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New Delhi | London | Philadelphia | Panama
The Health Sciences Publisher
Editors
GS Kulkarni ms ms (Ortho) Frcs Fics
director, professor and headpostgraduate institute ofswasthiyog pratishthan
miraj, maharashtra, india
directorsandhata medical research society
miraj, maharashtra, india
Sushrut Babhulkar ms (Ortho) mch (Orth) Liverpool, uK
director sushrut hospital
research centre and postgraduate institute of Orthopedics nagpur, maharashtra, india
secretary Trauma society of india
chief centre for Joint reconstruction and Trauma surgery
Under the Aegis of Indian Orthopedic Association
Textbook of OrThOpedics and Trauma
Third Edition
Volume 1
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HeadquartersJaypee Brothers Medical Publishers (P) Ltd.4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314E-mail: [email protected]
Jaypee Brothers Medical Publishers (P) Ltd.
Inquiries for bulk sales may be solicited at: [email protected]
Textbook of Orthopedics and Trauma (4 Volumes)
First Edition: 1999Second Edition: 2008Third Edition: 2016
ISBN: 978-93-85891-05-2
Printed at
Overseas OfficesJ.P. Medical Ltd.83, Victoria Street, LondonSW1H 0HW (UK)Phone: +44-20 3170 8910Fax: +44(0) 20 3008 6180E-mail: [email protected]
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Website: www.jaypeebrothers.comWebsite: www.jaypeedigital.com
© 2016, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers.All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.Ja
ypee
Brot
hers
Dedicated toMy wife Shashikala
and Children Milind, Sunil, Rajiv, Vedavati, Ruta and Vidisha, Sujay and Madhura
for their untiring help
— GS Kulkarni
My father Professor Dr Sudhir Babhulkar, who inculcated in me the art of Orthopedics,
My mother Aruna who created the passionate me, my loving wife, Dr Nandini, and
lovely daughters Sanskriti and Siddhi
for sparing me for Orthopedic Academics
— Sushrut Babhulkar
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contributors
AA Kulkarni dental clinic Bijapur, Karnataka, india
A Devendra associate consultant (Orthopedics and Trauma surgery) Ganga hospital coimbatore, Tamil nadu, india
Aashish Gulati specialist registrar Trauma and Orthopedics east midlands south rotation, uK honorary research Fellow nuffield department of Orthopaedics rheumatology and musculoskeletal sciences (ndOrms), university of Oxford, uK
Abhay Nene consultant spine surgeon Wockhardt hospital pd hinduja hospital and medical research center mumbai, maharashtra, india
Abhinav Agarwal senior resident department of Orthopedics all india institute of medical sciences (aiims) new delhi, india
Abhishek Kulkarni rainbow superspecialty hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
Abhishek Srivastava senior spine Fellowship (uK, singapore) consultant spine surgeon department of spine surgery primus superspecialty hospital new delhi, india
Achut Rao professor in Orthopedics postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
Aditya Kaushik honorary consultant hand and reconstructive microsurgeon nanavati superspecialty hospital mumbai, maharashtra, india
Aditya menon Bombay Orthopedic research Fellow mumbai, maharashtra, india
Aditya N Aggarwaldepartment of Orthopedicsuniversity college of medical sciences and Guru Teg Bahadur (GTB) hospitalnew delhi, india
Aditya Pawaskar assistant professor Lokmanya Tilak municipal medical college mumbai, maharashtra, india
Aditya Prasad Panda association of spine surgeons of india (assi) spine Fellow department of Orthopedics apollo hospitals chennai, Tamil nadu, india
Ajay Chandanwale dean and professor BJ medical college and sassoon General hospital pune, maharashtra, india
Ajay Puri chief (Orthopedic Oncology) professor and head (surgical Oncology)Tata memorial center and homi Bhabha national institutemumbai, maharashtra, india
Ajay Singh Thakur department of Orthopedics
Ajoy Prasad Shetty senior consultant spine surgeon division of Orthopedics Trauma and spine surgery Ganga hospital coimbatore, Tamil nadu, india
AK Jain professor and head department of Orthopedics university college of medical sciences (ucms) and Guru Teg Bahadur (GTB) hospital new delhi, india Visiting professor The Tamil nadu dr mGr medical university chennai, Tamil nadu, india
Alaric Aroojis pediatric Orthopaedic surgeon Kokilaben dhirubhai ambani hospital mumbai, maharashtra, india
Alex Sonaru northwestern university department of Orthopedic surgery chicago, illinois, usa
Aman Dua Orthopedic, Joint replacement sugeon consultant Joint replacement surgeon and Orthopedic surgeon primus superspecialty hospital new delhi, india
Amish Sanghvi consultant and head department of spine surgery sterling hospitals rajkot, Gujarat, india
Amit Chanduka associate consultant department of neurosciences sakra World hospital, Bengaluru, Karnataka, india
Amit Jhala consultant spine surgeon director and head department of spine surgery chirayu hospital and hcG hospitals ahmedabad, Gujarat, india
Amit Narayan assi spine Fellowship spine Fellow indian spinal injuries center, new delhi, india
Amit Nath mishra chief of Orthopedic surgery max hospital noida and Greater noida, uttar pradesh, india
Amit Singla senior resident department of Orthopedics all india institute of medical sciences (aiims) new delhi, india
Amol Patil sushrut hospital research centre and postgraduate institute of Orthopedics ramdaspeth, nagpur, maharashtra, india
Amol Tambe assistant professor and consultant upper Limb surgeon upper Limb clinical specialist physiotherapist The derby shoulder unit department of Trauma and Orthopaedic surgery royal derby hospital derby Teaching hospitals nhs Foundation Trust, uK
Anagha Vaze consultant psychiatrist institute for psychological health Thane, maharashtra, india
Anand J Thakur consultant Orthopedic surgeon pd hinduja hospital and medical research center mumbai, maharashtra, india
Anant Joshi e-52, Lokmanya nagar Th Kataria marg mahim mumbai, maharashtra, india
Anil Agarwal department of Orthopedics school of medical sciences and research sharda university Greater noida, uttar pradesh, india
Anil Arora department of Orthopedics school of medical sciences and research sharda university Greater noida, uttar pradesh, india
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Anil Bhat professor and head unit of hand and microsurgery department of Orthopedics Kasturba medical college manipal, Karnataka, india
Anil Bhatia academic head plastic surgery Bombay hospital, mumbai, india consultant plastic surgeon Bai Jerbai Wadia hospital for children mumbai, maharashtra, india
Anirban Chatterji rainbow superspecialty hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
Ankit Varshneya postgraduate institute of swasthiyog pratishthan miraj, maharashtra, india
Ankur Nanda Fellowship in deformity and degenerative spine surgery spine consultant indian spinal injuries center new delhi, india
Ankush Varshneya postgraduate institute of swasthiyog pratishthan Fracture and Orthopedic hospital miraj, maharashtra, india
Anoop Jhurani consultant department of Orthopedics Fortis hospital Jaipur, rajasthan, india
Aravind Kumar consultant spine surgeon Khoo Teck puat hospital singapore
Archi Agarwal associate professor department of nuclear medicine and molecular imaging Tata memorial hospital mumbai, maharashtra, india
Areena D’Souza spine Fellow indian spinal injuries center new delhi, india
Arun mullaji Joint replacement surgeon Breach candy hospital and Lilavati hospital mumbai, maharashtra, india
Arun Pal Singh professor of Orthopedics Bharati Vidyapeeth deemed university medical college and hospital sangli, maharashtra, india
Arjun Veigus inlaks and Budhrani hospital pune, maharashtra, india
Arvind Bhave professor of Orthopedics Bharati Vidyapeeth medical college pune spine surgeon deenanath mangeshkar hospital pune, maharashtra, india
Arvind Kulkarni consultant spine surgeon, mumbai spine scoliosis and disc replacement centre Bombay hospital, mumbai mumbai, maharashtra, india
AS Rao pediatric Orthopedic surgeon
Ashish Babhulkar head department of shoulder and sports injuries deenanath mangeshkar hospital sancheti institute of Orthopedics for rehabilitation pune, maharashtra, india
Ashish Gulati specialist registrar Trauma and Orthopedics east midlands south rotation, uK honorary research Fellow ndOrms, university of Oxford, uK
Ashish Gulia associate professor Orthopedic Oncology department of surgical Oncology secretary, BsT-dmG Tata memorial hospital mumbai, maharashtra, india
Ashish Shah assistant professor Orthopedic Foot and ankle surgery university of alabama Birmingham, aL, usa
Ashok K Shyam director The arthritis clinic, mumbai sancheti institute for Orthopedics and rehabilitation, pune chief researcher and head indian Orthopedic research Group Thane, maharashtra, india Founding Trustee indian Orthopedics research society editor, Journal of Orthopaedic case reports
Ashok Rajgopal chairman, medanta Bone and Joint institute medanta—The medicity Gurgaon, haryana, india
Ashwath Acharya associate professor unit of hand and microsurgery department of Orthopedics Kasturba medical college manipal, Karnataka, india
Attique Vasdev associate director Knee division medanta Bone and Joint institute medanta—The medicity, Gurgaon, haryana india
Atul Bhaskar Fellowship Training in pediatric Orthopedic (sickkids—Toronto) pediatric Orthopedic surgeon Bombay hospital institute of medical sciences rn cooper hospital mumbai, maharashtra, india
AV Gurava Reddy consultant Joint replacement surgeon hyderabad, Telangana, india
B mohapatra post doctral Fellowship in spine surgery sydney, australia consultant spine surgeon indian spinal injuries center, new delhi, india
Baldev Dudani head department of Orthopedics ruby hall clinic pune, maharashtra, india
Bassam A masri clinical assistant professor and head division of reconstructive Orthopedics university of British columbia Vancouver, Bc, canada
BB Joshi consultant in hand surgery and reconstructive surgery Jess research and development centre mumbai, maharashtra, india
BB Kanaji Jess research and development centre mumbai, maharashtra, india
BD Pujari shree hospital, extension area miraj, maharashtra, india
Bharath R associate consultant department of neurosciences sakra World hospital Varthur, hobli, Bengaluru, Karnataka, india
Bharat R Dave spine surgeon stavya spine hospital and research institute ahmedabad, Gujarat, india
Bhaskar Borgohain associate professor north eastern indira regional institute of health and medical sciences neigrihms shillong, meghalaya, india
Bhaskarananda Kumar Former professor unit of hand and microsurgery department of Orthopedics Kasturba medical college manipal, Karnataka, india
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Bhavin Jankharia consultant radiologist piramal diagnostics—Jankharia imaging mumbai, maharashtra, india
Bhavuk Garg assistant professor (Orthopedics) editor-in-chief, iJri all india institute of medical sciences new delhi, india program chair Texilla american university, south america Former consultant, postgraduate institute of medical education and research (pGimer) chandigarh, india Fellow in arthroplasty (J and J) Fellow in Trauma and Orthopedic surgery (Germany) robert roaf Fellow, assi spine Fellow, dartmouth spine Fellow (usa) srs spine clinical Fellow (usa) aadO Trauma Fellow (hong Kong) Former senior research associate (csir, icmr)
Bidre upendra consultant spine surgeon Jain institute of spine care and research (Jisar) Bhagwan mahaveer Jain hospital Bengaluru, Karnataka, india
Binu P Thomas professor and head paul Brand centre for hand surgery christian medical college and hospital Vellore, Tamil nadu, india
Bm Diwanmal postgraduate institute of swasthiyog pratishthan miraj, maharashtra, india
BS Diwanconsultant Orthopedicsdiwan hospitalsangli, maharashtra, india
Chasnal Rathod pediatric Orthopedic Fellowship (Korea) pediatric Orthopedic surgeon cerebral palsy clinic Jupiter hospital mumbai, maharashtra, india
Cherry Kovoor pediatric Orthopedic and Limb reconstruction specialist ernakulam medical center and specialist hospitals Kochi, Kerala, india
Chirag Thonse Orthopedic consultant st martha’s hospital Bengaluru, Karnataka, india
Chong Jin Yeo hand and microsurgery section department of Orthopedic surgery Tan Tock seng hospital singapore
Christopher e Gross rush university medical center chicago, iL 60622
CJ Thakkar 801, shantanu st martin road, mumbai, maharashtra, india
Clement Joseph Orthopedic surgeon sports and arthroscopy G Kuppuswamy naidu memorial hospital coimbatore, Tamil nadu, india
Clive Duncan professor and chairman division of reconstructive Orthopedics university of British columbia Vancouver, Bc, canada
Conor JC Gouk royal devon and exeter hospital exeter eX2, sOW, uK
D Patil sushrut hospital and research centre ramdas peth nagpur, maharashtra, india
David Pedowitz associate professor department of Orthopedic surgery sidney Kimmel medical college Thomas Jefferson university The rothman institute philadelphia, pennsylvania, usa
David Stanley consultant shoulder and elbow surgeon department of shoulder and elbow surgery sheffield Teaching hospitals nhs Foundation Trust sheffield, uK
David V Rajan professor and head department of arthroscopy and sports medicine Kovai medical center and hospital coimbatore, Tamil nadu, india
Deepthi Nandan Adla senior consultant Orthopedic surgeon continental hospital hyderabad, Telangana, india
Deepu Banerji director department of neurosurgery Brain and spine center Fortis hospitals Ltd, mumbai, maharashtra, india
Devanand Fellowship in spine (sshri) minimally invasive and complex spine Fellow (ucsF, san Fransisco), usa clinical and research Fellow in scoliosis (south Korea) associate consultant spine surgeon stavya spine hospital and research institute ahmedabad, Gujarat, india
Dhiren Ganjawala consultant Orthopedic surgeon nhL municipal medical college ahmedabad Ganjawala Orthopedic hospital pediatric Orthopedic surgeon ahmedabad, Gujarat, india
Dinshaw Pardiwala Jiwan-Flat. 7a, ii Ld ruparel marg malabar hill mumbai, maharashtra, india
DK mukherjee p 281, narkal danga main road, Kolkata, West Bengal, india
DK Taneja 178, anoop nagarindore, madhya pradesh, india Dominic K Puthoor department of Orthopedics amala institute of medical sciences Thrissur, Kerala, india
Donald S Garbuz clinical instructordivision of reconstructive Orthopedicsuniversity of British columbiaVancouver, Bc, canada
DP Bakshi da-3, sector 1 salt Lake city Kolkata, West Bengal, india
Dror Paley professor of Orthopedic surgery maryland centre for Limb Lengthening and reconstruction Baltimore, usa
emmanuel Bhore postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
eric J lew resident mercy health Foot and ankle residency avon, Ohio, 44011 usa
Fares S Haddad clinical and reserach Fellowdivision of reconstructive Orthopedicsuniversity of British columbiaVancouver, Bc, canada
Fouad Tariq Aziz postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
Frank luckino III resident mercy health Foot and ankle residency avon, Ohio, 44011, usa
G omkarnath associate professor department of Orthopedics Gandhi medical college secunderabad, india
GA Anderson professor of Orthopedic surgery head department of hand surgery and Leprosy reconstructive surgery christian medical college and hospital Vellore, Tamil nadu, india
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Gautam Zaveri consultant spine surgeon Jaslok hospital and research center mumbai, maharashtra, india
Girish Chinnaswamy Tata memorial hospital mumbai, maharashtra, india
Gregory Ian Bain associate professor department of Orthopedics and Trauma discipline of anatomy and pathology university of adelaide royal adelaide hospital and modbury public hospital south australia, australia
GS Kulkarni director, professor and head postgraduate institute of swasthiyog pratishthan miraj, maharashtra, india director sandhata medical research society miraj, maharashtra, india
Guido marra northwestern university department of Orthopedics surgery chicago, illinosis, usa
Gurunath S Wachche associate professor (Orthopedics) Lee-shaw Fellowship - singapore 2002 uaB-iFas Fellow - usa 2014 Wachche hospital solapur, maharashtra, india
Gururaj m Sangondimath spine consultant indian spinal injuries centre new delhi, india
Hari Ankem consultant Orthopedic surgeon apollo health city hyderabad, Telangana, india
Harish Bhende 5, satjangad co-Op. housing society 166-d, dr. ambedkar road, dadar (e) mumbai, maharashtra, india
Harshit Gehlot postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
HC Goyal additional director of General health services (dGhs), nirman Bhavan new delhi, india
Hemant Wakankar B-89, Tulshibagwale colony devchhayaa, sahakar nagar road parvati pune, maharashtra, india
Himani Kolhatkar physiotherapist aB healthcare pune, maharashtra, india
Hiranya Kumar Seenappa professor department of Orthopedics Vydehi institute of medical sciences and research center Bengaluru, Karnataka, india
Hitesh Chauhan pediatric Orthopedic surgeon director rainbow superspecialty hospital and children’s Orthopedic center ahmedabad, Gujarat, india
Hitesh Shah associate professor and pediatric Orthopedic surgeon Kasturba medical college manipal, Karnataka, india
HK Pande Wanless hospital miraj, maharashtra, india
HK Sugathan clinical Fellow (Foot and ankle surgery) stockport nhs Foundation Trust poplar Grove stockport sK2 7Je, uK
Hariram Jhunjhunwala d/4, sunita 62, pedder road mumbai, maharashtra, india
HS Chhabra chief (spine service) medical director indian spinal injuries center new delhi, india
I lorenz Former chairman department of Traumatology and reconstructive surgery Katharinen hospital, stuttgart, Germany
Ignacio Ponseti emeritus professor university of iowa, iowa, usa
IK Dhammi consultant Orthopedic surgeon department of Orthopedics university college of medical sciences (ucms) and Guru Teg Bahadur (GTB) hospital new delhi, india
Ishwara Keerthi consultant spine surgeon department of spine surgery Kmc hospital mangaluru, Karnataka, india
J Aronson
J Dheenadhayalan director and head division of Orthopedics Trauma and spine surgery Ganga hospital coimbatore, Tamil nadu, india
J maheshwari delhi institute of Trauma and Orthopedics sant parmanand hospital new delhi, india
Jaideep Dhamale rainbow superspeciality hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
Janardhana Aithala associate professor and in-charge (spine clinic) department of Orthopedics Kasturba medical college and hospital mangaluru, Karnataka, india
Javahir A Pachore plough share, 4/a, 415 sitladevi Temple road mahim (W), mumbai, maharashtra, india
Jayanth Sampath consultant pediatric Orthopedics surgeon Bangalore institute of movement research and analysis (Bimra) Bengaluru, Karnataka, india
Jayita Deodhar psychiatric unit and department of palliative care Tata memorial hospital mumbai, maharashtra, india
Je Herzenberg associate professor division of Orthopedic surgery university of maryland Baltimore, usa
Jean Destandau neurosurgeon endospine surgery center maybelle clinique Bel-air 138, avenue de la republique, 33200 Bourdeaux, cedex, France
Jennifer Gerres resident mercy health Foot and ankle residency 36711, american Way Blvd avon, Ohio, 44011 usa
Jeniffer Piezto
Jennifer Prezioso staff department of Foot and ankle surgery mercy health clinical Faculty mercy health Foot and ankle residency 36711, american Way Blvd avon, Ohio, 44011, usa
Jeremy Burnham university of Kentucky elbow shoulder research centre department of Orthopedic and sport medicine usa
Jitendra mangwani consultant Trauma and Orthopaedic surgeon university hospitals of Leicester infirmary square Leicester, Le1 5WW, uK
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JJ Patwa Trauma, ilizarov, Orthopedics, Orthoplastic reconstruction, hand, spine and Joint replacement surgeon
JK Patil apple diagnostic centre, Vyapari peth Kolhapur, maharashtra, india
Joseph J Dias professor of hand and Orthopedic surgery university hospitals of Leicester Leicester, uK
John S lewis Orthopedic surgery specialist charlotte, north carolina, usa
JR Hanson
Justin Gettings northwestern university department of Orthopedic surgery chicago, illinois, usa
Jwalant mehta consultant spinal deformity surgeon royal Orthopaedic hospital Birmingham, uK
K Chakraborty da-3, sector 1 salt Lake city, Kolkata, West Bengal, india
K Hardinge Writington General hospital, uK
Krishnamurthy Sridhar director institute of neurosciences and spinal disorders head Brain and spine surgery Global health city, chennai, Tamil nadu, india
K Venkatesan professor spinal disorders surgery unit christian medical college (cmc) and hospital Vellore, Tamil nadu, india
KA mansukhani
Kalpesh Shah
Kanniraj marimuthu Orthopedist apollo hospitals, chennai, Tamil nadu, india
Kanthan Theivendran shoulder Fellow The derby shoulder unit department of Trauma and Orthopedic surgery royal derby hospital derby Teaching hospitals nhs Foundation Trust, uK
Kapil Gangwal rainbow superspeciality hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
Karthik Kailash senior consultant nova specialty hospitals chennai, Tamil nadu, india
Kartik Hariharan consultant Orthopaedic and Foot and ankle surgeon, royal Gwent hospital newport, south Wales, uK
Kavita Iyenger
Kekre P consultant spine surgeon sundaram medical Foundation chennai, Tamil nadu, india
Kelly Bumpus resident, mercy health Foot and ankle residency 36711 american Way Blvd avon, Ohio, 44011, usa
Kenny S David professor and head spinal disorders surgery unit department of Orthopedic surgery christian medical college and hospital Vellore, Tamil nadu, india
Ketan Gandhi assistant professor department of Orthopedics Bharati Vidyapeeth medical college and Bharati hospitals and research centre pune, maharashtra, india
Ketan Pande consultant Orthopedic and spinal surgeon division of spinal surgery sushrut hospital research centre and postgraduate institute of Orthopedics ramdaspeth nagpur, maharashtra, india
Ketan S Khurjekar chief spine surgery services sancheti hospital pune, maharashtra, india
Kevin lim pediatric Orthopedic Fellowship (sickkids - Toronto) canada
Kevin murr university of Kentucky elbow shoulder research centre department of Orthopedic surgery uK
Khalid Alquwayee clinical and reserach Fellow division of reconstructive Orthopedics university of British columbia Vancouver, Bc, canada
Khushboo Pilania
Kiran m Doshi Kolhapur institute of Orthopedics and Trauma (KiOT) Kolhapur, maharashtra, india
Kiran KV Acharya assistant professor department of Orthopedics Kasturba medical college manipal, Karnataka, india
Kiran Patnakar apple diagnostic centre Vyapari peth Kolhapur, maharashtra, india
Kiran Sasi P assistant professor paul Brand centre for hand surgery christian medical college and hospital Vellore, Tamil nadu, india
Kirti Ramnani rainbow superspecialty hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
KN Shah Fracture and Orthopedic hospital ahmedabad, Gujarat, india
KP Srivastava emeritus professor of Orthopedics sn medical college agra, uttar pradesh, india
Kumar Kaushik Dash assistant professor department of Orthopedics Grant medical college sir JJ Group of hospitals mumbai, maharashtra, india
KV menon senior consultant (Orthopedics) Khoula hospital muscat, sultanate of Oman
lauren l Kishman resident mercy health Foot and ankle residency 36711 american Way Blvd avon, Ohio, 44011 usa
laxmi Vas consultant pain specialist director ashirvad institute of pain management and research mumbai, maharashtra, india
leena Jain
leonid Solomin
madhura Kulkarni pGi of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharahstra, india
mahendra S Kudchadkar healthway hospital, Goa, india
mahesh Kulkarni Joint replacement clinic pune, maharashtra, india
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mahesh menon consultant department of pain medicine and palliative care services department of integrated Oncology Kokilaben dhirubhai ambani hospital and medical research institute mumbai, maharashtra, india
malhar Dave Orthopedic and Foot and ankle surgeon abhishek hospital Vadodara, Gujarat, india
malini lawande consultant department of mri, Balabhai nanavati hospital mumbai, maharashtra, india
mallikarjun Balagaon postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
manan Gujarathi postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
mandar Acharya rainbow superspecialty hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
mandar Agashe pediatric Orthopedic Fellowship (Korea) KJ somaiya hospital, mumbai, maharashtra, india
mandeep Dhillon chairperson, aO Trauma india president, indian association for sports medicine amritsar, punjab, india Founder president indian Biological Orthopedics society past president, indian arthroplasty association past president indian Foot and ankle society past president, north Zone iOa professor and head, Orthopedics head department of physical medicine pGimer, chandigarh, india
mandeep Shah
mangal Parihar mangal anand hospital mumbai, maharashtra, india
manik menezes specialist, plastic surgeon international modern hospital dubai, uae
manish Chadha professor of Orthopedic Bharati Vidyapeeth deemed university medical college and hospital sangli, maharashtra, india
manish Khanna Former consultant, sGpGi, Lucknow charter secretary General, indian Orthopaedic rheumatology association associate professor of Orthopedics, Government medical college, ambedkarnagar, uttar pradesh convener Orthopedics, stem cell society of india mumbai Former secretary, Vice president, indian Foot and ankle society, mumbai nominated indian member, international clubfoot study Group chief consultant, apley clinic Orthopedic centre Lucknow, uttar pradesh, india
manoj Kumar Goyal a-6, meera Bagh pashchim Vihar, new delhi
manoj Kumar Shukla professor department of Orthopedics Vydehi institute of medical sciences and research center, Bengaluru, Karnataka, india
manoj Padman rainbow superspecialty hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
