Ortho Front

March 2009
Orthofront
BOMBAY ORTHOPAEDIC SOCIETY
editorialboard
Editor-in-chief Dr. Nicholas Antao Asst. Editor Dr. Alaric Aroojis Board Members Dr. Vikas Agashe Dr. Manish Agarwal Dr. Mihir Bapat Dr. Harish Bhende Dr. Mohan Desai Dr. Sangeet Gawhale Dr. Arvind Goregaonkar Dr. Anil Karkhanis Dr. Pranjal Kodkani Dr. Rujuta Mehta Dr. Subranshu Mohanty Dr. Abhay Nene Dr. Dinshaw Pardiwalla Dr. Aseem Parekh Dr. Hemant Patankar Dr. Ram Prabhoo Dr. Ajay Puri Dr. Arvind Thakur Dr. Sudhir Warrier
Editor's Note
The tremendous effort of the editorial team needs to be lauded as the first issue of the Orthofront was appreciated by the members. The evidence to this was the congratulatory sms's, letters and emails that followed with the inaugural issue. Many felt that the magazine was just light reading that one could assimililate the take home messages easily, was so pleasant to read that they could finish it at one go, as it was very interesting and finally they could get the deliberations of the clinical meeting at their own clinics without attending the meeting. So just a big thank you on behalf of the editorial board for the appreciation, it was the worth the effort. The second issue brings another conglomeration of clinical meetings with difficult and interesting cases, relevant articles from all speciality branches and above all some follow-ups of important cases presented in the earlier clinical meetings and published in the first issue. Your positive feedback has given impetus to our editorial team to put their best foot forward again. We were a little disappointed at the lack of response to our Orthoquiz. Surely, the response was not difficult or were you just too lazy to respond. Do respond to this time, there's a prize waiting to be won. We are in the continuous process of learning and improvising. Efforts are being made too utilize the commentary of experts in the field while putting up and working the clinical case. If you have any idea that you would like to share with us, we would be too pleased to study the same and try to implement them. As the outgoing President of our esteemed society and also the editor of the Orthofront I had the opportunity to witness the strong bonding and cooperation of my executive committee members to execute a number of innovative agenda and items in the calendar of events 2008-09. I am overjoyed that my dream to serve you as the President of our esteemed society has been fulfilled and I am happy to have left my footprint in the sands of time. Yes I can proudly say that together we achieved much.
Dr. N. Antao
contents
Editor's Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Biopsy of Musculoskeletal Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Management of Infected Total Joint Replacement . . . . . . . . . . . . . . . . . . 6 Controversy: Open fracture-to close the wound primarily or not? . . . . . 10 An article review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Recent advances in cartilage reconstructive surgery in India Guidelines - Pathological Fractures in Children . . . . . . . . . . . . . . . . . . . 17 Modern Trends In Spinal Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . 20 The ten commandments of hand fractures. . . . . . . . . . . . . . . . . . . . . . . 24 Selected Case Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 (BOS Clinical Meeting Nair Hospital) Selected Case Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 (BOS Clinical Meeting Sion Hospital) Ortho Quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Follow-up of some cases presented earlier . . . . . . . . . . . . . . . . . . . . . . 35 The BOS - All India Best Resident Award . . . . . . . . . . . . . . . . . . . . . . . . 36 Forum On Ethical And Legal Concerns In Orthopaedic Practice . . . . . . 37 Guest Lecture: Dr. Freddie Fu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Biopsy of Musculoskeletal Tumors

Dr. Ajay Puri, Dr. Manish Agarwal
A biopsy is perhaps the most vital step in the diagnostic workup of bone and soft tissue tumors. It is important that a clinician knows how to obtain adequate material in the least traumatic way without jeopardising subsequent local control of the tumor. A poorly placed biopsy incision, a poorly performed biopsy, or the complications of a biopsy make it difficult to salvage an extremity and, in some instances, may affect the survival of the patient. Ideally, the biopsy must be performed by or under the supervision of the surgeon who will be carrying out the final treatment. Biopsy should be regarded as the final diagnostic procedure, not as a shortcut to diagnosis. It should be performed after all the imaging studies have been performed. The optimum integration of clinical and radiographic information prior to biopsy has important implications for the diagnosis of bone tumors, and is necessary for accurate pathologic interpretation. This is where the multidisciplinary cooperation between radiologist, clinician and the pathologist becomes vital. Though the material obtained by an open biopsy is generally adequate in quantity and less challenging to the skills of the pathologist, it is a more traumatic procedure. It involves greater tissue trauma, more blood loss and higher risk of complications such as hematoma, infection and pathologic fracture. If a tourniquet is used there is always a fear that the oozing from tumor vessels after the tourniquet is released may contaminate large areas of the limb. An open biopsy requires general anaesthesia. It is less forgiving and a correct technique is of utmost importance if limb salvage is considered. The skin removed at final procedure is more and can compromise closure during salvage surgery. Percutaneous biopsy of bone offers several advantages compared with open procedures. A needle biopsy can be performed as an out-patient procedure under local anaesthesia with very low morbidity. It does however require a skilled and experienced pathologist to reach an accurate diagnosis. Needle biopsies can reach deep areas of the skeleton that are otherwise accessible only by open operation and multiple specimens can be obtained without increasing morbidity.
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When a needle biopsy is non-diagnostic, it can easily be repeated, or an open biopsy can be performed without major morbidity to the patient. Healing of a wound is not endangered and thus, treatment with radiation and chemotherapy can be started immediately if necessary. There is less disruption of soft tissue and fascial planes. There is less risk of increased stress risers and pathological fractures. In areas which are difficult to access such as the spine or pelvis the needle biopsy can be guided using CT imaging or an image intensifier to ensure accurate targeting. Regardless of the type of biopsy, its placement is critical. For appropriate placement of the biopsy, the surgeon needs to know the probable diagnosis and the extent of the tumor and should have established an operative plan prior to biopsy. He should not be concerned only with obtaining a tissue diagnosis but should also think about the definitive operative procedure. Transverse incisions in the extremities are almost always contraindicated because the site of the incision cannot be excised en bloc with the longitudinally directed segments of bone or musculo aponeurotic compartments. Therefore, a longitudinal biopsy incision must always be used in the extremity. The major neurovascular structures should be avoided because if they are contaminated during the biopsy they may have to be sacrificed during the definitive procedure that follows. The biopsy tract also should not traverse a normal anatomical musculoskeletal compartment in order to reach a compartment that is involved by tumor, so that it will not be necessary to remove both compartments at the time of the definitive procedure. The common sites are mentioned in Table 1. In adults the needle biopsy is performed under local anaesthesia. For children a short general anaesthesia may be required. After adequate preparation of the skin the shortest path to the lesion is used, avoiding important neural and vascular structures and not traversing anatomical compartments. In case of soft tissue tumors the specimen is obtained from the mass using the Tru-cut needle-biopsy system. In case of bone tumors the specimen is easily obtained from the soft tissue component. The sample from the soft tissue
Ortho front March 2009
TABLE 1
Clavicle Scapula
Through an incision that is parallel to the long axis of the clavicle An oblique incision which passes from superior lateral over the acromian to distal medial near the level of the inferior corner of the scapula. Through anterior deltoid Posteriorly Along a line passing from the pubic tubercle to the anterior superior iliac spine over the iliac crest and to the posterior superior iliac spine depending upon the location of the lesion. Another incision line from ASIS to greater trochanter. Never through the buttock. Through the lateral approach. Do not cross IM septum. Anterior, medial or lateral and proximal to the suprapatellar pouch. Never through the rectus femoris. Do not enter the joint Anteromedial or anterolateral aspect. Do not enter the joint. Never midline thro the patellar tendon. operative hematoma is prevented. If a tourniquet is used it must be applied without exsanguination and must be released prior to closure so that hemostasis can be achieved. The biopsy site must be closed carefully to prevent necrosis. Suction drains should not be used if malignant disease is likely, as the drainage tube tract can be a site for tumor spread and will have to be excised en bloc with the biopsy site. If a drain must be used, the tract should be adjacent to and in line with the biopsy incision. If the facility for frozen section exists then it is preferable to ask the pathologist to comment if the material obtained during biopsy is representative. This can reduce the incidence of repeat biopsies due to inadequate material. All the material collected at biopsy should be processed at one place. It is a bad idea to divide the material and send it to different pathology laboratories. Due to the heterogeneous nature of many sarcomas this can lead to different reports and more confusion. For any discrepancy, it is better to seek subsequent opinions on the same material by sending slides and blocks for review. A biopsy therefore not only plays a vital role in diagnosis but can also have a bearing on definitive management and ultimate survival of the patient. Though technically simple it requires considerable thought and planning prior to its execution in order to be of maximum benefit to the surgeon and the patient.
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Proximal Humerus Distal Humerus Pelvis
Hip & proximal femur Distal femur
Proximal tibia
mass is as representative as from the intraosseous component. Where the lesion is entirely intraosseous, bone has to be penetrated. For obtaining cores from bone the Jamshidi needle is used. Avoid biopsying heavily calcified or ossified and necrotic areas. In an open biopsy the correct technique is even more critical in order to reduce the complication rates. The incision should be as small as compatible with the obtaining of an adequate tissue specimen. No flaps must be raised so that tissue contamination is at a minimum. From the incision, one must directly move down to the area of interest. The periphery of any malignant tumor is its most viable, representative and diagnostic portion, whereas the central portion is often necrotic. If a malignant bone tumor has a soft tissue extension, a biopsy from the soft tissue is representative and it is not always necessary to biopsy the bone. Violating the cortex of a bone that contains malignant tumor may lead to pathological fracture. A biopsy from the soft tissue component is as representative and easier to obtain. If the bone must be opened a small circular hole should be made with a trephine, so that only minimum stress-risers are created. If a hole has been created in the bone, it should be plugged with Gelfoam or methylmethacrylate to prevent bleeding into the soft tissues. Meticulous hemostasis is necessary so that substantial postOrtho front March 2009
Management of Infected Total Joint Replacement

