Current Concepts in Intramedullary Nailing of Femoral Shaft fractures CURRENT CONCEPTS IN INTRAMEDULLARY (IM) NAILING OF FEMORAL SHAFT FRACTURES

Siddhartha Sharma, Hitesh Gopalan U INTRODUCTION Intramedullary (IM) nailing is one of the preferred methods for treatment of femoral diaphyseal fractures. Successful intramedullary nailing results in a short hospital stay, a rapid return of motion in all joints, prompt return to walking, and a relatively short total disability time. HISTORY & EVOLUTION 1) IM nailing was first described by Gerhard Kuntscher, a German orthopaedist in the 1940s and the device came to be known by his name viz. K Nail. 2) Various generations of nails have been described as follows: a) First Generation Nails i) Have a characteristic longitudinal slot along the entire length of the nail. ii) Examples: K Nail, Grosse Kempf Nail (has a proximal portion which is tubular and allows better purchase and insertion of proximal locking screws). b) Second Generation Nails i) These are tubular nails without the slot and have provision for proximal and distal locking bolts.

ii) Examples: Russel Taylor Nail (has a clover leaf cross section) and Delta Nail (triangular cross section, thicker wall and thinner diameter). c) Third Generation Nails i) Are made from titanium alloys and may be solid or tubular. ii) Examples: Trigen Nail, Universal Femoral Nail (Synthes) INDICATIONS OF IM NAILING: 1) Transverse and short oblique fractures of the femoral shaft. 2) Comminuted Fractures: The nail should always be locked 3) Pathological fractures CONTRAINDICATIONS OF IM NAILING 1. Absolute but correctable contraindications: Hypovolemia, Hypothermia and coagulopathy. 2. Relative Contraindications: presence of previously inserted devices and pre existing deformity. 3. A narrow medullary canal may rule out IM nailing as an operative option. PRE OPERATIVE PLANNING 1. Good quality Anteroposterior and lateral radiographs of the injured extremity should be obtained to know about the fracture pattern, presence of comminution, medullary canal dimensions and the amount of femoral bow. 2. Length of IM nail: corresponds approximately to the distance between the tip of greater trochanter and the lateral epicondyle of femur. This can be measured directly on the uninjured extremity with a long ruler or on a radiograph, after correcting for magnification.

3. Pre operative skeletal traction is advisable. Many patients can have unpredictable delays in operation and traction maintains femoral length, prevents further soft tissue injury, limits the ongoing blood loss and provides patient comfort. A 2 mm pin inserted through the distal femur adequately tensioned on a traction bow and utilizing approximately 15 20 pounds of weight is recommended. TECHNIQUES OF IM NAILING 1) Antegrade Nailing. 2) Retrograde Nailing. ANTEGRADE IM NAILING 1) Most commonly used technique 2) Can be done via the Piriformis fossa or Trochanteric entry portals 3) Supine or lateral decubitus positions may be employed. ANTEGRADE NAILING - PATIENT POSITIONING: SUPINE VS LATERAL SNo 1. Technique SUPINE POSITION Fracture table used, traction applied to affected limb Normal limb: May be placed in hemilithotomy position, widely abducted or scissored 2. Advantages A. Ease of access for anaesthesiologist & nursing team Improved access to Piriformis fossa (therefore better for obese LATERAL POSITION Lateral decubitus position

B. Ease of imaging the entire femur C. Ideal for bilateral cases, cases with associated acetabular fractures, polytrauma patients and associated spine injuries (radiolucent table should be used instead of fracture table). 3.

patients)

Disadvantages A. Difficult access to entry A. Difficulty in point in case of obese imaging the patients proximal fragment B. Increased compartment pressures in the normalleg, especially with hemilithotomy position B. Difficulty in assessing rotation C. Distal fragment tends to tilt into valgus

ANTEGRADE NAILING - ENTRY PORTALS SNo PIRIFORMIS FOSSA PORTAL Location In the Piriformis Fossa, at the junction of anterior 2/3rdwith posterior 1/3rd TROCHANTERIC PORTAL From the Greater Trochanter, just lateral to the long axis of the femur A. Technically easier to obtain, especially in

1.

2.

Advantages

Colinear trajectory with the femoral shaft and therefore decreased risk

of iatrogenic comminution obese patients & varus malalignment B. It is more forgiving in terms of anterior translation as the bone is cancellous here. 3. Disadvantages A. Difficult to obtain in the obese patient B. Sensitive to anteroposterior translation: anterior positioning can cause iatrogenic bursting of proximal fragment due to increased hoop stresses. RETROGRADE IM NAILING INDICATIONS 1. Difficult access to proximal femur: Obese patients, Pregnant patients 2. Ipsilateral Pelvic fractures, femoral neck fractures, Patellar fractures, or Tibial fractures (floating knee). 3. Associated vascular injury, spinal injury or polytrauma patients: rapid stabilization of the femoral fracture can be achieved with the patient placed in the supine position on a radiolucent fracture table. 4. Distal metaphyseal fractures. DISADVANTAGES 1. Limited knee range of motion Since it is offset, there are higher chances of iatrogenic comminution and varus malalignment.