marcus Bateman upper Limb clinical specialist physiotherapist The derby shoulder unit department of Trauma and Orthopedic surgery royal derby hospital, derby Teaching hospitals nhs Foundation Trust, uK
mark A Hardy chief Foot and ankle surgery mercy health hospital systems clinical Faculty, case Western reserve university school of medicine director, mercy health Foot and ankle residency director, nOFa Foundation director, nOFa international Fellowship 36711 amercian Way Blvd. avon, Ohio, usa
mark Yuhas elbow shoulder research center department of Orthopedics and sport medicine university of Kentucky, Lexington, usa
mary Ann muckaden professor radiation Oncology and pallative care services Tata memorial hospital mumbai, maharashtra, india
maulin m Shah consultant pediatric Orthopedic surgeon OrthoKids clinic ahmedabad, Gujarat, india
mayilvahanan Natrajan
mH Patwardhan endocrine research centre Vantamure corner, sangli road miraj, maharashtra, india
michael Aynardi assistant professor department of Orthopedic surgery and rehabilitation penn state hershey, school of medicine hershey, pennsylvania, usa
milind Chaudhary centre for ilizarov Techniques chaudhary Trust hospital akola, maharashtra, india
milind G Kulkarni professor in Orthopedics postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
mohammed Sadiq senior resident department of Orthopedics all india institute of medical sciences (aiims) new delhi, india
mohinder Kaushal chief consultant (Orthopedics) endoscopic spine, Knee and sports surgeon chairman, department of Orthopedics and minimal access surgery, north india
muhammod Tariq Sohail
mukund R Thatte academic head plastic surgery Bombay hospital, mumbai consultant plastic and reconstructive hand and microvascular surgeon Bai Jerbai Wadia hospital for children mumbai, maharashtra, india
Nagesh Naik professor of Orthopedics Bharati Vidyapeeth deemed university medical college and hospital sangli, maharashtra, india
Nandan Adla consultant shoulder surgeon hyderabad, Telangana, india
Nandan Rao consultant in Orthopedics surat, Gujarat, india
Narayana Prasad shoulder and elbow Fellow department of shoulder and elbow surgery sheffield Teaching hospitals nhs foundation Trust sheffield, uK
Narendra Kumar magu department of Orthopedics medical college, rohtak, haryana
Naresh Kumar associate professor university of singapore, singapore
Narsimha Ramni pediatric Orthopedic surgery Fellow (usa) senior consultatnt pediatric Orthopedic surgery indraprastha apollo hospitals, new delhi, india
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Nayana Nayak department of plastic surgery Bombay hospital and institute of medical sciences mumbai, maharashtra, india
Nicolas Dedy upper Limb Fellow Gold coast university hospital southport, australia
Nikesh Shah Foot and ankle surgeon indrapuri hospital Vadodara, Gujarat, india
Nikhil Sharma research Fellow department of Orthopedics apollo hospitals Bengaluru, Karnataka, india
Nilendu Purandare associate professor deparment of nuclear medicine and molecular imaging Tata memorial hospital mumbai, maharashtra, india
Niraj B Vasavada head of department and chief surgeon department of minimal access and endoscopic spine surgery consultant spine surgeon shalby hospitals and Krishna shalby hospital ahmedabad, Gujarat, india
Nirmal C mahapatra associate professor in Orthopedics scB medical college and hospital cuttack, Odisha, india
Nirmal Raj Gopinathan professor postgraduate institute of medical education and research (pGimer), chandigarh, india
Nishit Patel assistant spine consultant indian spinal injuries centre new delhi, india
Nitish Arora postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharahstra, india
P menon postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
P Ramesh director and head, division of Orthopedics Trauma and spine surgery Ganga hospital coimbatore, Tamil nadu, india
P Sripathi Rao professor of Orthopedics Kasturba medical college manipal, Karnataka, india
P Suryanarayan plough share, 4/a 415 sitladevi Temple road mahim (W) mumbai, maharashtra, india
Pavan Desai consultant upper Limb surgeon surat, Gujarat, india
Pankaj Patel dean and professor of Orthopedics surgery nhL municipal medical college ahmedabad, Gujarat, india
Pankush Arorasancheti institute of Orthopedics and rehabilitation, pune indian Orthopedic research Group Thane, maharashtra, india
Parag Aland
Parag Sancheti sancheti institute for Orthopedics and rehabilitation pune, maharashtra, india
Parag Shah consultant shoulder and upper Limb surgeon Fracture and Orthopedics hospital ahmedabad, Gujarat, india
Parag Tamhankar rainbow superspecialty hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
Parmanand Gupta associate professor of Orthopedics Government medical college hospital chandigarh, india
PN Gupta
PN Jain professor anesthesiology critical care and pain head, division of pain department of anesthesiology critical care and pain Tata memorial hospital mumbai, maharashtra, india
Pradeep Agarwal director raffels hospital panchukla, haryana, india
Pradeep Kothadia Kothadia nursing home solapur, maharashtra, india
Pradeep Singh
Pradhyumn Rathi postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
Prakash Naik
Prakash P Kotwal professor and head department of Orthopedics all india institute of medical sciences (aiims) new delhi, india
Pramod Nagure consultant department of mri, Balabhai nanavati hospital mumbai, maharashtra, india
Prasad Krishnan academic director and consultant neurosurgeon national neurosciences centre peerless hospital complex Kolkata, West Bengal, india
Prasanna C Rathi postgraduate institute of swasthiyog pratishthan miraj, maharashtra, india
Prashant Deshmane plough share, 4/a 415 sitladevi Temple road mahim (W), mumbai, maharashtra, india
Prashant Kamble assistant professor department of Orthopedics seth Gs medical college and Kem hospital, mumbai, maharashtra, india
Praveen Bhardwaj consultant, hand and Wrist surgery division of plastic surgery hand and microsurgery and Burns Ganga hospital, coimbatore, Tamil nadu, india
Pravin Kanabar Love and compassion accident Free ahmedabad Former president, indian Orthopedic association indian arthroscopy society Gujarat Orthopedic association professor and head department of Orthopedics Km school of postgraduate medical and research nhL municipal medical college and Vs hospital ahmedabad consultant, Jaliyan Orthopedic hospital Keshav arthroscopy and sport medicine clinic ahmedabad, Gujarat, india
Premal Naik director rainbow superspecialty hospital and children’s Orthopedic centre, pediatric Orthopedic surgeon associate professor of Orthopedics smt nhL municipal medical college ahmedabad, Gujarat, india
Priti Patil consultant department of mri, Balabhai nanavati hospital mumbai, maharashtra, india
R Bhalla president, Trauma society of india past president, indian Orthopedic association professor of Orthopedics institute of medical sciences Banaras hindu universtiy, Varanasi, india
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Rajesh Parasnis consultant Orthopedics and spine surgeon Oyster and pearl hospital pune, maharashtra, india
R Rachha Fellow in Foot and ankle surgery stockport nhs Foundation Trust slepping hill hospital poplar Grove stockport, chestire, uK
R Raja Shanmugakrishnan registrar, division of plastic surgery hand and microsurgery and Burns Ganga hospital coimbatore, Tamil nadu, india
R Siwach department of Orthopedics pt. Bd sharma pgims 31/9J, medical enclaves rohtak, haryana, india
R Sreekanth assistant professor paul Brand centre for hand surgery christian medical college and hospital Vellore, Tamil nadu, india
Raghava Dutt mulukutla director and chief of spine surgery udai Omni hospital and apollo health city hyderabad, Telangana, india
Rajesh malhotra Fellow, revision Joint replacement and Bone Banking, princess alexandra hospital Brisbane, australia Fellow, Johnson and Johnson and roaf Fellowship (iOa) Fellowship in advance Trauma (aO/asiF), Germany Fellowship ranawat Orthopedic centre (rOc) senior Travelling Fellow (iOs uK) editor, Orthopedics Today convener Orthopedic initiative, india society of Bone mineral research past president delhi Orthopedic association (2012) secretary, regional Fragility Fracture network, india professor of Orthopedics all india institute of medical sciences new delhi, india
Rajesh Rohira Jess research and development centre no.10-OnGc colony, Bandra reclamation mumbai, maharashtra, india
Rajiv limaye consultant (Orthopedic surgeon) university hospital of north Tees stockton on Tees, uK
Rajiv Negandhi pediatric Orthopedic surgeon Fellow, pediatric Orthopedics (hong Kong uK singapore usa) postgraduate institute of swasthiyog pratishthan Fracture and Orthopedic hospital miraj, maharashtra, india
Rajiv Shah Orthopedic Foot and ankle surgeon past-president, indian Foot and ankle society managing director sunshine Global hospitals Vadodara-Bharuch-surat, Gujarat, india
Raju Gite Orthopedic surgeon dombivali, maharashtra, india
Ram Chaddha spine surgeon Lilavati, saifee, Wockhardt hospitals mumbai, maharashtra, india president, association of spine surgeons of india (2015-17) professor and head (Orthopedics) KJ somaiya medical college and General hospital mumbai, maharashtra, india
Ram Prabhoo W03, carlton court, perry cross road Bandra (W) mumbai, maharashtra, india
Ramani Narasimhan pediatric Orthopedic surgeon indraprastha apollo hospitals new delhi, india
Ramesh Kumar Sen Former professor of Orthopedics postgraduate institute of medical education research (pGimer), chandigarh director of Orthopedics Fortis hospital mohali, punjab, india
Randy R Bindra professor department of Orthopedic surgery Griffith university and Gold coast university hospital southport, australia
Rashmi Chopra consultant Orthopedic hand and Wrist surgeon apollo spectra hospital, new delhi, india
Rashmi Raut registrar department of plastic and reconstructive surgery Lilavati hospital and research center mumbai, maharashtra, india
Ravijot Singh senior resident Orthopedics all india institute of medical sciences (aiims) new delhi, india
Raviraj Patil postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharahstra, india
RB Dalal consultant (Orthopedic surgeon) honorary senior Lecturer university of manchester stockport nhs Foundation Trust, stockport, uK
Rl Thatte academic head plastic surgery Bombay hospital consultant plastic surgeon Bai Jerbai Wadia hospital for children parel, mumbai, maharashtra, india
Renuka Pai consultant pain specialist ashirvad institute of pain management and research mumbai, maharashtra, india
Rujuta mehta head department of pediatric Orthopedics BJ Wadia hospital for children consultant nanavati superspecialty hospital Jaslok hospital sushrusha hospital mumbai, maharashtra india
Ruta m Kulkarni associate professor department of Orthopedics pediatric Orthopedic and ilizarov surgeon postgraduate institute of swasthiyog pratishthan miraj, maharashtra, india
S Karunakaran associate professor of spine surgery department of Orthopedics madras medical college chennai, Tamil nadu, india
S lahkar
S Raja Sabapathy chairman division of plastic surgery hand and microsurgery and Burns Ganga hospital coimbatore, Tamil nadu, india
S Rajasekaran director and head division of Orthopedics Trauma and spine surgery Ganga hospital coimbatore, Tamil nadu, india
S Sane sane nursing home mumbai, maharashtra, india
S Siddiqui spine Fellow Jaslok hospital and research centre mumbai, maharashtra, india
SA Green director The problem Fracture service rancho Los amigos hospital 7601 e imperial highway downey ca, usa
SA Ranjalkar postgraduate institute of swasthiyog pratishthan miraj, maharashtra, india
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Sachin Tapasvi 8, status chambers 1221/a, Wrangler paranjape road, Off. Fc road pune, maharashtra, india
Sagar Saxena postgraduate institute of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
Sahil Batra spine Fellow indian spinal injuries centre Vasant Kunj, new delhi, india
Sajan K Hegde consultant spine surgeon head department of Orthopedics apollo hospitals chennai, Tamil nadu, india
Samarth mittal senior resident department of Orthopedics all india institute of medical sciences new delhi, india
Samir Dalvie spine surgeon hinduja and Breach candy hospitals mumbai, maharashtra, india
Samir Kumta consultant plastic surgeon and reconstructive microsurgeon Lilavati hospital and research centre mumbai, maharashtra, india
Sampat D Patil secretary indian Foot and ankle society director and head noble hospital, pune, maharashtra, india
Samuel B Adams department of Orthopedic surgery duke university medical center durham, nc
Sandeep Diwan postgraduate institute of swasthiyog pratishthan miraj, maharashtra, india
Sandeep Patwardhan professor (Orthopedics) pediatric Orthopedic specialist sancheti institute for Orthopedics and rehabilitation pune, maharashtra, india
Sandeep Vaidya pediatric Orthopedic surgeon mumbai, maharashtra, india
Sanjay B Kulkarni hospital infection control consultant Belagavi, Karnataka, india
Sanjay Garude 36/a 1st Floor, sai nivas road no. 2, sion (e), mumbai, maharashtra, india
Sanjeev Sabharwal professor department of Orthopedics chief pediatric Orthopedics rutgers-new Jersey medical school newark, new Jersey, usa rainbow superspecialty hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
Sanjit Singh
Sarvdeep Dhatt associate professor department of Orthopedic surgery postgraduate institute of medical education and research chandigarh, india
Satish Bhat consultant plastic surgeon Linea cosmetic clinic Balmatta, mangaluru Karnataka, india
Satish Rudrappa Fellow in complex spine and Thoracoscopic surgery (usa) Fellow in microvascular anastomosis (usa) senior consultant-neurosurgery and director skull Base surgery head department of spine surgery sakra World hospital Bengaluru, Karnataka, india
Saumyajit Basu consultant spine surgeon and program director of spine Fellowships neurosciences division park clinic Visiting spine surgeon department of Orthopedics Kothari medical centre Visiting Faculty for pediatric spine institute of child health Kolkata, West Bengal, india
Saurabh Kapoor complex spine Fellow Kings college hospital, London, uK
SC Goel president, Trauma society of india past president, indian Orthopedic association professor of Orthopedics institute of medical sciences Banaras hindu universtiy Varanasi, uttar pradesh, india
Selene G Parekh duke Fuqua school of Business durham, nc 27707, usa
Shailesh Hadgaonkar spine surgeon sanheti hospital pune, maharashtra, india
Shaligram Purohit assistant professor department of Orthopedics seth Gs medical college and Kem hospital mumbai, maharashtra, india
Shankar Acharya spine surgeon sir Ganga ram hospital new delhi, india
Shashank misra upper Limb surgeon sir Ganga ram hospital surya hospital new delhi, india
Shelton mcKenzie Fellow in Foot and ankle surgery department of Orthopedic surgery university of Texas medical Branch Galveston, Texas, usa 77555
Shirish Pathak consultant Orthoscopic surgeon deena nath mangesh hospital pune, maharashtra, india
Shishir Rastogi additional professor of Orthopedics all india institute of medical sciences (aiims) new delhi, india
Shiva Shankar Jha Jha hospital patna, Bihar, india
Shrikant Atreya
Shrinand V Vaidya plough share, 4/a 415 sitladevi Temple road mahim (W), mumbai, maharashtra, india
Shrinivasan
Shubhada Kher rehabilitation consultant spine clinic, Jupiter hospital mumbai, maharashtra, india
Shumayou Dutta spine Fellow (assi) mumbai spine scoliosis and disc replacement centre, Bombay hospital mumbai, maharashtra, india
Shubhranshu S mohanty consultant Orthopedics and Joint replacement surgeon Jaslok, sushrusha and nanavati hospitals mumbai professor (addl) and unit head in Orthopedics King edward memorial hospital mumbai, maharashtra, india
Siddhartha Sharma professor postgraduate institute of medical education and research (pGimer) chandigarh, india
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SKS marya director max superspecialty hospital new delhi, india
Sm Tuli senior consultant spinal diseases and Orthopedics Vidyasagar institute of mental health and neurosciences new delhi, india
Sneha Shah associate professor department of nuclear medicine and molecular imaging Tata memorial hospital mumbai, maharashtra, india
Sreeramalingam Rathinavelu spine surgeon Ortho One-orthopedic speciality centre coimbatore, Tamil nadu, india
Srikanthnara consultant Orthopedic surgeon Ozone institute of medical sciences hyderabad, Telangana, india
Srinath Kamineni elbow shoulder research center department of Orthopedic surgery university of Kentucky, usa
Srinivasa moolya spine Fellow indian spinal injuries centre Vasant Kunj, new delhi, india
SS Patil spine surgery Fellow assi Fellow minimally invasive spine surgery (usa, France) Fellow dynamic Fixation and soft stabilization of Lumbar spine (usa, France) Fellow spine-Oncosurgery (italy) Fellow sacro illiac pathologies and minimally invasive si Fusion surgery (usa) associate spine surgeon Wockhardt hospital, mumbai central hinduja healthcare surgical, Khar (W) sportsmed, parel mumbai, maharashtra, india
SS Rajderkar department of anatomy Government medical college miraj, maharashtra, india
Subir N Jhaveri usa/canada Fellowship Trained spine surgeon ahmedabad, Gujarat, india
Sudhir Babhulkar director sushrut hospital, research centre and postgraduate institute of Orthopedics nagpur, maharashtra, india
Sudhir K Kapoor head department of Orthopedics Lady hardinge medical college new delhi, india
Sudhir Kumar professor and head department of Orthopedics school of medical sciences and research sharda university Greater noida, uttar pradesh, india
Sudhir Warrier consultant hand surgeon Lilavati, hinduja, Jaslok, shushrusha sportsmed and sunridges hospitals Laud clinic mumbai, maharashtra, india
Sujay m Kulkarni postgraduate institute (pGi) of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
Sujit Joshi
Sujit Kadrekar clinical associate Kokilaben dhirubhai ambani hospital mumbai, maharashtra, india
Sujit Kumar Tripathy assistant professor department of Orthopedics all india institute of medical sciences Bhubaneswar, Odisha, india
Sunil G Kulkarni professor department of Orthopedics postgraduate institute of swasthiyog pratishthan, miraj, maharashtra, india aO Trauma india council member Vice president, Trauma society of india Former president national association of interlocking surgeons (naiLs) india
Sunny Gugale
Suresh Pillai spine surgeon Lakeshore hospital and research centre Ltd Kochi, Kerala, india
Sureshwar Pandey consultant Orthopedics surgeon emeritus professor, ranchi university Founder and director Gnh handicapped children hospital and rJs artificial Limb center Founder and emeritus president indian Foot and ankle society (affi-cip-iFFas) Founder and emeritus editor The Journal of Foot and ankle surgery ex-president, asia-cip (iFFas) Founder and chairman ramjanam sulakshana pandey cancer hospital and research and rehabilitation center ranchi, Jharkhand, india
Surya Bhan Orthopedician, Joint replacement surgeon consultant Joint replacement surgeon and Orthopedic surgeon primus superspecialty hospital new delhi, india
Suryaprakash Rao consultant spine surgeon max cure hospitals mediciti and madhapur hyderabad, Telangana, india
Sushrut Babhulkar centre for Joint reconstruction and Trauma surgery director sushrut hospital and research centre and postgraduate institute of Orthopedics secretary Trauma society of india chief nagpur, maharashtra, india sushrut hospital and research centre ramdaspeth, nagpur, india
Swaroop Gopal senior consultant neurosurgery director neurosciences department of neurosciences sakra World hospital Varthur hobli, Bengaluru, Karnataka, india
Taral Nagda rainbow superspecialty hospital and children’s Orthopedic centre pediatric Orthopedic surgeon smt nhL municipal medical college ahmedabad, Gujarat, india
Tarun Suri FnB Fellow park clinica Kolkata, West Bengal, india
Thomas J Kishen spine care centre manipal hospital Bengaluru, Karnataka, india
Thomas Palocaren associate professor pediatric Orthopedics christian medical college and hospital Vellore, Tamil nadu, india
Tushar Agrawal consultant pediatric Orthopedics surgeon Bombay hospital mumbai, maharashtra, india
Tushar Rathod assistant professor department of Orthopedics seth Gs medical college and Kem hospital mumbai, maharashtra, india
u Holz Former chairman department of Traumatology and reconstructive surgery Katharinen hospital stuttgart, Germany
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uday Phatak consultant physician sharada research institute miraj, sangli, maharashtra, india
V Paramshetti paramshetti hospital miraj, maharashtra, india
Vedant Vaksha Orthopedics, Fellow spine surgery (rochester, nY and cleveland clinic, Oh) assistant consultant spine services indian spinal injuries centre new delhi, india
Venkatdass pediatric Orthopedic surgeon Ganga hospital coimbatore, Tamil nadu, india
Venkatesh Rangarajan professor department of nuclear medicine and molecular imaging Tata memorial hospital mumbai, maharashtra, india
Vidisha S Kulkarni associate professor department of Orthopedics postgraduate of swasthiyog pratishthan Fracture and Orthopedics hospital miraj, maharashtra, india
Vikas Agashe Orthopedic surgeon pd hinduja hospital Kohinoor hospital dr agashe’s maternity and surgical nursing home mumbai, maharashtra, india
Vikas Tandon spine surgery deformity correction Fellowship usa minimally invasive surgery (Germany) consultant, spine surgeon indian spinal injuries centre new delhi, india
Vikram R lele chief of nuclear medicine department of radiology Jaslok hospital and research centre mumbai, maharashtra, india
Vikram Shah plough share, 4/a, 415 sitladevi Temple road mahim (W), mumbai, maharashtra, india
Viktor Vilensky
Vinod K Panchbhavi professor department of Orthopedic surgery chief, division of Foot and ankle surgery director, Foot and ankle Fellowship program department of Orthopedics university of Texas medical Branch Galveston Texas, usa
Vinod mishra
Viraj Shingade director children Orthopedic care institute pravira hospital, nagpur, maharashtra, india
Viren mishra consultant Orthopedics and Trauma hull and east Yorkshire hospitals, uK senior Tutor, hull York medical school Yorkshire, uK
Virendra Shandilya ec member of Opai rehabs, Vadodara, Gujarat, india
Vishal Kumar assistant professor department of Orthopedics postgraduate institute of medical education and research (pGimer) chandigarh, india
Vishal Kundnani consultant, spine surgeon Bombay hospital and research centre mumbai, maharashtra, india
Vivek Pandey Trauma, arthroscopy and Joint replacement service, Orthopedics surgery Kmc, manipal, Karnataka, india
Vivek Shankar assistant professor sports injury centre Vardhman mahavir medical college and safdarjung hospital, new delhi, india
VK Pande professor of Orthopedics (hand surgery) sms medical college and hospital Jaipur, rajasthan, india
Vm Agashe
Vm Iyer iyer Orthopedic centre and physiotherapy clinic 103, railway Line solapur, maharashtra, india
VT Ingalhalikar director spine clinic professor Orthopedic surgery Jupiter hospital Thane, maharashtra, india
Wilson Iype department of Orthopedics amala institute of medical sciences Thrissur, Kerala, india
Yash Shah Bombay hospital mumbai, maharashtra, india
Yathiraj BR clinical associate Kokilaben dhirubhai ambani hospital mumbai, maharashtra, inida
Yogesh Nathdwarawala consultant Orthopedic surgeon nevill hall hospital monmouthshire, uK
Yogesh Panchwagh senior registrar, Orthopedic Oncology Tata memorial hospital mumbai, maharashtra, india
Yogesh Pithwa Fellow of national Board of examinations spine surgery consultant, spine surgeon Bengaluru, Karnataka, india
Yuvaraja assistant professor department of Orthopedics pondicherry institute of medical sciences puducherry, indiaJa
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Foreword to the Third edition
It is a privilege and honor to write a foreword for the third edition of the Textbook of Orthopedics and Trauma. This textbook, which reflects the work and expertise of the Indian orthopedic surgeons, was made possible by the single effort of Dr GS Kulkarni when he brought out the first edition in the year 1999. In the span of merely 16 years, the textbook has become a popular and favored source of reference and learning for orthopedic surgeons and trainees alike around our country. The progress into third edition in a short period reflects the popularity and also the intention of its editor to keep the textbook current and relevant with all recent advances. The textbook has great relevance as the burden of orthopedic diseases is increasing globally, especially in developing countries like India. People suffering from joint disorders and low back pain include millions resulting in a major socioeconomic problem. Trauma, especially due to road-traffic accidents is also on the rise, and there is one death on the Indian roads every four minutes causing more than seven lakh people undergoing major injuries every year. Orthopedic surgery is also evolving rapidly. The tremendous advances in allied sciences of molecular biology, genetics, biomechanics, and metallurgy that are taking place at a rapid pace have brought a great change in the field. While all this has translated to better patient care and outcome, the trainees and the young surgeons face a challenge to keep up with the current knowledge. The textbook captures the entire spectra of orthopedics in a concise and precise fashion with contributions from many eminent surgeons. It thus fills the need adequately, and I am sure that the demand for the fourth edition will not be far away. I congratulate Dr Kulkarni for his enthusiasm and persistence towards making this book possible. He is a role model for all of us, and his energy, passion and commitment to a cause is a source of inspiration for many of us.