Dr. Shubhransu S. Mohanty, Dr. Mandar Agashe
Prosthetic total joint replacement has became a powerful tool in the management of severe disabling arthritis, with a success rate approaching 99%. Almost 1 million total joint replacements take place world wide every year and with the increasing longevity of senior citizens coupled with the demands of young, active arthroplasty recipients, it is estimated that this number may be even more year after year. However, despite its success, joint replacement surgery is not without complications, including aseptic loosening, dislocation, periprosthetic fracture, and the most dreaded one of all, infection. The rate of infection following total joint replacement is fortunately quite low, about 1% in hip and shoulder replacements and about 2% in knee replacements. The low rate of infection can be attributed to the routine use of peri-operative antibiotics, the use of clean-air filtering systems and scrupulous maintenance of operating room asepsis by OR personnel. Deep prosthetic infection impairs function and general health, and its management is difficult and expensive. Some infections are clearly blood borne but the source of most of the others can be traced to operative contamination by either room air or skin flora either the surgical teams or the patients. Cost-effective perioperative strategies are therefore critical in reducing the incidence of post-surgical infection. Classification : The Coventry classification of post operative wound infection is still widely used. Stage 1 infections occurred within 3 months of surgery, stage 2 infections occurred between 3 months to 2 years of surgery while stage 3 were late infections which occurred after 2 years of surgery. Schmalzried et al classified these infections according to the mode of infection- surgical, haematogenous or recurrent. However it is very difficult to accurately determine the exact mode of deep infection in each case. A new classification by Estrada et al (Table-1) reflects the increasing incidence of revision surgery and current management concepts. Table 1. Classification of infected total joint replacements. Category Definition
Positive intra operative culture Two or more intraoperative positive for the same organism Early post-operative infection Late chronic infection Apparent within one month of surgery Presenting after one month of surgery with insidious onset of symptoms
Acute hematogenous infection Acute onset of clinical symptoms in a previously well functioning joint. Prevention of infection after total joint replacement : Pre-operative evaluation and care and general measures like cessation of smoking and maintenance of hygiene, special attention should be paid to the medical co-morbidities. Diabetes should be adequately under control. In patients with rheumatoid arthritis, it is worthwhile to withhold methotrexate in the peri-operative period as it may cause immunosuppression. As a general rule, any sort of skin infection should be treated prior to surgery. Dental and urinary infections have to be treated. Peri-operative management : strategies to reduce the number of contaminant particles in the operative field are an important component of prophylactic efforts. There is some controversy regarding the use of routine pre-operative skin disinfection over a period of 12-24 hours with some experts saying that prior to immediate pre-surgical skin preparation, even routine hygiene is sufficient. Adhesive drapes are usually widely used though their exact benefit is yet to be documented. Good operative room discipline is essential in reducing post-operative infection rates. Reduction in the number
of OR personnel has proven effectiveness in reducing the number of colony-forming units in circulating air. Also use of systems combining high filtration efficiency, frequent air change and uni-directional air flow and by use of impermeable clothing or suit ventilation greatly helps in reducing shedding by operating room personnel. Antibiotic prophylaxis: The efficacy of antibiotic prophylaxis for the prevention of post surgical wound infections has been proved by several randomized control trials. The usual protocol followed in many centres is to give a broad spectrum antibiotic like a 1st or 2nd generation cephalosporin just prior to surgery, and further two injections after 12 and 24 hours later. Also antibiotic prophylaxis is needed to prevent haematogenous infection as in cases of dental sepsis, urinary tract infections etc. DIAGNOSIS AND MANAGEMENT OF INFECTION IN TOTAL JOINT REPLACEMENT Early post-operative infection: Early post-surgical infection is usually overt and purulent. Diagnosis is made by history and clinical examination itself. The patient has significant constitutional symptoms and fever, with local signs of acute inflammation. Ultrasound helps in locating the location of infected haematoma or localized abscess if any and helps in guiding ultrasound guided aspiration. The role of aspiration of joint fluid remains controversial with many surgeons using joint aspiration to guide their diagnosis and management though its use has not been proven by control trials. The C-reactive protein levels have got a high predictive value in the diagnosis than erythrocyte sedimentation rate. Soft tissue debridement with retention of prosthesis with impregnation of local anti-biotic cement beads is currently the mainstay of treatment Chronic deep seated infection: It is often difficult to diagnose chronic infection in total joint and to distinguish from aseptic loosening. Pain is the commonest presenting feature, with developing restriction of motion in previously well-functioning joint. There are very rarely any local signs of inflammation and a high degree of clinical suspicion is necessary to diagnose this entity. Serological investigations: Assessment of the white blood cell count is of limited benefit as it is frequently normal. The erythrocyte
sedimentation rate (ESR) and C-reactive protein (CRP) are key indicators in the patient who has no other reasons for their elevation such as rheumatic diseases or other inflammatory conditions. An ESR > 30 mm per hour has been shown to have a sensitivity of 82%, a specificity of 85%, a positive predictive value of 58% and a negative predictive value of 95%. The CRP is a better indicator of infection as it is more sensitive and returns to normal within the first three weeks after operation, compared to the ESR, which can take up to one year to become normal. A CRP value > 10 mg/l has been associated with a 96% sensitivity, a 92% specificity, a 74% positive predictive value and a 99% negative predictive value. If both the ESR and CRP are elevated, the probability of infection has been noted to be 83%, and when both are negative infection may be reliably excluded. RADIOLOGICAL INVESTIGATIONS Plain radiographs: Though plain radiographs are frequently normal in acute infections, chronic infection can cause radiographic changes, including periostitis, osteopenia, endosteal reaction, and rapid progressive loosening or osteolysis. Osteolysis and loosening may be non-specific but the possibility of infection must always be considered when these processes are rapid, particularly when there are no indicators of a mechanical cause. Magnetic reasonance imaging : MRI scans have got limited role to play in the demonstration of periprosthetic infections due to the artifacts due to the prostheses themselves. However newer techniques in MRI technology are on the horizon which can eliminate these artifacts and help in diagnosis of these periprosthetic infections. Radionuclide bone scan: A technetium-Tc99m (99MTc) isotope bone scan is often performed in the assessment of a failed THA. Although it has a high sensitivity, the low specificity for infection limits its use. Indium-111-labelled white cell scans have a much higher sensitivity in infection, which has been found to be 77%, with specificity of 86%, a positive predictive value of 54%, and a negative predictive value of 95%. However, this test is expensive and time consuming. Other isotopes have been investigated but none has demonstrated clinically useful sensitivity or specificity. The use of radioactive immunoglobulin G has also been described but has not become common, as its sensitivity and specificity were similar to those of standard laboratory investigations.
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Positron Emission Tomography: Positron emission tomography using fluorine-19-fluoro-2-deoxy-Dglucose has been used to detect sites of increased metabolic activity, suggestive of infection. The reported sensitivity of this method was 91.7%, with 96.6% specificity. However, areas that showed a non-specific increase in uptake were seen up to an average of 71 months after operation, even in uninfected THA. The authors concluded that the area of increased uptake may be more important than the intensity. Although these results are encouraging, further study is required. Microbiological analysis: The organisms most commonly isolated in infected Total joint replacements are Staphylococcus aureus and Staphylococcus epidermidis, followed by Gram-negative bacteria. Coagulase-negative staphylococci are increasing in prevalence in modern times .Also it is important to do the antibiotic sensitivities of these organisms isolated as they have neen shown to vary from time to time. Vancomycin resistance, for instance, in particular with enterococci, has been reported to be on the rise in enterococcal peri-prosthetic infections. This emphasises the importance of identifying the pathogen before initiating antibiotic treatment. Pre-operative aspiration: When there is a high index of suspicion of peri-prosthetic infection, the joint should be aspirated and the culture and sensitivities determined. A positive test is defined as a growth in two separate specimens. Growth in one specimen is generally not considered a cause for concern unless the clinical and serological features are worrisome, in which case the aspiration is repeated. Molecular biological investigation: Polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay have both been evaluated in the diagnosis of infected Total joint replacements. The PCR is highly sensitive. It is, however, very less specific due to its inability to distinguish between active and eradicated infections. Immunofluorescence microscopy and PCR have isolated colonisation with an organism in between 63% and 73% of extracted prostheses, compared to standard techniques, which detected colonisation in only 4% to 22%. INTRA-OPERATIVE CONFIRMATION Intra-operative gram stain: Intra-operative gram staining is a very good method of diagnosis of infection in total joint replacement though in a recent study a sensitivity of only 43 to 55 % was not noted though its
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specificity was very high in the range of 95 to 97 %. Owing to the wide variation in the reported sensitivity, intra-operative Gram staining should be interpreted with caution. Intra-operative tissue culture: The highest standard in the diagnosis of an infected THA has always been intra-operative tissue culture. Using a minimum of two positive samples, the sensitivity is 94%,and with 97% specificity. However, intra-operative tissue culture is not always positive, even in patients who are positive by all the other criteria mentioned and who symptomatically improve with management of their presumed infection. the exact reason for this is still to be found out. Intra-operative frozen section: Various definitions of a positive frozen section have been investigated in the literature. Studies that considered five polymorphonuclear leucocytes per high-power field to be indicative of infection have demonstrated a sensitivity between 43% and 100%, with a specificity ranging from 94% to 100 A frozen section can also be used to assess eradication of infection during reimplantation in a two-stage revision. TREATMENT 1) Antibiotic suppression: Antibiotic suppression as the sole modality of treatment should be reserved for those patients who are unable to undergo a one-stage or two stage revision surgery due to severe medical co-morbidities. There have been several studies investigating the rate of recurrence of infection with antibiotic suppression therapy, but the patient populations, the staging of the infection and methods of treatment have varied, making comparison of results difficult. Generally a broad spectrum antibiotic therapy including higher: antibiotics like Linezolid are used, though it is said that addition of rifampicin in the treatment regimen is very useful for the same. 2) Operative debridement: Operative debridement and retention of the infected prosthesis should be reserved for acute infections . The reported rate for eradication has been between 26% and 71% following open debridement Statistical analysis of the indications for operative debridement showed improved quality adjusted life expectancy and cost-effectiveness when revision arthroplasty was performed in young, healthy patients, whereas debridement was more beneficial in patients with
reduced life expectancy. This statistical model has not been confirmed clinically. 3) Resection arthroplasty: Resection arthroplasty should be reserved for patients whose medical condition makes a more extensive procedure unsafe. Overall, the poor functional results compared to revision THA make resection only a salvage procedure for the patient unable to tolerate a full revision. 4) Single stage revision: Single-stage exchange revision using antibiotic-loaded cement was first popularised in Europe. This technique has been recommended in immunocompetent patients with an acute or established chronic infection, sensitive to first-line antibiotics. For this technique to be successful, thorough debridement must be carried out and a course of parenteral antibiotics administered post-operatively for a minimum of six weeks. Before this major operation , a microbiological diagnosis has to be made and a complete plan regarding antibiotics to be given has to be worked out beforehand. A full range of implants have to be there, as well as the mechanical and soft tissue problems likely to be encountered have to be kept in mind. Custom-made prostheses may also be required when there is excessive destruction of bone. In general , every effort has to be made to conserve as much bone as possible. However, a number of studies comparing single-stage versus two-stage exchange all favoured the two-stage procedure. Elson had a 12.4% rate of failure with the single-stage method, compared to 3.5% with the twostage procedure. Very similar results were reported by Garvin et al in a large study, with a recurrence rate of 10.1% and 5.6% of cases, respectively. 5) Two-stage revision surgery : This has become the standard procedure throughout North America as well as the rest of the world..In this method, after the removal of the infected prosthesis, the patient is kept on a corse of parenteral antibiotics for a period of 3 to 6 weeks and the patients' ESR, CRP and joint aspirates are monitored for normalization.In most instances a temporary spacer of antibioticloaded cement is inserted at the first stage and removed at the second operation. High doses of antibiotic in the cement have been shown not to cause systemic toxicity. Usual antibiotics to be mixed with cement are Vancomycin, Gentamicin or Tobramycin.
Despite its widespread acceptance, two-stage revision has several controversial aspects, including the timing of the procedure, the use of antibiotic-loaded cement at the second stage and the use of uncemented components. The ideal duration of antibiotic therapy between stages has not been established, but a minimum of six weeks is the standard. As regards the timing of the second stage, recent studies have advocated revision between six weeks and three months after the first stage. Management of the deficiency in bone stock at the time of revision is a problem. Although allograft has been recommended for an aseptic revision, there is a theoretical concern that its use following infection may increase the rate of recurrence. However this has not been substantiated fully in clinical studies. 6) Antibiotic-loaded spacers: The articulated spacer provides proper soft-tissue and limb length between stages. This has several advantages, including improved function, preservation of bone stock, prevention of soft-tissue contracture and as a source of local delivery of antibiotics. However, the custom prosthesis was noted to provide higher hip scores, a reduced hospital stay and enhanced function between stages. At revision there was a reduced surgical time, reduced blood loss and transfusion requirements and a lower rate of post-operative dislocation. SUMMARY Infection in total joint replacement continues to be source of constant frustration to joint replacement surgeons worldwide. A high index of suspicion is necessary for the diagnosis of post-operative wound infection. Alongwith clinical examination and history, serological investigations like ESR and CRP along with joint aspirations help in diagnosis. Radiological investigations like plain radiographs, MRI scans and various Bone scans certainly aid in the diagnosis but are not diagnostic in themselves. Once diagnosed, post surgical wound infection has to be dealt with aggressively with long term anti-biotics, debridement, one stage or two stage revision surgeries being the various options available. All in all, the last word is yet to be said about this dreaded entity and we still await a definitive plan of management which can be used for all.
Controversy: Open fracture-to close the wound primarily or not? An article review
Dr. Mohan M Desai
The controversy continues on whether in the open fractures the wound be closed primarily. Traditional wisdom suggests that these wounds are better left open. In many cases, there is internal degloving and muscle damage is often unrecognised at the time of initial debridement. The borderline ischaemic muscle can get necrosed at a later date and if the skin is closed, it may potentially create a situation with decreased redox potentials and falling pH, encouraging anaerobic organisms like clostridia and others to grow. Fulminant and spreading necrotising myofascitis may ensue. The concept of 2nd look debridement early on at 24-48 hours emerged to obviate this. However with the advent of broader spectrum antibiotics, rigorous debridement, availability of pulse lavage, possibility of providing early soft tissue cover arose. There were articles on fix and flap suggesting day 1 flap cover for these injuries with better outcome. Proponents of delayed closure followed the older school of treating war injuries where the infecting organisms were mainly from the contamination from soil, clay, dust which occurred at the time of injuries. However in the civilian injuries it's now clear that the infecting organisms are mainly from the hospital nosocomial pattern rather than from the contamination. Patzakis et al found that only 18% of infections were caused by the same organism initially isolated in the perioperative cultures. More often, the infecting organisms were pseudomonas and gram negative organisms which reflected hospital nosocomial pattern. In the light of this, it is prudent that these wounds are closed early and not left open for a long period in the hospital environment.The early closure in these wounds can be in the form of early primary skin closure, skin grafting, day 1 flap. There were three previous such studies with retrospective cohort comparing early closure as opposed to the delayed closure. These are by Russell (1990),DeLong (1999), and by Hohmann (2006).They had some conflicting results. (figure 1 & 2) S. Rajasekaran publishes his experience with the technique of performing primary skin closure with
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Figure 1: Infection rate after primary versus delayed wound closure in open fractures. From: Orthopaedic trauma directions March 2007
Figure 2:Delayed union or nonunion following primary versus delayed wound closure for open fractures. From: Orthopaedic trauma directions March 2007.
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grade III compound fractures in JBJS(Br) February 2009.This is probably the first of its kind paper publishing the mid-term results of this technique at 5 years. They performed the primary skin closure in grade IIIA and B injuries if certain inclusion criteria were met. He excluded all fractures with vascular injuries requiring repair (Grade IIIC Gustilo). Only those cases were included where the debridement could be done within first 12 hours of injuries and after debridement there was no skin loss allowing primary closure without tension. He excluded the patients with drug dependent diabetes, peripheral vascular disease, patients with compartment syndromes or those with polytrauma with injury severity scores more than 25. He stabilised all these fractures either with primary internal fixation or with external fixation. It was necessary that the wound should not be contaminated with sewage or organic matter. He described wound healing classification and defined the outcome into excellent, good and poor groups. The wound healing had 4 groups; group Aprimary wound healing; group B-marginal wound necrosis not requiring surgical intervention; group Cwound necrosis requiring surgical intervention like secondary suturing; group D- wound necrosis requiring surgical intervention like flap cover. Out of 173 patients that were included in the study 143 patients had skin healing primarily. 26 patients healed without needing an additional surgical intervention.
One patient required repeat debridement and only 3 patients required a flap cover. It was interesting to note that of the 173 patients 161 patients had bony healing without requiring secondary intervention. 39 i.e. all the upper limb fractures united without requiring any secondary procedure . Overall infection rate was 9.2% .Out of which 6.4% were superficial infections and only 2.9% were deep infections. 92.5% of the fractures eventually united. Delayed union was observed in seven patients (4%) and nonunion in six (3.5%). Primary wound healing was observed irrespective of the size of the wound or the site. The presence of bleeding from the wound margins which could be apposed without tension was found to be more important than the size, nature, site of the wound or the method of internal fixation. In short, in carefully selected patients even in grade III A and B compound fractures it's safer to close the skin primarily. Rajasekaran emphasized that out of all the open fractures they treated only 33% of the patients were suitable for the primary skin closure and warned that closure of all wounds without adequate debridement and in the presence of tension would be disastrous.
REFERENCES: 1. S. Rajasekaran et al - Immediate primary skin closure in type-III A and B open fractures results after a minimum of five years - J Bone Joint Surgery 2009; 91B
With Best compliments from:
IPCA LABORATORIES
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Recent advances in cartilage reconstructive surgery in India

