tamil nadu orthopaedic journaltnojonline.com/wp-content/uploads/2018/04/tnoa-journal-feb2016.pdf ·...

Tamil NaduOrthopaedic Journal

Volume 42, Issue 1, February 2016

An official Journal of Tamil Nadu Orthopaedic Association

TAMILNADU ORTHOPAEDIC ASSOCIATION

OFFICE BEARERS 2015-2016

President SecretaryDr. C. Raja Ravi Varma Dr. S. Muthuraman

Immediate Past President President ElectDr. Nalli R Uvaraj Dr. R. Sivakumar

Vice- President Immediate Past SecretaryDr. S. Ramesh Babu Dr. V. Singaravadivelu

Joint Secretary EditorDr. M. Antony Vimal Raj Dr. C. Sugavanam

Fellowship SecretaryDr. P.T. Saravanan

Executive Committee Members

Chennai MaduraiDr. Nalli R Gopinath (Treasurer) Dr. P.V. Thirumalai MuruganDr. R. Prabhakar Singh Dr. T.C. Prem Kumar

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

Dr. M. Ilanchezhian

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

Editor

Dr. C. Sugavanam

Members of the Editorial Board

Dr. C. RajaRavi Varma Dr. S. Muthuraman Dr. R. Sivakumar

Dr. S. Ramesh Babu Prof. V. Singaravadivelu Prof. Nalli R Uvaraj

Dr. J. Dheenadhayalan Prof. P. Gopinath Dr. C. Vijay Bose

Dr. Terrence Jose Jerome Dr. G. Balasubramaniam Prof. R. Selvaraj

Prof. Narayana Reddy Dr. Krishnakumar Dr. M. Subbiah

Prof. Chandraprakasam

Tamilnadu Orthopaedic Journal Volume 42, Issue 1, February 2016

Contents

GENERAL

THE BEAUTY OF ORTHOPAEDIC SURGERY WHICH I LOVE AND PRACTICE 1

Prof. A. DevadossDevadoss Multispeciality Hospital, Madurai.

DOUBLE INTRAMEDULLARY SCHWANNOMA TREATED BY TOTAL EXCISION

& DURAL REPAIR 4Dr. S. Jaikish, P. YuvarajanDepartment of orthopaedics surgery, ATLAS hospitals,Tiruchirapalli.

SURGICAL TREATMENT OF RECURRENT LUMBAR DISC HERNIATION BY

TRANSFORAMINAL LUMBAR INTER BODY FUSION 6Dr. Sarangaraj Jaikish, Dr. Palanisamy YuvarajanDepartment of orthopaedics, ATLAS hospitals, Tiruchirappalli.

WEDGING OF PATELLA BET. FEMUR & TIBIA (LOCKED PATELLA)- RARE CASE IN LITERATURE 9

Dr. A. Senthil Kumar, Prof Dr. V. P Mohan Gandhi, Dr. C. DhaneshPrasadDepartment of Orthopaedic SurgeryGovernment Vellore Medical College & Hospital, Vellore.

MINIMALLY INVASIVE FIXATION OF CLOSED AND GRADE I & II COMPOUND PROXIMAL

TIBIAL INJURIES WITH LOCKING COMPRESSION PLATES - A CLINICAL STUDY 11Dr. K Meenakshi Sundaram, Dr. K Selvaraj, Dr K G Kandaswamy, Dr. I G Nagarajan,Vijayan Gopalakrishna Kurup, Department of Orthopaedics & Trauma CareVinayaka Mission Kirupananda Varier Medical College & Hospitals, Ariyanoor, Salem

SERENDIPITY IN ORTHOPAEDICS

SPINE

CASE REPORT

TRAUMA

FUNCTIONAL OUTCOMES OF INTRA ARTICULAR CALCANEAL FRACTURES TREATED BY

VARIOUS SURGICAL METHODS 18Dr. Muthukumar Balaji, Dr. Selvaraj. V, Dr. Satish Devadoss, Prof. A. DevadossDevadoss Multispeciality Hospital, Madurai.

ACETABULAR FRACTURES - CLINICAL OUTCOMES OF SURGICAL TREATMENT 24Dr. K Meenakshi Sundaram, Dr. K Selvaraj, Dr. K G Kandaswamy, Dr. I G Nagarajan,Vijayan Gopalakrishna KurupDepartment of Orthopaedics & Trauma CareVinayaka Mission’s Kirupananda Varier Medical College & Hospitals, Salem

CLINICAL EVALUATION OF LOCKING COMPRESSION PLATE FIXATION FOR

COMMINUTED OLECRANON FRACTURES 31Dr. K. Prabakaran, Dr. S. Jaikish,Department of Orthopaedic Surgery, ATLAS Hospitals, Tiruchirappalli.

RESTORING ANATOMY IN DISTAL HUMERUS INTER CONDYLAR FRACTURES WITH

LCPFIXATION 34Dr. Yuvarajan Palanisamy , Dr. S. JaikishATLAS Hopsitals, Trichy

GUIDELINES TO AUTHORS

TNOA MEMBERSHIP APPLICATION FORM

IOA MEMBERSHIP APPLICATION FORM

EDITORIAL

Dear TNOA Members

Greetings.In this issue, we have published various articles from authors across the state. Many thanks to all the

contributors. I would like to have more response from the members to contribute for our Journal. The journalcan grow only if more members are actively contributing. You may send your work at the preliminary stage toTNOA Journal , and prepare towards later publication in a Listed journal.

As the publications are becoming a standard requirement for career promotions and growth, the youngerTNOA members should concentrate on Data collection, Documentation as a standard daily practice. This wouldprovide opportunities for more publications and presentations.

I wish all the members a Happy New year enriched with Work, Joy, Health and Peace.Looking forwardto meet all of you at Ooty for the conference.

With Best wishes

Dr C SugavanamEditor

Tamil Nadu Orthopaedic Journal Vol.42, Issue 1, Feb 20161

THE BEAUTY OF ORTHOPAEDIC SURGERY WHICH I LOVE AND

PRACTICE

Prof. A. DevadossDevadoss Multispeciality Hospital, Madurai.

INTRODUCTIONNICHOLAS andry coined the term

orthopaedics in France in the year 1741. Though as thename implies it was initially developed with attention tochildren, the correction of spinal and deformities in allstages of life eventually became the corner stone oforthopaedic practice.In 1956 ,when I was a 3rd yearmedical student, Prof.M.Natarajan used to come fromMadras (Now Chennai) once a month to takeorthopaedic class as we had no qualified teacher inorthopaedic surgery at Madurai. His lecture andclinical demonstration for examinations of joints anddeformities were amazing and attractive, i decided totake up orthopaedic surgery as my future speciality inthe 3rd year it self and to get M.ch ortho from LiverpoolUniversity.At that time Prof.M.Natarajan was the onlyqualified Orthopaedic surgeon in the Whole state.

In 1950’s and 1960’s almost all fractures weretreated conservatively .All the more the Liverpool school(used to be called as Mecca of Orthopaedics) werevery conservative where we were taught that nofracture must be opened and it may get infected.

Early 1970’s,Prof.P.V.A .Mohandas broughtA.O Technique to India. I was one of those whoattended the first meeting, where Dr.Wellineger,Dr.Weller and Dr.Holtz had come. From then on lot ofnew things came in the A.O Technique, and newinstruments power drill etc... The most importantadvancement I felt was in the management of intraarticular fractures,the concept of immediate openreduction to get perfect congruity of articular surface,regid internal fixation and early mobilisation.

The functional outcome of intra articularfracture was really stunning than what we used to seeduring our earlier days. Of course with the advent ofCT scan we are much better for our planning. Of coursein tibial plateau fractures and pilon fractures skinproblems is devastating. Now for this fractures we knowthat “ Scan” ,”plan” and “span” is ideal. Once thewrinkle sign sets in, we can do the best for thefracture.

In surgery of Trauma, management ofdiaphyseal fractures using intramedularly interlockingnail is something we never dreamt when we were inLiverpool. Ofcourse one has to face the problem of fatembolism, but with the damage controlled orthopaedicswe are safe surgeons.

In open fracture management we have come along way in shortening the period of morbidity by the“fix and flap technique” with good wound debridement,skin and antibiotic cover. In olden days the orthopaedicward will be stinking like mad because of soiled plasterof paris using “ WInnett Orr”method .The patients willvery often end up with poor functional out come. Theusage of external fixation system by AO Group , Orthofixand Ilizarov technique have improved the technique oflimb reconstruction following complications due to openfractures in recent times. The amount of violence to thebone and soft tissues are enormous due to road trafficaccidents. The poly traumatised patients are being treatedin a better manner in tertiary care centers than before.We have best ICU Care, anaesthetic facilities bloodtransfusion servicesand better understating of post trau-matic systemic inflammatory response of the body andtreat them accordingly .

The only pitiable state of affairs we see almosteveryday is complications due to improper judgement ofchoosing the implant leading on to failure of the metal,non unions, infections, joint stiffness and deformities .Unfortunately there are no guidelines . The Americanacademy of orthopaedic surgeons have given guidelinesto all fracture management which the practicingorthopaedic surgeon must follow. Even then things cango wrong in spite of orthopaedic surgeon has followedthe guidelines. However in our set up the surgeon isforced to do certain number of surgeries by the higherauthorities. Hence the surgeon is forced to do thesurgery even when there is no indication or do someunwanted surgery. I feel that Tamil Nadu Orthopaedicassociations must do something like AAOS to giveguidelines to all traumatic and orthopaedic conditions and

SERENDIPITY IN ORTHOPAEDICS


their treatment, so that the surgeon will not falter toomuch and the patients will get better treatment. It is hightime TNOA insists on all the members attend the CMEprogrammes in various sub specialities in orthopaedicsand show their credit points to the TNOA to enable themto continue the membership in the TNOA, just like whatthey are doing in Bombay orthopaedic society .

After I qualified in 1967 with M.ch ortho fromLiverpool University, real advancement in orthopaedicsurgery happened. Our generation grew with that.In1970’s I had to go to U.K again for training in charnley’slow friction arthroplasty of hip, arthroscopy and othersubspecialties like spine, and Paediatric orthopaedics. Wehad to spend money from our own pocket. There wereno companies to sponsor us. I used to attend all SICOTand BOA meetings to update ourselves. IOA and TNOAalso helped us. I am a member of all the subspecialtysocieties in India being a teacher, I have to keep myselfupdated in all subspecialties as we are all generalorthopaedic surgeons. Now all subspecialties have gonesky high, we have to refer cases to all specialists in jointreplacement surgery, Arthroscopic surgery, spinesurgery, Paediatric orthopaedic surgery and others.Butwe had our days when we were allrounders.

Orthopaedic surgery and other branches of medicine.The beauty of orthopaedic surgery lies in the

knowledge we possess in the other fields of Medicine.

1.General Medicine:A patient with pain in the back may have

associated cough with expectoration and some timehaemoptysis. We must be able to auscultate and find outclinically and by radio imaging whether it is kochs’orbronchogenic Carcimona.(I wonder how manyorthopaedic surgeons in the present generation carry aStethescope)!!

Similarly patient may present with neck pain,wasting of small muscles of the hand, loss of sensationin the medial two fingers associated with Horner’s syn-drome and then the diagnosis must be Pancoast tumour. There are so many conditions where the orthopaedicsurgeons is capable of diagnosing many associatedmedical problems patient has.

2.General Surgery:It is nice that an orthopaedic surgeon is a good

clinician to diagnose surgical condition also. A 48 yearsold man was referred to me for pain right shoulder andalso temperature. It was diagnosed as ?septicarthritis ?tuberculosis of the shoulder joint by the referringgeneral surgeon.

On examination there were no inflammatory signs overthe shoulder, however there was limitation of extremesof rotation due to periarthritis as he being a diabeticalso. He complaint of pain abdomen which was attrib-uted to NSAID . However when examined his abdo-men, his liver was palpable and tenter. USG of abdomenrevealed an amoebic liver abscess with subdiaphragmaticextension irritating the diaphragm causing referred painto the Right shoulder.Actually the case was referred bya general surgeon, the orthopaedic surgeon made thecorrect diagnosis.Similarly we have detected lot of casesof Leriche Syndrome causing gluteal claudication initiallydiagnosed as sacroiliac arthritis.All these are possible aswe had a strong clinical acumen when we were un-dergraduates and strong basic sciences while doing pri-mary fellowship in U.K

3.Nephrology:In calcium homeostasis , the role of parathy-

roids, kidneys and intestines are well known. AsOrthoapedic surgeons we see lot of cases of deformi-ties of knees either genu valgus orVarus. Good percent-age of cases will end up in diagnosing them as vitamin Dresistant renal rickets. Very many of them are treatedas nutritional rickets.Many cases of genu valgum aretreated as renal rickets, but turned out to be multipleepiphyseal dysplasia or Morquio’s disease. In that waythe orthopaedic surgeon is the best in the world to makeappropriate diagnosis.

4.Orthopaedic Neurology:As an orthopaedic surgeon it is mandatory to

know orthopaedic causes for neurological deficit. Onepatient was treated by another surgeon for severe neckpain and radiating to leftshoulder and upper arm. Nextmorning patient developed paralysis of deltoid muscle.Patient was subjected for MRI etc of the spinal cordand shoulder and could not find anything wrong. Patientcame to me and we made a diagnosis ofAmyotrophicNeuralgia and was treated with steroids andphysiotherapy and patient improved well.

Another patient had fever followed by severeradicular pain in the left lower limb. He was treated asdisc prolapse by another surgeon. MRI revealed discbulges at L4-L5, L5 –S1.Patient was treated with bedrest and NSAID without any improvement. Patient com-plaint of redness of the left lower limb, the surgeon toldthe patient that it is due to drug allergy. Patient came tome after 3 days of his symptoms of radicular pain andredness of the left lower limb on the lateral aspect.Examination of lower limb revealed vesicles withreddish areas surrounding each vesicle and the diagno-

Prof. A. Devadoss


sis was herpes zoster along S1 dernatome.Patient was treated with acyclovir and steroids

and patient became better.As an orthopaedic surgeon we all must be

familiarwith upper motor neuron , lower motor neuronand peripheral nerve problems and must be able todifferentiate each type and refer the case to theneurologist whenever necessary.We must all be familiarwith electro physiological studies to help our patient inthe diagnosis and treatment.

CONCLUSIONOrthopaedic surgery is so interesting,

demanding and so vast. It stimulates the brain andpresents challenging conditions to one’s talent andknowledge of the subject. It involves the correlation ofother branches of medicine to make a correct diagnosis.One feels great when one makes the perfect diagnosiswhere the others missed. One must have a soundknowledge of basic sciences applicable to orthopaedicsurgery. The introduction of C-Arm , CT Scan and MRIhave all improved one’s diagnostic skills and also oursurgical capabilities. As health care providers, we mustall take measures, for the patient to be back on his feetand to return him to original activities of daily living. Evenwith all new subspecialties in orthopaedic surgerycoming into vogue, it is unfortunate that the conserva-tive management of ordinary orthopaedic problems like

The beauty of orthopaedic surgery which I love and practice

osteo arthritis of knees, neck pains and heel pains etcare not well taken care of by the present day orthosurgeons. The patients are given only tablets and thesurgeon has no time to explain about the condition, thecauses, the do’s and dont’s one has to follow. Mostimportantly the role of physiotherapy in easing the pain,is not at all advised. The younger ortho surgeons haveeasy access to internet , teleconferencing etc to makethem much more knowledgeable , unlike our times, whenwe had no google, internet etc. We could only refer heavyvolumes of books, unlike the handy iphone, tablet etc.Unfortunately surgeons today have less time for patientdoctor relationship and they do not realise it’simportance in their daily busy schedule. Those days whenwe were students, we were taught bedside manners andthe doctor patient relationship also.