S Rajasekaran MS MCh FRCS FACS PhD
Chairman Department of Orthopedic Surgery
Ganga Hospital Coimbatore, Tamil Nadu, India
President-Elect SICOTChair, International Research Commission, AOSpine
Past President, Indian Orthopedic AssociationPast President, Association of Spine Surgeons of India
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Foreword to the second edition
The Herculean task of bringing out the second edition is taken up by the editor Prof Dr GS Kulkarni to update and edit the present knowledge of orthopedics and traumatology. The textbook has an excellent collection of topics written by experienced and knowledgeable orthopedic surgeons. The scholarly work done by the editor is being published by M/s Jaypee Brothers under the aegis of Indian Orthopedic Association as its revised second edition. All the contributors have taken tremendous efforts to incorporate the present-day knowledge and recent trends of the concerned topics. Many orthopedic problems in developing countries are different from those in the Western country and most of the books, journals and publications are published from the West. The problems associated with osteosynthesis and recent trends in nailing interlocking have been elaborately written. The common problems of neglected fractures and their management which every surgeon encounters in the practice are well covered. The conditions associated with traumatology and their complications are nicely covered in this edition. The textbook has covered almost all the topics and conditions which we face day to day. This book will be relevant and definitely helpful to orthopedic surgeons and students. Dr GS Kulkarni with his vast experience and dedicated efforts has brought us the new edition of this book with a very high standard which will be helpful to the readers.
Prof (Dr) Sudhir BabhulkarMS (Orth) D Ortho PhD Orth DSc Orth FAMS
Past President Indian Orthopedic Association
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Foreword to the First edition
The Textbook of Orthopedics and Trauma being published by the Indian Orthopedic Association, edited by Dr GS Kulkarni, is the most useful undertaking. This textbook provides the collective experiences in the field of orthopedics and trauma of all the senior and experienced orthopedic surgeons of India. India is perhaps the foremost amongst the developing countries. The CATCH 22 of the word “developing” fails to reveal that if the whole population of countries like India is taken into account. A certain section may have reached a level of development almost near to that developed by the so-called developed countries, and certain section is plagued by poverty and ignorance. The orthopedic surgeons practicing in India are familiar and capable of dealing not only with diseases and disabilities that affect the prosperous dominant elite, who expect the same kind of health care as is available in the most developed countries of the world but also to be able to look after and treat adequately such conditions which have almost disappeared from those countries, e.g. paralytic poliomyelitis, pyogenic infections of bones and joints, tuberculous disease of bone and joints, mycotic infections, the neural and osteoarticular damage caused by Hansen’s infections especially among young children and infants, including the newborn. These diseases usually affect the poorer section of the society. The challenge of the orthopedic surgeons in developing countries, therefore, is more comprehensive and varied. They have to handle all these serious conditions with severe financial and infrastructural constraints. Considering these challenges, Dr Kulkarni has done an excellent job of selecting the topics and contributors for the book. Among all the developing countries, India happens to have a fairly well-trained body of orthopedic surgeons, who have had experience in the management of these wide variety of diseases and disabilities of the locomotor system. The contributors have taken great pains and have described in detail these subjects, which I am sure, will be extremely useful to the orthopedists of the developing countries. Lately, with the introduction of mechanization and high-speed transport facilities, there is increased incidence of high-velocity trauma causing polytrauma, which requires a very well-planned system of casualty care, which does not exist in countries like India. I am pleased to read the chapters on polytrauma written by eminent personalities. Dr Kulkarni is known to me since long. He is a devoted orthopedic academician. I also know many of the section editors and contributors. They are sincere hard-working group of orthopedic surgeons. The book points out the wisdom of senior orthopedic surgeons of India and fills the gap that exists in this field. The enterprise that the Indian Orthopedic Association is undertaking, is indeed most gratifying. I hope that the book will act as a pathfinder and a guide to help orthopedic surgeons, who are practicing in developing countries.
B MukhopadhyayEmeritus Professor
Patna
Orthopedics and trauma is the largest specialty of surgery, and especially, with the subspecialties in orthopedics which are now more than 15 in number, it obviously becomes difficult to encompass the total spectrum in its fullness in any textbook. However, I must give credit to Dr GS Kulkarni, who has made tremen dous efforts and that too successfully to cover most of the spectrum of this specialty in an adequate manner. Medical education and training with its threefold commitment to patient care, research and continuing education always presents a difficult challenge. The term “core curriculum” is used widely but seldom defined; therefore, selection and integration of essential information must form the basis for such publications. A good medical textbook should provide not only information but also a philosophy and approach which makes the knowledge relevant. The authors must have experience, ability and dedication to the mission of teaching. They should be scientifically accurate and capable of projecting their personalized approach. This is amply seen in this textbook. There are many reasons why prevention is still in its infantile stage. Grants for cancer and heart disease are largely available as this is considered a real science. The life of a cell can be turned round more easily than the mind of a motorcyclist. Looking at the prevention means stepping outside our familiar role as a curative orthopedic surgeon. Road trauma is a great challenge and fills the hospital beds to a great extent. Intoxication, designing of the roads, playground for children, police protection, bicycle tracks and maintenance of trucks and safe driving are some of the few issues which should be considered very logically for prevention of trauma, and these are the legitimate areas for research, even if they do not have the kudos of molecular biology or so much financial support. “Prevention is wholesale. Treatment is retail”.
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I am sure that these remarks will be helpful to the future thinking, and the present textbook mainly contributed by the Indian orthopedic surgeons will be a great boon for the orthopedic surgeons practicing not only in developing countries but also will be very informative to all who are devoted to this science and art. I am sure that these volumes must find their place in academic libraries all over the world.
KT Dholakia Hon FRCS (Eng)
Past President SICOT, Past President ASIPast President IOA, Past President ASSI
Emeritus Professor of OrthopedicsUniversity of Bombay
Sr Orthopedics Surgeon, Bombay Hospital Breach Candy Hospital and
PD Hinduja National Hospital
The art and science of orthopedics has changed remarkably. There has been an explosion in the orthopedic knowledge in recent years. The success of joint replacement, improvement in implant material with application of improved techniques and the new investigative techniques have made orthopedics a very exciting and rewarding specialty. Indian Orthopedic Association felt the necessity of a textbook, which can give more importance to commonly observed problems in clinical practice in our specialty as our problems are not similar to those seen in Western countries. The aim of the book is to provide authentic account of common conditions seen in our country more specifically for the young surgeons during and after their training. The newer develop ments like joint replacement, distraction osteogenesis (Ilizarov and Jess), interlocking intramedullary nail ing, spinal instrumentation and arthoscopy have been included. The operative details have been excluded as they are available in many books on operative orthopedics. The commonly prevailing problems of cold orthopedics have also been properly dealt with. There can be no better method of making the future of our specialty brighter than by ensuring that our trainee surgeons have the benefit of the knowledge and experience of their seniors. The contributors deserve full appreciation for doing their best in this regard and for giving their valuable time for this purpose. Dr Kulkarni is an expert editor, with enormous experience of editing journals and books. It is his dedication and constructive efforts that could provide us Textbook of Orthopedics and Trauma of such a high standard and value. He has done a commendable job for the Indian Orthopedic Association. I am sure that this book will be of tremendous value and help to its readers.
KP SrivastavaMS (Surg) MS (Ortho) D (Ortho) FICS
FACS FAMS FAIS FIAMS
PresidentIndian Orthopedic Association
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preface to the Third edition
A welcome addition is Sushrut Babhulkar, who is enthusiastic, an outstanding orthopedic surgeon, educator, and innovator. He has joined me as an associate editor.
—GS Kulkarni
The publication of third edition of the Textbook of Orthopedics and Trauma in 2016 includes a number of new features, and the most important one is an addition in the list of contributors, many of whom are young, representing newer generation. Orthopedic discipline is becoming a highly superspecialized branch. Almost every postgraduate resident wants to take up same specialty. However, in India, orthopods at periphery have to be the general orthopedic surgeons. This book is designed for them as well as for the resident who wish to become specialists. All the chapters are fully updated till 2015. Sections on poliomyelitis and leprosy have been deleted and some new chapters like vacuum-assisted closure and Masquelet’s membrane techniques have been added. We are grateful to our contributing authors, whose high level of information; clinical experience and dedication have made this book an excellent reference book for consultants and a must for postgraduate students. We sincerely thank the section editors who have done excellent work to edit the chapters. We plan to publish the fourth edition of this book in 2019 or 2020. Anybody who wishes to contribute is welcomed and is requested to contact us.
GS KulkarniSushrut Babhulkar
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preface to the First edition
Orthopedic knowledge is literally exploding at an astounding rate. No other surgical specialty has a greater number of procedures than orthopedics has the orthopedic market is also flooded with bewildering number of implants and instrumentation sets. The practicing orthopedic surgeons as well as the postgraduate students are at a loss to select the clinical material from the vast literature and the implants and instrumentation. This book serves as a quick text refresher and an easy reference to orthopedic surgeons. For postgraduate students, this book should be indispensible. Orthopedic problems of the developing countries are different from those in the West, and most of the books and journals on the subject emanate from the Western countries. Incidence of paralytic poliomyelitis, tuberculosis, chronic osteomyelitis, leprosy, etc. are rampant and so are the road-side accidents which are common in the developing countries. Conditions associated with trauma, such as nonunion (with or without infection), malunion, deformity stiff joints, etc. are day-to-day taxing problems. Even the sizes of Indian/Asian bones are smaller than those in the West. This disparity creates problems in inserting implants for the replacement of joints and for the treatment of fractures. Every orthopedic surgeon encounters a large number of cases of neglected trauma, deformities, infections and even tumors of bones and joints. Neglect of orthopedic disease is a common scenario, as also are the poor conditions of the operating rooms, and low quality of implants. Often, the surgical technique is not performed meticulously as described by different methodology. All these add to the complications. The textbook has been designed to adequately cover all such conditions which are missing from or inadequately described in the Western textbooks. The main aim of the book is to give comprehensive information about diseases and problems peculiar to the developing countries and to provide one source of orthopedic information. Each chapter is written by a surgeon who has a special interest in the subject. I take particular pride in the list of outstanding contributors, many of whom are leading authorities in their fields. An attempt is made to give a complete orthopedic knowledge, including basic and applied sciences and rehabilitation of musculoskeletal system. In a multiauthor book of this nature, some repetition is unavoidable but is useful. This is mainly addressed to the practicing orthopedic surgeons and postgraduate students in the developing countries. I am very much thankful to the Indian Orthopedic Association for asking me to edit this prestigious book.
GS Kulkarni
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acknowledgments
We are very grateful to Dr MS Ghosh of Kolkata, who convinced the Indian Orthopedic Association to publish the book. We express our gratitude to Milind, Sunil, Ruta, Vidisha, Rajiv Limaye, Sujay, Madhura and all the postgraduate students for their untiring help in completing this book. They have helped us by proofreading, correcting articles and writing a few articles. Our thanks to the stenotypists Arthur Shikhamani and Mr Pravind Sagare, who have tolerated us for the last 15 years. We sincerely thank all the orthopedic patients who are the backbone of the textbook. We are very much thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Mr Tarun Duneja (Director-Publishing), Mr KK Raman (Production Manager) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who have taken great pains in publishing the book in time, maintaining the international standards. We also sincerely thank to Mr DC Gupta (Senior Editor), Mr Gurnam Singh (Senior Proofreader), Mrs Yashu Kapoor (Senior Typesetter), Mr Manoj Pahuja (Senior Graphic Designer) and the entire production staff of M/s Jaypee Brothers Medical Publishers, for their professional expertise and their active role and cooperation in the production of the book.
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contents
Volume oNe
SEcTion 1: introduction and clinical Examination
Section Editor: Sureshwar Pandey
1. introduction and clinical Examination 1Sureshwar Pandey
2. Damage control orthopedics 12Anil Agarwal, Anil Arora, Sudhir Kumar
SEcTion 2: Basic SciencesSection Editor: Anil Arora
3. Functional and Anatomy of Joints 19Nagesh P Naik, Manish Chadha, Arun Pal Singh 3.1 Joints: Structure and Function 19
Nagesh Naik, Manish Chadha, Arun Pal Singh
3.2 Synovium Structure and Function 24 Nagesh Naik
4. Growth Factors and Fracture Healing 26Anil Agarwal, Anil Arora
5. Metallurgy in orthopedics 34Aditya N Aggarwal, Manoj Kumar Goyal, Anil Arora
6. Pathophysiology of Spinal cord injury and 37 Strategies for RepairManish Chadha
7. The Stem cells in orthopedic Surgery 47Manish Chadha, Anil Agarwal, Anil Arora
8. Bone: Structure and Function 52Gurunath S Wachche
9. cartilage: Structure and Function 55Gurunath S Wachche
10. Muscle: Structure and Function 59Gurunath S Wachche
11. Tendons and Ligaments: Structure and Function 62Gurunath S Wachche
12. Synovial Fluid 64Surya Bhan, Aman Dua
13. Synovial Disorders 71Surya Bhan, Aman Dua
14. Evidence-based Medicine and Research 78Ashok K Shyam
SEcTion 3: Diagnostic imaging in orthopedics
Section Editor: JK Patil
15. MRi and cT in orthopedics 89JK Patil
16. Musculoskeletal Ultrasound 135JK Patil, Kiran Patnakar
17. Advances in orthopedic imaging 144JK Patil, Priti Patil, Malini Lawande, Pramod Nagure
18. nuclear Medicine in orthopedics 149Vikram R Lele, Parag Aland
SEcTion 4: Metabolic Bone DiseasesSection Editor: Shishir Rastogi
19. osteoporosis and internal Fixation in 161 osteoporotic BonesSushrut Babhulkar
20. Vertebroplasty for osteoporotic Fractures 189Arvind Bhave
21. ochronosis 196GS Kulkarni, P Menon, Milind G Kulkarni, Sagar Saxena
22. Gout 199VM Iyer
23. crystal Synovitis 207Vidisha S Kulkarni
24. Rickets 208KN Shah, Prasanna C Rathi
25. Scurvy and other Vitamin-related Disorders 217KN Shah
26. Mucopolysaccharidosis 219RM Kulkarni, Mandar Agashe
27. Fluorosis 225Gurunath S Wachche
28. osteopetrosis 227Gurunath S Wachche
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SEcTion 5: Endocrine DisordersSection Editor: MH Patwardhan
29. Endocrine Disorders 231Gurunath S Wachche
30. Hyperparathyroidism and Bone 233MH Patwardhan, Parag Shah
SEcTion 6: Bone and Joint infectionsSection Editor: SC Goel
31. Pyogenic Hematogenous osteomyelitis: 243 Acute and chronicSC Goel
32. Septic Arthritis in Adults 262SC Goel, R Bhalla
33. Fungal infections 266Gurunath S Wachche
34. Miscellaneous Types of infections 269Gurunath S Wachche34.1 Gonococcal Arthritis 269
Gurunath S Wachche
34.2 Bone and Joints in Brucellosis 270Gurunath S Wachche
34.3 congenital Syphilis 271Gurunath S Wachche
34.4 Salmonella osteomyelitis 272Gurunath S Wachche
34.5 Hydatid Disease of the Bone 272Gurunath S Wachche
35. Postoperative infection 276GS Kulkarni
36. Prevention of Surgical Site infection in india 282Sanjay B Kulkarni
37. AiDS and the orthopedic Surgeon 294SS Rajderkar, SA Ranjalkar
SEcTion 7: Tuberculosis of Skeletal SystemSection Editor: SM Tuli
38. Epidemiology and Prevalence 301SM Tuli
39. Pathology and Pathogenesis 303SM Tuli
40. The organism and its Sensitivity 309SM Tuli
41. Diagnosis and investigations 310SM Tuli
42. Evolution of Treatment of Skeletal Tuberculosis 316SM Tuli
43. Antitubercular Drugs 318SM Tuli
44. Principles of Management of osteoarticular 321 TuberculosisSM Tuli
45. Tuberculosis of the Hip Joint 330SM Tuli
46. Tuberculosis of the Knee Joint 342SM Tuli
47. Tuberculosis of the Ankle and Foot 349SM Tuli
48. Tuberculosis of the Shoulder 353SM Tuli
49. Tuberculosis of the Elbow Joint 355SM Tuli
50. Tuberculosis of the Wrist 358SM Tuli
51. Tuberculosis of Short Tubular Bones 360SM Tuli
52. Tuberculosis of the Sacroiliac Joints 362SM Tuli
53. Tuberculosis of Rare Sites, Girdle and Flat Bones 364SM Tuli
54. Tuberculous osteomyelitis 368SM Tuli
55. Tuberculosis of Tendon Sheaths and Bursae 372SM Tuli
56. Tuberculosis of Spine: clinical Features 374SM Tuli
57. Tuberculosis of Spine: Radiographic 379 Appearances and Findings on Modern imagingSM Tuli
58. Tuberculosis of Spine: Differential Diagnosis 391SM Tuli
59. Tuberculosis of Spine: neurological Deficit 397AK Jain
60. Management and Results 416SM Tuli