Dr. Dinshaw Pardiwala
Articular cartilage injuries have remained a challenge to the orthopaedist for centuries. In the past decade, however, significant advances have occurred in cartilage surgery, and there are numerous surgical options available based on pertinent criteria (Fig. 1). The goal of cartilage reconstructive surgery is the restoration of the biomechanical and physiologic functions of articular cartilage by the complete reconstruction of its microarchitecture. These techniques include osteochondral autograft transfer, autologous chondrocyte implantation, and osteochondral allograft transplantation. Each of these is now available in India. Osteochondral Autograft Transfer (OATS) / Mosaicplasty OATS involves the transfer of osteochondral plugs from relatively non-weightbearing regions of the knee to restore damaged articular cartilage. The peripheral parts of both femoral condyles at the level of the patellofemoral joint serve as donor sites. The graft is secured in a press-fit manner, and no further fixation is required (Fig. 2). Although there are reports of treating
Fig. 2 : Osteochondral autograft mosaicplasty involves the pressfit transfer of osteochondral plugs from relatively nonweightbearing regions of the knee to restore damaged articular cartilage lesions upto 4 cm2 / 2 cm diameter.
large lesions with this technique, the ideal lesion is upto 4 cm2 / 2 cm diameter. Additionally, lesions deeper than 10 mm are not amenable to OATS alone, since plugs may not be long enough for adequate fixation. OATS can be performed through a small arthrotomy or arthroscopically, however, some lesions are more amenable to an open procedure, as the site may be inaccessible because of a posterior location or because of an inability to flex the knee sufficiently. In a prospective outcomes study, Jakob followed 52 patients who underwent mosaicplasty for an average of 37months[1]. Lesions sized up to 16 cm2 were included. The study found that 92% of patients reported increased knee function at latest follow-up. Biopsies were performed in four patients 4 to 41 months after surgery. Histologic examinations revealed that the transplanted cartilage retained its hyaline character.
Figure 1 : Decision making in the surgical treatment of chondral defects in the knee The KDAH algorithm.
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In a study comparing OATS to microfracture, Gudas performed a randomized controlled trial with 57 athletes[2]. 28 OATS and 29 microfractures were performed, with an average follow-up of 37 months. All lesions were 1 cm2 to 4 cm2. Results at 3 years demonstrated that 96% of the OATS group had good to excellent results, as compared to 57% of the microfracture group. When using return to sport as an outcome, comparison demonstrated that 93% of OATS patients were able to return to sport at 6 months, while only 52% of microfracture patients were able to return to sport at that time. Additionally, biopsies of the repair cartilage were performed at one year in 25 of the patients. Microfracture patients all had a fibrocartilaginous repair, while all OATS repairs retained their hyaline cartilage at one year. OATS has the advantage of being a single-stage procedure. Additionally, the defect is repaired with hyaline cartilage, as compared to fibrocartilage in microfracture. There is no risk of disease transmission as seen with allografts, and it is a relatively low-cost procedure with no requirement of ordering grafts or implants. However, this procedure does carry risk of donor site morbidity (patellofemoral pain and crepitus), with the potential of degenerative changes from graft harvesting. OATS can be a technically demanding procedure, as the surgeon needs to recreate the normal contour of the knee in three dimensions. OATS
is also limited to the treatment of cartilage defects less than 4 cm2, due to the limited amount of autologous tissue available. Although there is a seamless osseous integration of the plugs, a persistent gap remains at the level of the cartilage[3]. These gaps appear to be filled with fibrous tissue. This raises concern, since multiple persistent gaps might affect joint congruity and create a starting point for cartilage degeneration. Synthetic Mosaicplasty Implants Recently, the use of synthetic implants for the repair of focal defects (Fig. 3) has been advocated. These synthetic scaffolds, frequently consisting of polylactides-co-glycolides, can be used either alone for a focal defect or as a delivery vehicle for chondrocytes or growth factors. They are designed to be multiphasic in nature constructed of a porous cartilage phase and a porous bone phase and their degradation can be tailored (approximately 6 to 9 months). This multiphasic design allows one to address both the regeneration of articular cartilage, as well as the subchondral bone. Niederauer and colleagues showed that focal osteochondral defects treated with various implant constructs can be repaired with a hyaline-like cartilage[4]. Unlike OATS, this technique is not limited by defect size since any number of synthetic pegs may be implanted. Moreover, since there is no graft harvest, there is no donor site
Fig. 3 : Synthetic osteochondral implants (Trufit) have the ability to reconstruct large sized defects since any number of synthetic pegs may be implanted. Moreover, since there is no graft harvest, there is no donor site morbidity or further degeneration of the donor compartment as is of concern during mosaicplasty.
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Fig. 4 : Autologous chondrocyte implantation (Chondron) for a large lateral femoral condyle osteochondral defect. Following first stage arthroscopic cartilage biopsy and in vitro chondrocyte culture, the chondrocyte fibrin mixture is injected into the defect.
morbidity or further degeneration of the donor as is of concern during mosaicplasty. Autologous Chondrocyte Implantation (ACI) ACI was first reported by Brittberg and associates, in 1994, as an alternative for the treatment of articular cartilage injuries[5]. The investigators stated that this procedure produces a hyaline-like cartilage repair. It is a two-stage procedure, with the first step being the arthroscopic harvesting of chondrocytes from the patient's knee. The chondrocytes are then cultured in vitro and reimplanted back into the knee during a subsequent open operation. No relationship has been found between defect size and clinical outcome. Therefore, it seems that ACI is more amenable to larger defects than the previously described procedures. The first stage in ACI involves an arthroscopic evaluation of the focal chondral lesion. The surgeon should assess the size, containment, depth, and potential bone loss of the lesion. Lesions 3 mm to 6 mm deeper than the subchondral bone required bone grafting prior to ACI with the earlier generations of ACI, however with Chondron (4th generation ACI) this is not a limitation. The opposing surface of the cartilage defect should be assessed for degeneration. Grade III lesions of the opposing surface are considered a relative contraindication to ACI. The next step is the harvesting of the chondrocytes. This is performed with a core biopsy punch. The preferred locations include the lateral edge of the intercondylar notch or the superomedial trochlea. The subchondral bone should be slightly penetrated during this procedure to allow a fibrocartilage repair of the donor site. The cartilage specimens are sent to the laboratory in a sterile tube with culture medium. The harvested cartilage is enzymatically digested and the
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chondrocytes isolated. The cells are cultured for 4 weeks, which increases the number of cells by a factor of 100. Since the implanted cartilage cells need a stable environment in which to heal, predisposing factors such as meniscal pathology, ligamentous instability, and malalignment should be addressed prior to implantation. The second stage of the procedure takes place 4 to 6 weeks after the biopsy. Exposure is dependent upon defect location with common utilization of a medial or lateral parapatellar mini-arthrotomy. The first step in the second stage is defect preparation. All unstable and damaged cartilage is debrided back to a healthy, stable rim. Vertical walls are formed with a sharp blade to create a well-shouldered lesion. Care is taken to avoid penetration into the subchondral bone, as this would stimulate a fibrous response similar to microfracture or abrasion arthroplasty. Earlier generations of ACI used either a periosteal flap sutured to the cartilage rim to cover the cartilage defect and contain the injected cultured chondrocytes, or a collagen scaffold that is seeded with the patient's harvested chondrocytes (MACI - matrix induced chondrocyte implantation) as a means of chondrocyte delivery. Reports of complications, including graft hypertrophy using these techniques, led to the use of bioabsorbable fibrin constructs as an alternative. The 4th generation Chondron available in India utilises a chondrocyte fibrin construct that is injected directly into the defect, and which solidifies within 7 minutes of delivery (Fig. 4). These new chondrocyte delivery procedures have the potential benefits of decreased operating time, smaller incisions, even distribution of chondrocytes, and decreased pain. The repair construct is then checked for stability by moving the knee from full extension to flexion for 10 cycles. The postoperative protocol
involves early ROM, with the use of CPM. The patient is kept nonweightbearing for 6 weeks. Weightbearing is then progressed over the next 6 weeks. Patients are typically permitted to return to light sport at 6 months postoperatively. In a Swedish study, Peterson evaluated the long-term durability of 1st generation ACI[6]. 61 patients with focal cartilage defects of the knee underwent ACI and had an average follow-up of seven years. At 2 years, 50 (82%) patients had good to excellent clinical results. Additionally, 85% of patients with isolated femoral condyle lesions had good to excellent results. However, these outcomes were not as good in patellar lesions, where only 11 out of 17 patients (65%) had good to excellent results at 2 years. The outcomes seemed to improve over time, with 51 patients reporting good or excellent clinical results at latest follow-up (range 5 to 11 years.) Ten failures did occur; however, no failures occurred after 2 years. The investigators concluded
follow-up was 19 months, and average lesion size was 5 cm2. At one year, 88% of patients in the ACI group showed good to excellent functional scores, compared to 69% in the OATS group. Additionally, second look arthroscopy in 60 patients revealed that 82% of lesions treated by ACI had good or excellent repairs, as compared to only 34% in the OATS group. Biopsies of 19 patients in the ACI group were taken at one year. Seven of these repairs demonstrated hyaline cartilage of normal appearance, seven demonstrated a mix of hyaline and fibrocartilage, and five demonstrated a mainly fibrocartilage repair. Of interest, one patient was biopsied at both one year and two years postoperatively. At 1 year, the repair showed a mixture of hyaline and fibrocartilage; whereas after 2 years, the repair was mainly hyaline cartilage. This supports the claim of Peterson that these repairs can mature to hyaline-like cartilage as much as 2 years after implantation. No biopsies of the OATS group were
Fig. 5 : Osteochondral allograft transplantation for an extensive sectoral osteochondral defect of the femoral trochlea in a young male.
that if ACI is successful, a long-lasting, durable repair is achieved. Biopsy specimens were taken from 12 of the patients at a mean of 54 months postoperatively. 8 patients had repairs with hyaline-like cartilage characteristics, while 4 were fibrous in nature. In a multicenter prospective study in the United States, Browne studied 87 patients who underwent ACI[7]. Patients were followed for 5 years. The patients in this cohort had relatively large defects, measuring an average of 5 cm2. Additionally, 70% of these patients already had one failed cartilage repair procedure, making this a challenging patient population. Sixty-two patients had improved functional outcomes at five years. Six patients remained unchanged and 19 patients reported worsened conditions. The study concluded that ACI proved to be an effective treatment for large articular defects that failed previous attempts at restoration. Comparing ACI to OATS, Bentley conducted a prospective, randomized trial in 100 patients [8]. Mean
performed. The investigators concluded that ACI was superior to OATS; however, this study was of larger lesions, approaching the recommended upper limit for OATS. Osteochondral Allograft Transplantation A special situation arises when a large sectoral defect exists with significant bone loss. The only viable option in this situation is osteochondral allograft transplantation. The use of osteochondral allografts allows for the transfer of hyaline cartilage to repair the defect, while not being limited by its size. Moreover it is the only technique that can reconstruct large sectoral osteochondral defects three-dimensionally (Fig. 5). There is no donor site morbidity involved in the use of allografts. Additionally, allografts may be taken from younger, healthier donors in whom the quality of bone and cartilage is superior to that of the host. However, the use of osteochondral allografts is not without drawbacks. The use of fresh frozen allografts imparts a risk of disease transmission and possibly an
15
immunogenic response. Osteochondral allografts show a time-dependent loss of viable chondrocytes when refrigerated[9]. Therefore, allografts are of limited availability and should be transplanted within a narrow window of time. Bugbee and associates reported the results of allograft transplantation in 97 knees, with an average follow-up of 50 months[10]. Of 61 knees that had allografting to one surface, the authors reported good to excellent results in 79% of patients. Of 30 knees that underwent allografting to two opposing surfaces, only 53% had good to excellent results. A study by Ghazavi and coworkers showed an 86% success rate of 127 knees treated with osteochondral allografts. They demonstrated that graft survivorship was 95% at 5 years, 71% at 10 years, and 66% at 20 years[11]. REFERENCES
1. Jakob RP , Franz T, Gautier E, Mainil-Varlet P . Autologous osteochondral grafting in the knee: Indication, results, and reflections. Clin Orthop Relat Res. 2002;(401)170-84. 2. Gudas R, Kalesinskas RJ, Kimtys V, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy. 2005;21:1066-75. 3. Horas U, Pelinkovic D, Herr G, et al. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am. 2003;85:185-92.
4. Niederauer GG, Slivka MA, Leatherbury NC, et al. Evaluation of multiphase implants for repair of focal osteochondral defects in goats. Biomaterials. 2000;21:2561-74. 5. Brittberg M, Lindahl A, Nilsson A, et al. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med. 1994;331:889-95. 6. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, et al. Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med. 2002;30:2-12. 7. Browne JE, Anderson AF, Arciero R, et al. Clinical outcome of autologous chondrocyte implantation at 5 years in US subjects. Clin Orthop Relat Res. 2005;(436):237-45. 8. Bentley G, Biant LC, Carrington RW, et al. A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee. J Bone Joint Surg Br. 2003;85:223-30. 9. Malinin T, Temple HT, Buck BE. Transplantation of osteochondral allografts after cold storage. J Bone Joint Surg Am. 2006;88:762-70. 10. Bugbee WD, Convery FR. Osteochondral allograft transplantation. Clin Sports Med. 1999;18:67-75. 11. Ghazavi MT, Pritzker KP , Davis AM, et al. Fresh o s t e o c h o n d r a l a l l o g r a f t s f o r p o s t- t r a u m a t i c osteochondral defects of the knee. J Bone Joint Surg Br. 1997:79:1008-1013.
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Guidelines - Pathological Fractures in Children