The beauty of orthopaedic surgery lies in the men-tal satisfaction that we get from the patients after havingsaved their lives in a major accident and also make themwalk and use their limbs and return them to their originaljob. With the modern new methods of Jointreplacement surgeries, and Arthroscopic surgeries,we arein a better position to give them new life and have all theirleisure pursuits. To make this possible one must keep onupdating by attending conferences, CME programmes andreading journals. Money making is only the secondary beautyof orthopaedics , the satisfaction and the heartfelt thanksby the patient make the prime beauty of orthopaedics.


INTRODUCTIONTumours of the spinal column may be classified

by location as extradural, intradural, or intramedullary.Amongst all masses of the spinal column, intramedullarytumours are the least common to be encountered in thegeneral public. Their rare incidence commonly results inmisdiagnosis and improper diagnostic workup, resultingin delayed diagnosis. More common clinical entities suchas spondyloarthropathy, multiple sclerosis, or evenaortic dissection can be confused with intramedullarytumours as they may have similar clinical andradiographic presentations.Case report

40 years female presented with dull aching backpain with weakness of both lower limbs for 2 weeksduration. She had no traumatic accident & no otherprevious disorders such as skin hyperpigmented cafe ulait spots or cutaneous neurofibromas. Neurological ex-amination shows grade 1-2 power of both lower limbs,

bladder and bowel involvement and sensation isdiminished on both side below L1. DTR was absent onboth lower limbs. Gadolinium-enhanced MRI- showed6X2 cms well defined intramedullary elliptical lesionbehind the body of L2,3 and poorly differentiatedintramedullary lesion behind the S1 (double lesion).The operation was done with a standard posteriormidline approach after incising skin & fascia,paravertebral muscle erased, patient has underwentposterior laminectomy from L1-S1, after dural openingthe proximal tumour was in piecemeal which wasremoved completely from the nerve roots and distal onewas only clots which was aspirated and dural closuredone. Histopathological examination showedschwannoma. Patients was followed for aperiod 1 year at the intervals of 3, 6 12 months. Initialmobilisation was done with HKAFO orthosis with spinalsupport and neurology was gradually improved to grade4/5 power in both lower limbs at the end of 12 weeks.

Abstract : Spinal schwannomas are one of the most common primary tumours of thespine, but intramedullary schwannomas in non – neurofibromatous patients have beenreported rarely accounting for less than 1.1% of all schwannomas. Most of thesetumours have been reported as a single lesion in the spinal cord; rarely present asdumbbell intra & extramedullary lesions. 40 years female presented with dull achingback pain with weakness of both lower limbs for 2 weeks duration. Neurological ex-amination showed grade 1-2 power of both lower limbs, bladder and bowel involve-ment and sensation is diminished on both side below L1. DTR absent on both lowerlimbs, MRI- showed 6X2 cms well defined intramedullary lesion behind the body ofL2,3 and poorly differentiated intramedullary lesion behind the S1. Patient has under-went posterior laminectomy from L1-S1, after dural opening the proximal tumour wasin piecemeal which was removed completely from the nerve roots and distal one wasonly clots which was aspirated and dural closure done. Histopathology showed thelesion was schwannoma. Patients was followed for a period 1 year at the intervals of 3,6 12 months. Initial mobilisation was done with HKAFO orthosis with spinal supportand neurology was gradually improved to grade 4/5 power in both lower limbs at theend of 12 weeks. Ankle was last to gain to full power at the end of 24 weeks. Noevidence deterioration of symptoms at the end of 1 year.Keywords: schwannoma, intramedullary tumour, spinal cord tumour

DOUBLE INTRAMEDULLARY SCHWANNOMA TREATED BY TOTAL

EXCISION & DURAL REPAIR

Dr. S. Jaikish, P. YuvarajanDepartment of orthopaedics surgery, ATLAS hospitals,Tiruchirapalli.

SPINE


Ankle was last to gain to full power at the end of 24weeks. No evidence deterioration of symptoms at theend of 1 year.

DISCUSSIONSpinal tumours are traditionally divided into three cat-egories according to their relationship to the spinal cord,its surrounding membrane (the dura) and the bones (ver-tebrae) of the spine.These categories are: 1. Intramed-ullary 2. Extra-medullary but intra-dural 3. Extra-dural.Benign tumours tend to be slowly growing, are oftenwell-demarcated from the surrounding normal tissues(making them easier to remove completely) and do notspread (metastasize) around either spine (or brain) orthe rest of the body. Malignant (which usually meanscancerous) tumours are usually rapidly growing and tendto have extensions into the adjacent normal tissues mak-ing them difficult to remove completely unless some ofthat normal surrounding tissue can be sacrificed withoutcausing harm (not the case when it comes to the spinalcord or brain). They can also spread (often through thebloodstream) to other parts of the body. Any tumourthat has been completely removed surgically cannot (bydefinition) recur. But if fragments (even those too smallfor the surgeon to see) remain after the operation (whichis more likely with malignant tumours but can happenalso with a benign tumour) then further growth is likely.Kyeong-Sik Ryu et al published thoracic intramedullaryschwannoma accompanying by extramedullary beads likedaughter schwanommas, he removed intramedullarylesion fully and partial resection of extramedullarymasses were done. Conti et al., analysed iterature from1931 to 2002 & found only about 50 reported cases ofnon – neurofibroma related intramedullary schwannomas.Most of these lesions have been reported as singleintramedullary lesions, and more rarely as dumpbellintra- & extramedullary ones. Schwannomas originatefrom the Schwann cell. Schwann cells are absent in thecentral nervous system, thus it can explain the rarity ofintramedullary schwannomas. The pathogenesis ofintramedullary schwannoma is still not clear, and varioushypotheses have been reported. The origin of thesetumours include Schwann cells alone the intramedullaryperivascular nervous plexus, focal intramedullaryproliferation of Schwann cells in reaction to chronicdisease or trauma, ectopic Schwann cells originating frommigrating neural crest cells, and Schwann cells relatedto aberrant intramedullary myelin fibres. Schwann cellsin the posterior nerve root at the root entry zone areassumed to be one of pathogenesies of intramedullarytumours. A tumour arising from Schwann cells in this“critical area,” here the nerve root loses its sheath, couldenter the subpial area in the spinal cord and appear as

an intramedullary large one and extramedullary bead likesmall ones on the adjacent nerve roots. Schwanomma inthis case presented as well defined elliptical intramedul-lary lesion in lumbar area and illdefined intramedullarysacral lesion. Complete surgical excision is the treatmentof choice for spinal schwannomas, including intramedul-lary ones. In this case we have totally excised both thetumours.

REFERENCES1.Adelman LS, Aronson SM. Intramedullay nerve fibre & Schwanncell proliferation within the spinal cord Neurology. 1972;22:726-731.2.Brown KM, Dean A. Throcic intramedullary schwannoma.Neuropathol Appl Neurobiol. 2002;28:421-424.3.Conti P, Pansini G, Spinal neuromas: retrospective analysis & longterm outcome of 179 consecutively operated cases. Surg Neurol.2004;61:34-43.4.Kang JK, Song JU. Intramedullary spinal schwannoma. J NeurolNeurosurg Psychiatry. 1983;46:1154-1155.Vailati G, Occhiogrosso M, Troccoli V. Intramedullary thoracicschwannoma. Surg Neurol. 1079;11:60-62.

Dr. Jaikish et al

after dural openingtumour is exposed

dural closure afterremoval of tumour

Intramedullary spinaltumour in second level

Clinical picture


SURGICAL TREATMENT OF RECURRENT LUMBAR DISC

HERNIATION BY TRANSFORAMINAL LUMBAR INTER BODY

FUSION

Dr. Sarangaraj Jaikish, Dr. Palanisamy YuvarajanDepartment of orthopaedics, ATLAS hospitals, Tiruchirappalli.

ABSTRACT:Background: Recurrent lumbar disc herniation (RLDH) is a major cause of surgicalfailure, the incidence of which is reported from 5-11% (1). The optimal technique fortreating RLDH is remains disectomy more difficult, increasing the risk of dural tear ornerve injury. A perfectly done TLIF will be the answer for the recurrent lumbar discherniationMaterials and methods: Between 2010-2013, 10 patients (average age 38 range 25 –53 years) with recurrent lumbar disc herniation underwent reoperation with thetransforaminal lumbar interbody fusion (TLIF) technique (Titanium pedicle screwswith titanium TLIF cage or autologus bone graft) at our orthopaedic department. Allcases were followed up for 24-48 months.Results: Results were graded using Japanese orthopaedic association (JOA) scoresystem pre and post operation and during the follow-up period. The leg pain of allpatients was relieved within a week & the mean JOA score was improved from 9before surgery to 25 in all cases at the 2 years. No infection, no implant failures.Fusion assessed by follow up flexion and extension stress X-rays.Conclusion: Repeated discectomy for either ipsilateral or contralateral recurrencerequires the removal of more disc material and posterior elements, such as lamina orfacet joint, further invasion at the same surgical level can increase the risk ofsegmental instability. TLIF technique is an effective procedure with satisfactoryclinical results for the treatment of recurrent lumbar disc herniation. It can restorethe stability and lordosis of the lumbar spine, and has low complication rates.Keywords: recurrent lumbar disc prolapse, lumbar instability, TLIF, failed backsyndrome.

INTRODUCTIONRecurrent lumbar disc herniation (RLDH) is a

major cause of surgical failure, the incidence of which isreported from 5-11% (1). The optimal technique fortreating RLDH is remains disectomy more difficult,increasing the risk of dural tear or nerve injury. Somesurgeons believe that fusion is necessary for treating discherniation that relieves pain due to segmental instability.Repeated discectomy for ipsilateral or contralatetralrecurrence requires the removal of more disc materialand posterior elements, such as lamina or facet joint,further invasion at the same surgical level can increasethe risk of segmental instability. Several authors reportedthe results of posterolateral fusion PLF for RLDH, butthere are few reports on RLDH treated with thetransforaminal lumbar interbody fusion (TLIF) technique.

TLIF affords the opportunity to achieve stable threecolumn fixation with anterior support, simultaneousanterior and posterior fusion & inherent stability througha single posterior approach & unilateral placement ofinterbody cages. The purpose of this study is to evaluatethe efficacy of the TLIF techniques for the patients withRLDH.

MATERIALS & METHODSBetween 2011-2013 10 patients in ATLAS

hospitals underwent reoperation following primary lum-bar discectomy. There were 4 men 6 women with meanage of 46 years. The inclusion criteria in this study were1. Atleast 6 months of pain relief after primary discsurgery. 2. The presence of recurrent radicular pain


unresponsive to conservative treatment, leading to a re-peat operation 3. Recurrent disc herniation at the samelevel of previous discectomy, either the ipsilateral or con-tralateral side. 7 patients primarily treated with bilaterallaminectomy and discectomy & 3 patients were treatedwith fenestration discectomy were included in this study.

Surgical technique: under GA (6 pt), SA (4 pt) in proneposition, bilateral dissection was extended just lateral tothe facet joints through a midline posterior approach. Theepidural scar tissue in the area of the previouslaminectomy was left intact. Pedicle screw entry pointwas prepared in usual manner. Titanium pedicular screwsinserted above and below the affected level, thesymptomatic side pars interarticularis removed and ahemifacectomy performed on superior & inferior facetsat the level of the spinal segment to be fused. Thetraversing nerve root is protected by sliding a retractoralong upper surface of the pedicle of the inferiorvertebra. Complete disectomy done end plates prepared,after distracting the disc space, 2/3 space was packedwith laminectomy cancellous bone graft and titaniumTLIF cage introduced, the position was confirmed withC- Arm and posterior connecting rods inserted & woundclosed.

RESULTSRegular follow up was done at 3, 6, 12, 24

months clinical and radiological evaluation done. Leg paindecreased rapidly within 4 weeks & continued todecrease at the time of the latest follow up. Flexion &extension stress X - rays were evaluated at 12, 24 monthsfollow up. Criteria for a successful fusion were the lackof motion, anterior bridging bone and lack of lucencieson flexion & extension x-rays. The JOA score(Japanese orthopaedic association evaluation system forlow back pain syndrome) was determined via directquestioning to assess subjective symptoms, clinical signs& restriction of activities of daily living. The normal scorewas 29 points. The mean JOA score of the patientsshowed improvement, from 9 before surgery to 25 atfollow up of 2 years. Excellent in 70%, good in 30%patients. There no implant failure & infection in ourseries. One case we encountered dural laceration whichwas partially repaired and muscle patch was applied.There were no major complications as permanentneurological deficit, pulmonary embolism or death.

DISCUSSIONThe ideal surgical approach for recurrent disc

herniation remains controversy. Discectomy with fusionhas several theoretical advantages. The interbodyfusion reduces or eliminates segmental motion,

immobilises the spine, reduces mechanical stressesacross the degenerated disc space and may reduce ad-ditional herniation at the affected disc space. Revisionspinal surgery is more challenging than primary surgery,owing to the indistinct anatomical planes & perineuralscarring. Ebeling et al. (2) reported complication of 13%after repeated discectomy, and dural tears & infectionswere the most common problems. However TLIFprovides an approach through facetectomy to enterunscarred virgin tissue. Therefore the surgeon can ap-proach the target site safely without demandingdissection of the fibrotic scar tissues & excessiveretraction of scarred nerve root & dura, the potentialrisk of dural tear & nerve injury may also be decreased.Only 10 % (1 case) experienced dural tear duringsurgery in our series, which is lower than the previousreports.

Dr. Sarangaraj Jaikish et al

MRI before & after discectomy

Titanium TLIF implants excised disc

Excellent fusion and good pain relief


Surgical treatment of recurrent lumbar disc herniation by transforaminal lumbar inter body fusion

We used a single cage inserted diagonally fromthe symptomatic side. A more lateral entry point com-pared with PLIF is selected, which can reduce dura &nerve root retraction & minimise the risk of neurologicalinjury. Zhao et al. (4) demonstrated that, as onlyunilateral facetectomy is required for the insertion of asingle cage, the stiffness of the construction is signifi-cantly superior to the two cage fusion. Lehmann et al.(3) solid fusion has better functional outcomes than thosewith disc excision alone. Bone grafting of availablesurface area of the disc space is important for fusionsuccess. Before the insertion of cage, the preparedlaminectomy bone or iliac crest autobone graft wasgrafted in to the prepared disc space. We believe thatthe bone outside the cage has greater fusion potentialthan the bone inside the cage.

CONCLUSIONBased on the clinical outcomes transforaminal lumbarinterbody fusion is an effective procedure withsatisfactory clinical results for the treatment ofrecurrent lumbar disc herniation. It can restore thestability and lordosis of the Lumbar spine and has lowcomplication rates.

