and minor surgery needed to remove the implant. TENS is a safe, minimally invasive surgical technique with a lower complication rate, faster return to daily activities, excellent cosmetic and comparable functional results, which can be regard as an alternative to plate fixation of displaced midshaft clavicular fractures.


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How to Cite this Article: Gupta P, Vishwakarma AK, Gupta DK, Agarwal S, Singh N. Comparative Evaluation of Results after Internal Fixation of Fracture Clavicle by Titanium Elastic Nailing System/Plate. Journal of Bone and Joint Diseases July-Sep 2017;32(2):10-16.

 


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Ultrasonographic Evaluation of Achilles Tendon Healing after Percutaneous Tenotomy for the Correction of Congenital Clubfoot by Ponseti Method

Vol 32 | Issue 2 | July – Sep 2017 | page: 5-9 | Saurabh Agarwal, Ashutosh Kumar


Authors: Saurabh Agarwal [1], Ashutosh Kumar [1]

[1]Department of Orthopaedics, M.L.B. Medical College, Jhansi, Uttar Pradesh, India.

Address of Correspondence
Dr. Ashutosh Kumar,
Room No 60, Senior Boys Hostel
M.L.B. Medical College,
Jhansi-284128


Abstract

The Study is attempt to establish the regulation of Achilis tendon after percoetaneous tenotomy in idiopathic clubfoot patient as per ponsenti method of correction clinically and evaluation by ultrasound.The prospective study was conduct on 21 patients with idiopathic clubfoot deformity admitted in orthopaedic department of M.L.B. Medical College, Jhansi (UP) with reference to age and sex for the period from Aug 2014 to Aug 2016 babies with neurological condition, syndromic condition, recurrent and complex clubfoot case are excluded from the study. Detailed personal history was
recorded including age, sex, father and mother name, address and number of cast applied etc. A mean retraction of 2.26 mm (range 2.3 to11.0 mm) between tendon stump after tenotomy was observe using ultrasound and in each foot clinical evidence of successful tenotomy was taken as a definitive increase in dorsiflexion at the ankle and lack of a palpabale heel cord. Full leg corrective cast was applied for 3 week after 3 week ultrasound showed tendon healing with the tendon gape filled with irregular hypoechoic tissue and along with transmission of muscle motion to the heel. At 6 month after tenotomy there was structural filling a fibrillar aspect, mild or moderate hypo. Echogenicity and tendon scar thickening when compared with a normal tendon. 1 year after tenotomy USG showed a fibrillar structure and echogenicity at the repair site that was similar to a normal tendon
but with persistent tendon scaring thickness. There is fast reparative process after Achilles tendon percutanous section after reestablishing conducting between stumps. The reparative tissue evolved to tendon tissue with a normal USG appearance except for mild thickening suggesting a predominating intrinsic repair mechanism.
Keywords : Clubfoot, Achilles tendon healing, Ultrasonography.