61. Surgery in Tuberculosis of Spine 430SS Babhulkar, SM Tuli
62. operative Treatment 439SM Tuli
63. Relevant Surgical Anatomy of Spine 453SM Tuli
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64. Atypical Spinal Tuberculosis 456Anil Jain
65. The Problem of Deformity in Spinal Tuberculosis 460S Rajsekharan
SEcTion 8: Systemic complications in orthopedics
Section Editor: Sunil G Kulkarni
66. Shock 469Uday Phatak
67. crush Syndrome 472V Paramshetti
68. Disseminated intravascular coagulation 476Uday Phatak
69. Thromboembolism 479Uday Phatak
70. Fat Embolism Syndrome: Adult Respiratory 481 Distress SyndromeMilind G Kulkarni, Fouad Tariq Aziz
71. orthopedic Manifestations of Sickle cell 484 HemoglobinopathySS Babhulkar
72. Gas Gangrene and Tetanus 490Uday Phatak72.1 Gas Gangrene 490
72.2 Tetanus 491
SEcTion 9: orthopedic RheumatologySection Editor: Manish Khanna
introduction Manish Khanna
73. Rheumatoid Arthritis: Etiopathogenesis, 495 clinical Features and ManagementManish Khanna
74. Ankylosing Spondylitis and other Seronegative 502 SpondyloarthropathiesBhaskar Borgohain, S Lahkar
75. Surgical Management in Rheumatoid Arthritis 509Manish Khanna, Rashmi Chopra
76. crystal Deposition Disorders 515G Omkarnath
77. Juvenile Rheumatoid Arthritis 535Pradeep Agarwal, Manish Khanna
SEcTion 10: Peripheral nerve injuriesSection Editors: Mukund R Thatte, Anil Bhatia
78. injuries of Peripheral nerve 547Mukund R Thatte, RL Thatte
79. Electrodiagnostic Assessment of 553 Peripheral nerve injuriesKA Mansukhani, Mukund R Thatte
80. Painful neurological conditions of 560 Unknown EtiologyMandar Agashe, Mukund R Thatte
81. Management of Adult Brachial Plexus injuries 563Mukund R Thatte, Anil Bhatia, RL Thatte
82. injection neuritis 578Mandar Agashe, Mukund R Thatte
83. Median, Ulnar and Radial nerve injuries 580Vidisha S Kulkarni
84. Tendon Transfers 586Mukund R Thatte, RL Thatte
85. Entrapment neuropathy in the Upper Extremity 595Mukund R Thatte
86. Affections of Sciatic nerve 601Sunil G Kulkarni
87. Peroneal nerve Entrapment 603Sunil G Kulkarni
88. Anterior Tarsal Tunnel Syndrome 606Vidisha S Kulkarni
89. Lateral Femoral cutaneous nerve Entrapment 608Mandar Agashe, Mukund R Thatte
Volume TWo
SEcTion 11: Bone TumorsSection Editors: Ajay Puri, Prakash Naik
90. Principles of Management of Bone Tumors 613Ajay Puri
91. Radiology of Bone Tumors 622Khushboo Pilania, Bhavin Jankharia
92. Role of nuclear imaging 634Venkatesh Rangarajan, Nilendu Purandare, Sneha Shah, Archi Agrawal
93. Pathology of Bone Tumors 638Sujit Joshi, Yogesh Panchwagh
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94. Benign cartilage Tumors 641Dominic K Puthoor, Wilson Iype
95. other Benign and Miscellaneous Bone Tumors 653Ashish Gulia, Ajay Puri
96. Giant cell Tumor of Bone 664Ajay Puri, Ashish Gulia
97. common Malignant Bone Tumors 667Ajay Puri, Ashish Gulia
98. chemotherapy in Bone Tumors 675Girish Chinnaswamy
99. current Status of Megaprostheses 679 in Limb SalvageMayilvahanan Natrajan
100. Role of Allografts and Bone Substitutes 681Rajesh Malhotra, Ravijot Singh
101. Metastasis of Long Bones 689Sudhir K Kapoor, Saurabh Kapoor, Pradeep Singh
102. Spinal Tumors and Spinal Metastasis 696S Rajasekaran
103. Multiple Myeloma 711Ajay Puri, Ashish Gulia
104. Soft Tissue Sarcomas 714Ajay Puri
105. cancer Pain Management 717PN Jain
106. Palliative care and Quality of Life in 721 Advanced Bone and Soft Tissue cancerMary Ann Muckaden, Jayita Deodhar, Shrikant Atreya
SEcTion 12: BiomaterialSection Editor: Nagesh Naik
107. Biomechanics and Biomaterials in orthopedics 727Vikas Agashe, Nagesh Naik
108. implants in orthopedics 730Anand J Thakur, Mandeep Dhillon108.1 Metals and implants in orthopedics 730
Anand J Thakur
108.2 Bioabsorbable implants in orthopedics 738 Mandeep Dhillon
SEcTion 13: Fractures and Fracture Dislocation: General considerations
Section Editor: GS Kulkarni
109. Fractures Healing 743GS Kulkarni
110. Principles of Fractures and Fracture Dislocations 757GS Kulkarni, Sujay M Kulkarni
111. Stress Fractures 769Milind G Kulkarni, Madhura Kulkarni, Achut Rao
112. Principles of Two Systems of Fracture Fixation: 771 compression System and Splinting SystemGS Kulkarni, Nitish Arora
113. Recent Advances in internal Fixation of Fractures 799U Holz, I Lorenz
114. nonoperative Treatment of Fractures 813 of Long BonesDK Taneja
115. Treatment of Fracture of Shaft of Long Bones 820 by Functional castGS Kulkarni
116. open Fractures 825S Rajasekaran, J Dheenadhayalan, A Devendra, P Ramesh
117. negative Pressure Wound Therapy 845 (Vacuum-assisted closure)GS Kulkarni, Madhura Kulkarni
118. Soft Tissue coverage for Lower Extremity 852S Raja Sabhapathy
119. Bone Grafting and Bone Substitutes 860GS Kulkarni, P Rathi
120. Polytrauma: Management of orthopedic injuries 872 (Damage control orthopedics)Dhiren Ganjawala, Pankaj Patel
121. Abdominal Trauma 876BD Pujari
122. chest Trauma 880HK Pande
123. Trauma to the Urinary Tract 885S Purohit
124. Head injury 889Sanjay Kulkarni
125. Fractures of the Mandible 891AA Kulkarni
126. Temporomandibular Joint Disorders 897AA Kulkarni
127. compartment Syndrome 902GS Kulkarni, Nitish Arora
128. Anesthesia in orthopedics 912BM Diwanmal, Sandeep M Diwan128.1. orthopedic Anesthesia and Postoperative 912
Pain Management BM Diwanmal
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128.2 Local Anesthesia and Pain Management 926 in orthopedics
Sandeep M Diwan
129. Medical Aspects 935S Sane, BS Diwan 129.1 Medicolegal Aspects in orthopedics 935
S Sane
129.2 Medical Practice and Law 938 BS Diwan
SEcTion 14: intramedullary nailingSection Editor: Anand J Thakur
130. intramedullary nailing of Fractures 945Anand J Thakur
131. Plate Fixation of Fractures 978GS Kulkarni, Anand J Thakur131.1 Bone Screws 978
131.2 Plating 984
131.3 Locking Plate 989
131.4 Precontoured (Special Plating) 1005 Anand J Thakur
SEcTion 15: External FixatorSection Editor: Anand J Thakur
132. External Fixation 1013Anand J Thakur
133. Unilateral Dynamic Axial Fixator 1035Hiranya Kumar Seenappa, Manoj Kumar Shukla
134. Management of Trauma by Joshi’s External 1045 Stabilization SystemBB Joshi, BB Kanaji, Ram Prabhoo, Rajesh Rohira
SEcTion 16: ilizarov MethodologySection Editor: GS Kulkarni
135. The Magician of Kurgan: Professor GA ilizarov 1059HR Jhunjhunwala
136. Biomechanics of ilizarov Ring Fixator 1060GS Kulkarni
137. Biology of Distraction osteogenesis 1071J Aronson, GS Kulkarni
138. operative Technique of ilizarov Method 1078Milind G Kulkarni
139. Advances in ilizarov Surgery 1087SA Green
140. Bone Transport 1094GS Kulkarni
141. Fracture Management 1096RM Kulkarni
142. nonunion of Fractures of Long Bones 1100GS Kulkarni, Rajiv Limaye
143. corrections of Deformity of Limbs 1118Dror Paley143.1 normal Lower Limbs Alignment and
Joint orientation 1118
143.2 Radiographic Assessment 1124
143.3 Frontal Plane Mechanical and Anatomic Axis Planning 1126
143.4 Translation and Angulation—Translation Deformities 1128
143.5 oblique Plane Deformities 1146
143.6 Sagittal Plane Deformities 1153
144. calculating Rate and Duration of Distraction 1168 for Deformity correctionJE Herzenberg
145. Bowing Deformities 1171RM Kulkarni
146. osteotomy consideration 1182Dror Paley
147. Taylor Spatial Frame 1193Milind Chaudhary
148. ortho-SUV Frame 1199Mangal Parihar, Viktor Vilensky, Leonid Solomin
149. Management of Fibular Hemimelia Using 1205 the ilizarov MethodRM Kulkarni, Rajiv Negandhi
150. Foot Deformities 1213GS Kulkarni
151. Multiple Hereditary Exostosis 1230RM Kulkarni
152. Limb Length Discrepancy 1233DK Mukherjee, Mandar Agashe
153. Limb Lengthening in Achondroplasia and 1253 other DwarfismRM Kulkarni, Milind Chaudhary
154. Postoperative care in the ilizarov Method 1259Mangal Parihar
155. Problems, obstacles, and complications of Limb 1264 Lengthening by the ilizarov TechniqueDror Paley
156. complications of Limb Lengthening: 1278 Role of Physical TherapyArvind Bhave
157. Aggressive Treatment of chronic osteomyelitis 1281GS Kulkarni, Muhammod Tariq Sohail
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158. Thromboangiitis obliterans 1286GS Kulkarni
159. Late Effects of Poliomyelitis Management 1292 of neglected casesVM Agashe
160. Management of neglected cases of 1296 Poliomyelitis Presenting for Treatment in Adult LifeJJ Patwa
SEcTion 17: ArthroscopySection Editors: Anant Joshi, Dinshaw Pardiwala,
GS Kulkarni
161. introduction 1305Dinshaw Pardiwala
162. Diagnostic Knee Arthroscopy 1307P Sripathi Rao, Kiran KV Acharya
163. Loose Bodies in the Knee Joint 1313Sanjay Garude
164. Arthroscopy in osteoarthritis of the Knee 1317J Maheshwari
165. Anterior cruciate Ligament-deficient Knee 1319Yathiraj BR, Sujit Kadrekar, Dinshaw Pardiwala
166. Failed Anterior cruciate Ligament 1326 Reconstruction and Revision SurgerySujit Kadrekar, Yathiraj BR, Dinshaw Pardiwala, Anant Joshi
167. Posterior cruciate Ligament Deficient Knee 1332Yathiraj BR, Sujit Kadrekar, Dinshaw Pardiwala
168. Posterolateral Rotatory instability of the Knee 1337Sujit Kadrekar, Yathiraj BR, Dinshaw Pardiwala
169. Allografts in Knee Reconstructive Surgery 1344Sujit Kadrekar, Yathiraj BR, Dinshaw Pardiwala
170. Shoulder Arthroscopy: introduction, Portals 1352 and Arthroscopic AnatomyClement Joseph, David V Rajan
171. Superior Labrum Anterior and Posterior: 1360 Tears of ShoulderSujit Kadrekar, Yathiraj BR, Dinshaw Pardiwala
SEcTion 18: Trauma Upper LimbSection Editors: J Dheenadhayalan, Vidisha S Kulkarni
172. Fractures of the Shoulder Region 1369GS Kulkarni, Ankit Varshneya, Vidisha S Kulkarni, RM Kulkarni
172.1 Fractures of the clavicle 1369 Ankit Varshneya
172.2 Fractures of the Scapula 1374 GS Kulkarni, Ankit Varshneya,
Vidisha S Kulkarni, RM Kulkarni
173. injuries of the Shoulder Girdle 1376 GS Kulkarni, Milind Kulkarni, J Dheenadhayalan173.1 Acute Traumatic Lesions of the Shoulder
Sprains, Subluxation and Dislocation 1376 GS Kulkarni, Milind Kulkarni
173.2 Fractures of Proximal Humerus 1381 J Dheenadhayalan
174. Fractures of the Humerus 1396KP Srivastava, Madhura Kulkarni
SEcTion 19: injuries of ElbowSection Editor: Prakash P Kotwal
175. Fractures of Distal Humerus in Adults 1411Sudhir Babhulkar
176. injuries Around Elbow 1431Abhinav Agarwal, Prakash P Kotwal, Mohammed Sadiq176.1 Fractures of the olecranon 1431
Prakash P Kotwal, Abhinav Agarwal
176.2 Sideswipe injuries of the Elbow 1436 Prakash P Kotwal, Abhinav Agarwal
176.3 Monteggia Fracture Dislocation 1440 Prakash P Kotwal, Mohammed Sadiq
177. Dislocations of Elbow and Recurrent instability 1444Alex Sonaru, Justin Gettings, Guido Marra
178. Fractures of the Radius and Ulna 1449Prakash P Kotwal, Amit Singla
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SEcTion 20: Trauma Lower Limbs and Pelvis
Section Editor: GS Kulkarni
179. Fractures of Pelvic Ring 1455CJ Thakkar
180. Fractures of Acetabulum 1463Ramesh Kumar Sen, Sujit Kumar Tripathy
181. Fractures and Dislocations of the Hip 1482GS Kulkarni181.1 Protrusio Acetabuli 1482
Kiran M Doshi
181.2 osteitis condensans ilii 1484 Kiran M Doshi
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182. Fractures of neck of Femur 1485Milind G Kulkarni
183. intertrochanteric Fractures of Femur 1520GS Kulkarni, Rajiv Limaye, Sunil G Kulkarni
184. Subtrochanteric Fractures of the Femur 1547Sudhir S Babhulkar
185. Diaphyseal Fractures of the Femur in Adults 1558Pradeep Kothadia
186. Fractures of the Distal Femur 1568Narinder Kumar Magu
187. Extensor Apparatus Mechanism: injuries and 1584 TreatmentsShiva Shankar Jha
188. intra-articular Fractures of the Tibial Plateau 1597Sushrut Babhulkar, Amol Patil
189. Diaphyseal Fractures of Tibia and Fibula 1616 in AdultsS Rajasekaran
190. Pilon Fracture 1642Manan Gujarathi
SEcTion 21: injuries of the SpineSection Editor: Ketan Pande
191. cervical Spine injuries and their Management 1669Ketan Pande
192. Fractures and Dislocations of 1671 the Thoracolumbar SpineKetan Pande
SEcTion 22: neglected TraumaSection Editor: GS Kulkarni
193. neglected Trauma in Upper Limb 1675GS Kulkarni193.1 Displaced neglected Fracture of Lateral
condyle Humerus in children 1685 GS Kulkarni
193.2 neglected Physeal injuries 1688 GS Kulkarni
194. neglected Trauma in Lower Limb 1690GS Kulkarni194.1 neglected Fracture: neck of Femur,
Miscellaneous and other Fractures of Femur 1690
GS Kulkarni
194.2 neglected Fracture: neck of Femur 1703 GS Kulkarni
194.3 neglected Traumatic Dislocation of Hip in children 1707
GS Kulkarni
195. neglected Trauma in Spine and Pelvis 1710GS Kulkarni
SEcTion 23: HandSection Editor: Sudhir Warrier
196. Functional Anatomy of the Hand: Basic 1715 Techniques and RehabilitationPrakash P Kotwal, Vivek Shankar
197. Examination of the Hand 1722Vidisha S Kulkarni
198. Fractures of the Hand 1731Sudhir Warrier
199. Dislocations and Ligamentous injuries 1741Sudhir Warrier
200. crush injuries of the Hand 1748Aditya Kaushik, Ram Prabhoo
201. Skin and Soft Tissue cover in the Hand 1758Leena Jain, Samir Kumta, Rashmi Raut
202. Flexor Tendon injury 1775Sudhir Warrier
203. Extensor Tendon injuries 1784S Raja Sabapathy, Praveen Bhardwaj
204. congenital Hand Anomalies 1796Mukund R Thatte, Nayana Nayak
205. complex Regional Pain Syndrome 1800 (Sudecks Dystrophy)Sandeep Diwan, Madhura Kulkarni
206. infections in the Hand 1811Anil Bhat
207. Volkmann’s ischemic contracture 1823VK Pande, H Gehlot
208. Dupuytren’s contractures 1829Conor JC Gouk, Randy R Bindra
209. Stiff Fingers and Wrist 1836Vidisha S Kulkarni, Raviraj Patil
210. Disorders of the nail 1840S Raja Sabapathy, R Raja Shanmugakrishnan
211. Tumors and Swellings 1847GA Anderson
212. Hand Splinting 1858BB Joshi
213. Amputations 1876Vidisha S Kulkarni, Emmanuel Bhore
214. Arthrodesis 1887Binu P Thomas, Kiran Sasi P
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215. Fractures of carpal Bones 1897Aashish Gulati, Joseph J Dias
216. carpal instability 1904Sudhir Warrier
217. Kienböck’s Disease 1914Chong Jin Yeo, Gregory Ian Bain
218. new Horizons in Hand Surgery 1924Randy R Bindra, Nicolas Dedy
SEcTion 24: injuries of WristSection Editor: Prakash P Kotwal
219. Surgical Anatomy of the Wrist 1931Prakash P Kotwal, Samarth Mittal, Bhavuk Garg
220. Examination of the Wrist 1937Sureshwar Pandey
221. Fracture of the Distal End Radius 1944Prakash P Kotwal, Vivek Shankar
222. Distal Radioulnar Joint 1960Binu P Thomas, R Sreekanth
SEcTion 25: Disorders of WristSection Editor: Prakash P Kotwal
223. De Quervain’s Stenosing Tenosynovitis 1975Prakash P Kotwal, Samarth Mittal
224. carpal Tunnel Syndrome 1979Prakash P Kotwal, Samarth Mittal
225. chronic Tenosynovitis 1986Prakash P Kotwal, Samarth Mittal
SEcTion 26: Diseases of ElbowSection Editor: Parag Shah
226. introduction 1993Sudhir Babhulkar, Sureshwar Pandy, GS Kulkarni226.1 Anatomy and Biomechanics 1993
Sudhir Babhulkar
226.2 clinical Examination and Radiological Assessment 1999
Sureshwar Pandey, GS Kulkarni
227. Arthroscopy of the Elbow: The Basics 2008Jeremy Burnham, Kevin Murr, Srinath Kamineni
228. The Arthritic Elbow 2015Narayana Prasad, David Stanley
229. Miscellaneous Lesion of the Elbow 2022Sudhir Babhulkar, Mark Yuhas, Srinath Kamineni
229.1 Lateral and Medial Epicondylitis: Tennis and Golfer’s Elbow 2022
Mark Yuhas, Srinath Kamineni
229.2 Pronator Teres Syndrome (Anterior Elbow Pain) 2029
Sudhir Babhulkar
229.3 Anterior interosseous Syndrome 2030 Sudhir Babhulkar
229.4 Posteromedial Elbow impingement 2032 Sudhir Babhulkar
229.5 Valgus Extension overload Syndrome 2033 Sudhir Babhulkar
229.6 Triceps Tendon Rupture 2034 Sudhir Babhulkar
229.7 Biceps Tendon Rupture 2036 Sudhir Babhulkar
230. Stiff Elbow 2041Vidisha S Kulkarni, Madhura Kulkarni
231. Abnormal Heterotrophic calcification 2047 and ossificationVidisha S Kulkarni, Madhura Kulkarni
232. Supracondylar Fracture of the Humerus 2055 in childrenSudhir Babhulkar
SEcTion 27: Diseases of ShoulderSection Editor: Ashish Bhabhulkar
233. Functional Anatomy of Shoulder Joint 2069Deepthi Nandan Adla
234. clinical Examination of Shoulder 2079Ashish Babhulkar
235. Shoulder Positioning, Basic Portals and Beach 2089 chair versus Lateral Decubitus PositionAmit Nath Misra
236. Shoulder instability 2094Shashank Misra
237. instability with Glenoid Bone Loss 2106Sanjay Garude
238. Rotator cuff Tears 2108Vivek Pandey, Ajay Singh Thakur
239. Adhesive capsulitis (Frozen Shoulder) 2126Shirish Pathak
240. Acromioclavicular Joint injuries 2133Ashish Babhulkar, Aditya Pawaskar
241. Suprascapular nerve compression 2139Amol Tambe, Kanthan Theivendran, Marcus Bateman
242. Shoulder Replacement in Proximal 2144 Humerus FractureAshish Babhulkar, Pavan Desai
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243. Tumors Around the Shoulder 2154Yogesh Panchwagh
244. Shoulder Rehabilitation 2164Himani Kolhatkar, Ashish Babhulkar
SEcTion 28: cervical SpineSection Editors: HS Chhabra, S Rajasekaran,
Saumyajit Basu, Bhavuk Garg
245. The cervical Spine: Anatomy, Movement, 2177 Biomechanics, instabilityBharat R Dave, Amish Sanghvi, Devanand
246. Surgical Approaches to the cervical Spine 2192Satish Rudrappa, Vishal Kumar, Amit Chanduka, Bharath R, Swaroop Gopal
247. congenital craniovertebral Anomalies 2209Sanganagouda S Patil, S Karunakaran, Abhay Nene, Saumyajit Basu
248. cervical Disc Degenerative Disorders 2224Bhavuk Garg, Vikas Tandon
249. The inflammatory Diseases of 2246 the cervical SpineGururaj M Sangondimath, Ankur Nanda, Amit Narayan
250. cervical canal Stenosis 2263Bidre Upendra, Ketan Khurjekar
251. ossification of the Posterior Longitudinal 2272 LigamentAmit Jhala, Deepu Banerji
SEcTion 29: Lumbar Spine DisordersSection Editors: HS Chhabra, S Rajasekaran
252. clinical Biomechanics of the Lumbar Spine 2281Jwalant Mehta, Ishwara Keerthi
253. Examination of Spine 2289Janardhana Aithala, Saurabh Kapoor
254. Back Pain 2310VT Ingalhalikar, Laxmi Vas, Renuka Pai, Shubhada Kher, Anagha Vaze
255. investigations for Spinal Pathology 2335Yogesh Pithwa, Neeraj B Vasavada
256. Rehabilitation of Low Back Pain/conservative 2349 care of Back Pain and Back School TherapyHS Chhabra, Sahil Batra, Areena D’souza
257. Psychological Aspects of Back Pain 2366Thomas J Kishen, Ajoy Prasad Shetty
258. Degenerative Diseases of Disc 2371Samir Dalvie, Yuvaraja
259. Acute Disc Prolapsed 2380Gautam Zaveri, S Siddiqui, Srinivasa Moolya, Vishal Kundanani
260. Endoscopic Discectomy 2388Mohinder Kaushal, Jean Destandau
261. newer Techniques in Lumbar Spine Surgery 2394Sajan K Hegde, Aditya Prasad Panda
262. Surgery of Lumbar canal Stenosis 2404Aravind Kumar, Kenny S David, Naresh Kumar
263. Spondylolisthesis 2412KV Menon, Prashant Kekre, Rajesh Parasnis
264. Failed Back Surgery Syndrome 2421Shankar Acharya, Shailesh Hadgaonkar
265. complications in Spinal Surgery 2429Karthik Kailash, Subir N Jhaveri
266. Spinal Fusion 2438Arvind G Kulkarni, Shumayou Dutta, Pravin Kanabar
267. Ankylosing Disorders including Ankylosing 2447 Spondylitis and Diffuse idiopathic Skeletal Hyperostosis SyndromeRam Chaddha, Srikanthnara
268. Postoperative Spinal infection 2450Prasad Krishnan, Krishnamurthy Sridhar, K Venkatesan
269. Degenerative Scoliosis 2458Saumyajit Basu, Sreeramalingam Rathinavelu, Tarun Suri
270. Adolescent idiopathic Scoliosis 2467Suresh Pillai, Suryaprakash Rao
Volume FouR
SEcTion 30: The HipSection Editor: Sudhir Babhulkar
271. Surgical Anatomy of Hip Joint 2495Sudhir Babhulkar
272. Surgical Approaches to the Hip Joint 2498K Hardinge
273. Examination of the Hip Joint 2505Sureshwar Pandey
274. Biomechanics of the Hip Joint 2523Sudhir Babhulkar, Sushrut Babhulkar
275. Soft Tissue Lesions around the Hip 2525Sudhir Babhulkar, D Patil