REFERENCES1.Cinoti G, Roysam GS, Eisenstein SM, et al. Ipsilateral recurrent lumbar discherniation. A prospective, controlled study. JBJS Br. 1998;80: 825-832.2.Ebeling U Kalbarcyk H, Reulen HJ. Microsurgical reoperation followinglumbar disc surgery. J neurosurg. 1989;70: 397-404.3.Lehmann TR, Larocca HS. Repeat lumbar surgery. A review of patients withfailure from previous lumbar surgery treated by spinal canal exploration andlumbar spinal fusion. Spine 1981;6;615-619.4.Zhao J, Hai Y, Ordway N, et al. Posterior lumbar interbody fusion usingposterolateral placement of a single cylindrical threaded cage. Spine.2000;25:425-430.


WEDGING OF PATELLA BET. FEMUR & TIBIA

(LOCKED PATELLA)- RARE CASE IN LITERATURE

Dr. A. Senthil Kumar, Prof Dr. V. P Mohan Gandhi, Dr. C. DhaneshPrasadDepartment of Orthopaedic Surgery

Government Vellore Medical College & Hospital, Vellore.

INTRODUCTION AND PURPOSEDirect injury to knee usually results in stellate

fracture patella. Patella dislocation may occur in rareinstances. Still rarer is the wedging of patella betweenpatella and femur. Such a case was not found in the lit-erature. A single case of locked patella is presented.

MATERIALS AND METHODS18 yrs. male presented with injury to knee hit-

ting against stone while playing cricket. He was unableto walk, flex the knee.

On examination:A lacerated wound of about 4*1*1 cm. Knee in exten-sion, protruding patella visible through the skin. Kneemovements completely restricted. NodistalNeurovascular deficit.

X-ray showed wedging of patella in between tibial andfemoral condyles. No fracture detected.

CT showed:wedging of patella between femur & tibia.Nofracture detected.

MRI of knee showed:Partial Quadriceps disruption atsuperior pole attachment

Closed reduction under anaesthesia attempted,but failed.

Under spinal anaesthesia, Incision extendedproximally and distally exposing the quadriceps mecha-nism. Longitudinal incision made over quadriceps ten-don. Patella was found to be wedged in between femur& tibia. Quadriceps tendon was found to be partiallydetached from the patella. More than 80% of quadri-ceps tendon was still attached to the patella.Vertical in-cision made over Quadriceps tendon to facilitate reduc-tion. Patella was levered out of the tibio- femoral joint

CASE REPORT

with some difficulty. Patellar tracking was normal. Ver-tical incision made in quadriceps tendon sutured. Reti-naculum repair done. Full range of movements achievedon table. Limb maintained in posterior splint.Post op: suture removal on 12th POD.Range of motionexercises started as pain permitted.Patient able to fullyweight bear and walk with POP on 5th POD.


RESULTS AND DISCUSSIONInjury to knee usually results in stellate fracture

patella. In this rare case presentation wedging of patellawas found between femur and tibia. Due to prompt in-tervention full function was restored. There was no in-jury to quadriceps mechanism. Such a case is rare inliterature.


ABSTRACTFractures around the knee are one of the commonest injuries encountered in highvelocity trauma which are associated with high morbidity and mortality. Isolated frac-tures itself may lead to complications such as ARDS and pulmonary embolism.Being one of the major weight-bearing joint of the body fracture around it will be ofparamount importance. This necessitates early stabilization of fractures. Internal fixa-tion is the choice of treatment in fractures around the knee and Locking CompressionPlate (LCP) has shown to give the best results in terms of wound healing, free frominfection, early good range of motion, fracture union, return to work and the functionaloutcome.LCP is a hybrid plate technology and percutaneous bridge plating using locked screwsas a fixed angle device which allows much greater load bearing than regular platesavoiding medial and lateral plating. The LISS uses unicortical locking screws to allowmore elastic deformation than conventional plating systems.142 cases of proximal tibial fractures were treated by closed reduction in fracturetable and internal fixation by LCP between December 2006 and December 2014 atVinayaka Mission’s Kirupananda Variar Medical College & Hospitals. The patientswere evaluated clinically and radiologically for the outcomes. All the patients werefollowed up for an average of 6 months. Outcome was assessed using Knee SocietyClinical Ratings and radiographic analysis.

MINIMALLY INVASIVE FIXATION OF CLOSED AND GRADE I & II

COMPOUND PROXIMAL TIBIAL INJURIES WITH LOCKING

COMPRESSION PLATES - A CLINICAL STUDY

Dr. K Meenakshi Sundaram, Dr. K Selvaraj, Dr K G Kandaswamy, Dr. I G Nagarajan, Vijayan Gopalakrishna KurupDepartment of Orthopaedics & Trauma Care

Vinayaka Mission Kirupananda Varier Medical College & Hospitals, Ariyanoor, Salem

INTRODUCTIONThe knee joint is one of the major weight

bearing joints in the lower extremity. The proximaltibial fractures are one of the commonest intraarticularfractures and they present a difficult treatmentchallenge with historically high complication rates.Generally these injuries fall into two broad categories,high energy fractures and low energy fractures.

The majority of proximal tibial and tibial plateaufractures are secondary to high speed velocityaccidents and fall from height1 where fractures resultsfrom direct axial compression, usually with a valgus(more common) or varus moment and indirect shearforces2.

Extra-articular fractures of the proximal tibiausually secondary to direct bending forces applied tothe metadiaphyseal region of the upper leg, olderpatients with osteopenic bone are more likely to

sustain depression type fracture because their sub-chondral bone is less likely to resist axial directed loads3.

In the early 1960s, there was a great reluctancetowards operative management of these fracturesbecause of high incidence of infection, non-union,malunion, inadequate fixation and lack of properinstruments, implants as well as antibiotics. Then thetraditional management comprised of skeletal traction,manipulation of fracture and external immobilization inthe form of casts and cast bracings. These methods how-ever met with problems like deformity, shortening, kneestiffness, angulation, malunion, knee instability, and posttraumatic osteoarthritis.

The trend of open reduction /closed reductionand internal fixation has become evident in the recentyears with the improvement in understanding offracture personality. The aim of surgical treatment of

TRAUMA


proximal tibia fracture is to restore congruent articularsurfaces of the tibial condyles maintaining the mechani-cal axis and restoring ligamentous stability eventually canachieve functional painless and good range of motion inthe knee joint4.

So there was the birth of a new concept ofbiological fixation using the plates, otherwise called mini-mally invasive plate osteosynthesis (MIPO) where a per-cutaneously inserted plate is fixed at a distance proximaland distal to the fracture site through minimal exposure.Various clinical studies established that bone beneath arigid conventional plate are thin and atrophic whichare prone for secondary displacement due to insuffi-cient buttressing and secondary fractures after removalof plate. Fracture site takes longer period to osteosyn-thesis due to interruption of vascular supply to bone fol-lowing soft tissue and periosteal stripping. Elderly pa-tients with severe osteoporosis add further to the diffi-culties in the management of these fractures. Loss ofstable fixation in osteoporotic bones is of great concernin such elderly patients5.

This leads to the development of the internal andexternal fixators like multiple K-wires, cancellous screwfixation, manually contoured plates, T and L Buttressplates, knee span external fixators and Ilizarov fixators.As more and more concepts about biological fixationbecome clearer the innovation of plates progressed todevelopment of Less Invasive Stabilizing System(LISS). Research to combine these two methods haslead to the development of the AO locking compressionplate (LCP)6.

LCP is a hybrid plate technology andpercutaneous bridge plating using locked screws as afixed angle device which allows much greater load bear-ing than regular plates avoiding medial and lateral plat-ing. The LISS uses unicortical locking screws to allowmore elastic deformation than conventional plating sys-tems.

Locked implants are typically indicated inpatients with osteoporosis where pull-out of the screwsis problematic, fractures with metaphyseal comminutionwhere the medial cortex can not be restored, or a shortarticular segment.

ADVANTAGES OF LCP1. Anatomically pre-contoured: which reduces softtissue problems and eliminates the need for platecontouring2. LCP combi-hole: Intraoperative choice betweenangular stability and / or compression3. Guiding blocks: enable easy and correct mounting of

the threaded drill guides in the spoon part of plate4. Limited contact plate design: reduces plate-to-bonecontact, thus limiting vascular trauma5. Osteoporotic bones: better fixation of fracture in eld-erly patients6. Unicortical fixation option: unlike cortical screws whichrequires bicortical fixation7. Better preservation of blood supply of bone due tominimal soft tissue dissection8. Maintaining better articular congruency9. Length of bone is maintained in comminuted fractures10 Shorter stay in hospital

INDICATIONS1. Multifragmentary fractures of proximal tibia2. Intraarticular fractures (Schatzker type I to V)3. Metaphyseal fracture (Schatzker type VI)4. Grade I & Grade II compound fractures5. Periprosthetic fratures

FRACTURE CLASSIFICATION

SCHATZKER’S CLASSIFICATION10

Type - I — PURE CLEAVAGEA wedge shaped uncomminuted fragment is split off anddisplaced laterally and downwards. This fracture iscommon in younger patients without osteoporotic bone.Type – II — CLEAVAGE COMBINED WITH DE-PRESSIONA lateral wedge is split off, but in addition the articularsurface is depressed down into the metaphysis. Thistends to occur in older people with osteoporotic bone.Type - III — PURE CENTRAL DEPRESSIONThe articular surface is driven into the plateau. Thelateral cortex is intact. These tend to occur in os-teoporotic bone.Type – IV – FRACTURES OF MEDIAL CONDYLEThese may be split off as a wedge or may becomminuted and depressed. The tibial spines are ofteninvolved. These fragments tend to angulate into varus.Type – V – BICONDYLAR FRACTURESBoth tibial plateaus are split off. The distinguishingfeature is that the metaphysis and diaphysis retaincontinuity.Type – VI – PLATEAU FRACTURE WITH DISSO-CIATION OF METAPHYSIS AND DIAPHYSISA transverse or oblique fracture of the proximal tibia ispresent in addition to a fracture of one or both tibialcondyles and articular surfaces.

Dr. K. Meenakshi Sundaram et al


Minimally invasive fixation of closed and grade I & II compound proximal tibial injuries with locking compression plates - A clinical study

Fig.: SCHATZKER’S FRACTURE CLASSIFICA-TION

TYPE I TYPE II TYPE III

TYPE IV TYPE V TYPE VI

This study was designed to study the functional resultsof closed and Grade I & II compound proximal tibialfractures by closed reduction and internal fixation withLCP.

MATERIALS & METHODSIn this study, 142 patients with closed & open

grade I & II fracture of upper end of tibia were se-lected. All the cases were treated at VMKVMC & Hbetween December 2006 and December 2014 and fol-lowed for a minimum of 6 months.The method used for fracture fixation was closed oropen reduction and internal fixation with locking com-pression plate. The duration of follow-up ranged from 6months to 24 months.All the fractures in this series were post-traumatic.

Inclusion criteria· Patients presenting with traumatic proximal tibial frac-tures with or without osteoporotic changes· All types of upper end of tibia (Schatzker Type I to VI)· Patients above the age of 20 yearsExclusion criteria· Patients with open proximal tibial fractures· Children with proximal tibial fractures in whom growthplate is still open· Patients with pathological proximal tibial fractures otherthan osteoporosis· Patients managed conservatively or fixed with otherfixation systems like AO plate or condylar buttress plate.

On admission demographic data was re-corded and thorough history and clinical examinationwas done. We assessed the soft tissue injuries even inthe closed fractures followed by radiological assessmentof the fracture with Schatzker’s classification. Ifblisters were present, the surgery was delayed for 7-10days.

All cases received first aid in casualty with thor-ough examination to find out associated injuries. Patientswere subjected to routine preanaesthetic investigationsand additional investigations when indicated. Standardantero-posterior and lateral radiographs were taken andthe fracture classified according to AO groupclassification.

The antero-posterior and lateral X-rays wereevaluated for the extent of comminution and the likelylength of the plate was calculated. Since usually longplates are required to span the comminuted area andsuch long plates are not readily available, a prior calcu-lation is must.

All surgeries were performed under regional ana-esthesia and with a tourniquet in the supine position. Inour series, all fractures are reduced with traction in frac-ture table with C- arm guidance. The approach was ei-ther anteromedial parapatellar or anterolateralparapatellar incision. A small incision is taken on oneend of the fractured comminuted area without disturb-ing the soft tissue envelope of the fractured fragments.The incision is extended right up to the bone with theperiosteal tube opened. A sub-periosteal tract is madealong the surface where the plate is going to be appliedand extended across the fracture to the other side. Thetract is done with a special doubly angled periosteal el-evator available in different sizes. The plate used de-pended on the anatomy and location of fracture. It isinserted well beneath the depressed articular fragments,and by slow and meticulous pressure the articular frag-ments and compressed cancellous bones are elevated in


one large mass. Unless this is done, redisplacement andsettling can occur. We preferred packing cancellousbones which were obtained from the iliac crest into thedefect as this conforms much more nearly to the defectcavity.

As the fragments are elevated and reduced,temporarily fix the with multiple small Kirschner wires.Locking compression plate was used for fixation whichwas applied to the anterolateral tibial condyle which isprecontoured to confirm to the condyle and proximalmetaphysic. When properly contoured, it was securedto the condyle with appropriate locking / plaincancellous screws of sufficient length to engage theopposite medial cortex. Locking / cortical screws wereused to attach the plate to the shaft of the tibia.

After stable fixation, wound was closed in lay-ers. LCP was used as LISS with minimal incision overthe lateral aspect when closed reduction is done.If closed reduction could not be achieved or maintained,an open approach was required.

LCP for upper end of tibia are available in 3.5mm, 4.5 mm thickness, 4 holed to 12 holed. The lockingscrews are self-tapping and available in 4 mm and 4.5mm thickness.

PostoperativeIn the immediate postoperative period care was

given to the general condition, fluid balance, IV antibi-otic and analgesics as per the protocol. This helped us tomobilize the patient faster.Mobilization

Whenever stable internal fixation was achieved,the patient was mobilized after 48 hrs after removal ofthe drains, for 2-3 days the range of motion allowed was0-200 .From the 5th day the range of motion was gradu-ally allowed to be increased to 900 or more and aftersuture removal full range of movement was allowed.Whenever there was doubt about the stable fixationexternal splinting in the form of plaster of Paris slab wasgiven for support and advised to do static quadricepsexercises. Continue passive motion exercise (CPM)was done daily with temporarily removal of slab undercarefully supervision and splint reapplied. Partial weightbearing was delayed until 6 weeks and full weight bear-ing allowed after 12-16 weeks

RESULTSIn this study, 142 patients with traumatic proxi-

mal tibial fracture were treated. All cases were freshand there were 112 males and 30 females. The meanage was years ranging from 21 to 65 years. 96 patientswere with fracture on their right side and 46 on left side.142 of cases were caused by road traffic accidents and

26 were due to fall.Of the 142 proximal tibial fractures, 62 were

Schatzker type III, 30 was Schatzker type IV, 32 wereof Schatzker type V and remaining 18 were Schatzkertype VI. All were closed fractures. 120 out of 142 weretreated by MIPO and remaining 22 by open reduction.All patients were operated within 1-5 days of injury. Thesize of the plate was selected based on the type of frac-ture. 8 & 9 holed plates were used more commonly.