Introduction

Idiopathic congenital talipes equinovarus is a common condition affecting between 1 per 1,000 live births2,5,8. The Ponseti technique is well recognised in the management of clubfoot deformity with high success rates. This technique has decreased the need for extensive corrective surgery. Following the serial application of casts as per Ponseti’s original descriptions, a percutaneous Achilles tenotomy is undertaken to enable or improve foot dorsiflexion. The natural history of healing of the tenotomised tendon is not well understood. Several studies have claimed ultrasound to be useful and accurate in assessing the healing phase. In previous studies3,4, the reported length of time for tendons to achieve continuity based on ultrasound images and clinical assessment varied between six weeks to 45 months. We monitored the post-tenotomy healing process using high frequency ultrasound to understand the appearances of the healing tendon and the timescale over which the tenotomy healed. We also studied patients that had undergone an Achilles tenotomy several years previously to ascertain the longer-term effect of the Ponseti treatment. Ponseti recommends the use of a beaver eye blade scalpel to divide the tendon. This procedure is considered safe, although excessive bleeding and pseudoaneurysm formation have been reported1.  We carried out percutaneous tenotomy to correct equinus in patients treated with the Ponseti technique, and found that after 6 months, all cases showed clinical and ultrasonographic connections between the divided stumps in less than 1 year of age. Ultrasonography is reliable and reproducible in evaluating tendons following Achilles tenotomy (Ponseti method) for congenital clubfeet2,7. It can be used for assessment of tendon regeneration, quantitative measurement of tendon thickness and length of reparative tissue. We measured the size of the Achilles tendons in congenital clubfeet using ultrasonography before and after percutaneous tenotomy.  Material and Methods: The aim of the present investigation was to prospectively assess and characterize the Achilles tendon healing using ultrasonographic scanning after percutaneous tenotomy in patients with congenital clubfoot treated with the Ponseti technique in the department of Orthopaedics, MLB Medical College, Jhansi. Approval was obtained from our local ethical committee and inform consent from the parents of each patients was obtain. Inclusion Criteria: 1. Children with idiopathic congenital clubfoot treated with the Ponseti method who have undergone percutaneous Achilles tenotomy to correct  the residual equinus; 2. The primary and follow-up treatment have both been performed in our institution; and 3. Minimum follow-up of 1 year. Exclusion Criteria: 1.Associated malformations 2. Syndromic cases 3. Neurologic sequelae or parental noncompliance.  INTRODUCTION: Idiopathic congenital talipes equinovarus is a common condition affecting between 1 per 1,000 live births2,5,8. The Ponseti technique is well recognised in the management of clubfoot deformity with high success rates. This technique has decreased the need for extensive corrective surgery. Following the serial application of casts as per Ponseti’s original descriptions, a percutaneous Achilles tenotomy is undertaken to enable or improve foot dorsiflexion. The natural history of healing of the tenotomised tendon is not well understood. Several studies have claimed ultrasound to be useful and accurate in assessing the healing phase. In previous studies3,4, the reported length of time for tendons to achieve continuity based on ultrasound images and clinical assessment varied between six weeks to 45 months. We monitored the post-tenotomy healing process using high frequency ultrasound to understand the appearances of the healing tendon and the timescale over which the tenotomy healed. We also studied patients that had undergone an Achilles tenotomy several years previously to ascertain the longer-term effect of the Ponseti treatment. Ponseti recommends the use of a beaver eye blade scalpel to divide the tendon. This procedure is considered safe, although excessive bleeding and pseudoaneurysm formation have been reported1.  We carried out percutaneous tenotomy to correct equinus in patients treated with the Ponseti technique, and found that after 6 months, all cases showed clinical and ultrasonographic connections between the divided stumps in less than 1 year of age. Ultrasonography is reliable and reproducible in evaluating tendons following Achilles tenotomy (Ponseti method) for congenital clubfeet2,7. It can be used for assessment of tendon regeneration, quantitative measurement of tendon thickness and length of reparative tissue. We measured the size of the Achilles tendons in congenital clubfeet using ultrasonography before and after percutaneous tenotomy.

Material and Methods

The aim of the present investigation was to prospectively assess and characterize the Achilles tendon healing using ultrasonographic scanning after percutaneous tenotomy in patients with congenital clubfoot treated with the Ponseti technique in the department of Orthopaedics, MLB Medical College, Jhansi. Approval was obtained from our local ethical committee and inform consent from the parents of each patients was obtain.