Dr. Rujuta Mehta
Diagnosis Trivial trauma or no h/o trauma Common sites femur, humerus, tibia Pre-existing lesion- e.g cyst eroding at least 1 cortex or weight bearing area of bone eg calcar Treat cause and effect keeping growth in mind. Management Role of Bone grafts fillers like G bone Adjuvant therapy Role of conservative management/ intra-lesional injections etc. Choice of implant-IM support v/s plates
Fig 3: I.M Stabilisation of fibrous dysplasia lesions
Complications
Fig 1: Fracture in pre-existing fibrous dysplasia ,thro core biopsy scar
Resurgery/refracture rates Complications of adjuvant therapy Non-unions etc. Migration of implants
Investigations Skeletal survey, arthrograms Role of scannogram, alignment views USG, CT with/without 3D, MRI Hormonal assays /markers/other serological tests
Infection and implant migration complicating refracture in osteogenesis inperfecta
CONGENITAL PSEUDOARTHROSIS TIBIA Case 1 - Swapnali 3 yrs old at presentation- given a protective brace, child non compliant, tripped over a bed-sheet and fractured thro the cystic area. Gen Exam-caf au lait spots on back and abdomen, no other stigmata. Operated
Fig 2: MRI of the same lesion as fig 1 showing larger area of involvement than on X-ray.
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of disease tissue ,with Im nailing with cancellous BG iliac crest ,with re bone grafting
Distraction and compression for 3 mths, consolidation 3 mths. Im nail retained 1 yr. Resulting union. Further plan protection in brace till skeletal maturity and retaining the IM support exchange nailing with a watch on ankle valgus and limb length discrepancy. Case 3 - Ishaan On follow up since 6 mths of age 5 yrs of age till date not yet fractured, refuses brace- both angulation and deformity improving, fibula more involved, Tibia intact.
primarily technique of complete excision of pseudarthrotic segment and surrounding diseased softy tissue, contralateral tibial interposition graft with IM nailing engaging calcaneum also-antegrade, with cancellous grafting with protection in palster 6 mths . Result: Complete union. Further plan protection in brace till skeletal maturity and retaining the IM support exchange nailing with a watch on ankle valgus and limb length discrepancy Case 2 - Manali Presented at 11 mths , IM nailing with onlay maternal Tibial grafting with fixation done, devise retained 1.5 yrs no union. Ilizarov done at 3.5 yrs of age ,with re-excision
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Further plan Intervention with Excision and IM nailing including fibula fixation with BG and further protection when the fracture occurs.
Case 4 - Soleha Primary : live vascular fibula done at 1.5 yrs of age, fixed with IM nailing, united but refractured within 8 mths. Treated with simple Bone grafting and repeat I M nailing with protection in plaster for 6 mths and brace then on.
IM support till skeletal maturity and Bone grafting works well in average hands Ilizarov and life vascular fibula excellent primary union rates but high refracture rates, problems of LLD and ankle valgus to be watched for particularly if fibula is not addressed. Both procedures technically demanding and long learning curve, better as a reserve procedure for failed cases at a later age. REFERENCES :
1. EPOS study JPO B vol 9. No 2. 2000. 2. Boero S,Catagni M et al.JPO 1997,17:675-84 3. Pho RWH et al. JBJS Br.1985;67:64-69
Messages Difficult condition to treat, later surgery marginally better results as disease itself remains less active as age advances and burn's out. Complete excision with IM nailing and retaining the
4. Dror Paley, Maurizio Catagni CORR 1982 ,no 280. pg 8193 5. Pathology and natural History of CPT Harold Boyd. CORR 166: 5-13, 1982
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Modern Trends In Spinal Tuberculosis