Out of 142 patients, 127 patients showed radio-logical union with in 6 weeks. Average flexion of kneewas 105 degree with more than 89% patients havingknee range of motion more than 1100. Average kneeextensor lag was 8 degrees. Out of 142 patients 12 hadlimb shortening. 6 patients had varus / valgusmalalignment.

Results are summarized in charts and tables below.

Table 1 AGE DISTRIBUTION

Age group (year) Number of patients

21-30 21

31-40 65

41-50 23

51-60 12

> 60 21

Total 142

Most of the patients belong to 21-50 yrs of age groupwho are more prone for RTA.

Table 2 SEX DISTRIBUTION

Sex Number of patients

Male 112

Female 30

Total 142

Most of our patients were male. It reflects the generalpopulation which visit our both out patient as well as theemergency trauma section.



Table – 3 LATERALITY OF FRACTURE

Laterality of fracture Number of patients

Right 96

Left 46

Total 142

In our series, there is a slight right sided predominancecompared to the left side.

Table - 4 TYPE OF FRACTURE - SCHATZKER’S CLASSIFICATION

Type of fracture Number of patients

III 62

IV 30

V 32

VI 18

Total 142

In our series the majority of the fractures were found tobe of type IV, V and VI fracture types which are usuallyassociated with high velocity road traffic accident.

Table – 5 METHOD OF REDUCTION AND FIXATION

Method of reduction Number of patients

ORIF 22

MIPO 120

Total 142

We used MIPO technique in 68 patients. Both the dura-tion of procedure and soft tissue injuries were less com-pared to ORIF technique.

Wound healing also was better and faster comparing toORIF technique. It demands more surgical techniquesand we found as the study progressed that the operativetime need for MIPO decreased as we matured more inthis technique.

Table – 6 SURGICAL APPROACH

Side Number of patients

Anteromedial 26

Anterolateral 116

Total 142

Table – 7 SIZE OF PLATE USED

PLATE SIZE No

5-7 Holed 38

7-9 Holed 74

10-12 Holed 30

Total 142

Table – 8 RADIOLOGICAL UNION

Union (Weeks) No. of cases

< 16 97

16 – 18 22

19 – 20 12

21 – 22 6

Delayed Union 3

Non-Union 2

Table – 9 TIME AT WHICH FULL WEIGHT BEARING ACHIEVED

FWB ACHIEVED TIME No. (Weeks)

8 – 12 88

13 – 16 46

16 – 20 5

>20 3

Total 81

Clinical & functional outcomeBoth knee scores and functional scores (KSCRS22, 23)calculated with each mounting to a total of 100 points.

Minimally invasive fixation of closed and grade I & II compound proximal tibial injuries with locking compression plates - A clinical study


Clinical score:Total 100 points [Pain – 50 points + ROM – 25 points +Stability – 25 points]

TABLE 10

Pre-op mean Post-op mean

27.52 92.72

At the time of latest follow-up, pain was adequately re-lieved in 75 knees (92.59%) and the average range offlexion was 131 degrees (range 124 to 138 degrees)and all the knees (100%) had normal anteroposteriorand mediolateral stability.

Functional score:Total 100 points [Walking distance – 50 points + Stairclimbing – 50 points]

Pre-op mean Post-op mean

19.42 88.61

Grading of results based on KSCRS in this study

Grade – Score No. of knees (%)

Excellent (>85) 98 (69.01)

Good (70-84) 29 (20.42)

Fair (60-69) 12 (8.45)

Poor (<60) 3 (2.1)

Out of 142 cases treated, 98 cases gave excellent re-sult, 29 cases came out with good result, fair in 12 cases,and 3 cases of poor results.

CASE I

CASE II

CASE III

DISCUSSIONProximal tibial fractures, one of the

commonest intra articular fractures, incidence of thisfractures are increasing regularly due to RTA and at thesame time surgical treatment options for the same arealso being modified continuously.

In this series, 81 patients with proximal tibialfractures were included, and the overall final outcomeof the surgical management with LCP was assessed interms of regaining the lost knee function using KneeSociety Clinical Rating System22, 23.

The recent development of LCP has revolution-ized the treatment by overcoming the few drawbacks ofconventional buttress plate such as wound gaping,infection, implant failures, deformities like varus andrepeated surgeries like flap cover, implant removal etc.



The LCP is an internal fixation system which isa hybrid of LC-DCP and LISS.

As the plate was tightened to obtain absoluterigidity the friction between the under surface of theplate and the cortex of the bone increased many timeresulting in interference of the periosteal blood supplyas long as the plate was there.

On the contrary, if the rigidity of the platefixation was inadequate it leads to resorption at thescrew bone interface leading to non union.

Hence if we desire a good fixation withminimal interference to the biology of the bone, thisrequires a new thinking in the concept of implant as wellas in the concept of internal fixation. This change ofconcept is what is termed as “Biological fixation”.The concepts of biological fixation consists of13· Indirect reduction· Adequate stability· Reservation of osteogenic potential· Limited bone – plate contact

The period of immobilization was againindividualized depending on the security of stablefixation. The benefits of early knee motion includereduce of knee stiffness and improved cartilage healing(regeneration) and promote good callus formation andremodeling.

The LISS is akin to an internal fixator, whichprovides comparable stability to double plating constructsin a biomechanical evaluation by Goesling et al.

CONCLUSIONThus we conclude that the locking compression

plate system with its various type of fixation act as angood biological fixation including difficult fracturesituations especially when fracture is severelycomminuted and in situations of osteoporosis. It providesrigid fixation of the fracture fragments and surgicalexposure for the plate placement requires significantlyless periosteal stripping and soft tissue exposure thanthat of other techniques.

We also suggest that the proper understandingprinciples of LCP and MIPO technique with properpreoperative planning of surgery can give goodbiological fixation for proximal tibial fractures.

REFERENCES1.Schulak DJ, Gunn DR. Fracture of the tibial plateaus. Clin Orthop1975 June; 109:166-177.2.Koval KJ, Hulfut DL. Tibial plateau fracture: evaluation and

treatment. J Am Acad Orthop Surg 1995; 3(2):86-94.3.Biyani A, Reddy NS, Chaudhary et al. The results of surgicalmanagement of displaced tibial plateau fracture in the elderly. Injury1995; 26(5):291-297.4.Wagner M. General principles for the clinical use of the LCP.Injury 2003 Nov; 34, Suppl 2: B31-42.5.Sommer C, Gautier E, Muller M. For clinical application of theLCP. Injury 2003 Nov; 34, Suppl 2:B43-54.6.Stoffel K, Dietaru. Biomechanical testing of the LCP how canstability in locked internal fixator be controlled. Injury 2003 Nov; 34,Suppl 2:B11-9.7.Sobotta. Atlas of human anatomy. Putz R, Pabst R edts. 21st edn,vol. 2 Philadelphia, Lippincott Williams and Wilkins; 2000. p. 263-347.8.Susan, Standring. Gray’s anatomy. Newell RLM, Davies MS, edts.29th edn, Spain, Elsevier Churchill Livingstone; 2005. p. 1471-86.9.Netter FH. Anatomy. In : Teterboro new Jersey Icon learningsystem. 3rd edn. 2003. p. 488-94.10.Whittle AP, Wood II GW. Fracture of lower extremity. Campbelloperative orthopedics. Canale ST ed. 10th edn, Vol. 3. New York,Mosby; 2003. p. 2782-2796.11.Waddell JP. Fracture of the tibia and fibula. Court Brown C,Penning D, edts. Oxford, Butterworth; 2000. p. 38-54.12) Egol KA,Su E, Tejwani NC, Sims SH, Kummer FJ, Koval KJ. Treamtent ofcomplex tibial plateau fractures using the less invasive stabilizationsystem plate. J trauma 2004; 57: 340-46.12.De Coster TA, Nepola JV, Choury GY. Treatment of proximal tibiafracture. A ten year follow up study. Clin Orthop Relat Res 1994; 196-204.13.Mazone CG, Guanche CA, Vrahas MS. Athroscopic managementof tibial plateau fractures. Am J Orthop 1999; 28:508-1514.Mills WJ, Work SE. Open reduction and internal fixation of highenergy tibial plateau fractures. Orthop Clin North Am 2002; 33:177-98 IX.15.Fulkarson E, Egol KA, Kubiak EN, et al. Fixation of diaphysealfractures with a segmental defect a biomechanical comparison oflocked and conventional plating techniques. J Trauma 2006;60(4):830-35.16.Messmer P, Regazzoni P, Gross T. New stabilization techniquesfor fixation of proximal tibial fractures (LISS/LCP). Ther Umsch2007; 60:762-67.17.George A, Brown, Spraque. Cast brace treatment for plateauand bicondylar fracture of tibia. Clin Orthop 1976; 119:184.18. Sirkin MS, Bono CM, Reilly MC and Behrens FF.Percutaneous methods of tibial plateau fixation. Clin Orthop 2000June; 375:60-68.19.Palmer I. Compression fracture of lateral tibial condyle and theirtreatment. J Bone & Joint Surg 1939; 2(AM):674.20.Duparc, Ficat. Fracture of the tibial plateau in Insall et al surgeryof the knee. 2nd edn, Vol 2. New York, Churchill Livingstone; 1994. p.1074.21.Roberts JM. Fractures of the condyles of tibia, an anatomical andclinical end result study of 100 cases. J Bone & Joint Surg 1968; 50(AM):1505.22.Terry Canale. Campbell’s Operative Orthopaedics. Ninth edition.Vol 1. Mosby-Year Book, Inc 1998. 251-252.23.Raymond Y L Liow, Karen Walker, Mohammad A Wajid, et al. Thereliability of the American Knee Society Score. Acta Orthop Scand2000; 71 (6): 603–608.

Minimally invasive fixation of closed and grade I & II compound proximal tibial injuries with locking compression plates - Aclinical study


FUNCTIONAL OUTCOMES OF INTRA ARTICULAR CALCANEAL

FRACTURES TREATED BY VARIOUS SURGICAL METHODS

Dr. Muthukumar Balaji, Dr. Selvaraj. V, Dr. Satish Devadoss, Prof. A. DevadossDevadoss Multispeciality Hospital, Madurai.

AbstractIntroduction: Calcaneal fractures are a challenge for orthopaedic surgeon due to thecomplex fracture pathology. 75% of calcaneal fractures are intra articular. Debatecontinues regarding the management of calcaneal fracture. We aim at evaluating thefunctional outcomes of intra articular calcaneal fractures treated by various surgicalmethods.Methods:In our study, 32 patients (26 unilateral and 6 bilateral) with intra articularcalcaneal fractures as per Essex-Lopresti classification and sanders classification wereoperated on with open reduction and locking calcaneal plates, closed reduction andpercutaneous fixations , primary triple arthrodesis within 3 weeks of injury. Patientswere followed up clinically and radiologically at least for 1 year. Functional outcomewas assessed using the American Orthopaedics Foot and Ankle Society score.Results: In our study 38 feets were operated, in that 28 cases operated by plating, 8cases by percutaneous technique and 2 cases by primary triple arthrodesis. AverageAOFAS score for plating was 84.6; percutaneous technique was 78.4. & arthrodesispatients had excellent functional outcome, with a score of 81.3.Conclusion: Open reduction and internal fixation with locking calcaneal plate givessound functional outcome, i.e. restoring anatomically reconstruction of height, width,Bohler’s and Gissiane’s angles of the calcaneum, and allowing early mobilization. Per-cutaneous screw fixation can also be considered which yields good functional outcomeand less post operative complications in sanders type II fractures. Primary subtalar ortriple arthrodesis has had good reported results for select high-energy injuries.

INTRODUCTIONCalcaneal fractures account for 2% of all

fractures, 60% of tarsal bone fractures. 10% offractures are bilateral and 75% are intra articular1. 10%of calcaneal fractures are associated with vertebraefractures1. Mechanism of injury in majority of patients isaxial loading1. Other mechanisms are brake pedalinjuries and high velocity trauma. Current developmentin imaging technology has allowed better understandingof this complex fracture pathology. Sanders classifica-tion of intra articular Calcaneum fractures is widely usednow days because of its proven correlation withmanagement and prognosis2.Treating calcaneal fractures is a challenge for the ortho-

paedic surgeons. While many authors suggest that thebest results are obtained by surgical methods (openreduction and internal fixation, percutaneous screwfixation or subtalar arthrodesis), others advocate aconservative treatment method3. The conservativetreatment invariably leads to long-term consequences ofpain, disability, decreased ankle and subtalar motion,increased morbidity, prolonged recovery and disturbedgait and deformity with short and wide heel,posttraumatic arthritis, sub-fibular impingement causingperoneal stenosis, tendinitis, or dislocation.The inconsistent clinical results and frequentcomplications of open reduction have made it difficult to


standardize surgical management of these injuries.4Openreduction and internal fixation is difficult in achievinganatomic reduction and strict adherence to surgicalprinciples is mandatory to achieve a good outcome2.Conventional calcaneal plate invariably leads to incon-sistent results. Due to the above concerns, we evaluated the Functional outcomes of intra articular cal-caneal fractures treated by various surgical methods.

MATERIALS AND METHODAll patients with closed calcaneal fractures who

were treated surgically from june 2011 to dec 2014 atthe institute for orthopaedic research and accident sur-gery( IORAS) were included in the study. 32 patientswith 26 unilateral and 6 bilateral calcaneal wereavailable for the final follow up. All these patients withintra articular calcaneal fractures, as per Essex-Lopresticlassification and sanders classification2 were treatedwith open reduction and internal fixation with lockingcalcaneal plates or closed reduction and percutaneousfixation with K-wire/schanz pin or primary triplearthrodesis within 3 weeks of injury. Patients withextra-articular undisplaced or compound calcanealfracture were excluded from the study. Patients whopresented 3 weeks after were also excluded from thestudy. This study had Ethical clearance from the ethicalcommittee of the institute. All patient consented for tak-ing part in the study.

Antero-posterior, lateral and axial viewradiographs of calcaneum were done. CT scan was doneroutinely to assess the amount of comminution andarticular depression. Patients were evaluated forassociated injuries. In cases that needed open reduction,initially below knee slab applied with limb elevation andice pack fomentation were given to decrease swelling.Patients were operated once swelling subsided andwrinkle sign appeared , which was usually between 7th

to 10th day.All ORIF patients were approached via lateral

approach with the application of tourniquet undersuitable anaesthesia5. An L-shaped incision, deep downto periosteum and bone was made to create fullthickness periosteal-cutaneous flap, starting 4 cm abovethe lateral malleolus midway between posterior borderof fibula and Achilles tendon and curving into thetransition zone between glabrous and nonglabrous skinparallel to sole up to the base of the 5th metatarsal(fig 1a). Full thickness periosteal-cutaneous flaps weregently retracted and elevated, performing subperiostealdissection, and held out with Kirschner wires placed intothe talus, exposing the entire lateral wall of thecalcaneus proximal to distal, till the calcaneocuboidjoint(fig 1 b). The articular surface was fully visualized

by inverting the foot(1c & d). Under image intensifier,anatomical reduction of the articular margin was achievedmaintaining the height of the calcaneum. Bone substi-tutes were used if needed and provisional fixation wasdone using Kirschner wires(fig 1 e). Appropriate size oflocking calcaneal plate (small, medium or large) wasapplied that extends from the anterior process of thecalcaneum up to the most posterior aspect of the tuber-osity and fixed with locking screws(fig 1 f). Wound wasthoroughly washed and meticulously closed in layers anda below knee slab applied. Closed reduction andpercutaneous fixation was done with K-wires or schanzpin and a below knee slab applied. Schanz pin andk- wires were removed after 3 weeks.