Inclusion Criteria: 1. Children with idiopathic congenital clubfoot treated with the Ponseti method who have undergone percutaneous Achilles tenotomy to correct  the residual equinus; 2. The primary and follow-up treatment have both been performed in our institution; and 3. Minimum follow-up of 1 year.
Exclusion Criteria: 1.Associated malformations 2. Syndromic cases 3. Neurologic sequelae or parental noncompliance.
Material Used Figure 1: Soft cotton and plaster roles Figure
2: Tenotomy kit – # 15 blade with handle,     xylocaine, syringe
Patients were placed in a prone position and the feet were dorsiflexed to maximum to make the Achilles tendon taut. Achilles tendons of both feet were scanned approximately 1 cm above the calcaneal insertion. In patients with unilateral clubfoot, the normal foot was used as a referent. Longitudinal scans assessed the echotexture, echogenicity, and continuity of the tendon. Transverse scans assessed the shape, echotexture, echogenicity, thickness, and width of the tendon. The medial aspect of the Achilles tendon was incised under general anaesthesia. The extent of tenotomy was assessed by a ‘pop’ sound and giving way, correction of equinus, and appearance of a palpable gap in the tendon. Postoperatively, a cast was applied for 3 weeks, with the foot in abduction and maximum dorsiflexion. The cast was then replaced with foot abduction braces. Ultrasound scan was done on third week, 6months and one year followed tenotomy

Results

Between august 2014 and august 2016, 21 patients fulfilled the inclusion criteria, with 30 feet. Mean age at tenotomy was 16.7 weeks, ranging from 6.3 to 40.5 weeks. The mean thickness of the affected Achilles tendon before tenotomy was 2.52mm, ranging from 1.70 to 4.20mm. In patients with unilateral deformities, the normal tendon mean thickness in the non-affected foot was 2.50mm (SD=0.43), ranging from 2.00 to 3.60mm. There was no evidence of difference between normal and affected tendons in ultrasonographic appearance figure 3 and thickness before the tenotomy (P=0.45). Results: Between august 2014 and august 2016, 21 patients fulfilled the inclusion criteria, with 30 feet. Mean age at tenotomy was 16.7 weeks, ranging from 6.3 to 40.5 weeks. The mean thickness of the affected Achilles tendon before tenotomy was 2.52mm, ranging from 1.70 to 4.20mm. In patients with unilateral deformities, the normal tendon mean thickness in the non-affected foot was 2.50mm (SD=0.43), ranging from 2.00 to 3.60mm. There was no evidence of difference between normal and affected tendons in ultrasonographic appearance figure 3 and thickness before the tenotomy (P=0.45). Figure 3: Ultrasound scan before tenotomy it shows homegenosly echoic fibrillar structures arrow.

A. Osseous Portion of Calcaneum , B. Tibia. Ultrasound performed immediately after tenotomy[Figure 4]  showed a hypoechoic area between stumps separated by a mean distance of 5.65mm (range: 2.3 to 11.0mm; . Initially the gap had a hyperechoic image with reverberating echotexture represented by air penetration, and immediately afterwards, the image became hypoechoic due to the hematoma formation. However, the residual connections between stumps persisted in some cases, and these cases required division under ultrasound guidance.

Figure 4: Achilies tendon longitudinal image just after tenotomy showing stump retraction is initially filled by air and soon replace by hematoma. There was 1 case of unusual bleeding, which was controlled by digital pressure, and this did not compromise foot perfusion or interfere with the treatment. Three weeks after tenotomy,[Figure 5] the ultrasound scans showed that the tendinous gap was filled with hypoechoic, disorganized repair tissue, with a loss of the fibrillar architecture, ill-defined margins, and scarring with varied characteristics. Figure 5: Achilles tendon longitudinal image 3 week after tenotomy The tenotomy space is filled with hypoechoic tissue displaying disorganized fibrillar pattern.Six months after the tenotomy[Figure 6], a well-formed tendinous structure could be observed, with a fibrillar appearance similar to normal tendon, but with slight or moderate hypoechogenicity and focal tendon thickening at the tenotomy site.   Figure 6: Achilles tendon longitudinal image 6 month after tenotomy. Tendon tissue regeneration occurred with fibirllar pattern near normal echogenicity. One year after tenotomy[Figure 7], focal tendon thickening persisted in the repaired area, although the fibrillar pattern and echogenicity were similar to those of normal tendons . The mean thickness in operated tendons at this time was 4.03mm.   Figure 7: Achilles tendon longitudinal image 1 year after tenotomy.Echotexture similar to a normal tendon with slight thickening at the tenotomy site.