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276. Girdlestone Arthroplasty of the Hip 2527Sudhir Babhulkar, Sushrut Babhulkar
277. osteotomies around the Hip 2529Sudhir Babhulkar, Sushrut Babhulkar
278. Avascular necrosis of Femoral Head and 2539 its ManagementDP Baksi
279. Pelvic Support osteotomy by ilizarov 2546 Technique in childrenRM Kulkarni
SEcTion 31: injuries of the Knee JointSection Editor: Sunil G Kulkarni
280. Surgical Anatomy and Biomechanics 2553 of the Knee Emmanuel Bhore
281. Knee injuries 2560Raviraj Patil, David V Rajan, Clement Joseph Medial collateral Ligament injuries
of the Knee 2579David V Rajan, Clement Joseph
282. Dislocations of Knee and Patella 2585DP Baksi
SEcTion 32: Diseases of the Knee JointSection Editor: Shubhranshu S Mohanty
283. clinical Examination of Knee 2593Nirmal C Mohapatra, Shubhranshu S Mohanty
284. congenital Deformities of Knee 2608Shaligram Purohit, Kumar Kaushik Dash
285. Disorders of Patellofemoral Joint 2611Ajay Chandanwale, Nikhil Sharma, Anoop Jhurani, Tushar Rathod
286. osteoarthritis of Knee and High 2622 Tibial osteotomyShubhranshu S Mohanty, Kumar Kaushik Dash
287. osteochondritis Dissecans of the Knee 2630Nandan Rao, Prashant Kamble, Ketan Gandhi
288. Miscellaneous Affections of Knee 2634Kumar Kaushik Dash, Tushar Rathod, Prashant Kamble, Nikhil Sharma, Shubhranshu S Mohanty288.1 Quadriceps contracture 2634
288.2 Bursae Around the Knee 2637
288.3 Stiff Knee 2639
288.4 Hemophilic Arthropathy of the Knee 2644
289. Recent Advances in Knee Joint 2646Kumar Kaushik Dash, Shubhranshu S Mohanty
SEcTion 33: injuries of the Ankle and FootSection Editor: Mandeep Dhillon
290. Functional Anatomy of Foot and Ankle: 2657 Surgical ApproachesJR Hanson, Sureshwar Pandey, Jitendra Mangwani
291. Biomechanics of the Foot 2666Mark A Hardy
292. General considerations of the Ankle Joint 2673Mandeep Dhillon, Siddhartha Sharma, Nirmal Raj Gopinathan, Rajiv Shah, Sarvdeep Dhatt292.1 Examination of the Ankle Joint 2673
Mandeep Dhillon, Siddhartha Sharma, Nirmal Raj Gopinathan
292.2 Radiological Evaluation of the Foot and Ankle 2681
Rajiv Shah, Sarvdeep Dhatt
293. Fractures of the Ankle 2694RB Dalal, HK Sugathan
294. Ligamentous injuries around Ankle 2707Kartik Hariharan, Sanjit Singh
295. Talar and Peritalar injuries 2715Mandeep Dhillon, Siddhartha Sharma
296. injuries of the Midfoot 2726Vikas Agashe, Aditya Menon, Raju Gite
297. injuries of the Forefoot 2735Sampat D Patil, Sureshwar Pandey
298. Tendon injuries around Ankle and Foot 2741Sureshwar Pandey, Rajiv Limaye
SEcTion 34: Disorders of Ankle and FootSection Editor: Rajiv Shah
299. Pediatric Foot and Ankle Disorders 2753RM Kulkarni, Rajiv Negandhi, Mandeep Dhillon299.1 Metatarsus Adductus 2753
RM Kulkarni, Rajiv Negandhi
299.2 congenital Vertical Talus 2755 Mandeep Dhillon
300. Hallux Valgus 2761Mark A Hardy, Jennifer L Prezioso, Eric J Lew, Lauren L Kishman
301. First Metatarsophalangeal Disorders 2783Yogesh Nathadwarawala301.1 Hallux Rigidus 2783
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301.2 Hallux Varus 2785
301.3 Disorders of Sesamoids 2786
302. Disorders of Lesser Toe 2787Jitendra Mangwani302.1 Metatarsalgia 2790
Rajiv Limaye
303. Adult-aquired Flatfoot 2791Rajiv Shah, Rajiv Limaye
304. Pes cavus 2795GS Kulkarni, Rajiv Shah
305. Heel Pain 2805Rajiv Shah, Pankaj Patel
306. Achilles Tendon Disorders 2810John S Lewis, Selene G Parekh
307. Ankle Arthritis 2815Christopher E Gross, Samuel B Adams, Selene G Parekh
308. Disorders of Hindfoot and Midfoot Joints 2820Vinod Mishra
309. Diabetic Foot 2824Vinod K Panchbhavi, Shelton McKenzie
310. Rheumatoid Foot Disorders 2829RB Dalal, R Rachha, Malhar Dave, Nikesh Shah310.1 indian Perspective 2834
Malhar Dave, Nikesh Shah
311. nerve Disorders in Foot and Ankle 2836Ashish Shah, Kavita Iyenger
312. Benign Tumors of the Foot and Ankle 2846Mahendra S Kudchadkar
313. charcot neuroarthropathy 2852Vinod K Panchbhavi, Shelton McKenzie
314. nail Disorders in Foot and Ankle 2861Mark A Hardy, Jennifer L Prezioso, Frank Luckino III, Kelly Bumpus
315. orthotics in Foot and Ankle 2873Virendra Shandilya, Nikesh Shah, Malhar Dave315.1 Rational Prescription 2881
Nikesh Shah, Malhar Dave
316. Recent Advances in Foot and Ankle 2882Michael Aynardi, David Pedowitz
SEcTion 35: Pediatric orthopedics: Trauma
Section Editor: Atul Bhaskar
317. Physeal injuries 2893Sandeep Patwardhan
318. Fractures of the Shaft of the Radius 2902 and Ulna in childrenAtul Bhaskar, Alaric Aroojis
319. Fractures around the Elbow in children 2907Rujuta Mehta
320. Fractures of the Distal Forearm, Fractures and 2923 Dislocations of the Hand in childrenAtul Bhaskar
321. Fractures of the Humeral Shaft in children 2931Kevim Lim
322. Fractures and Dislocations of 2935 the Shoulder in childrenMandar Agashe
323. Fractures and Dislocations of 2941 the Spine in childrenArvind Kulkarni
324. Fractures of the Pelvis in children 2949Mandar Agashe
325. Fractures of the Proximal Femur in children 2954Atul Bhaskar
326. Fracture neck of Femur in children 2962Rujuta Mehta
327. Fractures and Dislocations of the Knee 2982Premal Naik, Mallikarjun Balagaon
328. immature Skeleton 2992Rajiv Negandhi
329. Fractures and Dislocations of 2995 the Foot in childrenAtul Bhaskar
330. Birth Trauma 3000Chasnal Rathod
331. The Battered Baby Syndrome (child Abuse) 3008Chasnal Rathod
SEcTion 36: Pediatric orthopedics: General
Section Editors: Premal Naik, Rajiv Negandhi 332. General Pediatric orthopedics 3013
Premal Naik, Parmanand Gupta, Jayanth Sampath, Rajiv Negandhi, Hitesh Shah, Rujuta Mehta, Sandeep Diwan332.1 clinical Examination of child with
orthopedic Problem 3013 Parmanand Gupta
332.2 Gait Analysis 3021
i. normal Gait 3021 Jayanth Sampath, Rajiv Negandhi
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ii. Abnormal Gait 3025 Hitesh Shah
332.3 Genetics in Pediatric orthopedics 3028 Rujuta Mehta
332.4 Anesthetic consideration in Pediatric orthopedics 3038
Sandeep Diwan
333. congenital Anomalies 3042Premal Naik, Ignacio Ponseti, Dhiren Ganjawala, Hitesh Shah, Atul Bhaskar, Tushar Agrawal, Yash Shah, Thomas Palocaren, RM Kulkarni, Rajiv Negandhi, Sandeep Patwardhan333.1 congenital Talipes Equinovarus 3042
(Management of clubfoot) Ignacio Ponseti, Dhiren Ganjawala, Hitesh Shah
333.2 congenital Vertical Talus 3056 Atul Bhaskar
333.3 congenital Knee Dislocation 3060 Tushar Agrawal, Yash Shah
333.4 Developmental Dysplasia of the Hip 3066 Thomas Palocaren
333.5 congenital coxa Vara 3073 Thomas Palocaren
333.6 congenital Pseudarthrosis of Tibia 3076 RM Kulkarni, Rajiv Negandhi
333.7 Shoulders: Sprengel Shoulder 3089 Sandeep Patwardhan
334. Limb Deficiency 3096Premal Naik, Cherry Koovor, Thomas Palocaren, Rujuta Mehta, Mukund R Thatte334.1 congenital Femoral Deficiency 3096
Cherry Koovor
334.2 congenital Tibial Deficiency 3102 Thomas Palocaren
334.3 congenital Radial Deficiency (Radial club Hand) 3104
Rujuta Mehta, Mukund R Thatte
335. Bone and Joint infections and Sequel 3112Premal Naik, Hitesh Shah, Narsimha Ramni, Maulin M Shah3351. neonatal Septic Arthritis 3112
Hitesh Shah
335.2 neonatal osteomyelitis 3114 Narsimha Ramni
335.3 Management of Sequelae of childhood Bone and Joint Sepsis 3118
Maulin M Shah
336. Bone Dysplasia 3129Premal Naik, Jaideep Dhamale, Taral Nagda, Abhishek Kulkarni, Parag Tamhankar, Milind Chaudhary 336.1 osteogenesis imperfecta 3129
Jaideep Dhamale, Taral Nagda, Abhishek Kulkarni, Parag Tamhankar
336.2 Achondroplasia 3149 Milind Chaudhary
336.3 Arthrogryposis Multiplex congenita 3153 Premal Naik
337. Regional Problems 3160Premal Naik, Sanjeev Sabharwal, Rajiv Negandhi, Jaideep Dhamale, Kirti Ramnani, Sandeep Vaidya, Manoj Padman, Anirban Chatterji337.1 Slipped capital Femoral Epiphysis 3160
Sanjeev Sabharwal
337.2 Transient Synovitis 3165 Rajiv Negandhi, Jaideep Dhamale
337.3 idiopathic chondrolysis of Hip 3167 Premal Naik
337.4 chondromalacia Patellae 3170 Sandeep Vaidya
337.5 Recurrent Patellar Dislocation 3172 Manoj Padman
337.6 osgood-Schlatter 3176 Manoj Padman
337.7 Madelung Deformity 3178 Anirban Chatterji
338. Paralytic Disorders 3179Premal Naik, Viraj Shingade, Dhiren Ganjawala, Mandar Acharya, Kirti Ramnani, Venkatdass, Kapil Gangwal, Anil Bhatia338.1 Meningomyelocele 3179
Viraj Shingade
338.2 cerebral Palsy 3185 Dhiren Ganjawala
338.3 Muscular Dystrophy 3195 Kirti Ramnani
338.4 other neurological Disorders 3196
i. Spinal Muscular Atrophy 3196 Kirti Ramnani
ii. Hereditary Motor and Sensory neuropathies 3197 Venkatdass
iii. congenital Absence of Pain (Analgia) 3201 Kirti Ramnani
iv. Friedreich’s Ataxia 3201 Kapil Gangwal
v. obstetrical Palsy Anil Bhatia
339. Perthes Disease 3216Hitesh Shah
340. Angular Deformities in Lower Limb 3221GS Kulkarni, RM Kulkarni, Rajiv Negandhi
341. Toe Walking 3229GS Kulkarni, RM Kulkarni, Rajiv Negandhi
SEcTion 37: MicrosurgerySection Editor: Samir Kumta
342. Microvascular Surgery 3233Samir Kumta, Satish Bhat, Manik Menezes
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SEcTion 38: ArthroplastySection Editor: Javahir A Pachore
343. Total Hip Arthroplasty 3249Javahir A Pachore, HR Jhunjhunwala, Vikram Shah, Shrinand V Vaidya, Prashant P Deshmane, Kanniraj Marimuthu, P Suryanarayan, Baldev Dudani, Ashok K Shyam, Pankush Arora, Arjun Veigus343.1 cemented Hip Arthroplasty: An overview 3249
Javahir A Pachore, HR Jhunjhunwala, Vikram Shah
343.2 An overview of Uncemented Total Hip Arthroplasty and Recent Advances 3300
Shrinand V Vaidya, Prashant P Deshmane
343.3 Revision Total Hip Arthroplasty 3304 Kanniraj Marimuthu, P Suryanarayan
343.4 Bipolar Hip Arthroplasty 3316 Baldev Dudani, Ashok K Shyam,
Pankush Arora, Arjun Veigus
344. Total Knee Arthroplasty 3320Hemant Wakankar, Sushrut Babhulkar, AV Gurava Reddy, Sachin Tapasvi, Chirag Thonse, Mahesh Kulkarni, Siddharth Shah, Arun Mullaji, Harish Bhende, Parag Sancheti, Ashok K Shyam, Sunny Gugale, Khalid Alquwayee, Fares S Haddad, Bassam A Masri, Donald S Garbuz, Clive P Duncan, Vikram Shah, Kalpesh Shah, Ashok Rajgopal, Attique Vasdev 344.1 overview and Basic concepts 3320
Hemant Wakankar
344.2 indications and contraindications 3328 Sushrut Babhulkar
344.3 Preoperative Evaluation 3331 AV Gurava Reddy
344.4 Prosthesis Designs consideration 3334 Sachin Tapasvi, Chirag Thonse
344.5 Primary Total Knee Arthroplasty: Approaches and incision considerations 3341
Mahesh Kulkarni
344.6 correction of Varus and Valgus Deformity During Total Knee Arthroplasty 3345
Siddharth Shah, Arun Mullaji
344.7 Soft Tissue Balancing in Total Knee Replacement 3349
Harish Bhende
344.8 Unicompartmental Knee Arthroplasty 3355 Arun Mullaji, Siddharth Shah
344.9 complications of Total Knee Arthroplasty 3360 Siddharth Shah, Arun Mullaji
344.10 Long-term Results of Total Knee Arthroplasty 3367
Parag Sancheti, Ashok K Shyam, Sunny Gugale
344.11 Approaches for Revision Knee Arthroplasty Surgery 3374
Khalid Alquwayee, Fares S Haddad, Bassam A Masri, Donald S Garbuz, Clive P Duncan
344.12 Principles of Revision TKR for Aseptic Loosening 3379
Hemant Wakankar
344.13 infected Total Knee Replacement 3381 Vikram Shah, Kalpesh Shah
344.14 Results of Revision Total knee Arthroplasty 3386 Ashok Rajgopal, Attique Vasdev
345. Shoulder Arthroplasty 3391 Amit Nath Misra, SKS Marya
346. Total Elbow Arthroplasty 3407DP Baksi
347. Ankle Arthroplasty 3415 Rajiv Limaye
SEcTion 39: ArthrodesisSection Editor: Sudhir Kumar
348. Shoulder Arthrodesis 3419Sudhir Kumar, IK Dhammi
349. Hip Arthrodesis 3426AK Jain, IK Dhammi
350. Knee Arthrodesis 3435IK Dhammi
351. Ankle Arthrodesis 3441Sudhir Kumar, AK Jain, IK Dhammi
352. Retrograde Tibial nailing for Arthrodesis 3449 of Ankle and Subtalar JointsGS Kulkarni
SEcTion 40: AmputationsSection Editor: Nagesh Naik
353. Amputations 3459R Siwach, AS Rao, Sujay M Kulkarni
SEcTion 41: Rehabilitation: Prosthetics and orthotics
Section Editor: Nagesh Naik
354. Prosthetics and orthotics: An introduction 3483Nagesh Naik
355. Upper Extremity Prostheses 3490Nagesh Naik
356. Rehabilitation of Adult Upper Limb Amputee 3497Nagesh Naik
357. Lower Limb Prosthesis 3503Nagesh Naik
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358. Upper Limb orthoses 3520Nagesh Naik
359. Lower Limb orthoses 3529Nagesh Naik
360. Physical Therapy and Therapeutic Exercises 3541Nagesh Naik
361. orthopedic Rehabilitation 3553Nagesh Naik
362. Rehabilitation of Spinal cord injury 3557HC Goyal, Nagesh Naik
363. Disability Process and Disability Evaluation 3568Nagesh Naik
364. Wheelchair and Mobility Aids 3571Nagesh Naik
365. Spinal orthoses 3574Nagesh Naik
366. Elbow Rehabilitation 3585Hari Ankem
Index I-1
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IntroductionTo improve the rotational stability, interlocking concept was introduced, where thick, hollow nail was introduced after closed reduction under C-arm control and nail was locked on both ends to improve the rotational stability of the construct under C-arm control. Today, interlocking nail of tibia, femur and humerus is well established for diaphyseal fractures, for proximal and distal end of long bones, there are newer methods of locking plate, is now becoming a preferred treatment.
Tibia Interlocking Nail
Indications They include the following:• All closed fractures of the tibia, fresh, or nonunion and
malunion. Except those at the ends of the bone.• Deformity correction.• Limb-lengthening procedures.• Arthrodesis.
Procedure of Tibia Nailing
Position of the PatientOn the special table, the patient is positioned supine, a calcaneal pin is passed, and the knee is placed in 90° of flexion. Some surgeons use a supine position on an ordinary table. I personally prefer to use an ordinary table with the knee hanging down at the end or side of the table. The procedure below is described for standard position with calcaneal traction on fracture table first and then on ordinary table (Fig. 1).
Fracture ReductionThe fracture is reduced by traction through the calcaneal pin and confirmed on C-arm. The calcaneal pin should be put parallel to
the ankle-axis to avoid varus or valgus malalignment. The pin is tied to the table with the specially provided stirrup, so that traction can be adjusted while operating. Apply traction on foot piece and reduce fracture manually, and keep traction slightly in distraction, as this helps reduction and passing of guidewires and reamers. Confirm on C–arm, the position of reduction, and then proceed to pass the guidewire.
Surgery on Ordinary TableThe patient lies supine at the edge of the table so that the leg hangs free at a 90° flexion (Fig. 2), or he can lie on the table with straight knee and it is pulled out of the table on the side and knee is kept hanging on side of the table (Fig. 3), or knee is bent at 90° and hip is externally rotated, and entry to the medullary cavity is obtained (Fig. 4). At times while passing the nail, this 90° flexion
Fig. 1 Tibial traction
Intramedullary Nailing of Fractures
Chapter130
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Fig. 2 Hanging leg-I
Fig. 3 Hanging leg on side
Fig. 4 Hanging leg on table
Fig. 5 Split patellar tendon approach
Fig. 6 Medial patellar tendon approach
Point of EntrySome people use a vertical midline incision, starting from the tuberosity, proximally until the patella. However, a transverse incision is cosmetically more acceptable, but exact placing of transverse incision is mandatory; my suggestion is vertical incision is more user friendly. Splitting the patellar tendon or retracting the patellar tendon laterally can gain access to the proximal tibia (Figs 5 and 6). The latter allows access to the tibia without splitting the tendon, but needs retraction of the tendon on lateral side, which is more restricting when knee is flexed. The advantage of the split tendon approach is that it ensures the entry point in the midline. It is shown now that when tendon is split and surgery is done, no damage occurs to the tendon. Anterior knee pain in
is not enough and the knee may have to be bent more than 100°. This position takes very little set-up time and is very handy for any eventualities. Even if one wants to change over to plating, this position is very forgivable. This is the position I use routinely.
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interlocking, initially, was thought to be related to injury of the tendon, which is now shown not related. My preference is split tendon and be in midline, in line of the medullary cavity. A large curved bone awl is used to open the proximal tibial cortex anteriorly at a point 1–1.5 cm below the joint line (Fig. 7). In a smaller patient, it is just below the joint line. I have experienced that at times the space is so small that the starting point has to be just below the articular surface, and a risk of joint exposure exist, which is of no clinical importance. The point of entry has to be in the line of the medullary cavity. The current interlocking nails are stronger nails and will not bend on entering the medullary cavity. The center of the medullary cavity is on the medial half of the tibial tuberosity (Fig. 8).
It is not medial to the tibial tuberosity but is on medial half of tibial tuberosity. A curved awl is taken, entered at the chosen point and directed posteriorly; once halfway in the bone, it is angled to go downward in the direction of the medullary cavity. Once this passage is made, a small noncannulated rigid 7 mm, and later 8 mm reamer is inserted from this point of entry, connecting to the medullary cavity. This step is a must. Do not start putting in the guidewire until the point of entry is connected to the medullary cavity, otherwise the nail insertion will not be in the line of the medullary cavity.
Problems of Point of EntryIf the point of entry is on the tuberosity, the tuberosity will avulse on introduction of the nail and the nail will be exposed in the upper part (Figs 9A to C). The tuberosity is not connected to the medullary cavity; it is only a projection from the bone. So, must remain proximal to the tuberosity.
Fig. 7 Point of entry Fig. 8 Center of medullary cavity
Figs 9A to C Wrong point of entry
A B C
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Fig. 10 Wrong medial point of entry
Fig. 11 Old deformed upper tibia, point of entry laterally in line of medullary cavity
If one is not in the midline, but on the medial side, then reaming will be possible, as the reamer is flexible. But when the nail is introduced, there may be a fracture of the upper end of the tibia (Fig. 10). In case there is an old fracture with malunion, treated by plastering, you will have to choose the point of entry in line with the medullary cavity, wherever it falls (Fig. 11).
ReductionWhen patient is on the traction table, reduction is always achieved and confirmed on C-arm, before starting the procedure. Hanging leg position of reduction is achieved while passing the guidewire by applying traction, slight varus and flexion on the fracture site, and then guidewire is negotiated surgeon should hold the leg in desired reduced position, while guidewire is passed by the assistant.
Insertion of GuidewireAfter connecting the point of entry with the medullary cavity, an olive tipped guidewire is passed into the medullary canal. Closed reduction is carried out and the guidewire is negotiated into the distal fragment. Grating of the bone is felt when the guidewire passes through the distal fragment and the bony end point is experienced on pushing the guidewire distally. It has been observed that if the guidewire has come out inadvertently after reaming, this grating is not felt during reintroduction of the guidewire after reaming.