Surgical Method

Dr. Muthukumar Balaji et al

Fig. 1a Fig. 1b

Fig. 1c Fig. 1d

Fig. 1e Fig. 1f

In our study 38 feets were included, in that 28cases were treated by plating, 8 cases by per-cutaneoustechnique and 2 cases by primary triple arthrodesis.We used bone substitute in 11 cases of comminuted cal-caneal fractures to prevent collapse.

POST OPERATIVE CARE: Check x-rays anteropos-terior, lateral and axial views were taken. Active rangeof motion was started after suture removal for patientunderwent plating and three weeks after for patients


who underwent per-cutaneous fixation. Gradual increasein weight bearing was started. Full weight bearing wasallowed only after 12 weeks in all unilateral cases. Inbilateral fractures it was started after 8 weeks with pneu-matic functional brace and crutches.Patients were followed up clinically and radiologically atregular interval for minimum period of one year and re-sults were analyzed by using AOFAS American Ortho-paedics Foot and Ankle Society (AOFAS) scale.6 Themain emphasis of American Orthopaedic Foot and AnkleSociety (AOFAS) Ankle-Hind foot scale was on painand the functional activities. A normal person would score100 points.

Table 1

80 – 92 Excellent result

70 – 79 Good result

60 – 69 Fair result

less than 60 Poor result

RESULTSThe mean age of patients in this study was 38

yrs( 19- 58 yrs). The average follow-up period in ourstudy was 23.6 months(range 12-40 months). Theaverage AOFAS score for plating group was 84.6, with20 patients(71.4%)having excellent [fig 2 a-e ]and6(21.5%) having good results (fig 3a-e) and 2 (7.1%)having fair results respectively. Average subtalar rangeof motion was 17o. Average AOFAS score forper-cutaneous technique was 78.4, with 2 patientshaving excellent, 4 patients had good,1 patient had fairand 1 patient had poor outcome). 2 sub-talar arthrodesispatient had excellent functional outcome with an AOFASscore of 81.3. Eight patients had associatedcompression spine fractures and three patients hadfemur shaft fracture and two patients had talus frac-tures and two patients had pubic rami fractures.The mean Bohler’s angle in patients who underwent orifwith bone substitute was Post-operatively 27.20 as

compared to 25.40 for those whom substitute was notused and at final follow-up it was 24.30 and 23o

respecitively. Similarly the mean Gissane’s angle wasPost-operatively 123.70 in bone substitute group ascompared to 121.20 for the non bone substitute group.At final follow-up it was 117.20 and 114.90respectively.

Sub-talar arthritis was seen in 4 patients (10.5%),whereas sural nerve hypoaesthesia in 1 patient. None ofthe patients had compartment syndrome, heel pad prob-lems, peroneal tendinitis, reflex sympathetic dystrophyor implant failure in this series.

FIG 2 : Radiographs of a case of intra-articularfracture (same patient as in fig 1) with excellentfunctional result with AOFAS score of 88.

fig 2 a pre-operative fig 2 b post operative

fig 2 c :7 months post operative fig 2 d :18 months post operative

Functional outcomes of intra articular calcaneal fractures treated by various surgical methods


fig 2 e: following implant removal

FIG 3 radiographs of a case of intra-articular fracturetreated by orif with lcp , this patient had an AOFAS scoreof 79.

Fig. 3 a pre-operative images

Fig 3b before and after articular fragmentreduction

Fig 3c intra operativeimage

Fig 3d posterative images

Fig 3 e: 9 months post operative

DISCUSSIONIn the literature, the management of calcaneal

fracture varies from conservative treatment, open fixa-tion, percutaneous fixation, primary subtalar arthrodesis,delayed primary arthrodesis to calcanectomy. There isno consensus in the current literature regarding theoptimal treatment of intra-articular fractures of thecalcaneum. The surgical treatment for intra-articularcalcaneal fractures has been increasing due to superiorclinical and radiological results over conservativemethods.7,8 Treatment of intra-articular calcanealfracture by modern operative intervention with openreduction and internal fixation remains challengingbecause of a lack of familiarity with operative technique,difficult fixation and fear of postoperative complication.9

The timing of the surgery is one of the mostimportant determinants for the outcome of treatment anddetermined by subsidence of edema and appearance ofwrinkle sign, persistence of which may lead to softtissue healing problems and high infection rate, whilesurgery after 3 weeks of injury causes difficulty inreduction, due to early consolidation of fracture9. Henceit is better to delay surgery till soft tissue heals andduring this pre-surgical period patients should bemanaged by splinting with proper padding, limbelevation and soft tissue care. In our study, all patientswere operated within a mean of 7.6 days (range 4-20days), in consistent with other reported series.

In our study good functional outcome wasobtained for sanders type 1& type II fractures treatedby percutaneous fixation. Excellent outcomes occuredfor sanders type III, type IV fractures treated by inter-nal fixation with plating. Percutaneously fixed SandersType –I, Type II intra articular fractures had an goodfunctional outcome score from other series also4. Infractures fixed with open reduction and internal fixationwith bone substitute and plating, the functional outcomescore was excellent in Sanders Type-II fractures and



was good in Sanders Type-III and Type IV fracturesfrom other series as compared to our series which re-sulted in excellent results.1 For severely comminutedhigh energy intra articular fractures with subtalar talusfractures treated by primary subtalar arthrodesis,excellent functional outcome was the result. 4,10

Use of bone grafting remains controversial for thetreatment of calcaneus fractures. While many authorssuggest that the calcaneus with cancellous structure willrecover fast and there is thus no need to use bonegrafting, there are also authors like Scheper et al usedbone cement as a substitute to bone graft to preventcollapse and reported full weight bearing as early as 3weeks.11 In our study we used bone substitute in 11patients with severe comminuting fractures to preventcollapse. The Bohler’s angle and Gissane’s angles didnot differ significantly from immeadiate post operativeperiod and at final followup in patients whom orif withadded bone substitutes was done when compared to thosewhom it was not used in our series(p<0.05).

Zeman P et al studied surgical treatment ofintra articular calcaneal fractures by orif with lockingcompression plate from a extended lateral approach.Early post-operative complications were noted in sixpatients (20.7 %). Wound dehiscence occurred in two(6.9 %), necrosis of wound edges was seen in two (6.9%), and early superficial infection responding toantibiotics occurred in two patients (6.9 %).12 Only twopatients (6.9 %) reported poor outcome. Ourcomplication rates were similar to their series. Thefunctional score obtained in our series was comparableto those observed by Zeman et al.12 In plating, mostcommon complications reported are incision flapnecrosis and superficial or deep infection ranging from5% to 15%. Two patients with three feets (7.9%)including a bilateral calcaneal fracture(smoker) ,had flapnecrosis at incision site and were treated by wounddebridement and reverse sural artery flap (fig 4 a & b).Four patients (10.5%) had superficial infection and weretreated by dressing and antibiotic therapy. One patienthad deep infection and was treated by implant exit andVAC dressing and later secondary suturing, 8 month postoperatively.

Fig. 4a

Fig. 4b

In cases with no ensured anatomic reduction,heel and calcaneofibular impingement pain is commonduring the early period, while arthritic complaints arecommon in the late period. In our study 4 patients hadsubtalar arthritic changes and pain. The inversion andevertion motion of these patients were significantlydecreased. We suggested shoe modifications. After themodification of the shoes our patients were pleased, butthere was no significant recovery in functional score,they were all scheduled for triple arthrodesis procedurein the future.

Goma et al evaluated the results of modifiedminimally invasive surgical technique for the treatmentof intra-articular fractures of the calcaneus. They hadNo wound infection or skin sloughing in that series,However soft-tissue swelling of the heel persisted withvariable degrees in 20 (77%) feet 1 year after surgery.They believe that the new technique is an effective andsafe alternative for intra-articular calcaneal fracture fixa-tion.13 Their results are encouraging and may be the idealsolution to all the complications as mentioned earlier.

CONCLUSIONOpen reduction and internal fixation with

locking calcaneal plate gives sound functional outcome,i.e. restoring anatomically height, width, Bohler’s andGissane’s angles of the calcaneum, and allowing earlymobilization. However careful selection of patients anddelay of 7-10days gives excellent functional results.Percutaneous screw fixation can also be considered andyields good functional outcome and less post operativecomplications in sanders type I & II fractures. Primarysubtalar or triple arthrodesis has had good reportedresults for select high-energy injuries.

REFERENCES1) Vivian D’ Almeida, Thomas Devasia, Nikku M, Ashwin Kamath.“Functional Assessment Following Open Fixation of CalcanealFractures”. Journal of Evolution of Medical and Dental Sciences2014; Vol. 3, Issue 42, September 08; Page: 10482-10489.2)Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment

Functional outcomes of intra articular calcaneal fractures treated by various surgical methods


in 120 displaced intraarticular calcaneal fractures. Results using aprognostic computed tomography scan classification. Clin OrthopRelat Res. 1993 May; 290:87-95.3)Richard Buckly, Suzanne Tough, Robert Mccormack et al. OperativeCompared with Nonoperative Treatment of Displaced Intra-ArticularCalcaneal Fractures: a prospective randomised controlledmulticenter trial. J Bone Joint Surg Am. 2002;84:1733- 44.4) López-Oliva Mu˜noz F, Forriol F. Manejo actual de las fracturasintraarticulares del calcáneo. Rev esp cir ortop traumatol.2011;55(6):476-484.5) Benirschke SK, Sangeorzan BJ. Extensive intra-articular fracturesof the foot. Clin Orthop. 1993;292:85-91.6) Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS,Sanders M. Clinical rating systems for the anklehindfoot, midfoot,hallux, and lesser toes. Foot Ankle Int 1994;15:349-53.7)Buckley R, Tough S, McCormack R, Pate G, Leighton R,Petrie D, etal. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlledmulticenter trial. J Bone Joint Surg [Am] 2002;84:1733-44.8) Schepers T, van Lieshout EM, van Ginhoven TM, Heetveld MJ,

Patka P. Current concepts in the treatment of intraarticular calcanealfractures: results of a nationwide survey. Int Orthop 2008;32:711-5.9)Wei Zhang, Erman Chen, Deting Xue, Houfa Yin and Zhijun Pan.Scandinavian Journal of Trauma, Resuscitation and EmergencyMedicine (2015) 23:1810) Meena DK, Sharma SB, Rajawat AS, Tyagi MK, Meena RK,Thalanki SK. Functional outcome of subtalar arthrodesis using doublelag screw technique. J Orthop Traumatol Rehabil 2014;7:56-8.11)Schepers T, van Lieshout EM, van Ginhoven TM, Heetveld MJ,PatkaP (2008) Current concepts in the treatment of intra-articular calcanealfractures: results of a nationwide survey. Int Orthop 32:711–71512) Zeman P, Zeman J, Matejka J, Koudela K. Long-term results ofcalcaneal fracture treatment by open reduction and internal fixation usinga calcaneal locking compression plate from an extended lateral approach.Acta Chir Orthop Traumatol Cech. 2008 Dec;75(6):457-64.13)Mohamed A. Gomaa, Ahmed El Naggar, Ashraf S. Anbar. A newminimally invasive technique for the treatment of intraarticularfractures of the calcaneus preliminary results : Egyptian OrthopedicJournal 2014, 49:225–230.



ACETABULAR FRACTURES - CLINICAL OUTCOMES OF

SURGICAL TREATMENT

Dr. K Meenakshi Sundaram, Dr. K Selvaraj, Dr. K G Kandaswamy, Dr. I G Nagarajan,Vijayan Gopalakrishna Kurup

Department of Orthopaedics & Trauma CareVinayaka Mission’s Kirupananda Varier Medical College & Hospitals, Salem

INTRODUCTIONOver the last 20 years orthopaedic trauma

surgeons have been faced with a growing number ofpatients with severe pelvic injuries. The fractures ofacetabulum concern 2% of fractures and it is difficult tobe diagnosed and treated. They are mainly caused byhigh energy traffic accidents (90 %) and lead to posttraumatic arthritis and avascular necrosis irrelevantly thetype of the treatment6, 11, 12. Improvements in automo-bile safety, pre-hospital care, resuscitation and transportas well as standardized protocols for treatment have allcontributed to improved survival after these devastatinginjuries. Long-term goals in treating pelvic injuriesinvolve the correction of deformity, prevention of latedeformity and instability and restoration of pain-freefunction. Although there may always be unavoidableconsequences of severe pelvic injury, surgeons must stillquestion the way pelvic injuries are treated andcontinue to explore controversies that may ultimatelyalter treatment regimens or outcomes.The results of conservative orthopaedic treatment arevery disappointing. It is difficult if not impossible, that

the articular surface of acetabulum is completely restoredor that sufficient stability is ensured which allows earlymobilization of hip.The surgical treatment is also difficult because of,1. Deep location of the hip2. The existence of serious neuro-vascular struc-tures near the acetabulum3. The special anatomy and topography of the hip24

Hence for open reduction and internal fixation of ac-etabular fractures, an appropriate approach and adequatevisualization of the fracture lines are essential.Acetabular fractures, especially displaced ones, consti-tute serious intra-articular injuries, caused byhigh-energy trauma and are often accompanied by pos-terior hip dislocation or other musculoskeletal injuries thatmay significantly affect the treatment protocol as wellas the end-result 6,7,8. Displacement of the fracture endsby more than 2 mm is known to increase the danger ofpost-traumatic arthritis and lead to a poor functionaloutcome. Surgical treatment of displaced acetabularfractures is considered the treatment of choice today,

ABSTRACTThe results of operative treatment of acetabular fractures, performed in VinayakaMission Kirupananda Variar Medical College and Hospital from July 2006 to July2015, 32 patients had an open reduction and internal fixation of an acetabular fracture.25 were males and 7 were females, with an age ranging from 28 to 62 years (average:36.7 years). The mechanism of injury was a motor vehicle accident in most cases(85%). The fractures were classified with Judet-Letournel classification. The patientswere operated upon within 1-8 days (average: 4 days). The Kocher-Langenbeck sur-gical approach was used in 22 cases and ilioinguinal approach in 10 patients. Osteo-synthesis was achieved with either lag screws alone or with a combination of lag screwsand a buttress plate. Follow-up ranged from 6 months - 9 years (average: 3.8 years).Clinical evaluation according to the D’ Aubigne-Postel scoring system gave 23 excel-lent (71.9%), 6 good (18.8%), 2 fair (6.3%) and 1 poor (3.1%) results. Early postop-erative complications included 1 case of unexplained bleeding through drain tube for8 days and superficial wound infection in another 3 patients. Operative treatment ofacetabular fractures although demanding, bears very good results.Key words: Acetabular fractures, surgical treatment, Judet-Letournel classification.


because it ensures the best possible anatomical recon-struction of the joint surface, thus increasing the chancesof a satisfactory functional result 6, 8, 11, 15.