Discussion

Healing of the tendon has classically been described as involving extrinsic or intrinsic factors or a combination of the two. Recent studies2-7 has suggested that embryonic mechanism may responsible for healing in the adult tendon. Thus the rapid healing in infants aged one to two months in whom progenitor cell are abundant, could involve the same mechanism.

Ultrasound tendon examination is accepted as a reliable method for routine tendon assessment providing tendon measurement, morphology and texture, ultrasound scan of 6 months shows maturation of healing tissue evidenced by an increasingly normal echogenicity and a fibrillar aspect of the parallel linear echotexture leading to conclude as predominantly intrinsic mechanism is responsible for the formation of a normal or near normal tendon2-7. Ultrasonography is a non invasive and dynamic tool for assessing prenatal clubfoot, severity of clubfoot, correction using single and different methods and Achilles tendon regeneration. Ponseti recommended tenotomy in patients up to 1 year age although we extend this age limit for revision in resistant cases it is possible that the prolonged healing seen in children older than one and half year of age a similar to that seen in adults in whom the gap in the Achilles heals with fibrous tissue rather than tendon fiber. We conclude that healing in percutaneous Achilles tenotomy follows sequential phases similar to those described in healing of tendons in a previous studies6,7. We should be cautious about performing Achilles tenotomies for clubfeet in children over the age of one and half year as such patients appear to have slower healing with an added potential risk of adhesion formation.


References

1. Dobbs MB, Gordon JE, Walton T et al. Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of clubfoot deformity. J Pediatr Orthop 2004: 24: 353-357.
2. Barker SL, Lavy CB, Correlation of clinical and ultrasonographic findings after Achilles tenotomy in idiopathic clubfoot. J Bone Joint Surg Br. 2006: 88: 377-379.
3. Govind Kumar Gupta, Sudha Rani, Chinmany Sahu and SB Singh : Redevelop of Achilles tendon after percutaneous tenotomy in idiopathic clubfoot patients as per ponseti’s method of orrection clinical and using two needle. International Journal of Recent Scientific Research, Aug 2015,Vol 6, Issue 8, : 5665-5671
4. S. Marleix, M. Chapuis, B. Fraisse, C. Tréguier, P. Darnault, C. Rozel, M. Rayar, P. Violas : Idiopathic club foot treated with the Ponseti method. Clinical and sonographic evaluation of Achilles tendon tenotomy. A review of 221 club feet. Orthopaedics & Traumatology: Surgery & Research, Volume 98, Issue 4, Pages S73-S76.
5. Saini R,Dhillon MS, Tripathy SK, Goyal T, Sudesh P, Gill SS, Gulati A. Regeneration of the Achilles tendon after percutaneous tenotomy in infants: a clinical and MRI study. Journal of pediatric orthopedics. Part B 19:4 2010 Jul pg 344-7.
6. Mangat KS,Kanwar R, Johnson K, Korah G, Prem H. Ultrasonographic phases in gap healing following Ponseti-type Achilles tenotomy. The Journal of bone and joint surgery. American volume 92:6 2010 Jun pg 1462-7.
7. Agarwal A, Qureshi NA, Kumar P, Garg A, Gupta N. Ultrasonographic evaluation of Achilles tendons in clubfeet before and after percutaneous tenotomy. Journal of orthopaedic surgery (Hong Kong) 20:1 2012 Apr pg 71-4.
8. Ponseti IV. Congenital club foot: fundamentals of treatment. New York, NY: Oxford University Press; 1996:82–84.


How to Cite this Article: Agarwal S, Kumar A. Ultrasonographic Evaluation of Achilles Tendon Healing after Percutaneous Tenotomy for the Correction of Congenital Clubfoot by Ponseti Method. Journal of Bone and Joint Diseases Jul-Sep 2017;32(2):5-9.

 


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