ReamingSuccessful introduction of the guidewire is confirmed with the C-arm and then the tibia is reamed with a flexible reamer over the olive tip guidewire. The olive tip stops the reamer from progressing into the joint and helps in retrieval of the jammed or broken reamer if it occurs. A nail 1–1.5 mm smaller than the thickest reamer used is chosen. There are a few surgeons who feel that power reamer should be avoided to avoid heat necrosis of the medulla and they use only cannulated solid hand reamers. As bigger size solid hand reamers will not be able to negotiate the isthmus and, also, it is difficult to ream tight isthmus with hand reamers. They ream only the proximal part of the medullary cavity and use thinner nail. I have always felt and done power reamer, and used 9 mm nail most of the time in tibia and 11 mm nail in femur. Though, occasionally, one may not be able to ream more and may need to use 8 mm tibia and 10 mm in femur. This is very infrequent in my practice.
Insertion of NailAfter the medullary canal has been reamed to the correct length and width, the olive tip guidewire is exchanged without losing the reduction of the fracture. A flexible teflon sleeve is passed over the olive tipped guidewire until it is at the lower end of the tibia. Teflon sleeves have a small metal marker (Fig. 12) close to their
Fig. 12 Nail insertion
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tip to facilitate localization. After positioning the sleeve, the olive tipped guidewire is removed. The nontipped guidewire is passed down the tibia through it and the sleeve is then removed. These days, single guidewires are used where same guidewire is used for reamer and, on same guidewire, nail can be passed. This is due to smaller canal of the reamer which does not allow reamer to bypass the end of guidewire, and bigger channel of the nail, which allows guidewire to be extracted out after passing a nail.
Assessment of Nail LengthPut identical length of the guidewire to intramedullary guidewire on the level of bone point of entry. Subtraction of the remaining exposed guidewire, which is intramedullary from the total length of the equal size guidewire, gives the length of the nail. A direct measurement of the guidewire, which is outside the bone, which is not overlapping the inside guidewire, gives the length of the nail (Fig. 13). Alternatively, a radiolucent calibrated measuring ruler can be used to measure the length of the nail (Fig. 14). This length can be checked again by putting the chosen nail on the bone. In mid-shaft fractures, the nail length is chosen so that the tip of the nail remains 1.5–2 cm proximal to the end of the bone for
future dynamization, if required. I suggest, in mid-shaft fractures, ream longer and put a slightly shorter nail. Say, like, ream upto 340 mm and use nail of 320 mm, this will allow dynamization, if needed. In such mid-shaft transverse fractures, I suggest, only do dynamic mode nailing on at least one end of the nail. The nail is then mounted on the insertion jig. If the medullary canal has been adequately reamed, the nail can usually be pushed manually with comparative ease, without hammering. The last part of nail introduction may need gentle hammering. While the nail is passing the fracture area, the surgeon should keep the fracture well reduced and C-arm be used while the nail is passing in straight line in the distal medullary cavity so that iatrogenic fracture does not occur while hammering the nail. Nail should be pushed past the fracture site, and once the nail has entered the distal fragment, only then hammer may be used to push down the nail finally. Minor degrees of malreduction can be corrected merely by the passage of the nail over the fracture, particularly if the fracture is near the isthmus. Holding the jig controls rotation of the nail when passing through the tibia. After the nail has been pushed into the distal fragment, the guidewire is withdrawn. All the nuts and the screws on the jig are tightened if they have become loose while hammering the nail. The traction on the bone is released and the foot is thumped to push the distal fragment proximally, and thus impact the fracture. The distal locking screws are then passed as described below. The distal-most screw is inserted first. The guidewire is reintroduced in the nail. The metal sound produced by contact of the guidewire with the interlocking screw confirms that the screw is within the nail and not outside. Then the proximal screw of the distal two screws is inserted and the guidewire similarly confirms its presence. Then the proximal locking screws are passed with the help of the premounted jig after back-slapping the jig to achieve the impaction at the fracture. Confirm that the limb is in proper rotation while passing the proximal screw (Fig. 15). Use nail of 1 mm or 1.5 mm smaller than the last reamer used. In mid-shaft and proximal fractures, the distal end of the nail should be about 2 cm short to allow dynamization later. But in distal tibia fractures nail must be subchondral to get maximum stability.
Fig. 13 Measuring the length of the nail, by two guidewires
Fig. 14 Alternate means of measurement to measure length of nail, by calibrated measuring ruler
Fig. 15 Avoid malrotation of limb: Distal fragment in external rotation. The distal screws be removed and reintroduced through different cortical holes after correcting the rotation
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Distal LockingAn image intensifier is used for distal locking. A mechanical aiming device to do distal locking, fitted to the proximal side of the nail, does not work. All the nails change shape on being passed down the medullary canal of the tibia and the distal screw holes do not end up correctly aligned with the jig, unlike in proximal locking where the distance is short and nail torsion does not occur. There are various techniques described for locating the distal holes:• Free hand with C-arm.• The use of a special distal aiming device attached to the C-arm
(Grosse Lafforgue device).• The use of radiolucent drilling handles.• The use of the orthofix device later adopted by AO, where a
proximally mounted jig is used for distal locking.• The author’s method without C-arm.
The time required for distal locking is more than for proximal locking, and carries a higher risk of radiation to the patient and the surgeon.
Free Hand TechniqueThis is used in most of the surgeries all over. The patient’s leg is positioned between the source of the X-ray beam and the aiming device. The image intensifier is positioned so that the locking hole appears as a perfect circle on the monitor. This is an important point; any oval-shaped hole is not acceptable. Position the image intensifier so that the distal locking hole is in the center of the monitor and not at the edge. Magnify the image of the hole. It is easier to insert a screw with a magnified image. Then adjust the C-arm in such a position as to get a perfect round circle on the screen and only then proceed with the distal locking. If the image is not round but oval, it must be corrected to achieve the round circle. There are three different types of oval shapes which can be seen on the image intensifier, depending on the position of the limb in relation to the image intensifier. The image will get resolved by moving the image intensifier in one direction, i.e. either in horizontal or a vertical arc or it will have to be moved in both these planes, as shown in Figure 16. Do not change position of the limb to make circle round when hanging leg position is used. Leg is generally externally rotated and flexed at knee, and rested on the operation table (Fig. 17). After the circle has been located, following routine is suggested: First, under C-arm, mark the skin along the longitudinal axis of the nail. Then draw another horizontally at 90° to this line on skin at the level of the hole; this makes an entry point of the locking screw on skin (Fig. 18). Once this level has been found, the Steinmann pin is introduced on the bone to mark the point of entry for the locking hole using a radiolucent rod, to avoid exposure to the hands of the surgeon. Once the point is located with Steinmann pin, use hammer on the Steinmann pin to make a pit on the bone to mark the starting point at which drilling can be started (Fig. 19). In cortical bone, Steinmann pin does not mark easily and, if you use hammer more energetically, it will make a crack in the bone. It is easy to mark on the cancellous bone. So, if distal locking is done at lower end of the bone, where cancellous bone is present, this mark with Steinmann pin will be easily done. If nail stops at the cortical bone and distal locking is planned at that level, then I feel direct drilling with the drill sleeve to avoid the loosing of the point is
Fig. 16 Adjust C-arm according to the circle seen
Fig. 17 Position of leg on operation table for distal locking
Fig. 18 Mark the medullary cavity on skin and holes in nail
more fruitful. The drilling can be done on this point, confirming on C-arm. The self-cutting fixation bolt of a proper size, as measured by depth the gauge, is inserted through the protection sleeve.
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I have observed, that in early learning phase, and trying to lock percutaneously is more demanding and time-consuming, compared to locking with an incision made until the bone. Make a skin incision long enough extending for both screws. Expose the bone and put two spikes. Under the C-arm, localize the point for locking and make a bone impression with the K-wire, so the drill will not skid. Now drill the hole. When an attempt is made to drill at the chosen site percutaneously, the drill skids and the chosen site is lost and the whole procedure has to be repeated. Locating the hole becomes easy and quick, when an incision is made and the center of the bone is visible.
C-arm Mounted Jig (Gross Lafforgue Device) (Fig. 20)The sterile jig mounted on the C-arm is first adjusted by the radiology staff so that the perfect round of locking holes is seen on the screen, then the surgeon puts the protection sleeve on this jig and puts the screw in the usual way.
OrthofixIn order to use a nail-mounted jig, orthofix has made specific instruments. The nail is introduced in the medullary cavity, the deformation of the nail is measured by passing a drill distally from the anterior tibia and then the distance is measured, and the jig is adjusted; the drill and screw are introduced from this jig without the C-arm. This is a very successful innovation, but is not 100% successful. In longer nails and thinner nails, it has a small failure rate. This device has not yet been accepted for common use. Proximal locking is done with the proximal jig mounted on the nail. This is not used by many surgeons. Navigation system now can easily locate the hole without X-ray exposure to the surgeon. After the operation, the patient is advised partial weight bearing, and then full weight-bearing as per patient comfort in noncomminuted fracture.
Distal Locking if the C-arm Conks Out during Surgery
Distal Locking without C-arm In the uncomfortable event that only available C-arm conks out after anesthesia and when surgery has already started, nailing and locking is yet to be done. I am describing this following procedure where operation can be completed. I had described this method in The Journal of Bone and Joint Surgery: British volume 1994 for using locking nail without C-arm. Nailing can easily be done once guidewire is passed and we can check it up with X-ray. Nail is introduced and now distal locking is carried out. If free hanging knee position is used, with jig attached to the proximal end, rotate the hip in external rotation and flex knee (Fig. 18) and adjust it on the table so that leg is resting steady on the operation table. Take a same length nail to that which is inserted in the tibia. Keep that nail on the surface of the medial
Fig. 19 Use of radiolucent handle for distal interlocking—transparent device is helpful
Fig. 20 C-arm mounted device for distal locking
Fig. 21 Identical nail use for distal locking
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Fig. 22 Marking on skin for finding locking hole
Fig. 23 Interpretation of X-ray
Fig. 24 If extra hole is made, block it to drill
Fig. 25 Final placing of locking screw
side of the leg which is resting on the table (Fig. 21). Adjust the nail so that proximal end is matching. Draw a line from the proximal end on the upper level of the inserted nail (Fig. 22). Now take the other identical nail and adjust it matching this skin line on the upper end. Hold it firmly and put sterile tape, if available. Ethistrip or adhesive skin drape is useful. Now nail strapped on the surface matched on the inserted nail and skin marked of the locking distal holes, draw line at the distal holes on the skin. Now remove the nail so that skin marking of the nail is present on the medial side of the nail. On the approximate point of distal locking holes, pass K-wires on these two points as if they are exactly on point on the skin. Two K-wires of 2 mm in diameter are drilled through, which are supposed to roughly match the hole in tibia but not lie exactly over it. An X-ray is taken to see the relation of the tip of the K-wire and the distal locking holes inside the nail (Fig. 23). The wires are removed, a single incision made on the lower end of the tibia medially. The periosteum is elevated and the impression made by the drilled K-wires on the bone is located. The correct drilling point for locking is judged from the radiograph. This is called the “judged point”. Study the radiograph and accordingly select a point exactly on the hole of the nail inside by viewing the relationship of the tip of the K-wire passed earlier and the location of the hole in relation to this K-wire. After localizing the judge point, a second K-wire is used to make an impression on the judged spot, so that the drill does not skid (Fig. 24). A 4–5 mm drill hole is made in the near cortex at the judged point. This hole is countersunk to improve the angular vision inside the tibial medullary cavity. This hole is washed out with saline to remove blood and to clear the view inside the tibial medullary cavity a thin gauze piece can be used to clear this hole
for better visibility. In spite of the tourniquet, a small amount of oozing does occur. Using a 3–4 mm suction tip and a good light source vertically down, one can see the hole inside the tibia nail and a K-wire can be used to feel it. Once the hole is located, takes a 3.2 mm drill bit and manually inserts it through the hole in the near cortex, and in the nail till it touches the opposite cortex. Now, mount the power drill and drill the far cortex. The cortex is drilled with a 3.2 mm drill through the hole tapped and a 4.5 mm screw of the desired length passed. If the drill bit is passed directly by power drill, there may be change in its direction, which may result in its breakage. This works as a substitute for adjusting a perfect round hole on C-arm. The same procedure is repeated for the other holes. The cortical hole in the near cortex may be expanded in case of inability to locate the distal hole. If this hole becomes bigger, than a washer may be used. This may happen in an early stage of learning curve. If the hole is not seen at this site where the tibia is opened with a 4.5 mm drill, there are three possible reasons:1. The tibia hole is directly over the hole in the nail and, hence,
the metal is not visible.2. The tibia hole is far away from the nail hole. Take another X-ray
by readjusting the guidewire.3. If only half the hole is seen.
In some situations, the hole in the near cortex matches the hole in the nail, but not exactly. Thus only a part of the hole in the nail can be seen through the cortical hole (Fig. 25). In this situation, drill another hole in the cortex adjacent to the first. While making this second hole, block the first hole with the drill bit. This will prevent the drill bit from slipping into the first hole while making the second hole.
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A 4.5 mm cortical screw or bolt is introduced through the second hole after tapping the far cortex. Distal-most hole is locked first and confirmed with a guidewire passed from the upper end of the nail. If the screw is inside the nail, a metallic sound will be heard due to the guidewire hitting the screw. This was very well described as tik tok method of confirmation by Dr Shiv Shankar of Sholapur. He also used this method to locate the K-wire in the distal holes. After locating it and before putting the screw in the distal holes, observe the distance. If it traveling down, this will get shorter as the locking progresses sequentially proximally, confirming the position of the screw in the nail. After locking distally, it achieves compression at the fracture, either by compression nail or by backslapping on the proximal-end of the nail with a jig. Then proximal-holes are locked. With experience, the accuracy of distal locking by this method is 100%.
Traps to be Avoided during Tibia Interlocking Nail• Point of entry, above tibial tubercle in the center below joint
level, not on tibial tubercle.• Tendon splitting assures midline entry and knee can be flexed
beyond 90°, if required.• Keep fracture reduced while passing nail to avoid iatrogenic
fracture.• Do not lock when fracture is distracted.• Nail size 1–1.5 mm smaller than last reamer.• Correct length necessary, change the nail if nail is not of correct
length.• Adjust as perfect circle, on the hole, while distal locking by
changing the C-arm axis.• Keep distance between leg and C-arm longest for space for
drill to work.• In early learning curve making, an incision on distal end makes
life comfortable.• While drilling for distal locking, adjust drill straight in line of
the hole.• While removing the reamer, keep guidewire pushed down.• Keep anterior of nail in line, avoids rotation of nail while
introduction.• Stabilize the fracture with hand and align them while passing
nail to avoid iatrogenic fracture.• Push nail with hand across the fracture and start hammering
only after fracture is bypassed.
Lower One-third Fracture of the TibiaLower one-third fractures are a very special problem. The tibia has a good uniform medullary cavity until the junction of the upper two-thirds and lower one-third. At this junction, the medullary cavity starts expanding up to the subchondral bone at the ankle (Fig. 26). The nail has a good hold in the upper fragment. It has a poor hold immediately at the fracture and just distal to it. A good mechanical fixation is the one where the nail has a good bony contact on both sides of the fracture for at least 5 cm. In lower one-third fractures, this hold is poor distally. The distal locking screw also gives better stability if the holes are away from the fracture, which is not possible in the lower one-third fractures. At least
three locking bolts in multidirection are necessary for stability. It is advisable to use a nail which has distal screws at the lower most end of the nail and which is placed nearer, so that distally three screws can be passed (Fig. 27). Most newer nails are universal nails, which are proper for use in shaft fractures, distal fractures and proximal tibia fractures, thus reducing the inventory.
Fig. 26 Expanding distal medullary cavity
Fig. 27 Distally placed holes for distal fracture locking
Figs 28A to C New nails
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Most of the newly available nails are designed for this. Shorter intervals between distal locking screws, and if desired at right angles to each other, is provided in these new nails (Figs 28A to C). Lower one-third fractures are very easy to reduce by closed methods but if the guidewire goes to either side in the distal medullary cavity, and not in the center of the bone, angulation will develop at the fracture site while passing the nail (Figs 29A and B). Therefore, from the beginning, the guidewire in these fractures must end at the center of the tibia. To ensure this, keep the fracture reduced well while inserting the wire in the distal fragment. If the guidewire is not in the center of the bone, the following procedure is done. Withdraw the wire till the fracture site and then reduce the fracture perfectly, push a thinner nail over the guidewire and push that nail into the lower fragment in the corrected position, taking with it the guidewire (Figs 30A to F). Withdraw the nail leaving guidewire behind, and then proceed with reaming and nailing in the routine manner. If you try to reintroduce the wire alone, in center of the tibia, it will tend to go in the same track. This can also be achieved by passing Schanz pin in only one cortex on both the fragments, and then reducing the fracture and passing the guidewire in the center. Polar screw inserted in the path of a nail, going in the undesired direction will also direct the nail in the center (Fig. 31).
Figs 29A and B Nail is not in center—nail is eccentric giving deformity
Figs 30A to F How to readjust guidewire in center
Fig. 31 Polar screw
Figs 32A and B How polar screw can redirect the guidewire
Polar Screws These are screws or any metal which can obstruct the path of the nail or guidewire in the direction it is going and redirect it in the desired direction in the center of the medullary cavity.
How to Execute?Study where guidewire is going, for example, if it is going on medial side of the ankle and desired path is on lateral side to reach in the center of the tibia, plan out imaginary line that which guidewire should change the direction proximally, to end up in center of the bone that is the spot from where metal block has to act, so introduce screw slightly above this spot and push it in. We are changing the track and hence preferably two blocks will have to introduce in the projected path at a distance of about 2 cm to each other. It is also suggested that you make a tract in which the guidewire will travel by making cluster of screws two on one side and one or two other side of the tract so that nail will travel in this path only (Figs 32A and B). Practical observation is that guidewire will pass but when after reamer we try to pass the nail, the nail directly hits the polar screws which we have put as exact diameter of nail, may be bigger than the space created. This can be solved by keeping
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the guidewire in the center till it is hammered in subchondral bone of the lower end. Now ream, which is going to be in correct place. Once having reamed and the guidewire is subchondral, now remove the polar screws and pass the nail, nail has to pass in the desired center position of the medullary cavity. With experience, this problem becomes infrequent. Instead of the polar screws, one can also use thick wires temporarily to redirect the nail in the proper direction and can remove the K-wires at the end of the procedure. I use mainly 2.5 mm K-wires, as polar wires (Figs 33 and 34). The question is asked whether polar screw, if it is introduced, should it be removed at the end of properly directed nailing. My view is, it is not needed after nail is properly directed and can be removed at the end of the operation. This will help if another surgeon interprets as a failed interlocking screw and malign the original surgeon’s name. Second light hearted view is, leave all polar screws in position as a policy, so that if ever any of the locking screws has missed the hole, you can always say that it was polar screw which you had introduced and it is not the missed locking screw. The tip of the nail should be introduced fully into the distal subchondral bone to increase the stability of the construct. Unlike in mid-shaft fractures, it was mentioned that nail should end few millimeter short of the end of reaming to facilitate, dynamization, if required.
Generally, lower one-third fractures are accompanied by fracture of the fibula at the same level. Fixation of the fibula increases the stability of these fractures. If the fracture of the fibula is at the same level and is not communited, plating the fibula or nailing the fibula, before nailing the tibia, is advisable (Figs 35A and B). This will ensure that the tibial guidewire will go in the center. However, if the fibular fracture is greatly communited and it is not possible to establish normal anatomy, and if the fibula is first fixed in a malposition, then the tibia will also be in malposition. In such a case, it is recommended to first fix the tibia by putting a guidewire in the center, over which nail is passed without any deformity and then to fix the fibula in the position it is lying (Figs 36A and B). Do not ever dynamize by removing distal screws in distal tibia fracture (Figs 37 to 39). For practical purpose, dynamization does not work in distal tibia delayed union, I am making a drastic statement, but this is my gut feeling. Distal tibia healing is not by profuse callus, like isthmus fracture. Lower the fracture lesser the callus. It heals more like a cancellous bone and, hence, bone approximation is more important here. Nail it, thump it on the foot, put distal screws, back slap on upper end and lock proximally. If available, use compression nail. Distal tibia oblique fracture is a different fracture than transverse fracture. Do not lump them as distal tibia fracture and treat them, so many times fracture line goes till ankle joint, this fracture should be treated by interfragmental screw and 3.5 neutralizing locking or simple plate. I feel distal tibia oblique and spiral fractures should be treated by interfragmentary screw and neutralizing plate. Distal third transverse fracture should be treated by interlocking nail; with three distal; screws. The open reduction and internal fixation of fractures of the lower third and lower fourth of tibia by plates and screws requires a special mention. At times, it is difficult to pass three interlocking screws in the nail in these fractures. Also, in fractures with a large butterfly fragment, open reduction and fixation of the fragment is necessary to obtain a good bony contact. In these situations, the interlocking nail is not an ideal implant. The open reduction, interfragmentary screw fixation and a neutralization plate are most suitable for these fractures. I recommend the use of 3.5 mm reconstruction plate or precontoured distal tibia locking plate which is thinner 3.5 mm screws and 3.5 mm cortical screws for these fractures of tibia (Figs 40 to 56).Fig. 33 Nail not in center
Fig. 34 Polar guidewires centering the nail
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In elderly persons, these fractures occur in osteoporotic bones and in the lower one-third fractures, there is bone crushing, which causes instability and delays healing. In such situations, I feel primary bone grafting is very useful.
Traps to be Avoided in Lower One-third Fracture• Fibula fixation is a must if both fractures at same level.• If fibula fracture is not communited, plate fibula first before
tibia nailing so that tibia guidewire will go in the center.• If fibula fracture is greatly communited, nail tibia first keeping
guidewire in center followed by plating of fibula in the position it is lying.
• For maximum stabilization, nail length must be long enough to remain subchondral in the distal fragment.
• Guidewire should be in the center of tibia at lower end.• Choose a nail with the distal-most holes; all standard nails do
not have this, beware.
Figs 35A and B Fibula plating if fracture at same level: (A) Prior fixation of fibula with plate could correct the angulation at the fracture of fibia; (B) Intramedullary wire is an alternative in transverse fracture
Figs 36A and B Comminuted fibula first nail tibia in center and then fix fibula
Fig. 37 Oblique fracture—Lower 1/3 tibia
Fig. 38 Not uniting
Fig. 39 Distal dynamization, fracture stability compromised: Dynamization at near fracture is not good. I would choose, distal locking plate
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A B C
Figs 40A to C (A) Long oblique fracture; (B) Lower one-third tibia; (C) Treated with plate osteosyntheses. Note interfragmentary screw
Fig. 41 Preoperative Fig. 42 Day 1
Fig. 43 2 months Fig. 44 Broken screw
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Fig. 45 Nail removal
Fig. 46 Had to make posterior incision to remove this Fig. 47 Locking plate
Fig. 48 Six months united Fig. 49 Preoperative
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Figs 50A and B (A) Day 1; (B) 5 months Fig. 51 Distal one-third fracture
Fig. 52 Prebent plate Fig. 53 Oblique fracture
Fig. 54 Ten years interfragmental screw with nail works ok Fig. 55 Oblique fracture
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• We are not wedded to nailing, keep distal locking plate available when operating distal tibia, which is not a transverse fracture.