A turning point in the treatment of displacedfractures of the acetabulum, the pioneering work of Judetand Letournel8 that established the surgical treatment asmethod of choice. Most authors agree that the ideal goalof treatment is anatomic reduction of articular surfacewith mechanically and biologically sufficient stability thatwill allow early active mobilization of the joint. Thesetargets can be achieved with the right timing with indi-cated material of osteosynthesis8, 11, 12, 13.Criteria for conservative management included displace-ment of the fracture ends by less than 5 mm andretained continuity of the acetabular dome as shown inthree x-ray projections with no traction applied and aCT-scan 4, 7, 8, 9, 14.

The aim of this study is to present the results ofsurgical treatment of a series of acetabular fractures, toevaluate the functional outcome, as well as to establishthe outcomes of surgical treatment in these fractures.

MATERIALS AND METHODSFrom July 2006 to July 2015, 32 acetabular

fractures (25 males and 7 females) were managed inour hospital surgically. The age range was from 28-62years, an average of 36.7 years.

The main cause of injury was road traffic acci-dent (85% of cases). Pre-operative radiologic evalua-tion constituted of a plain AP view of the pelvis as wellas CT-scan. The indication for surgery was based onthe initial evaluation of these radiographs. Other factorsthat influenced surgical indication were presence of as-sociated injuries and the general condition of the patient.Fractures were classified according to the Judet –Letournel classification8 and according to this 14 poste-rior column fractures (43.75%) 10 both column frac-tures (31.25%) and 8 anterior column with posterior wallfractures (25%) were included (Table 1). Fractures thatwere displaced by more than 5 mm with concomitantdisruption of the bony continuity of the acetabular domewere treated surgically.

Posterior dislocation of the hip was present in 9patients (28.13%); six were reduced with immediateclosed reduction, while the remaining one was reducedintra-operatively. Pre-operative skin traction was appliedon all patients. Open reduction and internal fixation wasperformed 1-8 days following the initial injury (mean: 4days). Kocher-Langenbeck approach was performed in22 cases and ilioinguinal approach in 10 patients withinvolvement of anterior column.

Before the surgery, patients were examined

clinically and radiologically. Simple anteroposterior ra-diograph and computed tomography was applied fordocumentation of diagnosis and preoperative planning.The computed tomography with three dimensionaltechnique is essential for a more detailed pre-operativeplanning (choice of approach, extent of displacement,evaluation of coexistence of loose bodies13.

The main operative goal was to achievereconstruction of the anatomy of the innominate boneand the articular surface of the acetabulum. 22 patientswere performed surgery with Kocher-Langenbeckapproach and 10 patients were done with ilioinguinalapproach. Fixation of the fracture was achieved with4.0 mm or 3.5 mm interfragmentary screws combinedwith a reconstruction plate in all fracture types. Intra-operative findings included loose intra-articular osteo-chondral fragments in 13 cases (40.63%), chondrallesion of either the acetabulum or the femoral head in 6hips (18.75%) and depression of the articular cartilageof the acetabulum in 4 hips (12.5%).

Physiotherapy exercises were started from the1st day of surgery and he was mobilized to high sittingposition with quadriceps training. Following the surgicaldrain removal, patients were mobilized with non-weightbearing using walking frame for 1 month, partial weightbearing for the following 3 weeks and started full weightbearing from 2 months onwards. Hip abductor andquadriceps strength training was continued through outthese 2 months. All patients received low molecularweight heparin thromboprophylaxis for 2 months.

RESULTSThe follow-up schedule was 3, 6 and 12 months

post-operatively and subsequently at two years whenthe operative outcome had been finalized and finalevaluation of fracture healing and functional outcomecould be performed quite reliably. Post-operativefollow-up ranged from 6 months to 5 years with a meanof 3.2 years. Fracture fixation outcome wasradiologically evaluated with an AP X-ray of the pelvisfrom the mean displacement in the basic projection. Andpatients were functionally evaluated with the D’Aubigne-Postel scoring system 12 (Table- 5) with the parameters:the pain, the motion of the hip and the ability of walking.

Fracture reduction and fixation was checked withearly post-operative X-rays, while at a later stageX-rays helped in the evaluation of the presence ofcomplications such as osteonecrosis, post-traumaticosteoarthritis and heterotopic ossification. Based on theradiologic criteria used by Matta 8 the result wasconsidered excellent when the hip joint had a normalappearance on plain X-rays, good when a small degreeof subchondral sclerosis, joint space narrowing and



osteophytosis were present, fair when joint space wasnarrowed up to 50% and considerable osteophytosis andsubchondral sclerosis were present and poor when thejoint space was narrowed by more than 50%, a degreeof femoral head collapse as well as clear signs ofosteoarthritis were present. Based on the above-men-tioned radiologic criteria the result was excellent in 18patients (56.25%), good in 10 (31.25%), fair in 2 (6.25%)and poor in 2 (6.2%) (Table-3).

Clinical assessment was performed accordingto the D’Aubigne-Postel scoring system, with pain, abil-ity to mobilize and joint mobility being evaluated. Ac-cording to those criteria our results were excellent (17-18 points) in 23 patients (71.9%), good (15-16 points) in6 (18.7%), fair (12-14 points) in 2 (6.3%) and poor (<12points) in 1 (3.1%). (Table-4)

Results were evaluated as regards the fracture.

In this procedure it was evident that out of the 14posterior column fractures 12 (85.71%) had an excel-lent or good result and the remaining 2 (14.28%) a fairor poor. Out of the 10 both column fractures 9 (90%)had an excellent or good result and the remaining 1 (10%)a fair or poor. Out of the 8 anterior column with posterwall fractures all (100%) had an excellent or goodresult.

Immediate complication included uncontrollablebleeding in one patient through the suction drain whichlasted for 7 days. There was superficial woundinfection in 3 patients which were subsequently healedwith appropriate antibiotics and wound care, Sciatic orother nerve paresis was not recorded.

Late complications included femoral headosteonecrosis in one patient (Case 5) after 1 year ofsurgery. He has undergone a total hip replacement.

Acetabular fractures - Clinical outcomes of surgical treatment


CASE 1

CASE 2

CASE 3

CASE 4

CASE 5

CASE 6

DISCUSSIONSurgical treatment of displaced acetabular

fractures is beyond any doubt the treatment of choice,because it gives the better chances for anatomicalreconstruction of the joint6, 7, 8, 10, 15. The goals of surgi-cal treatment are the correction of significantdeformity, prevention of late deformity and instability,and restoration of pain-free function5, 7, 8, 13. By far thecommonest complication of these fractures is post-trau-matic osteoarthritis of the hip, which often leads to atotal hip replacement5, 7, 8. Other less frequentcomplications are osteonecrosis of the femoral head,osseous defects of the acetabulum, shortening of theaffected limb and heterotopic ossification3,5,6,7,8,16

The main criterion for surgical management isthe degree of displacement of the fracture ends of theacetabulum. In our series the criterion used for surgicalmanagement was a fracture displacement of more than5mm. This was the criterion suggested by Matta8 andJohnson et al4. Patients in our series were operated uponbetween the 1st and 8th day following the initial injury,with a mean of 4 days. Delay of operative managementwas usually the case in polytrauma patients withvarious other injuries that were in ICU for prolongedperiods of time. Most authors prefer to place thepatient in a prone position for the approach of suchfractures 6,8,10. We feel that the approach and position-ing we used, allow for adequate exposure for thefixation of the fractures of the posterior column of theacetabulum, which are the commonest fracture pattern.The goal of operative management was anatomicreduction of the fracture and subsequent stable internalfixation, with combination of interfragmentary screws

Acetabular fractures - Clinical outcomesof surgical treatment


and a reconstruction plate. Anatomic reduction wasachieved in 18 (56.25%) of cases, which is consideredto be very satisfactory8,9,10,15. The post-operativeapplication of skeletal traction is a contentious issue andmost authors nowadays suggest that it should not be usedprovided that the internal fixation achieved is rigidenough7,8,9. We have not used skeletal traction post-op-eratively in all our patients, which in turn would prolongtheir rehabilitation time and we feel that implementationof post-operative skeletal traction can be totallyabolished in cases where internal fixation is stableenough.

Our results were evaluated on the basis of bothclinical and radiologic criteria, as well as according tofracture type8,10,13. Radiologic evaluation showed 88.5%of excellent or good results and 12.5% of fair or poorresults, while clinical evaluation showed 90.6% ofexcellent or good results and 9.4% of fair or poorresults. An analogy between clinical and radiologicresults was recorded in our cases, a fact supported bythe literature as well7,8,13. The rate of excellent and goodresults in our series 90.6% is considered verysatisfactory. Similar results have been reported byLetournel10 and Matta12,13,14. If results were associatedwith the fracture type it was clear that simple fracturesgave a better outcome than complex fractures, as ex-pected, because in simple fractures anatomic reductionwas achieved more often.

Heterotopic ossification was not a seen in ourseries of patients. The rates of heterotopic ossificationreported by various authors in series of acetabularfractures surpass 50% in some series 2,3,5,8,15,21. Matta12

in a series of 262 patients where no prophylaxis againstheterotopic ossification was administered reports a rateof heterotopic ossification as high as 82%. Weadministered indomethacin to all of our patients and webelieve it has drastically lowered the rate of heterotopicossification. Indomethacin is believed to decrease therate of this complication to about 30-45%.

Femoral head osteonecrosis was recorded inone patient who subsequently underwent a total hipreplacement. Matta14 reports a rate of femoral headosteonecrosis of 3%, while Moroni33 brings it up to 7%.Post-traumatic osteoarthritis was recorded in 1 patient(5%) who underwent a total hip replacement. This rateof post-traumatic osteoarthritis is considered quitesatisfactory, in view of the fact that rates of 20-55% arereported in the literature 4,7,8,10,13,16. The presence ofposterior dislocation of the hip, a chondral lesion of thefemoral head or the acetabulum, failure to obtainanatomical reduction and complex as opposed to simplefractures are thought to be the main predisposingfactors for the advent of post-traumatic osteoarthritis

and femoral head osteonecrosis.

CONCLUSIONIn conclusion, we believe that surgical treatment

of acetabular fractures leads to a satisfactory outcome,provided the operation is carried out by an experiencedsurgeon within the first few days following the initial in-jury and anatomic reduction of the fracture is achieved.

REFERENCES1.Benum P. Fractures of The Acetabulum. Effort-European Federationof National Associations of Orthopaedics and Traumatology. 1995;2, 98-109.2.Âosse J.M., Reinert M., Ellwanger F., Slawson R., Mc Devitt.Heterotopic Ossification as a Coplication of Acetabular Fracture.JBone and Joint Surg. 1988; 70-A8, 1231-1237.3.Bray J.T., Esser M., Fulkerson L. Osteotomy of the Trochader inOpen Reduction and Internal Fixation of Acetabular Fractures. JBone and Joint Surg. 1987; 69-A5, 711-717.4.Brooker A., Bowerman J., Robinson R., Riley L. Ectopic OssificationFollowing Total Hip Replacement. J Bone and Joint Surg. 1973; 55-A, 1629.5. Chip Routt L.M., Swiontkowski F.M. Operative Treatment ofComplex Acetabular Fractures. J Bone and Joint Surg. 1990; 72-A6,897-9046.Deo D.S., Tavares R.K., Pandley K.R., EL-Saied G., Willett M.K.,Worlock H.P. Operative management of acetabular fractures inOxford. Injury Int J Care Injured. 2001; 12, 581-586.7.Goulet A.J, Bray J.I. Complex Acetabular Fractures. Clin Orthopand Rel Res. 1989; 240, 9-20.8.Judet T., Judet J.,Letournel E. Fractures of the Acetabulum:Classification and surgical approaches for open reduction. J BoneJoint Surg. 1964; 46-A, 1615.9.Kaempfee F.A., Bone L.B., Border J.R. Open reduction and internalfixation at acetabular fractures heterotopic ossification and othercomplications. J Orthop Trauma. 1991; 5, 43910.Letournel E. Acetabular Fractures. Classification andManagement. Clin Orthop. 1980; 151, 81.11.Matta M.J. Fractures of the Acetabulum: Accuracy of Reductionand Clinical Results in Patients Managed Operatively within ThreeWeeks after the Injury. J Bone and Joint Surg. 1996; 78-A(11), 1632-1645.12.Matta M.J., Mehne K.D., Roffi R. Fractures of the Acetabulum.Clin Orthop and Rel Res. 1986; 205, 241-250.13.Matta M.J., Anderson M.L., Epsein C.H., Hendrics P. Fracturesof the Acetabulum. Clin Orthop and Rel Res. 1986; 205, 230-240.14.Moroni A., Caja L.V., Sabato C., Zinghi G. Surgical treatment ofboth - column fractures by staged combined ilioinguinal and Kocher-Langenbeck approaches. Injury. 1995; 26(4), 219-224.15.Pantazopoulos T., Mousafiris. Surgical Treatment of CentralAcetabular Fractures. Clin Orthop and Rel Res. 1989; 246, 57-64.16.Panatazopoulos T.H., Nicolopoulos S.C Moussafiris C. Surgicaltreatment of acetabular posterior wall fractures. Acta Orthop Hell.1989; 40, 87-95.17.Templeman C.D., Olson S., Moed R.B., Duwelius P., Matta M.J.Surgical Treatment of Acetabular Fractures. AAOS InstructionalCourse Lectures. 1999; 48, 481-496.18.Zinghi G., Moroni A. Acetabular fractures. Editions Scientifiqueset Medicales Elsevier SAS (Paris). Surgical Techniques inOrthopaedics and Traumatology. 2000; 55-400-F-10.19.Benum P. Fractures of The Acetabulum. Effort-EuropeanFederation of National Associations of Orthopaedics andTraumatology. 1995; 2, 98-109.