Dr. Abhay Nene
Introduction: Spinal Tuberculosis is on the rise not only in the subcontinent, but also in the western world. As more and more cases present to orthopedic clinics all over the world, academic and clinical interest in tuberculosis amongst surgeons is rising. This article reviews our understanding of spinal tuberculosis, and takes us through some of the current thinking on the subject. Newer concepts, some different from traditional beliefs, also come forth in the ensuing discussion. Epidemiological trends: Spinal TB (and most forms of extra pulmonary TB) is believed to be reactivation of dormant disease (from childhood exposure) rather than fresh airborne infections. A transient state of lowered immunity is often responsible for disease reactivation. Due to this reason, Multi Drug Resistant (MDR) TB is thought to be less common in extra pulmonary TB than in pulmonary TB, (which is often a de novo, airborne infection and hence more likely to be from newer, resistant strains) Having said that, MDR TB in the spine is not at all uncommon, and has managed to make surgeons uncertain of their diagnosis and management, causing great concern towards this unfavorable modern trend. The percentage of MDR TB spine in children is much higher than adults, and that in urban centers has been reported to be higher than in rural settings. The reported rates of MDR TB spine in our country vary from 5 to 20%. XDR TB (extremely drug resistant TB is the latest twist in this saga of growing drug resistance, where the organism acquires resistance to all injectable anti TB drugs. Pathology of Spinal TB Once affected, there is trabecular destruction in the vertebral bodies, typically starting from close to the end plates (area of maximum blood circulation) in a single vertebra or along with its apposing counterpart. There is a secondary, avascular necrosis of the disc adjacent to the endplates , giving rise to the typical 'spondylodiscitis' Rarely, the lesion can affect the center of a vertebral
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body causing central body collapse / vertebra plana. Posterior element affection and skip lesions are the other commoner varieties seen in practice. 'Disc sparing' lesions are being seen commonly today, making radiological diagnosis more and more intriguing. The clinical relevance of these new forms of Spinal TB is that radiological diagnosis can no longer be as 'certain' as in the past, and all lesions have to be viewed with suspicion, keeping the mind open for multiple differentials including spinal tumors. Types of spinal affection in TB 1. The Classic lesion is Spondylodiscitis 2. Central Body lesions 3. Paradiscal disease with disc sparing 4. Posterior element TB 5. Skip lesions involvement multiple non-contiguous vertebral
6. Ivory vertebra sclerotic reaction 7. Intra spinal tuberculomas Presentation of Spinal TB Spine TB often presents with the innocuous symptom of back pain, which may not be acute or severe. The classical constitutional symptoms of fever, loss of appetite and weight loss are often missing, and are certainly not a mandatory feature for making the diagnosis. With the MRI so commonly prescribed early in the symptomatology, TB lesions are often being detected very early, with no overt signs. It has indeed happened in the author's experience that symptoms ironically began only after institution of AKT ! In most cases, though, local tenderness should make one suspicious. Paraspinal muscle spasm, rest pain, and neurological localizing signs with constitutional symptoms are seen as the disease advances. Other symptoms are characteristic of the site of involvement. For example, headache, vertigo and
restriction of neck rotations in Occipito cervical TB, fixed flexion deformity of hip in lumbar TB with a psoas abscess, etc. Tip: Suspect TB in young adults with thoracolumbar back pain of over 3 weeks duration, and local tenderness, and ask for presence of constitutional symptoms. Keep the differential of osteomalacia and spondylo-arthropathy in mind. Clinico-radiological DD of TB spine Other infections fungus, pyogenic Benign tumors GCT, ABC Malignant tumors round cell tumors, (lymphoma, cordoma), mets, myeloma Osteoporotic fractures Degenerative spine (with Modic changes) Imaging in Spinal TB 1. X rays : Always the first investigation in all cases of suspected spinal TB, X rays are notorious for missing out early lesions. In fact, obvious bony destruction may not be apparent for upto 3 months from the time the disease set in. Hence, in case of clinical suspicion, one would be well advised to go ahead with advanced imaging, and not be under a false sense of security that the x ray may offer. The obvious advantage of an x ray is its low cost and hence mass availability. Also, in proven cases, the surgeon often falls back on the xray to assess spinal alignment and deformity , and the follow up of the same. 2. MRI : Clearly the gold standard in imaging of TB spine, the MRI is largely responsible for the advancements in the non surgical management of spinal TB. Early diagnosis and hence early institution of treatment is possible, precluding progression to mechanical instabilities and deformities. The MRI also helps assess progress of the disease on treatment, as well as healed status of the disease. Apart from the obvious disadvantage of high costs, the MRI has been found to be 'over sensitive', and if not interpreted in the correct perspective, can show an amplified disease status. Hence, while MRI remains the best investigation for diagnosing, prognosticating and determining healing, the old adage of 'treat the man, not the scan' should be kept in mind while planning
treatment for spinal TB. 3. CT Scan : Despite the MRI, CT scans remain the imaging modality of choice in Occipito-cervical lesions and SI joint lesions. MRI defines the O-C1C2 area rather poorly, and often cannot differentiate inflammatory from infective etiology in the SI joints. Also, CT scans are useful in defining the extent of the bony destruction when surgical reconstruction is planned in spinal TB. The other situation where CT scans are used in spinal TB would be in the imaging of a post op spine, where stainless steel implants have been used. Diagnostic modalities in spinal TB Conclusive diagnosis of spinal TB can be made by histopathology alone, and all other forms of diagnosis are calculated guesses made with clinical judgment and experience. Of course, in a large percentage of cases, such clinicoradiological diagnosis proves to be correct retrospectively. Hence clinico radiological diagnosis and 'therapeutic trial' of AKT has been extensively used in the endemic subcontinent. It offers great cost advantages and wide applicability. However, with newer forms of spinal TB surfacing in the recent era, this method of non-histological diagnosis has come under scrutiny, as the 'hit-miss ratio' becomes less and less favorable with increasing numbers of cases. Especially with the growing percentage of MDR TB, biopsy for diagnosis and importantly for tissue culture and drug sensitivity should be standard practice. 1. Tissue Biopsy : CT or USG guided biopsy is today the gold standard of diagnosis of spinal TB, and is now widely recommended, as it is now being offered as a fairly cost effective, out patient procedure. Not only can one confirm the diagnosis (about 80% true positives with CT guided transpedicular 'core' biopsies performed with 11G bone biopsy needles), but more importantly, the tissue can be sent for culture and sensitivity to primary and secondary line AKT, making the reliability of treatment almost foolproof. Other sources of tissue diagnosis should be kept in mind, if available, eg., sputum AFB smear and culture in case concomitant lung lesions. are present , becomes a much easier method of sensitivity detection than vertebral biopsy. 2. Other parameters like TB IgG, TB IgM and Mantoux
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tests seem to have very little predictive value, and should not be performed in all cases. ESR, though non specific, can give an idea of disease progress, and hence is commonly used at follow up examinations. Chemotherapy in Spinal TB: Though a detailed review of the various available medications and regimens available for spinal TB today are beyond the scope of this text, and have been covered in other chapters, the following principles are important in clinical practice: 1. A four drug AKT consisting of INH, Rifampacin, Ethambutol and Pyrazinamide is the standard 'first line' prescription that most cases are susceptible to. 2. Apart from guaranteed absorption, there is no benefit of injectable streptomycin over the standard 4 drug AKT. 3. Inadequate dosage is the commonest cause for poor response in clinical practice. 4. All patients on AKT should be closely monitored for compliance and side effects. 5. Empirical addition of an extra drug (Eg. Ciprofloxacin) to the primary 4 drug regimen should be condemned, and only contributes in creating more resistant organisms 6. Whenever a clinical or laboratory diagnosis of MDR TB is made, a minimum of 2 new drugs (ideally 3 new drugs) should be added, and the treatment should be carried on for a minimum of 6 months after clinical 'healing' 7. Secondary line drugs are more expensive, less effective and have more side effects than all primary line AKT 8. There is little consensus in the orthopedic community of the duration of AKT in spinal TB, and the treatment period varies from 6 to 18 months at various centers 9. Nine to 12 months seems to be the most acceptable duration of AKT in spinal TB. 10.Criteria for 'healed status' are ill defined, and largely based on clinical and radiological judgment. Surgical considerations in spinal TB: Early diagnosis, improved tissue culture methods, and
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better understanding of chemotherapy for TB has made surgery for spinal TB less common today. After an era of aggressive surgery for 'debridement' and 'reducing disease load', the froth has settled and modern medicine recommends a more structured and protocol based non surgical approach to the majority of cases. As often quoted, 'Spinal TB in the absence of unsightly deformity or significant neurological deficits, is a medical rather than a surgical disease'. We as surgeons should keep this fact firmly planted in our minds when we plan the treatment methods for specific cases in a clinical setting. Indication For Surgery In Spinal TB Significant neurological deficit (rendering the patient unable to walk) (paraplegia, cauda equine syndrome, foot drop ) Diagnosis in doubt Neurological deficit / Pain / Instability not recovering after a fair trial (about 6 weeks) of conservative treatment. Children (pre growth completion) if kyphosis predicted Late onset paraplegia / late lumbar canal stenosis. Principles of surgery in spinal TB: 1. Approach is based on the nature of the lesion, the levels affected, the indication for surgery (neurology / instability / diagnosis) and the patient's general condition 2. Adequate neural decompression and optimum reconstruction of the spinal column. 3. Tissue to be sent for biopsy and culture-sensitivity 4. Use of implants is safe and effective in spinal TB 5. No surgery can substitute correct chemotherapy Modern trends in surgery for spinal TB 1. With advancement in image guided minimally invasive biopsy techniques, the need for surgical biopsy has considerably reduced. In fact, multiple attempts at closed spinal biopsy can be made before considering an open surgical biopsy. 2. Use of implants has become extensive. As against the older belief that implants are unsafe in the
presence of the infection, it has been proved by laboratory studies that stainless steel as well as titanium can be safely used in the presence of tuberculous pus. Implants have made surgical reconstruction more reliable and predictable, and return to function quicker. 3. Specifically, use of anterior implants and cages in spinal TB has been debated recently, as these lie at the site of the infection, and take anchor into diseased or inflamed, osteopenic bone (as against posterior implants which stabilize from the non affected posterior structures) However, recent literature suggests that titanium implants pose no problems in presence of active disease. Take Home Messages 1. 2. 3. Spinal TB is commoner than generally thought of. It has no socio-economic barriers A high index of suspicion, is essential for early diagnosis and treatment Spinal TB has many close differentials, which should not be overlooked
4.
Tissue diagnosis/culture should be attempted in all cases, but is not mandatory for starting treatment. Therapeutic trial of AKT is a valid alternative if clinico-radiological suspicion is high MDR TB is common, and must be thought of in poor responders Monitor all patients on AKT regularly Spinal TB with in the absence of grotesque deformity and major neurological deficit is a medical disease Abscesses, instabilities, neurological deficits all can respond to a patiently monitored protocol of non surgical management
5. 6. 7. 8.
9.
10. When surgery is indicated, be prepared for the necessary aggression 11. Tailor the surgery to the lesion and the patient 12. Excellent surgical technique is not a substitute for correct , sensitive chemotherapy.
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The ten commandments of hand fractures