• Transverse fracture nail. Long oblique fracture plate.• Precontoured distal tibia medial and lateral anterior plates are
very good for distal tibia lower one-third and lower one-fourth fractures.
Upper One-third and One-fourth FracturesUpper one-third fractures are very tricky. Recent nails have very proximal Herzog bends, which are good for proximal tibia nailing (Fig. 57). The point of entry for these fractures is most proximally, so that the nail can go in the proper line. Distinct angulation occurs at the fracture site while the nail is passing from the proximal fragment to the distal fragment, until the Herzog bend is fully introduced. After the nail is fully seated, the bone falls back into proper alignment often not always. Most of the time, when the guidewire is passed, it initially tends to go posteriorly and comes out from the fracture site. Holding the reduction with a towel clip or clamps percutaneously can control this. It can also be helped by passing a polar screw in lateral
Fig. 56 Anatomical reduction and no plaster Fig. 57 Angulation of fracture: upper one-third tibia at the Herzog’s bend in AO nail
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Figs 58A to C Open reduction is a good option: GK type nail with a bend at the upper end is required for these fractures
direction to block nail going posteriorly. Use of the polar screw has helped the nail positioning most of the time. If it is not possible to control this segment, an open reduction may be needed. Open reduction and 3.5 lag screw to stabilize the upper fragment is a good option to get perfect alignment as seen in Figures 58A to C. For upper one-third, make a point of entry proximally just underneath the articular surface and then try to pass the awl and then guidewire parallel to anterior cortex of proximal tibia so that line of medullary cavity is met in direct line. If one cannot pass this guidewire properly, then open the fracture and go to the anterior part of the proximal fragment at the fracture site and pass a guidewire hugging the anterior cortex from the fracture site retrograde and come out from the point of entry. This way the nailing can be adequately done in these difficult fractures. Intramedullary nail fixation of proximal tibial fractures has a significant complication rate. Malunion after intramedullary nail fixation of proximal tibial fractures is high. The deformities, which occur, are valgus angulation in the coronal plane, flexion deformity in the sagittal plane and posterior translation at the fracture site (Figs 59A to D). Valgus deformity occurs due to medial point of entry, which is not in same line in proximal fractures with
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Figs 59A to D Leg screws in oblique fracture Fig. 60 Valgus angulation at the fracture site following inter locknailing for proximal third tibia fracture
Fig. 61 Flexion deformity at fracture Fig. 62 Angulation corrected when point of entry on lateral side instead of medial sides
medullary cavity. It is also contributed to some degree by the shape of the proximal tibia. The anteroposterior width of the tibia is much narrower on the medial side than it is on the lateral side and the medial cortex of the tibia forces the nail laterally. The fracture that is most typically seen in the proximal part of the tibia begins in the lateral aspect of the proximal part of the tibia, and extends medially and distally. Therefore, often there is no lateral cortex to help guide the nail distally and keep the nail aligned properly. Once the nail engages the distal segment, valgus angulation occurs because of the mismatch between the so-called nail entrance angle and the tibial canal. Additionally, the origin of the musculature of the anterior compartment acts as a tether on the lateral tibial surface proximally, which may contribute to valgus angulation if any gap remains at fracture site during the nailing procedure. Flexion deformity is due the shape of the nail and insertion of the nail with the knee flexed. AO nail with proximal bend contributes to anterior angulation and posterior translational
deformities. When the fracture is proximal to the bend in the
nail, it can displace up to 1 cm with the distal fragment typically
translating posteriorly in the sagittal plane (Figs 60 to 62).
SuggestionThe starting point must be placed at the edge of the articular surface. This position is anterior to the axis of the medullary canal so the nail initially must be directed posteriorly to enter the canal. The inability to extend the knee during nail insertion because of the presence of the patella contributes to flexion of the proximal part of the tibia at the fracture site. There are several potential solutions to the problem of malreduction of proximal tibial fractures during nailing. The most important recommendation is that the entry portal of the nail be made in line with the axis of the medullary canal as possible. This is facilitated by use of a lateral portal placed high on the tibia, at the edge of the articular surface. This places the nail insertion site directly over the medullary canal in the coronal plane and as close as possible to the axis of the canal in the sagittal plane. Furthermore, this entry portal has been shown to reduce the strain within the cortex during nail insertion. Hernigou and Cohen advocated a so-called anterior approach to the proximal part of the tibia through the patellar tendon. Tornetta and Collins recommended that a semi-extended position with a partial
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medial knee arthrotomy be utilized in certain circumstances. This position both neutralizes the deforming force of the quadriceps on the proximal segment and allows the patella to be subluxated laterally, after which the femoral trochlea can be used to guide the nail placement. This approach provides ideal exposure of the ideal entry point without risking knee pain from splitting the patellar tendon. In order to prevent the proximal tibial fragment from flexing, the nail must be placed as anteriorly in the proximal fragment as possible. Another technical contribution to the management of malreduction of tibial fractures is the concept of blocking (polar) screws as advocated by Krettek et al. and by Cole. This technique,
which is simple to perform, involves the placement of bicortical
screws into the tibia prior to introduction of the nail. The screws serve to narrow the medullary canal in the tibial metaphysis
and have been shown to increase the stability of the bone-nail
construct. Because proximal fractures are commonly oriented
from distal and anterior to proximal and posterior, nails used in proximal fractures are not forced anteriorly as they are in mid-shaft fractures. The blocking screw essentially functions as a substitute posterior cortex, keeping the nail close to the anterior cortex as it is maintained in a mid-shaft fracture. Thus, the blocking screw is placed in the posterior half of the proximal part of the tibia in the sagittal plane, blocking the nail from passing posteriorly and abolishing the flexion and translational forces. Similarly, an anteroposterior screw placed laterally in the metaphyseal region will substitute for the lateral cortex, keep the nail at midline and prevent valgus deformity. Proximal locking screws from the tibial nail set should be used for the blocking screws and they may be left in place after the nail is locked. Two proximal screws that are perpendicular to one another should be used when possible for proximal locking. Tornetta et al. reported on 73 proximal fractures for which they had used an algorithm to decide (Figs 63A and B) if any special techniques were needed to maintain reduction during nailing. In the operating room, they make a lateral radiograph of the tibia
with the knee in flexion. If the fracture goes into anterior angulation, they use a semiextended approach. If posterior translation occurs, a blocking screw is utilized. If both deformities are present, both techniques are used. Other techniques that have been advocated to prevent malreduction of the proximal part of the tibia include provisional reduction and fixation of the fracture with unicortical plates or a distractor. If the fracture is too proximal, then plating may have to be considered. If the fracture is comminuted in elderly patients with porotic bones, nailing with massive grafting is necessary. Crushed porotic bones do not heal just because closed nailing is done which happens as a rule in young patients. This is my observation in all porotic-crushed fractures of the femur, tibia and femoral neck; they behave differently from comminuted fractures in younger patients. I think last is yet not said on managing the proximal tibia fractures. Due to all these problems and solutions suggested in literature, there is still a major problem of malunion of these fractures (Flow chart 1). Alternate treatment of locking plate is now a viable solution. I have almost fully changed over to locking plates in proximal tibia fractures.
Traps for Proximal Tibia Fractures• The point of entry needs to be as proximal as possible and
slightly lateral.
• You need to keep the knee in at least 120° of flexion in order to pass the guidewire parallel to the anterior cortex and near the anterior cortex, which is necessary.
• Some time you have to keep knee extended, as discussed.• Preoperatively, check that the knee can be flexed to this
maximum position. So, it is important to take these fractures on an ordinary table where the knee joint can be manipulated rather than on a fracture table.
• Do not hesitate to open the fracture and pass the guidewire retrograde from the fracture on anterior cortex of the proximal fragment coming out at the point of entry.
• Keep the guidewire anteriorly all the time and reduce the fracture.
• Hold the reduction while passing the nail.• If required, pass an interfragmentary screw.• I have never regretted opening the fractures to put the
interfragmentary screw in long oblique.• Closed reduction does not guarantee a union. Close
approximation almost guarantees a union.• Graft the crushed bone in the bone gap.• Locking plate is treatment of choice for me rather than accept
a little mal-reduction (Figs 64 to 70).
Locked Nails of the FemurAll the newer nails are variation of old designs and most have amalgamated all the features in the same nail suitable for nailing
Figs 63A and B Semiextended position: (A) Anterior entry gives angulation; (B) Posterior entry corrects
Flow chart 1 Algorithm for managing proximal tibia fracture
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Fig. 64 Preoperative Fig. 65 Angulation of tibia (Three months)
from proximal femur to distal femur, giving choice to the surgeon. Now, newer nails are capable of doing locking in dynamic modes, both proximally and distally. Most can be used by passing proximal
locking screws in neck of the femur, from greater trochanter to lesser trochanter, and transverse in proximal femur. Distally, multi-direction multiscrew facility for distal femur antegrade nailing.
Fig. 66 Precontoured plate
Fig. 67 Preoperative Fig. 68 Nine months after plating perfect alignment
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Fig. 69 Preoperative
Fig. 70 Locking plate nonunion: Another patient normal plate bent on table become a stress riser. Too many screws like DCP but no compression like DCP
Fig. 71 Femur position with supracondylar pin: Supine position of patient on the traction table
Now, most available nails are designed to be passed from the tip of greater trochanter, rather than, piriformis fossa. They and are made of titanium or 316LVM stainless steel. Analysis of different types of nails is very interesting. Stainless steel and titanium nails appear to give equal results. Nails with a closed section (circular nails) and those with an open section (slotted nails) also provide similar results. Closed-section nails offer increased torsional rigidity. But this property has no clinical significance and may lead to increased communition at the fracture site if difficulty is found in passing the nail. Wall thickness has been studied in detail, and attempts have been made to increase the strength and augment the fatigue resistance of the nail. However, there is little evidence that these differences translate into a higher clinical success rate. The only important factor related to nail design is that more rigid nails require further over reaming and perfectly placed starting points in piriformis fossa to prevent communition. Newer nails with proximal 6° bend to accommodate the point of entry at the tip of the greater trochanter is a very useful
innovation. This avoids the problems encountered with finding piriformis fossa and problems to do this in supine position. Retrograde intramedullary femur nailing is introduced now as an extension of supracondylar nail. There are many surgeons who believe that it is better than antegrade nail. Antegrade insertion gives tip of nail pain due to heterotopic bone formation at the tip, while retrograde nail has no knee pain. Retrograde femur nailing is considered to be the treatment of choice for patients with obesity, ipsilateral femoral and tibial fractures (floating knee injuries), ipsilateral femoral neck and shaft fractures and multiple traumas.
Closed Nailing of the FemurA special fracture table and C-arm are necessary for closed nailing. Traction can be applied through an orthopedic boot or a skeletal pin in the lower femur. Generally, a boot is enough when surgery is done early; however, in fat patients or in delayed surgery, skeletal traction through the lower femur should be used. Care must be taken that the pin does not obstruct nail insertion and is parallel to the axis of the knee joint. A gentle overdistraction aids reduction. Closed nailing is difficult if the fracture is more than 10 days old.
Procedure
Position
Supine PositionThe patient is placed supine on an orthopedic table; hence, it is easy to assess the correct length and rotation. Many surgeons prefer the supine position, as it takes less time to position the patient and rotation control is better. Anesthetist and radiological staff are more comfortable in this position. However, entry point exposure is difficult in this position, the limb needs to be internally rotated and adducted for piriformis fossa entry point (Fig. 71). The newer nails are designed with titanium with a 6° bent proximally so that it can be introduced from the tip of the trochanter avoiding messy exposure of the piriformis fossa, these are most suitable.
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Lateral PositionIn obese patients, the preferred position on the traction table is the lateral position, as it provides easy access to the greater trochanter. However, it is more difficult to visualize the upper femur on the image intensifier in this position (Figs 72A and B). It may also be difficult to control the position of the distal fragment in distal femoral fractures with the patient in the lateral position. The distal fragment tends to drift into valgus and the rotational alignment cannot be easily judged.
Reduction in Supine PositionSufficient traction is applied to the leg to achieve distraction for achieving the reduction. The limb is adducted to allow access to the greater trochanter. This is important because, if the leg is
not adducted, there is difficulty in gaining access to the proximal femur in the line of the medullary cavity. The upper torso is tilted to the opposite side to gain working space on the trochanter (Fig. 73).
IncisionThe incision for closed femoral nailing starts at the level of the greater trochanter and is carried proximally for approximately 10–15 cm. The most common mistake regarding the incision is to center it on the greater trochanter, which will need proximal extension of the incision. Shorter incision where guidewire is passed near the trochanter, will not meet the trochanter at a proper angle and, hence, starting point is 10 cm proximal. In obese patient, about 15 cm proximal to the tip of the trochanter, is a desirable point of entry (Fig. 74). Subcutaneous fat and deep fascia are incised. Subsequently, palpation rather than visualization of the relevant structures help to carry out the surgery.
Figs 72A and B Lateral positions of patient on the traction table with (A) Pin traction; (B) Boot
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Fig. 73 Upper portion tilted
Fig. 74 Point of entry for femur nailing
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sleeve can be used to pass the reamers to expand the medullary cavity (Fig. 76).
Introduction of GuidewireAfter removal of the hand reamer, an olive tipped bent guidewire is passed down the medullary canal as far as the fracture site. The presence of the bend in the guidewire allows the surgeon to “feel” for the distal fragment by rotating the guidewire. By rotating the guidewire, it is usually possible to enter the distal fragment (Fig. 77). The sagging of the fracture is a common occurrence seen on the C-arm. During reduction, sagging should be corrected by hand or by a crutch, under the fracture, before passing the guidewire in the distal fragment. This sagging should be kept corrected even while passing the reamer and the nail. If reduction is not achieved, then a small diameter nail with the handle is passed in the proximal fragment over the guidewire (Figs 78 and 79). This device brings the proximal fragment to the distal fragment. Maintaining the distraction facilitates the reduction. The olive tipped guidewire is passed in the distal fragment through this reduction device. Similar type of device
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Figs 75A to C Locate piriformis fossae in C-arm and pass: (A) Steinmann pin in correct direction over this in correct direction over this; (B) Pass a cannulated gauge to make an entry in medullary cavity; (C) Pass beaded guidewire through the tube
Fig. 76 Large tube to guide the guidewire and reamers. Large incision is avoided
Fig. 77 Presence of a bent guidewire helps to feel the proximal end of distal fragment
Point of EntryMore rigid stainless steel nail, with straight upper end, need piriformis fosse point of entry. While nails with 6° proximal bend will have a tip of the trochanter as a point of entry, the piriform fossa is selected as the point of entry, as it provides direct access to the femoral shaft. However, the tip of the trochanter is not in the line of the medullary cavity. The argument against the points of entry in the piriform fossa is that there is more chance of avascular necrosis of the head of the femur. However, this has not been shown in studies with a large series of cases. The entry point is identified in the piriform fossa and slightly posteriorly at junction of anterior two-thirds and posterior one-third on the trochanter, and is perforated with the bone awl. This position of entry, at junction of anterior two-thirds and posterior one-third is not easy to define on C-arm and, hence, palpating the trochanter is a better method to determine this. Most dependable is to see the image in C-arm in the lateral view and find out the line of the femur in lateral view, and adjust point of entry on this line on trochanter. This way, one would not ever miss it. If the starting position is more medial, it is difficult to pass the nail into the medullary canal and fracture of the femoral neck may occur. The curved bone awl is driven on the medial edge of the tip of the trochanter so that, when reamed, it will remain in perfect direction. Direction is checked with the C-arm. A hand reamer of gradually increasing thickness is passed through the point of entry connecting the medullary canal. Care must be taken that the hand reamer is driven in the correct direction, as it is possible to perforate the medial cortex if the wrong direction is chosen. This is checked with the C-arm while the hand reamer is making progress. The titanium nails are not that rigid and those which have a smaller 6° bend proximally are advised to be introduced from the tip of the trochanter. One should follow the instructions of the manufacturer’s for this decision. Alternatively, percutaneously, under C-arm, at the piriformis fosse, a Steinmann pin is passed, over which a cutting chisel makes the passage in the femur avoiding a bigger incision. This cutting chisel makes a passage from tip of the piriformis fossa till the beginning of the medullary cavity (Figs 75A to C). A 13 mm drill
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Fig. 78 The small diameter nail on the handle
Fig. 79 Introduction of this nail into the proximal fragment helps to control the proximal fragment to achieve reduction
Fig. 80 New tube which has small bent to negotiate distal fragment
• In case of rotational malalignment, the diameters of the medullary cavity of the proximal and the distal fragments will appear different (Fig. 83).
• Keeping the patella face upwards and straight should keep the distal fragment in neutral rotation. In this position, if the lesser trochanter appears prominent, then the proximal fragment is in external rotational malalignment (Figs 84A and B).
The guidewire is passed distally into the metaphyseal bone of the distal femur to avoid the risk of backing out after correct rotational alignment is obtained. Reamers are introduced over the olive tipped guidewire. The initial reamer is end cutting and enlarges the track to 8 mm. Subsequently, the side-cutting reamers are used in 0.5 mm or 1 mm increments to enlarge the track. Care should be taken to ream the entire length of the femur. Reaming of the comminuted area is unnecessary and potentially harmful to the muscle envelope around the femur. The reamer should be pushed through the comminuted area. If the middle fragment in a segmental fracture needs reaming, then it should be held percutaneously with the towel clip or by opening the fracture. Once the reaming is completed, the beaded guidewire is exchanged for the plain wire with plastic tube.
Fig. 81 Reduction device. The gap between 2 prongs can be adjusted for size of femur or tibia. The prongs are put on opposite side of the limb and reduction achieved
is also available which can also work as a curved tip guidewire (Figs 80 and 81).
Correction of Rotation during ReductionDuring the reduction, even if the guidewire goes in the distal fragment, rotation alignment is not achieved all the time. During surgery proper rotation can be judged by several ways:• Cortical step sign in the presence of rotational deformity;
proximal and distal cortical thickness at the fracture site appears different on the image intensifier (Fig. 82).
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Fig. 82 Cortical steps sign. Two cortices at fracture if not equal there is malrotation
Fig. 83 Difference in the diameters of medullary canals of proximal and distal fragments suggest malrotation
Figs 84A and B Appearance of lesser trochanter with rotational malalignment of distal fragment: (A) Lesser trochanter in neutral rotation; (B) Lesser trochanter appears prominent in rotational malalignment in patients with externally rotated proximal fragment
Insertion of NailThe appropriate nail, about 1–1.5 mm thinner than the last reamer used (my choice is 1.5 mm thinner), is mounted on the proximal jig and is gently pushed on the plain guidewire as far as it can go into the medullary cavity. Nail should be pushed and not hammered till it crosses the fracture site by at least 2 cm. This can only be done if nail is 1.5 mm thinner than the last reamer used. The nail can now be hammered into the femur. Initially, it should be introduced only by hand pushing till it crosses the fracture site so that the tip is just over the fracture. The fracture should then be fully reduced and the nail hammered home. Be careful to hold the reduction while the nail is passing into the distal fragment. Excess traction should be slackened and the foot-end thumped proximally before putting the distal interlocking screw. The guidewire should be removed before the nail is finally embedded in the metaphyseal bone.
Lower One-third FemurWhile treating lower one-third fractures, the olive tipped guidewire should be passed into the center of the distal fragment. The reamer and the nail always follow the guidewire and, therefore, an eccentrically located guidewire result in malpositioned nail. If the guidewire is placed close to the medial or lateral cortices, a valgus or varus deformity will ensue in these lower one-third fractures. Using the polar screw, as described earlier, to control the nail passing on the side, is also a very useful method for achieving the central position of the guidewire.
Insertion of the Interlocking Screws
Distal Locking of the FemurDistal locking is done exactly as described for the tibia.
Free hand technique: The patient’s leg is positioned between the source of the X-ray beam of C-arm and the aiming device. The image intensifier is positioned so that the locking hole appears as a perfect circle on the monitor. This is an important point; any oval-shaped hole is not acceptable. Position the image intensifier so that the distal locking hole is in the center of the monitor and not at the edge. Magnify the image of the hole. It is easier to insert a screw with a magnified image. Then adjust the C-arm in such a position as to get a perfect round circle on the screen and only then proceed with the distal locking (Fig. 85). If the image is not round but oval, it must be corrected to achieve the round circle. There are three different types of oval shapes which can be seen on the image intensifier depending on the position of the limb in relation to the image intensifier. The image will get resolved by moving the image intensifier in one direction, i.e. either in horizontal or a vertical arc, or it will have to be moved in both these planes, as shown in Figure 16, after the circle has been located, following routine is suggested: First, under C-arm, mark the skin along the longitudinal axis of the nail. Then draw another, horizontally, at 90° to this line on skin at the level of the hole; this makes an entry point of the locking screw on skin as described for tibia (Fig. 22). Once this level has been found, the Steinmann pin is introduced on the bone to mark the point of entry for the locking hole using a radiolucent rod, to avoid the exposure to the hands of the surgeon. The drilling can be done on this point confirming
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on C-arm with radiolucent drill, if available. An adequate sized Steinman pin can be introduced to make a hole in the cancellous bone (Fig. 19). The self-cutting screw of a proper size, as measured by depth the gauge, is inserted through the protection sleeve. I have observed that in early learning phase, and trying to lock percutaneously, is more demanding and time-consuming compared to locking with an incision made until the bone. Make a skin incision, long enough extending for both screws. Expose the bone and put two spikes. Under the C-arm, localize the point for locking and make a bone impression with the K-wire, so the drill will not skid. Now drill the hole. When an attempt is made to drill at the chosen site percutaneously, the drill skids and the chosen site is lost and the whole procedure has to be repeated. Locating the hole becomes easy and quick, when an incision is made and the center of the bone is visible. As described earlier, the distal locking is done prior to proximal locking. Between the two distal holes, the distal-most hole is locked first. The fracture is impacted by back slapping the nail after distal locking.
Proximal Locking of FemurThe proximal cross-screw is inserted in the standard manner. First, a drill sleeve is inserted into the proximal jig and drill bit is passed down the drill sleeve; if the drill bit hits the metal, then a check should be made that the jig has not become loose. After the nail is locked on both sides, the patient is mobilized in a few days on partial weight-bearing with support, and gradually changed over to full weight-bearing once the fracture starts consolidating in about 6–8 weeks. Full weight-bearing is not advised in thinner nails and in comminuted fractures.The nail does not hold the bone very well in the fractures of the shaft femur at the junction of upper two-thirds and lower one-third, where the medullary cavity is widening. Results are not as good as the ones with the fracture at the isthmus where the maximum stable reduction and fixation can be done by good fitting nail. Comminution is also more likely at this junction in osteoporotic elderly people. In these distal fractures, nail should engage in the subchondral area of the distal femur to increase the stability. For the comminuted fractures of lower third of femur or for the fractures extending to the distal articular surface, interlocking nail
Fig. 85 Perfect round hole and drill
is not an ideal implant, as the hold of the screws in distal fragment would not be adequate. Supracondylar nail or biological locking plating is a suitable mode of fixation in such cases with bone grafting, if needed or if open, reduction was needed.