20.Âosse J.M., Reinert M., Ellwanger F., Slawson R., Mc Devitt.Heterotopic Ossification as a Coplication of Acetabular Fracture.JBone and Joint Surg. 1988; 70-A8, 1231-1237.21.Bray J.T., Esser M., Fulkerson L. Osteotomy of the Trochader inOpen Reduction and Internal Fixation of Acetabular Fractures. JBone and Joint Surg. 1987; 69-A5, 711-717.22.Brooker A., Bowerman J., Robinson R., Riley L. Ectopic OssificationFollowing Total Hip Replacement. J Bone and Joint Surg. 1973; 55-A, 1629.23.Chip Routt L.M., Swiontkowski F.M. Operative Treatment ofComplex Acetabular Fractures. J Bone and Joint Surg. 1990; 72-A6,897-90424.Deo D.S., Tavares R.K., Pandley K.R., EL-Saied G., Willett M.K.,Worlock H.P. Operative management of acetabular fractures inOxford. Injury Int J Care Injured. 2001; 12, 581-586.25.Goulet A.J, Bray J.I. Complex Acetabular Fractures. Clin Orthopand Rel Res. 1989; 240, 9-20.26.Judet T., Judet J., Letournel E. Fractures of the Acetabulum:Classification and surgical approaches for open reduction. J BoneJoint Surg. 1964; 46-A, 1615.27.Kaempfee F.A., Bone L.B., Border J.R. Open reduction and internalfixation at acetabular fractures heterotopic ossification and othercomplications. J Orthop Trauma. 1991; 5, 439

28.Letournel E. Acetabular Fractures. Classification andManagement. Clin Orthop. 1980; 151, 81.29.Matta M.J. Fractures of the Acetabulum: Accuracy of Reduction andClinical Results in Patients Managed Operatively within Three Weeksafter the Injury. J Bone and Joint Surg. 1996; 78-A(11), 1632-1645.30.Matta M.J., Mehne K.D., Roffi R. Fractures of the Acetabulum.Clin Orthop and Rel Res. 1986; 205, 241-250.31.Matta M.J., Anderson M.L., Epsein C.H., Hendrics P. Fracturesof the Acetabulum. Clin Orthop and Rel Res. 1986; 205, 230-240.32.Moroni A., Caja L.V., Sabato C., Zinghi G. Surgical treatment ofboth - column fractures by staged combined ilioinguinal and Kocher-Langenbeck approaches. Injury. 1995; 26(4), 219-224.33.Pantazopoulos T., Mousafiris. Surgical Treatment of CentralAcetabular Fractures. Clin Orthop and Rel Res. 1989; 246, 57-64.34.Panatazopoulos T.H., Nicolopoulos S.C Moussafiris C. Surgicaltreatment of acetabular posterior wall fractures. Acta Orthop Hell.1989; 40, 87-95.35.Templeman C.D., Olson S., Moed R.B., Duwelius P., Matta M.J.Surgical Treatment of Acetabular Fractures. AAOS InstructionalCourse Lectures. 1999; 48, 481-496.Zinghi G., Moroni A. Acetabular fractures. Editions Scientifiques etMedicales Elsevier SAS (Paris). Surgical Techniques in Orthopaedicsand Traumatology. 2000; 55-400-F-10.

Acetabular fractures - Clinical outcomes of surgical treatment


CLINICAL EVALUATION OF LOCKING COMPRESSION PLATE

FIXATION FOR COMMINUTED OLECRANON FRACTURES

Dr. K. Prabakaran, Dr. S. Jaikish,Department of Orthopaedic Surgery, ATLAS Hospitals, Tiruchirappalli.

INTRODUCTIONOlecranon fractures comprise 10% of all upper

extremity fractures 1. Noncomminuted transversefractures with articular displacement are the mostcommon type. After reduction, they can be effectivelystabilized with tension band wiring 2. Comminutedfractures of the olecranon, especially those involving thecoronoid process and those associated with a trans-ole-cranon fracture-dislocation, often require plate fixationbecause tension band fixation cannot provide enoughstability to allow early postoperative motion of theelbow. In addition, plate fixation lowers the risk offatigue failure caused by extreme bending stresses. Since1883, there have been many reports on plate fixation ofcomminuted olecranon fractures, with variable results,as noted by Hak and Golladay in a review article. Platefixation is the current gold standard for the treatment ofthese comminuted fractures. precontoured plating of theolecranon, in which the proximal end of the plate is

wrapped around the tip of the olecranon, leads to goodresults when used for the treatment of oblique fractures.Because of the precontoured shape of the plate, orthogo-nal screw fixation can be used to augment this construct.

This intramedullary & locking screw can beapplied in combination with the locking compression plateand acts as an internal splint, analogous to anintramedullary nail, providing more support for theconstruct. The purpose of the present study was toevaluate the results of locking compression platefixation when combined with an locking screw in aconsecutive series of patients with a comminutedolecranon fracture. The results were evaluated with useof validated outcome scores.

MATERIALS AND METHODSBetween 2011 - 2014, 12 consecutive patients

with an acute comminuted olecranon fracture weremanaged with a 3.5-mm locking compression plate. The

ABSTRACT:Back ground : olecranon fractures comprise 10 % of all upper extremity fractures.Transverse fractures can be treated with TBW, comminuted fractures managed withplate fixation, but placement of an axial intramedullary screw may obstruct the place-ment of bicortical scresws in the ulnar shaft. To overcome this problem, unicorticalscrews can be applied with use of a contoured locking compression plate. The presentstudy was designed to assess the effectiveness of this fixation method.Materials & methods: 12 patients presented with comminuted olecranon fractureswere managed with precontoured locking compression plate and locking screws from2011 – 2014 at Atlas hospitals, Tiruchirappalli. All patients were followed up for aperiod of 12 -48 months. Male : female 9 :3.Results: All fractures have healed well. The mean time of fracture union was 12 weeks.Results were analysed according to the mayo elbow score. 10 had excellent, 1 hadgood & 1 fair out come. The mean range of elbow movement was from 10 – 140degrees at the end of one year.Conclusion: In the treatment of comminuted olecranon fractures, a precontoured lock-ing compression plate with locking screws provides sufficient stability for early post-operative functional rehabilitation, with an excellent fracture union rate and very goodclinical outcomes.Key words: comminuted olecranon fracture, olecranon LCP


fixation technique consisted of contoured dorsal lockingcompression plate fixation with a proximally inserted3.5-mm intramedullary screw and a minimum of twounicortical locking screws distal to the fracture. Allpatients gave consent to participate in the present studyand were followed at regular intervals at least until thetime of osseous healing, defined as the presence ofcrossing trabeculae on both anteroposterior and lateralradiographs. Fracture union was assessed by thetreating orthopaedic surgeon. All patients were invitedto return for assessment of the elbow at a minimumduration of follow-up of twelve months, and sixteenpatients returned after a mean duration of followup oftwenty four months (range, twelve to forty-eight months).At the time of the latest follow-up, the ranges of motionof the elbow and forearm, varus-valgus instability, nerveinjury, were assesed. Forearm strength in flexion,extension, pronation, and supination was ratedsubjectively with use of a 6-point Likert scale rangingfrom 0 (no contraction) to 5 (normal strength).

RESULTSThe study group included four women and eight

men with an average age of 42 years (range, 24 - 68years). All were acute fractures & two of which wereopen and classified as Gustilo-Anderson grade II onecase & another case grade III B. The coronoid processwas involved in five patients, all of whom had a type-3fracture according to the system of Regan and Morrey.Two patients had a posterior fracture-dislocation, andone had an anterior transolecranon fracture-dislocation.Nine fractures involved the right upper extremity, andthree #s involved the left. According to the AO system,there were five multi fragmentary metaphyseal ulnarfractures (type A3.2); four intra-articular proximal ulnarfractures, including one multi fragmentary olecranonfractures (type B1.1), one simple fractures of both theolecranon and the coronoid process (type B1.2), and twomultifragmentary combined intra-articular extra-articu-lar ulnar fractures (type B1.3); The mechanism of in-jury was a fall from a height for two patients, and motor-cycle accident for ten patients. The interval betweenthe injury and operative treatment was 3 – 12hrs. Allfractures were healed. The mean time to union was threemonths (range, two to five months). These patients werefollowed at least until osseous union. The postoperativearc of flexion at the time of the latest follow-up wasfrom a mean extension deficit of 10(range, 0 to 30;) to amean flexion of 140 (range, 120 to 150). The arc ofrotation of the forearm was from a mean supination of71 (range, 10 to 80) to a mean pronation of 74 (range, 10to 80). Results were analysed with mayo elbow score

Dr. Prabakaran et al

includes pain 45 pts, motion 20 pts, stability 10pts,function of elbow 25 pts. Scores were greater that 90-excellent, 75-89 good, 60 – 74 fair & scores below 60 ispoor. In our series 10 patients had excellent, 1 had good& 1 fair results. One fair result case is an elderly patientwith grade III open injury of elbow with radial nervepalsy with uncontrolled NIDDM under gone wound de-bridement & internal fixation with olecranon LCP andSSG was done in same sitting. 12 weeks later he hadundergone tendon transfer for radial nerve palsy. He hadsuperficial infection in the follow up and restriction ofextension of 30, flexion of 100 degree and restriction ofsupination & pronation.

DISCUSSIONThe aims of operative treatment of comminuted

intraarticular olecranon fractures are realignment of thelongitudinal axis, restoration of joint stability, articularcongruity, normal strength, and a pain-free functional arcof motion of the elbow. Postoperatively, immediatefunctional rehabilitation of the elbow is essential giventhat immobilization after an injury, even for a period ofas short as three weeks, has been shown to adversely


affect the range of motion of the elbow and the func-tional outcome. Therefore, stable fixation is important.Furthermore, long-term reliability of plate fixation is cru-cial because extreme bending stresses at the proximalpart of the ulna occasionally can lead to fatigue failureof internal fixation devices. The locking compression platediffers substantially from similar devices in that it allowsfor the insertion of distal unicortical locking screws.In the present case series, we found the lockingcompression plate fixation technique to be a secure andeffective treatment option as it led to a 94% rate of goodor excellent results, with no instances of constructfailure, nonunion, or major complications after a meanduration of follow-up of nearly two years. The maincomplication encountered was hardware prominence,especially when the patient leaned on a table. Ourfindings are comparable with those reported in previousstudies of olecranon plating. Anderson et al. reported onthirty-two patients who were managed with congruentplate fixation for the treatment of olecranon fractures,nine of which were comminuted. That type of plate hasseveral differences from the locking compression plate.It does not have locking capability, and therefore it re-quires bicortical screw fixation. In the study by Ander-son et al., 92% of the patients had a good or excellentresult, but among the patients with a comminutedolecranon fracture the mean DASH score (26) and meanMEPI score (88) were slightly less favorable than thescores in our patients. Bailey et al., in a retrospectivestudy, reported on the use of plate fixation for sixteenpatients with comminuted olecranon fractures. After amean duration of follow-up of three years, 94% of thepatients had a good or excellent outcome and the meanDASH and MEPI scores were 11 and 88, respectively.No significant relationship between functional outcomeand fracture patterns was found. Finally, Simpson et al.reported a good or excellent result for twenty-seven(73%) of thirty-seven comminuted olecranon fracturesthat were treated with contoured low-contact dynamic

compression plating. The average arc of elbow motionin those studies ranged from 107 to 130 of flexion to 9 to14 of extension deficit, and postoperative motion wastherefore comparable with that in our series. Limitedextension may have been caused by the proximal part ofthe plate, although none of the patients had radiographicsigns of hardware impingement with the elbow inextension. Nevertheless, when applying this plate, thesurgeon should be sure that impingement in the olecra-non fossa does not occur when the elbow is extended.The limitations of the present study include itsretrospective nature, the small number of patients, andthe relatively short duration of follow-up. Asosteoarthritis develops over the course of many years,no conclusions can be drawn from the present serieswith regard to the rate and severity of ulnohumeralosteoarthritis. Nonetheless, the present study had sev-eral strengths, such as the inclusion of consecutive pa-tients and the use of multiple validated patient-based as-sessment scores.

CONCLUSIONIn summary, this method of pre contoured

fixation of comminuted olecranon fractures seems toprovide enough stability to allow for the early start ofpostoperative functional rehabilitation with a predictablyhigh rate of fracture-healing.

REFERENCES1. Simpson NS, Goodman LA, Jupiter JB. Contoured LCDC platingof the proximal ulna. Injury. 1996;27:411-7.2. Ring D, Jupiter JB, Sanders RW, Mast J, Simpson NS.Transolecranon fracture dislocation of the elbow. J Orthop Trauma.1997;11:545-50.3. Bailey CS, MacDermid J, Patterson SD, King GJ. Outcome of platefixation of olecranon fractures. J Orthop Trauma. 2001;15:542-8.4. Anderson ML, Larson AN, Merten SM, Steinmann SP. Congruentelbow plate fixation of olecranon fractures. J Orthop Trauma.2007;21:386-93.5. Hak DJ, Golladay GJ. Olecranon fractures: treatment options. JAm Acad Orthop Surg. 2000;8:266-75.

Clinical evaluation of locking compression plate fixation for comminuted olecranon fractures


RESTORING ANATOMY IN DISTAL HUMERUS INTER CONDYLAR

FRACTURES WITH LCP FIXATION

Dr. Yuvarajan Palanisamy , Dr. S. JaikishATLAS Hopsitals, Trichy

AbstractIntroduction: Distal humerus fractures remain some of the most challenging injuries tomanage. They are commonly multifragment occurs in osteopenic bone and have com-plex anatomy with limited options for internal fixation.Treatment outcomes are oftenassociated with elbow stiffness, weakness and pain. ORIF of distal humeral fracturesusing modern locking plate fixation principles is considered the standard treatment.Material and methods: 22 patients of distal humeral fractures treated in ATLAS hospi-tals during the period from 2011 to 2014 with follow up was ranging from 12 months to48 months.Distal humeral fractures with intercondylar extension were included in thisstudy.mechanism of injury was fall in outstretched hand-12 cases,RTA-8 cases and fallfrom height -2. In our series, 2 fractures were type A3, 3 fractures were type B1, 7fractures were type C1, 6 fractures were type C2, and 4 fractures were type C3. 17cases were managed with triceps flap approach and 5 cases were done with olecranonosteotomy approach.17 cases were male patients and 5 patients were female patients.Age group was ranging from 22 years to 72 years. All these patients were treated withmodern LCPfixation. Elbow immobilization done with above elbow slab for 4 weeks.Elbow mobilization was started after 4 weeks. Results were analysed using MEPS Score-excellent in 5, good in 15, fair in 1 and poor in 1 .Conclusion Modern locking platefixation is an excellent method of fixation in intercondylar fractures of distal humerus.Olecranon osteotomy affords the best visualization of the articular surface of the distalhumerus and is a valuable approach for comminuted articular fractures.Key words: Distal humerus, intraarticular fracture, comminuted fracture, LCP fixation

INTRODUCTIONElbow is a hinged joint with single axis of

rotation (trochlear axis).Trochlea is a center point witha lateral and medial column. Medial and lateral columnsdiverge from humeral shaft at 45 degree angle.Thecolumns are the important structures for support of the“distal humeral triangle”. The fracture pattern may berelated to the position of elbow flexion when the load isapplied. Radial nerve is the most commonly injured nervefollowed by median nerve.

Injuries involving distal end of the humerusrepresent a constellation of complex articular fractures.Distal humeral fractures account for 2%-6% of allfractures and about 30% of all elbow fractures1. Thesefractures are usually treated by open reduction andinternal ûxation (ORIF) in order to restore anatomicalalignment and allow functional rehabilitation soon after

surgery.2,3.Ever since the description of these fractures,the fractures management has passed through variousstages like bag of bones technique,cast or splint,k-wirefixation,External fixator,open reduction and elbowarthroplasty.4,5,6,7,8,9.However,with respect to anatomicreduction,reconstruction of the joint congruity,stable fixa-tion and functional outcome,it is generally accepted thatinternal fixation gives the most favorable outcome fordistal humerus fractures .10,11The standard method cur-rently used by most surgeons is to apply two plates per-pendicular at 90 to each other or parallel plates.12,13.Themulti-fragmentary component of these fractures withcomminution of the articular surface makes challengingtask for an operating surgeon to do anatomical reduc-tion and fixation .Conventional plates have a high inci-dence of implant failure and substantial stability espe-cially in osteoporotic bone.11.The high incidence of fail-


Dr. Yuvarajan Palanisamy et alure rate in these fractures is due to insufficient area forinsertion of many screw in a small sized distalfragment,resulting in poor stability at bone-plateinterface.14,15.Pre-countored distal humerus lockingcompression plate (LCP)provide higher stability bymultiple screw purchase in small distal fragment.16,17.The present prospective study was planned to evaluatethe result outcome following restoration of the distal hu-merus anatomy by using LCP-DHP.