Dr. Hemant Patankar
1. Don't forget the basics Proper history Consideration of Associated injuries to: 1. Skin, 2. Tendon, 3. N- V status, 4. Polytrauma Radiographs in THREE VIEWS = A-P , LAT, OBLIQUE Existing hand trauma is complicated by Vertical incisions Ideally Dorsal zig zag incision with Extensor tendon splitting Approach and Meticulous suturing of the tendon with Prolene using inverted knots and skin suturing with non braided sutures/ 2. Have the best equipments and keep all implants ready C ARM Use Tube up position Radiolucent Hand Board with Firm Support Base Regional anaesthesia Pneumatic tourniquet ENT, OPHTHALMIC, & DENTAL instruments 26,28,30 SWG SS rolls Precision Instruments: Low Speed, High torque drill (EPen Synthes) 3. Treat Base fractures by closed means Closed reduction and maintenance by External splints / traction (Extra-articular) External fixation (Intra-articular) (Rarely) Internal fixation for Avulsion fractures 4. Treat Head fractures with open reduction & internal fixation Intra- articular fractures require stability and congruity for recovery of function. 5. Treat Transverse Shaft # with Closed reduction (preferable) and antegrade, flexible, intramedullary nailing Exceptions: Proximal shaft fractures, Thumb pph Treated with Flexible Retrograde Intra-medullary Nailing At the same time, avoid damaging PIP& MP joints by penetrating wires 6. Treat Long Oblique Spiral # with open reduction and internal fixation Spiral # require perfect anatomic reduction Imperfect reduction Results in shortening, malrotation, adhesions This Cannot be prevented with closed reduction and fixation 7. Use External fixation sparingly and judiciously External fixation has a limited role in the management of hand fractures External hand frame for base Pph # Transfixation frame for # shaft Mph, # base Mph, Thumb# and I.P . Jt. Dislocations Unilateral frame for Rolando & Reverse Rolando fractures 8. Never disregard & discard the finger nail Distal broken half of the nail bed is firmly attached to the nail Essential for healing of Dph # Template for nail bed helps in Reformation of normal nail Recovery of painless functional fingertip 9. Hand splints are indispensable for recovery of function Imm. Post-op = SAFE POSITION Followed by static and dynamic splints There is often no need of formal physiotherapy or occupational therapy 10. Closed reduction is the best method of treatment of hand fractures It requires great skill and experience. However, maintenance of closed reduction is very demanding especially in cases of articular and spiral fractures
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Selected Case Presentations