Observations and Tips in the use of the Interlocking Nailing Procedure in the Tibia and Femur• The length of the desired nail is very crucial. It can be measured
on the table by two guidewire of the same length. Put one guidewire in medullary cavity till nail needs to be introduced on the distal end. Measure the guidewire which is protruding out of the medullary cavity from, the tip of the bone entry point. Put another same length guidewire on the tip of the bony entry point till end of the protruding guidewire, put artery forceps on this level of the second guidewire as marker. Length renaming from this artery forceps is the length of the nail which has to be taken (Figs 86A and B). A radiographic ruler can also measure the length of the nail. It is placed adjacent to the bone and viewed under the image intensifier to determine the appropriate length.
• When the nail is fully inserted in tibia, it must stop at the level of the bone on the upper end and not project outside; it will irritate the ligamentum patellae and cause a painful knee (Figs 87A to C).
• If the nail is short, please do not push the nail down the medullary cavity in order to get the length; exchange the nail after putting in the guidewire. If the nail is introduced deep inside the upper end of the tibia to get more length distally, it will damage the upper tibia as the jig digs in the bone (Fig. 88).
• The nail should remain 2 cm short of the subchondral bone at the lower end to accommodate dynamization, if required later. This can be done only in fractures of the middle one-third. In lower one-third fractures, this is not advisable because the maximum length is needed for stabilizing this fracture. In distal one-third fractures, nail must end up in subchondral bone for maximum stability. Dynamization by removing distal screws is never done in distal one-third fractures (Figs 89A and B).
Figs 86A and B (A) Measurement of nail length by two-wire method; (B) Ruler placed on the bone and with C-arm, direct reading obtained
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• The reaming is done at least 1 mm more than the nail size. Stop reaming once resistance is encountered while increasing the reamer size, and then push the proper sized nail manually as far as it will go into the medullary cavity.
• Do not start hammering the nail before it has engaged in the medullary cavity of the distal fragment. Listen to the sound of the hammering and, if it changes, stop before the next blow of the hammer, or you could jam the nail, making it very difficult to remove. Also, if the nail is passed when fracture is not well reduced, it may penetrate through the cortex and would lead to the splintering of the cortex (Fig. 90).
• If the fracture of the femur is badly comminuted and after the nailing there is a big gap on one side of the bone, primary bone grafting should be considered (Figs 91A to C).
• If there is a big butterfly fragment, which is away from the bone at both the ends for more than 4–5 mm, then open reduction and repositioning of the piece should be considered to avoid delayed healing (Figs 92A and B).
• Long, oblique fractures in reduction is not stable, can be better treated by opening it, and putting a lag screw from one cortex avoiding the medullary cavity and then putting in locking nail (Fig. 93).
• Fractures of the shaft femur at the junction upper two-thirds, and the bone which is widening just below the isthmus, is a difficult problem. The nail does not hold the bone very well
Figs 87A to C Nail not fully inserted painful: Defective entry points. (A) Nail too out; (B) Nail too in; (C) Avulsion of the tibia tuberosity
Fig. 88 Do not try to put nail down to compensate for short length
Figs 89A and B Do not dynamize by removing distal screws
Fig. 90 Nail hitting on anterior cortex, created fracture
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Figs 91A to C Medial void, grafted
Figs 92A and B Repositioning of fully turned piece
Fig. 93 Leg screw after open reduction
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and, in this situation, the results are not as good as the ones with the fracture at the isthmus where the maximum stable reduction and fixation can be done by good fitting nail. In such lower fractures, multidirectional, at least three screws construct should be used to improve stability of the construct. Comminution is also more likely at this junction, especially so in a slightly osteoporotic elderly people. In these situations, primary grafting will be a good option, if nailed, or I would strongly consider locking plate for these fractures without grafting.
Open FracturesOpen fractures, when arriving within 4–6 hours to the hospital, are treated through debridement of the wound and primary nailing in all nailable fractures up to grade IIIB of Gustilo and Anderson classification (Fig. 94). Debridement is the main treatment. On arrival, first inspection is done preferably by the treating surgeon and it covered with sterile towel. Subsequently, the wound should not be seen by other people, does not be a peeping Tom before taking the patient into the operation theater. Patient must be started on second generation or third generation intravenous (IV)
antibiotics immediately. Culture from the wound from superficial layer at this stage, is not of any value. Under anesthesia, in sterile operation theater, the wound is thoroughly inspected and washed with soap and water. This scrubbing is very important and plenty of time must be spent is scrubbing the wound. Excise all dead muscle and skin tissue. Decision of dead muscle tissue is done by few observations. While cutting, muscle bleeds if it is vascular. It has a reddish color, and not brown color, if viable, and it must twitch when pressed with forceps, if viable. All doubtful tissue also must be excised. Bone without substantial soft tissue attachment is a source of infection and, hence, it should be removed. Now, once satisfied with debridement, use a jet lavage and clean up the wound. Do not use jet lavage before debridement as it may send material deep inside wound (Fig. 95). Now, stabilize the bone with interlocking nail in all nailable fractures. If fracture is not nailable, like in metaphyseal area, then ex-fix is applied. Static nailing is most desirable. If there is small
Fig. 94 Compound fracture
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bone loss, then I suggest nail could be applied in distraction to maintain the length, and gap can be grafted later, or dealt with appropriately. Bones are covered with muscles and the skin, if not easily closed, be kept open for future closure or, if needs skin graft, it can be done on same sitting, whether flap should be done on day one or wait for wound to stabilize for 3–4 days is a debatable issue. My choice is cover bones with muscles, if possible, and keep skin open, see the wound after 24 hours and after 48 hours, and if wound is good, flaps can be done after 4–5 days. If wound needs second debridement, it must be done daily under anesthesia, till it is stable. Then flap can be done. Since nailing is done, skin surgery is most easily done without obstruction of ex-fix. Conventionally, open fractures of tibia have been treated primarily by external fixation. After the healing of the wound, the external fixation is replaced by definite internal fixation (nail or plate) or plaster. However, this kind of treatment has been associated with many drawbacks, like pin tract infection, delayed union and malunions. Recently, many authors have reported excellent results with primary interlocking nailing in open fractures of grades I, II, III and IIIA (Fig. 1). Today, the external fixation is considered only as a temporary mode of fixation in grade IIIB and grade IIIC fractures. It has to be replaced by another definitive mode of internal fixation after the wound healing. External fixation as a definitive treatment, even with subsequent dynamization, has a higher rate of nonunion. The infection rate in primary interlocking nailing in open fractures is no different from that in external fixations. The wound management and skin covering procedures are much easier to execute with the intramedullary nail than with external fixation. AO has recommended unreamed solid nails, essentially thin nails, for open fractures to avoid infection. It is known that reaming leads to bone necrosis. However, this bone necrosis gets revascularized in about 3–4 weeks. It was felt that this can result in higher rates of infection in the presence of bacteria in open fractures. There are reports showing that the solid nail carries a lower risk of infection than the hollow nail due to the glycocalyx attachment in the hollow part of the nail.
Fig. 95 Jet lavage after debridement
Thin unreamed nails have higher rate of nail breakage; nonunion and second surgery. Unreamed thin nail needs protection from weight bearing. A thick, reamed nail should replace this unreamed nail once the wound has stabilized. Some authors have been using only reamed hollow nails for open fractures and they believe that, even in an open fracture, the infection rate is not higher with thick reamed nails. This is definitive treatment and does not need second surgery. In my own experience, I have never used an unreamed thin nail in compound fractures. Any open fracture, where nailing is indicated, is treated by the thickest reamed nail. Before carrying out internal fixation in an open fracture, a thorough irrigation and debridement of the wound must be done. All the drapes and gloves are changed and the patient is redraped for internal fixation. Locked thick reamed nail is put to stabilize the fracture and the wound is treated on its merit. If the wound is clean and noninfected, primary suturing is done in experienced hand. If in doubt, keep the wound open and do a relook debridement after every 2 days till wound is clean. Clean wounds can be sutured. Large wounds can be either treated with free skin graft, local flaps or live free pedicle graft at the earliest. Even bone grafting can be done before skin cover in clean wounds. Today grades IIIB and IIIC are primarily treated with external fixation to be exchanged for thick reamed interlocking nails, after the skin lesions have healed. It is recommended that the pins are removed and the pin tracts are allowed complete healing in plaster cast for 2–3 weeks before the reamed nail is introduced to avoid infection. The evidence suggests that delay of 2–3 weeks before nailing, after pin removal, decreases the infection rate. There are many reports where it has been shown that even in grades IIIB and IIIC, primary nailing is preferred treatment. It has the same infection rate as external fixation, which is always higher in grades IIIB and IIIC compound fractures. Primary nailing helps in handling wounds much better. Compound fractures need delayed bone grafting in a higher percentage of cases than closed fractures. All these comments of primary nailing are valid only when patient comes to hospital within 4 hours or 6 hours after accident. If patient arrives to the hospital after 1 day, then prognosis changes. Compound fractures with pouring pus, when arriving after 3–4 days, cannot be treated by primary nailing. It has to be treated by debridement and ex-fix till infection is controlled.
DynamizationDynamic locking refers to placing screws at only one end of the nail. In the static mode, screws are inserted at the both ends. The theoretical advantage of dynamic locking is that it permits axial movements at the fracture site. This was thought to be useful for fracture healing and, hence, was a normal practice to correct the initial static locking to the dynamic mode for fracture healing. Dynamization is done by removing the locking screw from the longer fragment, thus converting the static mode of fixation to the dynamic mode. Healing of the fracture is observed in 80% of cases without dynamization. Thus, it should be carried out only if the fracture is not showing signs of consolidation between 8 weeks and 12 weeks. Static locking gives stability to the fracture, allowing for the maintenance of length and correct alignment. However, it does not allow axial loading of the fracture.
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Numerous fractures consolidate very well without dynamiza-tion. So the described systematic procedure of dynamization, oriented solely to time intervals and not to the radiological observation of fracture healing, has to be rejected. Dynamization is done by removing the screw from the longer segment, e.g. in a lower one-third fracture, it is preferable to remove the screw from the proximal fragment. However, the proximal screw removal leads to migration of the nail proximally, which can irritate ligamentum patellae in tibia. The nail tip should have some space to travel distally while a fracture is collapsing. This is possible only in mid-tibial or mid-femur fractures. This is not possible in the distal fractures where maximum possible length and stabilization is achieved by pushing the nail into subchondral bone and putting in two locking screws distally. Thus, removal of the distal screws does not result in dynamization. If the nail is subchondral, then dynamization will not occur even if you remove the screw. Dynamization does not work if, over time, there is new bone formation around the end of the nail of the tibia (Fig. 96). This new bone formation also occurs in the femur at the upper end. Hence dynamization, if done, by removing the upper screw, will not work. If interlocking is done only at one hole then bone may grow into the other hole, which is empty (Figs 97 and 98).
This will not allow dynamization on removal of the interlocking screw. In the newer nails, the nail can be put in dynamic mode at both ends of bone.
Points to Ponder• Dynamization is not necessary in all cases.• If dynamization has to be done, do it by 8–12 weeks, if fracture
is not healing; it does not work, if delayed all the time.• Confirm before dynamization that there is enough space
distally for the nail to migrate after dynamization.• Confirm that there is no new bone formation at the tip of the
nail distally.• Allow full weight bearing, after dynamization, for it to act.• Dynamization by removing proximal screw does not work
consistently.• In mid-shaft fractures, keep nail short of distal end for future
dynamization, if needed. Ream fully till distal end and then put nail short in primary surgery.
• In transverse fractures, do dynamic nailing by screws in oval holes only on both sides if nail provides that or at least on one side dynamic nailing should be done. This is not applicable in comminuted fracture where only static nailing is done.
• There is no role of dynamization in comminuted fracture where, if dynamized, it will lead to shortening and nail breakage.
• Exchange, fully reamed till distal end of bone and then putting slightly short thick nail in dynamic mode is more certain than only dynamization in long standing delayed union, or if above factors are present, which will not allow dynamization to act.
Supracondylar NailThe intramedullary supracondylar nail has been developed by Green, Seligson and Henry. It addresses a spectrum of problems that may arise in fractures of the distal femur. The primary indication for its use is in supracondylar fractures (Figs 99A to D). Other indications include pathologic fractures, malunions, failed distal femoral osteosynthesis, distal femoral fractures in osteoporotic patients and supracondylar fractures after total knee replacement.
Fig. 96 New bone at distal end
Fig. 97 Formation of bone in unlocked holes of the nail results in failure of dynamization-I
Fig. 98 Formation of bone in unlocked holes of nail results in failure of dynamization-II
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After advent of distal femur locking plate, this nail had been less utilized, but now since, nonunion of distal femur plates have been frequently reported, supracondylar nail has revived. It is technically less demanding than other methods of fixation of supracondylar fractures. The procedure does not require open reduction of the metaphyseal fragments of the fracture and, therefore, causes less damage to the blood supply of these fragments. This nail which was primarily indicated also for comminuted fractures of the supracondylar region of the femur, which extend into the articular surface, has now been replaced with distal locking plate. Now the nails are available in short length, five or seven holes, or long nails going right upto lesser trochanter. The nails are designed to permit the distal driving end to be countersunk below the level of the articular surface of the femur. Locking in proximal part is helped by putting the holes, anteroposterior direction. Locking in lateral direction is difficult in upper thigh.
Surgical TechniquePreoperative planning: Good preoperative radiographs of the injured femur should be used to estimate nail length and plan an approach to supplemental fixation.
Assessment of nail length and size: Use of the longer nail results in centralization of the nail in the isthmus and reduces its intramedullary deviation laterally or medially. Centering in the diaphysis prevents varus and valgus angulation. The nail should extend proximally from the intercondylar femoral notch so that at least two interlocking screws can be placed distal and proximal to the fracture line to achieve a stable osteosynthesis. With longer nails (25 cm), it is not necessary to place screws in all the proximal holes unless they are required for treatment of a fracture with diaphyseal extension. The thigh of many patients becomes wider more proximally, making it harder to place interlocking screws percutaneously. Severely displaced fractures should be stabilized before surgery in skeletal traction to maintain length and minimize complications (fat embolism syndrome, deep venous thrombosis, etc.). It is always recommended to use the largest diameter implant suitable for the patient, without causing disruption at the fracture site.
Patient positioning: Place the patient in the supine position on a radiolucent table. The leg should be draped free. The knee is flexed to 30–40° with a leg roll under the fracture, and not under the knee joint. Rotational alignment is achieved by aligning the iliac crest, patella and first web space of the foot.
Surgical procedure: The knee joint is entered through a standard midline skin incision or medial parapatellar incision. Following the skin incision, the patellar tendon is incised vertically in a midline by splitting the longitudinal fibers. Small retractors are used to minimize trauma. Infrapatellar fat may need removal for a visibility in the knee joint (Figs 100A and B). The entry point is made in the intercondylar notch, just anterior to the origin of the posterior cruciate ligament. It is made with a straight awl. The entry point should be centralized with the condyles in anatomic alignment to ensure that the alignment will not deviate into a varus or valgus position. As the straight awl is positioned into the intercondylar portal, the A-P and lateral C-arm verify this. On A-P view, the straight awl should be directed proximally in a neutral position with respect to the condyles (not with respect to the shaft). In lateral view, it should be parallel to the anterior cortex, which is straighter and should be parallel to the mediolateral cortex of the femur in A-P view (Fig. 101). The shaft may not be in Figs 99A to D Supracondylar nail
Figs 100A and B Steps of operation
CB DA
BA
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proper alignment until the nail is placed and fracture reduction is obtained. Fracture reduction often occurs with placement of the nail into the intramedullary canal. If the entry point is neutral to the condyles, a long nail will centralize within the isthmus, which will help to ensure proper alignment of the condyles to the shaft. Once the awl is properly positioned, it is advanced deep into the metaphysis. The awl is removed and the standard ball tipped guide rod is advanced through the awl portal, past the reduced fracture and proximally into the shaft. Keep the guidewire parallel to the anterior cortex of femur and lateral cortex of femur in other plane. The entry portal and medullary canals are enlarged with intramedullary reamers. The reaming is begun with 8 mm and the canal is reamed upto a size which is 1–1.5 mm larger than the size of the nail to be inserted. Proximal reaming may be necessary if the isthmus is narrow and when 12 mm and 13 mm nails are used. After reaming is completed, the nail and intramedullary supracondylar nail (IMSC) drill guide are assembled. The nail is advanced over the guidewire into the distal condyles. Traction is applied at this time with a gentle pull behind the gastrocnemius with the knee in 45–60° of flexion. Once the nail is in the distal condylar fragment, it is advanced with hand pressure over the guidewire until the distal end of the nail is countersunk 1–2-mm below the articular surface. This is checked by disappearance of two rings marked on jig which indicates the nail is inside. Same can be confirmed on C-arm by passing a K-wire from the small hole in jig which indicates the position of the tip of the nail. Next, 2–3 distal interlocking screws are placed via the standard procedure, three screws then placed proximally. In a 25-cm nail, it may be difficult to lock the proximal most holes with the jig, as it may go posteriorly. The knee joint is copiously irrigated with pulse lavage. A drain is placed and the patellar tendon repaired with absorbable sutures. It is not necessary to fill in all the holes in the standard multihole nail. It is necessary to insert at least three locking screws in the distal fragment to get maximum stability. Screws should not be placed in areas of comminution. Some interfragmental motion of the supracondylar fragments may be present at the end of the procedure.
Postoperative Care In general, patients in whom rigid fixation is accomplished can be put on a hinged knee brace. Avoid unassisted straight leg rising in the early postoperative period. Full weight-bearing is not recommended in unstable comminuted fractures until early
signs of healing have occurred. I have observed cutting out of the nail anteriorly in marked porotic fractures, due to collapse of the fracture, giving knee movements restriction. This surgery is ideal in severely porotic bones where plating is an inferior treatment. In presence of pre-existing arthritic changes in knee, range of movements is decreased postoperatively. Otherwise, knee joint movements are not affected after supracondylar nail.
Retrograde Femur NailStandard femur nail gives insertion site pain due to new bone formation, and the difficulty of piriform fossa insertion has induced few workers to do interlocking femur nail from this intra-articular approach from knee joint, like supracondylar nail. It is shown to produce no complications in the knee joint. It is ideal for shaft fracture associated with neck fracture, where both fractures are treated ideally independently.
Locking PlateWith the advent of the locking plate, supracondylar nail is now having a tough competition for its survival. For all practical purposes intra-articular distal femur fracture is now treated by distal femur precontoured locking plate. Locking plate also can be done with atraumatic way by minimally invasive methods, if reduction of the metaphyseal fragment can be obtained by traction and joy stick methods.
What we did not Teach in Workshops?
TibiaTibia mid-shaft transverse fractures are always treated with compression nail and immediate full-weight bearing. While applying the compression, see at the fracture in C-arm, while tighten ing the screw. If no more compression is occurring at fracture, the topmost screw/bolt will start bending (Figs 102A to C). Stop compression and lock proximal second hole and remove the bent bolt and replace with good locking bolt. In comminuted fractures of tibia and femur, with multiple pieces, preoperatively measure the length of normal limb and
Fig. 101 Nail parallel to lateral and anterior cortex
Figs 102A to C Compression nail
B CA
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Fig. 103 Badly comminuted fracture fixed with static locking nail in normal length, note that burst pieces remain outside nail
Fig. 104 Secondary grafting done after 6 weeks and final result fracture well united in 5 months with normal length
Fig. 105 Badly comminuted burst fracture fixed with static locking nail in normal length, note that comminuted pieces remain outside nail. Piece with arrow is turned around
Fig. 106 This turned piece is put back in proper position after 8 weeks and massive grafting done
Fig. 107 Fracture healing
note it. Intraoperatively, apply distraction to achieve this length on the injured side and do a static nailing. Multiple pieces will unite, if in contact with callus in desired length, or fill up the gaps with bone graft in second stage and achieve the equal length (Figs 103 to 108). Upper tibia, if long, oblique fracture, do inter fragmental screw with 3.5 mm screw and nail it in normal position. Do not hesitate to do open reduction, if a good alignment is not obtained. Tibia lower one-third long, oblique fractures treat them with interfragmental screw and 3.5 mm long reconstruction plate and plaster below knee for 4 weeks or distal tibia precontoured medial or lateral, anterior plate. It is necessary to have two screws as interfragmental screws.
Fracture tibias with intact fibula: I always do oblique osteotomy of fibula after telling patient before surgery. Statistically, fracture may unite without osteotomy, but I do not want one more reason for nonunion.
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FemurDistraction at fracture helps reduction. Tight fit nail at isthmus does not allow dynamization as nail does not glide in medullary cavity. Back slapping the nail after removing the traction, to remove distraction at fracture before proximal locking, is necessary in all transverse and short oblique fractures. In such fractures, always put nail in dynamic holes with screws away from fracture at both ends, if nail provides this. I never dynamize a comminuted fracture. If such fracture is not healing in due time, I suggest graft it by opening the fracture by anterior approach so that medial grafting can be done, which is difficult on lateral exposure. Use plenty of graft, autograft plus allograft, or bone substitutes to supplement and to fill up all the
Fig. 108 At 2 years fracture healed in normal length. Bone still has to hypertrophy
gaps in the bone. If grafting is planned after about 8 months or 9 months, it may be better to change the nail which has already undergone deformation for such time to avoid early breakage of the nail. Upper one-third fractures are very tricky. If supine position is not helpful to achieve the reduction, I do not hesitate to changeover to lateral position before opening the fracture or do open reduction. Do not accept alignment which is not perfect. Polar screw is very helpful. Open reduction and temporary plate fixation with unicortical screw is also a good option. Nailing is desired and not plating. External rotation deformity is the commonest malunion in these fractures in supine position. Fractures at junction of upper two-thirds and lower one-third femur are prone to nonunion and nail breakage. This is the level at which bone expands and, hence, nail is loose in lower fragment while it is tight in upper fragment. I suggest, at lower end, use more interlocking bolts, in both AP and lateral direction, after pushing nail in subchondral bone to improve stability, or even retrograde femur nail is a better option than antegrade femur nail in such junctional fractures. Mid-shaft femur long oblique fracture, if does not fall in good alignment, I suggest do open reduction and reduce fracture with lag screw along with nail, or neutralize with locking plate. In badly comminuted fractures, the burst component may be either many pieces or one large piece. If it gets reversed and the cortical portion faces away from the medullary cavity (turned completely), initially closed intramedullary nailing hoping for healing to occur, was accepted. I feel that it is worthwhile to open the fracture and turn the piece around and graft, if needed. I must agree that the fracture can unite even if the fragment is turned completely, more so if the fragment is on lateral side with good medial continuity.
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