MATERIALS AND METHODSIn our series, 22 patients with distal humerus

fractures were treated in our hospital with pre-contouredLCP during the period from2011 to 2014 with follow upranging from 12 months to 48 months.Distal humerusfractures with intercondylar extension were included inour study. Mechanism of injury was fall in outstretchedhand in 12 cases, RTA in 8 cases and fall from height in2 cases. 17 cases were male patients and 5 patients werefemale patients. Age was ranging from 22 years to 72years. We classified the fracture pattern as per the OTAclassification. In our series, 2 fractures were type A3, 3fractures were type B1, 7fractures were type C1, 6 frac-tures were type C2, and4 fractures were type C3. Mostof the cases were type C fractures followed by type Band type A. Radiographic exam by Anterior-posteriorand lateral radiographs .Traction views may be helpfulto evaluate intra-articular extension and for pre-opera-tive planning (creates a partial reduction vialigamentotaxis).Traction remove overlap.CT scan washelpful in selected cases like Comminuted capitellum ortrochlea .Patient was positioned in lateral decubitusposition.17 cases were done with triceps flap approachand 5 cases were done with olecranon osteotomyapproach.Surgical technique: All the patients were operated inthe lateral decubitus position with the affected elbowflexed at 90*.17 cases were done with triceps flapapproach and 5 cases were done with olecranonosteotomy approach. Ulnar nerve was routinely identi-fied and isolated. The nerve was transported anteriorlyin all cases. After exposure, first step in the procedurewas reduction of the condyles and reconstruction of thejoint surface. Medial and lateral condyles were fixed to-gether with a cancellous lag screw. The next step wasto anatomically reattach the condyles to the humeralshaft. While doing this, we checked for properrestoration of the three dimensional alignment (coronalplane -carrying angle and internal rotation of the humeralcondyle, saggital plane –anterior humeral angle) of thehumeral condlyes. We always ensured the adequaterestoration of the trochlea width .Column stabilistaionwas done with two orthogonal or parallel plates. In 14

cases, plates were applied in an orthogonal mode.whereas; parallel plates were used in 8 cases. All thesepatients were treated with Modern LCP fixation. Elbowimmobilization was done with above elbow slab for 4weeks. Elbow mobilization was started after 4 weeks.The MEPS score was used to evaluate functional re-covery. It includes assessment of pain (45points), mo-tion (20), stability (10), function (25) and the total scoreof 100 points. Score >90=excellent, 75 -89 = good, 60-74 =fair, <74=poor.

RESULTSIn this study patients were followed up for up to

2 years. The average time to union was 14 weeks (range10-16weks).12 patients had >100* while 10 patients had70-100*ROM at elbow, with all patient exhibiting fullsupination and pronation. Excellent results were foundin 5, Good in 15, Fair result in 1 and poor in 1 of cases asper MEPS scoring system. Postoperative performanceof Type A was significantly better than the type B andtype C fracture. No patient had deep infection, implantfailure, Non-union of fracture site or olecranon osteotomysite. Only minor complications occurred in these study.2patients had superficial wound infection, 1 patient hadtransient ulnar nerve palsy, and 1 patient had metalprominence (olecranon k wires). Superficial wound in-fection settled with oral antibiotics.

Functional Anatomy

Surgical Anatomy


Restoring anatomy in distal humerus inter condylar fractures with LCP fixation

DISCUSSIONIntercondylar fractures of the distal humerus are

difficult to treat because of the nature of injury and thefact that it is one of the greatest challenges in terms ofsurgical fixation and absolute anatomical reduction.Surgical expertise is of paramount importance.19, 20.According to Gupta et al, it is due to complex anatomyof the elbow, small sized fracture fragments and thelimited amount of sub chondral bone in the distalhumerus .18 The risk of functional impairment followinga displaced distal humeral fracture is high, and it is nowgenerally accepted that the most favorable outcome ofdisplaced intraarticular fractures is provided by surgicalreconstructive procedure.14, 18. The treatment principlesin managing distal humeral fractures should be torestore the anatomy, axial alignment, stable fixation andto achieve good articular reduction. It provides a goodfunctional outcome .we managed all the cases with openreduction and internal fixation. Emergency wounddebridement was done in open fractures along withdefinitive fixation performed within 6 hours of an injury.However, in few selected cases temporary externalfixation was applied and the definitive procedure wasperformed in a later stages. Implants were determinedby the fracture pattern, bone quality, working length forfixation and surgeon’s preference. Intra-articularfractures were stabilized with Dual locking plate.One ofthe frequent clinically reported complication of an usageof the conventional plates is implant failure that occursby loosening of the bone-implant anchorage at distal frag-ment.21, 22, 23 To prevent such failure two principlesmust be satisfied: fixation in the distal fragment must bemaximized and all fixations in distal fragments shouldcontribute to stability between the distal fragments andthe shaft. This is possible only if as many screws aspossible are placed in the distal fragments; the screws inthe distal fragments lock together by interdigitation

Mechanism ofInjury

Surgical Exposures

Osteotomy Fixationoptions

Olecranon osteotomy ,Orthogonal plating

Olecranon osteotomy – single screw fixation


creating a fixed-angle structure and the plates must bestrong and stiff enough to resist breaking or bendingbefore union occurs.22 We preferred Lockingcompression plate for the above cited reasons. Lockingreconstruction plate was used to reconstruct the othercolumn wherever distal fragment was sufficiently large.RK Gupta et al mentioned that locking plates provide afixed plate screw construct with multiple screw optionsfor easy application in distal complex fractures therebyproviding angular stability.24.Korner et al biomechani-cally compared dual plate osteosynthesis usingconventional recon and locking compression plate. Heconcluded that biomechanical behavior depends moreon plate configuration than plate type. Whereas, recentstudies recommend the usage of locking platesespecially in a complex intraarticular distal humeralfractures which allows greater perioperative stability andearly rehabilitation. Moreover, invitro biomechanicalassessment has also shown that locking plates providebetter stiffness in bending and torsion than conventionalreconstruction plates.

According to Jacobson et al, there is consensusover the ideal surface for plate fixation in distal humeralfractures. Significant controversy exists about whetherorthogonal or parallel plating is superior for fixation ofdistal humeral fractures. These construct were stiffer incoronal plane than the saggital plane25. Thoughgeometrical (orthogonal) placement of plates providesbetter mechanical stability, it encompasses moreextensive soft tissue dissection and potential transposi-tion of the ulnar nerve. In contrast, posterior placementof plates does not involve elevation of anterior musclesand extensive release, thereby reducing the risk of myo-sitis ossificans. Furthermore, dorsal application of boththe plates provides steady enough configuration, requir-ing less extensive dissection and ulnar nerve retractionthereby resulting in a low incidence of complications.24

Patient positioning and adequate exposure of thefracture site is a prerequisite for treatment of distalhumeral fractures. Although various approaches havebeen described for the reduction and fixation, theposterior approach through an olecranon osteotomy, tri-ceps-splitting, and triceps reflecting are the mostcommon surgical approaches to the elbow. In our series,17 cases were done with triceps flap approach and 5cases were done with olecranon osteotomy approach.Triceps flap approach does not appear to be detrimentalto triceps strength and elbow function and is not associ-ated with iatrogenic risk of hardware complications.Triceps-splitting approaches have been postulated to havea negative effect on muscle strength on the basis of di-rect muscle injury with resultant fibrosis and injury tointramuscular nerve branches. However proper repair

of triceps muscle and aponeurosis in two layers followedby supervised physiotherapy does result in regaining nor-mal triceps strength.24 The exposure of articularsurface by this approach is definitely less than thatachieved by transolecranon approach but this can beimproved by further flexion of the elbow. It has the addedadvantage of retaining the whole olecranon to be usedas a template against which the articular fragments ofthe trochlea can be assembled.

As per Jupiter et al, transolecranon approach,provides complete posterior visualization, requiresolecranon osteotomy and is associated with possible complications such as prominence/migration ofhardware and possible displacement/nonunion ofosteotomy.14, 26. One patient had metal prominence dueto olecranon k wire. However, in our study, we did notreport any cases of non union of olecranon osteotomy.All fractures as well as the osteotomy united by 12-16weeks.

Incidence of ulnar nerve injury has been reportedin 5-15% of patients. In our study, the nerve wastransposed anteriorly in all cases. However, 1 patienthad transient ulnar nerve palsy which was recoveredwith conservative treatment.

As per Gofton et al 13% of his type c distalhumerus fractures had postoperative heterotopicossification .kundel et al, reported a high incidence ofheterotopic ossificans around 49% in his series of cases.Whereas, we encountered no case of postoperativeheterotopic ossification which may be due to meticuloussoft tissue dissection, adequate hemostasis, unobstructedpostoperative drainage, early functional mobilization andprophylactic oral indomethacin.

In our patients we immobilized the elbow for 4weeks with above elbow slab. Elbow mobilization likeactive and active assisted exercise was started after 4weeks. 12 (55%) patients had >100* while 10(45%)patients had 70-100*ROM at the elbow. Excellent re-sults were found in 5(22.7%), Good in 15(68%), Fairresult in 1(4%) and poor in 1(4%) of cases as per MEPSscoring system. Best treatment outcome was achievedwith type A fractures. Taking the fracture type into con-sideration, functional results deteriorated with degree ofjoint involvement, which is coherent with findings ofKorner et al4 that outcomes from type C fractures areless promising than type A.24.Moreover, similar resultshave been achieved with the use of precontoured LCPby other authors.27,28

CONCLUSIONAn anatomically pre-shaped distal humerus lock-

ing plate is a versatile implant providing stable-enoughfixation and helping restoration of articular surface for

Dr. Yuvarajan Palanisamy et al


good result and early rehabilitation.In contrast to conventional plating, we did not

encounter any case of non-union, implant failure even inelderly patients with osteoporosis.

Olecranon osteotomy affords the best visualiza-tion of the articular surface of the distal humerus and isa valuable approach for comminuted articular fractures.

The results of our study shows that DHP sys-tem is a useful option in distal humerus fractures espe-cially in type C injuries with comminuted small distalfragments, although larger control studies with long termfollow-up may be required before advocating it for widerapplication.

REFERENCES1. Robinson CM, Hill RM, Jacobs N, et al. Adult distal humeralmetaphyseal fractures: epidemiology and results of treatment. J OrthopTrauma 2003; 17(1):38-47.2. Srinivasan K, Agarwal M, Matthews SJE, et al. 2005. Fractures ofthe distal humerus in the elderly. Clin Orthop Rel Res 434:222–230.3. Anglen J. 2005. Surgical techniques: distal humerus fractures. JAm Acad Orthop Surg 13:291–297. 3. Ring D, Jupiter JB. 2000.Fractures of the distal humerus. Orthop Clin North Am 31:103–113.4. Eastwood WJ. The T-shaped fractures of lower end of the humerus.JBone Joint Surg Am 1937;19:364-95. Trynin AH. Intercondylar T fractures of elbow. J Bone Joint Surg1941;23(3):709-116. Mervyn Evans E. Supracondylar –Y fractures of the humerus.JBone Joint Surg Br 1953; 35-B: 381-5.7.Jones KG .Percutaneous pin fixation of fractures of the lower endhumerus.Clin Orthop Rela Res 1967;50:53-698.Deland JT,Walker PS,Sledge CB,et al.Treatment of post traumaticelbows with a new hinge –distractor.Orthopedics 1983;6:732-79.Tyson KC,BernardFM,Rochester, et al.Total elbow atrhoplasty asprimary treatment of distal humerus fractures in elderly patients.JBone Joint Surg Am 1997;79(6):826-3210.Haung TL,Chiu FY,Chaung Ty,et al.The result of open reductionand internal fixation in elderly patients with severe fractures of distalhumerus.a critical analysis of the results.J trauma 2005;58(1):62-911.Shimammura Y,Nishida K,Imatani et al.Biomechanical evaluationof the fixation methods of transcondylar fractures of the humerus.ONIplates versus conventional plates andscrews.Acta Med Okayamma2010;64(2):115-2012. O’Driscoll SW. 2004. Optimizing stability in distal humerus

fracture ûxation. J Shoulder Elbow Surg 14:186S– 194S.13. Hausman M, Panozzo A. 2004. Treatment of distal humerusfractures in the elderly. Clin Orthop Relat Res 425:55–63.14.Jupiter Jb.The Management of nonunion and malunion of thedistal humerus-a 30 year experience .J Orthop Trauma2008;22(10):742-5015.Wong AS, Baratz ME.Elbow fractures :distal humerus .J HandSurg Am 2009;34 (1):176-9016.Kaiser T,Brunner A, Hohendorff B, et al Treatment of supra andintra articular fractures of the distal humerus with the LCP distalhumerus plate : a 2 year follow up J shoulder Elbow Surg2011;20(2):206-1217.CelliA, Donini MT, Minervini C. Use of pre-contoured plates intreatment of C2,C3fractures by open reduction and internal LCP-DHP experience .Chir Organi Mov 2008 ;57-6418. Gupta R, Khanchandani P. Intercondylar fractures of the distalhumerus in adults: a critical analysis of 55 cases. Injury 2002;33(6):511-5.19.Aitken GK,Rorabeck CH.Distal humeral fractures in the adult.ClinOrthop 1986;207:191-720.Pollock JW, Faber KJ,Athwal GS.Distal humerus fractures .OrthopClin North Am 2008;39:187-20021. Korner J, Lill H, Müller LP, et al. Distal humerus fractures inelderly patients: results after open reduction and internal fixation.Osteoporosis Int 2005; 16 Suppl 2:S73-9.22. Doornberg JN, van Duijn PJ, Linzel D, et al. Surgical treatmentof intra-articular fractures of the distal part of the humerus. Functionaloutcome after twelve to thirty years. J Bone Joint Surg Am 2007;89(7):1524-32.23. O’Driscoll SW. Optimizing stability in distal humeral fracturefixation. J Shoulder Elbow Surg 2005; 14(1 Suppl S):186S94S.24.Rakesh Kumar Gupta,Vinay gupta,etal Locking plates in distalhumerus fractures :study of 43 patients.chinese journal of traumatology2013;16(4):207-21125. Jacobson SR, Glisson RR, Urbaniak JR. Comparison of distalhumerus fracture fixation: a biomechanical study. J South OrthopAssoc 1997; 6(4):241-9.26. McKee MD, Kim J, Kebaish K, et al. Functional outcome afteropen supracondylar fractures of the humerus. The effect of the surgicalapproach. J Bone Joint Surg Br 2000; 82(5):646-51.27. Imran M, Intikhab T, Najjad MKR, et al. Functional outcome ofElbow Reconstruction after using precontoured locking compressionplate. The Journal of Pakistan Orthopedic Association 2014 ;1:35-828.Aggarwal S,Kumar V,Bhagwat KR,et al AO etra articular distalhumerus locking plate :extended spectrum of usage in intra-articulardistal fractures with metaphyseal extension –our experience with 20cases.Eur J surg Traumatol 2014 ;24(4):505-11.

Restoring anatomy in distal humerus inter condylar fractures with LCP fixation

tamil nadu orthopaedic journaltnojonline.com/wp-content/uploads/2018/04/tnoa-journal-feb2016.pdf ·...

Documents