BOS Clinical Meeting Nair Hospital
CASE 1: Unilateral neglected DDH in a 10 year old boy A 10 year old, school going boy presented with a progressive limp and shortening of right lower limb. Parents noticed a limp since the child started walking and DDH was diagnosed at the age of 3 years. Surgery was advised but parents refused. Patient has 6 cm of right lower limb shortening and hip instability but full ROM. Xrays show a high-riding hip dislocation with severely dysplastic acetabulum which is well seen on the 3D reconstruction CT scans. The case was presented for opinion regarding the best method of management especially in view of delayed presentation. Literature review: One stage treatment of CDH in children between 310 years consisting of open reduction, femoral s h o r t e n i n g a n d p e l v i c o s t e o t o m y. Ryan et al JBJS(A),1998;80;336-344. Greater trochanter hip arthroplasty in children with loss of femoral head A.E.Freeland JBJS(A)1980; 62;1351-1361 Illizarov hip reconstruction includes acute valgus and extension osteotomy at proximal part of femur combined with gradual distraction for realignment and lenghtening at second more distal femoral osteotomy. Rozbruch et al JBJS(A) 2005; 87, 10071018. CASE 2 : Chronic osteomyelitis of humerus with pathological fracture A 13 year old boy presented with pain, swelling and inability to move left shoulder following a trivial fall 3 months ago. No fever or constitutional symptoms. On examination the patient had warmth, swelling and tenderness of left arm and painful movements of left shoulder. WBC count, ESR and CRP were raised. Xrays showed chronic osteomyelitis of left proximal humerus with large sequestrum and pathological fracture. MRI showed pathological fracture and soft-tissue abscess. Members' Opinion : Some members in the house recommended an attempt of open reduction, femoral shortening, VDRO and acetabuloplasty. The paediatric orthopaedists and some senior members cautioned against reduction at this late age which is fraught with complications of redislocation, AVN and hip stiffness. A trochanteric arthroplasty is not a good option at this age especially in view of the severe acetabular dysplasia. They felt that a subtrochanteric valgus pelvic support osteotomy (Schanz) would be a better option at this age. This could be combined in one stage with a distal femoral lengthening and varization osteotomy as popularized by Ilizarov and Dror Paley (Ilizarov hip reconstruction).
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Members' Opinion : Members recommended that sequestrectomy and debridement be performed and the resultant gap stabilized by an EXFIX. Children sometimes have a good potential to heal spontaneously and the gap might be bridged by sub-periosteal bone regeneration. Oral antibiotics would be required for a period of 4 6 weeks to bring the disease under control. The resultant bone defect could be reconstructed later with distraction techniques or by using a vascularized or non-vascularized fibular graft. Literature review: A case of replacement of the upper end of the humerus by a fibular graft reviewed after twentynine years Kenneth Clark J Bone Joint Surg (Br), May 1959; 41-B: 365 368 Transplant of the upper extremity of the fibula replace the upper extremity of the humerus. Schauffler J Bone Joint Surg Am. 1926;8:723-726.
Old Xrays
Members' Opinion : Fixation 1) Removal of implants 2) Fixation with locking plate and graft Total elbow replacement Literature review: Linked elbow replacement: salvage procedure for Nonunion of fracture of distal end of humerus. JBJS(A) 2008;90;1939-1950. NU not amenable to internal fixation, 92 elbows, 6.5 yrs mean FU. 74% pt no to mild pain as compared to pre op moderate to severe pain in 85% Rate of prosthetic survival 96% at 2 yrs, 82% at 5 yrs, 65% at both 10 and 15 yrs. Nonunion of fracture of distal end of humerus. Ackerman,JBJS(A)1988;70:75-83. 20 patients 13 extra articular, 7 intra Articular. 17 united, 2 excision of distal end and replacement with an allograft. All EA had best results, IA did less well. Most of them have long term disability CASE 4 : Lumbar canal stenosis with hemivertebra A 30 year old male, taxi driver presented back pain and claudication since 3 years. He was non-diabetic but a chronic smoker smoking one pack daily since 12 years. Lumbar spine examination was normal, SLR was free, there was no neurological deficit and distal pulses were well palpable. Xrays of lumbar spine showed right L4 incarcerated hemivertebra.
CASE 3 : Non union of TY condylar # of distal humerus A 45 year old male, right-handed shopkeeper presented with pain and restricted movements of the left elbow since 2 years. He had h/o fall 2.5 yrs ago and sustained a TY condylar fracture of the left distal humerus which was operated and fixed with plates and screws. Implants were removed after 6 months. On examination, patient has cubitus varus with 3cm of humeral shortening. There is marked elbow instability with varus laxity of 55 degrees and ROM from 0 90 degrees flexion. Xrays show non union TY condylar # of left distal humerus with some resorption of fracture fragments. Patient desires a mobile and stable elbow to perform activities of daily living.
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Members' Opinion : Conservative treatment, physiotheraphy and exercises and psychological counselling Epidural steroids and facetal blocks and physiotheraphy Dynamic stenosis at L5/S1needs osteotomy to correct deformity and fixation CASE 5 : Non union supracondylar fracture femur with posterolateral knee instability and varus limb alignment A 35 year old male farmer sustained a compound injury to right thigh and leg 1.5 yrs back. Immediate external fixation done for tibia with ring fixator and temporary stabilisation for femur with rush nail. Delayed ORIF done for supracondylar fracture femur after 2 months when the femoral wound had completely healed. The operative and postoperative period was uneventful with the operative wound healing completely with no evidence of infection. Tibial external fixator was removed after a period of 2 months with application of above knee cast which was kept for 6weeks. On examination, tenderness is present at lower end femur with prominent implant. There is 20 degree varus deformity of right knee with laxity, knee ROM is 90 degrees flexion, with 10 degree hyperextension with 20 degree of extension lag. There is femoral shortening of 9 cms and tibial shortening of 2 cms. Currently the patient is disabled due to instability and limp.
The case was presented for opinion regarding the best method of management. Members' Opinion : Removal of the implants and osteotomy on stages to correct the deformity and get the length with use of Ilizarow. Use of medial buttress plate and bone grafting and later Illizarow and correction of deformity in stages using Ilizarow. Literature review: Skyhar MJ et al. J Bone and Joint Surg;75A(5),1993:694-699 In patients with chronic posterolateral instability, limb alignment must be evaluated before posterolateral reconstruction is considered. If the patient has varus knee alignment and a lateral thrust in the stance phase of gait, simple soft tissue posterolateral reconstructions fail because of chronic repetitive stretching
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Selected Case Presentations

BOS Clinical Meeting Sion Hospital
Case 1: Complete Rotator Cuff Tear With Subluxation of Humeral Head History: 25 years old male right hand dominant h/o trauma 7 months back dislocation shoulder reduced by local doctor Immobilised for 2 weeks Now complaints of inability to perform movements at left shoulder absent initial abduction Examination: Deltoid, supraspinatus, infraspinatus atrophy No sensory deficit Antero-superiorly subluxated humeral head Absent active glenohumeral abduction Passive movements free Drop arm test positive Clinical Photographs: Investigations: EMG study: normal motor unit potentials in left shoulder muscles, normal motor nerve conduction velocity, normal sensory action potential X-rays CT Plates
Members' Opinion Some members were of opinion to fuse the shoulder not knowing the function of the muscles after a tear of many months. Photographs: Attempted Abduction Others opined about repair of the torn rotator cuff, either open or mini-open or totally arthroscopic. The importance of doing a subacromial decompression and mobilization of the rotator cuff was also discussed. There was also discussion on the work of C.Gerber from Switzerland regarding use of Pectoralis major transfer in situations when it is not possible to suture.
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J BONE JOINT SURG AM. 2001 JAN;83-A(1):71-7
Surgical repair of chronic rotator cuff tears. A prospective long-term study. Cofield RH, Parvizi J, Hoffmeyer PJ, Lanzer WL, Ilstrup DM, Rowland CM. Department of Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA. Standard tendon repair techniques combined with anterior acromioplasty, postoperative limb protection, and monitored physiotherapy can produce consistent and lasting pain relief and improvement in range of motion. Improving the results of this procedure will depend upon the development of new techniques to address the active motion and strength deficiencies following repair of massive rotator cuff tears
J BONE J SURG 1999 JUL;81(7):991-7
radius and that could be result of subluxation There was suggestion that it was definite triangular cartilage complex injury and it needed to be repaired either open or arthroscopically. References: Scheker et al reported improvement in 9 of 14 patients who underwent reconstruction of the dorsal radioulnar ligament with use of a tendon graft woven through drill holes in the radius and ulna (J Am Acad Orthop Surg 1995;3:95-109 )
J BONE J SURG 1995;3:95-109
Long-term functional outcome of repair of large and massive chronic tears of the rotator cuff. Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD. Department of Orthopaedic Surgery, New York University, Hospital for Joint Diseases, New York City 10003, USA, Repair of a large or massive tear of the rotator cuff can have a satisfactory long-term outcome. The results of the present study suggest that more than one year is needed for complete restoration of strength. The strength of the affected shoulders still did not equal that of the unaffected, contralateral shoulders by the time of the long-term follow-up Case 2: POST-TRAUMATIC DISTAL ULNAR INSTABILITY History: 16 Yrs /male /student A/h/o fall on both palms 2 yrs back pain both wrists distal ulnar instability Members Opinion: There was opinion between members regarding possibility of congenital origin Some members felt there was a malunited fracture
Bach recently described a technique in which reattachment of the TFCC is augmented with a distally based strip of the extensor carpi ulnaris tendon woven through drillholes in the distal ulna and radius. Petersen and Adams studied the biomechanics of numerous reconstructive procedures in a cadaver model and found that procedures that created a tether between the radius and the ulna reestablished stability better than those that created a tether between the distal ulna and the ulnar carpus. Breen TF, Jupiter JB: Extensor carpi ulnaris and flexor carpi ulnaris tenodesis of the unstable distal ulna. J Hand Surg [Am] 1989;14:612-617.
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Clinical Photographs:
DRILL HOLE IN DISTAL RADIUS
ECU WEAVED THOUGH HOLE IN DISTAL RADIUS
X-ray
ECU THREADED THROUGH DISTAL ULNA AND SUTURED
DISTAL ULNA TRANSFIXED IN REDUCED POSITION BY K-WIRE
CT Plates
Post-operative above elbow cast for 3 weeks and below elbow cast for 3 weeks. Case 3: Neglected fracture dislocation elbow History: 13 years old boy h/o trauma 4 months back Local treatment support given removed after 1 week Mobilised after 1 week Findings: Flexion upto 30 degrees Bony block Painless
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MRI There is complete dislocation at the ulnotrochlear and radiocapitular joints with posterior displacement of the ulna and radius. The proximal radioulnar articulation is normal. There is suspicious fracture of lateral supracondylar region with a large intraarticular free bony fragment. Member's Opinion Rule out myositis Open reduction and internal fixation with collateral approach
CLIN ORTHOP RELAT RES. 2005 FEB;(431):21-5
Treatment given: Initially elbow reduction , debridement, External fixator applied spanning forearm and arm plastic surgery. Further follow up of patient was in plastic surgery. Present Status: Fixed flexion deformity of elbow in 30 degree with jog of movement . Forearm fixed in mid-pronation Healed scar No e/o infection Good hand function No pain
Neglected dislocation of the elbow. Mahaisavariya B, Laupattarakasem W. Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand intermediate-term to long-term results of 24 patients treated after late open reduction of neglected posterior elbow dislocation in terms of the elbow, particularly noting joint mobility. The mean interval from injury to operation was 7.9 months (range, 1-60 months). The posterior approach with V-Y muscleplasty was used in most patients with 2 to 3 weeks postoperative immobilization. The average preoperative arc of elbow flexion was from 17 degrees with an average maximum flexion of 27 degrees (range, 560 degrees ) and an average flexion contracture of 10 degrees (range, 0-30 degrees ). At the time of final followup, the average arc of elbow flexion was 82 degrees with an average of maximum flexion of 122 degrees (range, 90-150 degrees) and an average flexion contracture of 40 degrees (range, 0-75 degrees) Case 4: Chronic Unreduced Posterior Dislocation Of Elbow Case History: 35 yrs / Male / carpenter A/h/o Road Traffic Accident : two and half yrs back. Sustained circumferential injury degloving injury left arm and forearm with posterior dislocation left elbow.
Patients C/C: Stiff elbow. Patient demands movement Problems: Two and half yrs old chronic unreduced dislocation. Poor skin condition. Members opinion: In view of the bad skin condition to leave it alone To improve the condition of the skin with help from plastic surgeon and then do a open reduction but do not guarantee any results Literature: Dislocation can be closely reduced up to 3 weeks After three weeks its difficult to get close reduction so it should be openly reduced After three months cartilage is damage. Replacement or arthrodesis can be consider after that.
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Case 5: Intra Medullary Plating For stabilisation Of Comminuted fracture
Femoral shortening Midline globular swelling over the occipital region
CLINICAL PHOTOGRAPH
ANTERIOR DIMPLE
Members' Opinion This case can be treated with plate osteosynthesis (locking plate)
CLINICAL PHOTOGRAPH: SIDE & BACK
Putting a plate might disturb blood supply. If one needed to remove the implant one has to break the bone and remove the implant Case 6: Unilateral Fixed Flexion Deformity Knee In A Newborn History 6 months old female child Born of full term normal delivery Left knee flexion deformity since birth Progressive flexion deformity at knee with age Gradually increasing swelling over the occipital region Examination Hip movements free Knee fixed flexion deformity Knee dimple anteriorly Quadriceps atrophy Hamstring tightness present
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MRI A deficiency of the muscle groups is seen in the left thigh mainly in the anterolateral aspect. The vastus group is predominantly affected. A prominence of intermuscular fat is noted. The visualised muscles show normal signal intensity.
femoral shortening could be considered in the second stage to correct residual or recurrent deormity. References Congenital aplasia of the patella and the distal third of the quadriceps mechanism. Varghese RA, Joseph B. Paediatric Orthopaedic Service, Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka State, India. Congenital absence of the patella and aplasia of the muscles are very rare anomalies. We describe a 4year-old boy with bilateral congenital aplasia of the patella and agenesis of the distal third of the quadriceps muscle who was unable to walk owing to the lack of active knee extension. The features of this child differed from all other conditions associated with patellar aplasia. The continuity of the quadriceps mechanism was restored and he began walking normally. This appears to be the first report of the combination of aplasia of the patella and the distal third of the quadriceps that was successfully treated. Case 7: Chronic Slipped Capital Femoral Epiphysis In 13 Yrs Old Girl Case History: Trauma to left hip 6 months back Inability to bear weight on left lower limb since then . Patient has inability to squat and sit cross legged since age of 2 yrs.
Members' Opinion The knee fexion deformity is severe and appears like a popliteal pterygium. Child otherwise does not appear to have any dysmorphic features or features of Arthrogryposis. Quadriceps muscle appears very atrophic and attenuated. Parents should be counseled that there is a high risk of recurrence following correction of knee flexion deformity. Soft tissue posterior knee release including posterior knee capsulotomy could be atempted in the first stage with serial casting to correct the knee FFD as much as possible. Risk of neurovascular compromise is very high. Ilizarov fixator could also be attempted by an experienced surgeon though risk of complications is higher. Supracondylar extension osteotomy with
Patient is mentally retarded, h/o convulsion since birth with hospital admissions for hypocalcemic tetany. On examination: Flexion, external rotation attitude left lower limb True supratrochanteric shortening: 2cm
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Problems Chronic SCFE Changes of avascular necrosis present Members' Opinion: Child has severe grade of chronic SCFE. CFE appears viable otherwise. In situ cancellous screw fixation is difficult in view of the severe grade of slip. Open reduction and crescentic neck osteotomy by the Fish or Dunn technique is a better choice, but risk of AVN and stifness are high if not performed with caution. J Am Acad Orthop Surg 1996;4:173-181 Open Reduction And Femoral Osteotomy IOWA ORTHOPAEDIC JOURNAL: 2 cases SCFE with AVN Femoral transtrochanteric anterior rotational osteotomy.
ORTHO QUIZ - 2
25 yr old female came with pain in the (L)ankle. She gave history suggestive of ankle sprain 6 months back and massage. On clinical examination she had very tender swelling, below the medial maleolus , firm to hard about 2cms by 2cms,, fixed, nonfluctuant, noncompressible and non-pulsatile. The veins around were not engorged. There was painful abduction movt at the ankle. Varus movt was not painful. Flexion and extension of the ankle were normal. MRI & CT scan were not done due to financial constraints. What is your probable diagnosis after looking at the sclerotic area below the medial malleolus on the xray and mode of management? The closest entry will get the orthoquiz prize. Pl send your answer Dr. N.Antao email id: narantao@gmail.com
ANSWER TO ORTHO QUIZ - 1
MELERREOSTOSIS
The mass was removed in small bits arthroscopically and patient was completely symptom free
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Follow-up of some cases presented earlier

Four part fracture dislocation proximal humerus Anterior deltopactoral approach for reduction of the fracture and fixation with a locking plate. Posteriomedial approach to deliver the head fragment lying loose in the subcutaneous tissue. 6 months FU of the patient - Fracture and implants in position (difficult to comment on union and AVN), No pain, Return of 75% passive range of glenohumeral movements, No instability, NO AXILLARY NERVE RECOVERY - no active shoulder movements.
Post -op
RECURRENT CTEV
Pre -op
The foot was corrected with JESS Fixator
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The BOS - All India Best Resident Award
The BOS- All India Best Resident Award was convened by Drs. R.Y. Prabhoo and Derick de Lima and more than 150 PG students from all over India appeared for the theory exam on line. We selected 10 best students from their score and 8 came for the practical exam held at Holy Spirit Hospital, Andheri. The students were assessed in clinical cases, instruments, pathology, radiology, operation knowledge, emergency handling skills, ward work, preoperative and post operative care and rehabilitation and ethical issues in orthopedic practice. The examiners were Dr. L N Vora, Dr. Ashith Rao, Dr. Naresh Danani, Dr. R Y Prabhoo, Dr. Derick DeLima, Dr. Mohan Desai, Dr. Rajesh Gandhi, Dr.
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Manhar Shah, Dr. Milind Sawant, Dr. Sunil Shahane, Dr. Sanjay Londhe, Dr. Rajesh Shirishkar and Dr. N.A Antao. The winning candidates were awarded prize money of Rs.5,000/-, a certificate and a trophy. The winners were the guests of BOS for WIR OC 2008. Dr.Kanniraj M from SMS College Jaipur, won the first prize, Dr.Kartik S. Murugappan from AIMS(Delhi),the second and Dr.Geethan I from Madras Medical College Tiruchipalli was awarded the third position. This major unique event was facilitated by MEDLEY Pharmaceuticals Limited.
Forum On Ethical And Legal Concerns In Orthopaedic Practice
It was for the first time in the history of Orthopaedics in India that a forum of this nature was held. This event was supported by FIAMC BIOMEDICAL ETHICS CENTRE (FBMEC) AND FORUM FOR ETHICS SOCIETY (FFES) in Mumbai. The faculty came from a of galaxy of speakers chosen from our own members, legal luminaries, members of Medicolegal cell of Association of Medical Consultants, members of FBMEC and FFES.
Besides members from Mumbai, there were delegates who had come from different parts of the country and were very enriched with the contents and deliberations. They even suggested that this should be made an annual event. A booklet published on the Glimpses into the proceedings of the Forum has been enclosed. We thank Dr. Stephen Fernandes Executive Director (FBMEC) for helping us compile the proceedings
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Guest Lecture: Dr. Freddie Fu
Dr. Freddie Fu, President, International Society of Arthroscopy (ISAKOS) from Pittsburg USA and pioneer of ACL double bundle technique, was invited to give a guest lecture on Current status of ACL reconstruction using Double bundle Technique. Over 100 delegates including members and PG students attended this highly informative, academically exciting and inspiring lecture. U S Vitamins was instrumental in mobilizing the PG students for this lecture.
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March 2009

BOMBAY ORTHOPAEDIC SOCIETY

Biopsy of Musculoskeletal Tumors

Proximal Humerus Distal Humerus Pelvis

Hip & proximal femur Distal femur

Management of Infected Total Joint Replacement

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With Best compliments from:

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Recent advances in cartilage reconstructive surgery in India

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Guidelines - Pathological Fractures in Children

Fig 3: I.M Stabilisation of fibrous dysplasia lesions

Resurgery/refracture rates Complications of adjuvant therapy Non-unions etc. Migration of implants

Infection and implant migration complicating refracture in osteogenesis inperfecta

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Modern Trends In Spinal Tuberculosis

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The ten commandments of hand fractures

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Selected Case Presentations

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Ortho front March 2009

Ortho front March 2009

Selected Case Presentations

J BONE JOINT SURG AM. 2001 JAN;83-A(1):71-7

DRILL HOLE IN DISTAL RADIUS

ECU WEAVED THOUGH HOLE IN DISTAL RADIUS

ECU THREADED THROUGH DISTAL ULNA AND SUTURED

DISTAL ULNA TRANSFIXED IN REDUCED POSITION BY K-WIRE

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Case 5: Intra Medullary Plating For stabilisation Of Comminuted fracture

Femoral shortening Midline globular swelling over the occipital region

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ANSWER TO ORTHO QUIZ - 1

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Follow-up of some cases presented earlier

The foot was corrected with JESS Fixator

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The BOS - All India Best Resident Award

Forum On Ethical And Legal Concerns In Orthopaedic Practice

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Guest Lecture: Dr. Freddie Fu

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