2. Patella baja: inadequate room for the nail between the patella and the tibial condyle with the knee in flexion. 3. Open fractures: risk of septic arthritis of the knee ENTRY PORTAL At the Blumensaat line, 1 cm anterior to the origin of Posterior Cruciate Ligament (PCL). RETROGRADE NAILING - PEARLS & PITFALLS 1. Use of reamed and snug fit locked nails is essential to avoid delayed union and non union. 2. The distal tip of the nail must be countersunk into the subchondral bone of the distal femur. This will prevent its impingement on the patella in knee flexion. 3. The nailed should be locked doubly distally. This prevents telescoping of the nail distally into the knee joint which can occur in cases of comminuted fractures. REAMED Vs UNREAMED NAILING ADVANTAGES OF REAMED NAILING Reamed nailing remains the gold standard for IM nails. Prospective randomized controlled trials have shown reamed IM nailing to have union rates approaching 99% with low complication rates. The overall better healing rates can be attributed to: 1. Increased cortical contact area of the nail & thereby better stability. 2. Beneficial inflammatory response to reaming. 3. Deposition of local bone graft at the fracture site. DISADVANTAGES OF REAMED NAILING

These are mainly theoretical and include: 1) Increased marrow pressures, pulmonary artery pressures and higher rates of fat embolism. a) These phenomenon have been demonstrated only in animal studies. b) The phenomenon of embolism is limited & transient. c) The rates of fat embolism in reamed and unreamed nails are similar. d) Fat extravasation is greatest during insertion of nail in the medullary cavity and is not dependent upon increased intra medullary pressure. 2) Endosteal thermal damage & endosteal cortical blood supply disruption. a) The disrupted endosteal blood supply regenerates rapidly and this accounts for high healing rates with reamed nails. b) However, thermal damage should be minimized by using sharp reamers with deep cutting flutes. The process of reaming should be slow and smooth. SPECIAL CASES 1. OPEN FRACTURES a. These are much less common than in the tibia, and a good soft tissue cover around the femur accounts for the fact that extensive soft tissue injury must occur before the compounding takes place. Small skin wounds may disguise severe underlying muscle and periosteal injury. b. The most important risk factor in the development of infection is the severity of initial trauma rather than the timing of initial debridement. It is therefore prudent to wait for the medical condition

of the patient to stabilize before proceeding onto management of the open fracture. c. The principles of treatment are the same as for other open fractures. All non viable tissues should be debrided and thorough lavage done. Debridement should be repeated at 24 48 hours in case of highly contaminated fractures. d. The only contraindication to immediate IM nailing in an open fracture is a case with grossly contaminated medullary canal and severe soft tissue damage. In such cases, provisional external fixation is done to permit serial debridement and thorough lavage. Once the canal has been thoroughly cleansed, conversion to intra medullary nailing may be done. e. Most gunshot injuries need debridement of the entry and exit wounds only. The deeper tissues may be left as such. Exceptions to this rule include close range shotgun injuries and high velocity gunshot injuries, which are managed as other open femoral fractures. 2. POLYTRAUMA a. The timing of IM nailing in polytrauma patients should be optimized to prevent further deterioration of the patients medical status. b. IM nailing is associated with release of inflammatory mediators, surgical blood loss and hypothermia, which may jeopardise borderline polytrauma patients, especially those with pulmonary compromise. c. It is therefore prudent to follow the principle of damage control orthopaedics. Fracture stabilization can be achieved in a quick and effective manner by using monolateral external fixators. This can be converted to IM nailing once the patients medical condition improves and there are no signs of pin track infection.

d. Recently,Unreamed retrograde nailing with or without proximal locking has been advocated as an alternative to external fixation in such cases. 3. VASCULAR & NEUROLOGICAL INJURY a. These are rare injuries and are associated with penetrating trauma. b. Traditionally, treatment protocols center on skeletal stabilization followed by vascular repair. The monolateral external fixator can be applied rapidly and the fixation can be converted to IM nailing within two weeks, having ensured that there are no pin site infections. c. However, recent clinical evidence has shown that vascular repair can be done immediately and definitive skeletal stabilization can be safely accomplished subsequently. Reversing the traditional sequence has the advantage of reducing the ischemia time and avoiding the need for a fasciotomy. Definitive fracture fixation can be performed afterwards without the danger of disrupting the vascular repair. 4. IPSILATERAL FEMORAL SHAFT AND PROXIMAL FEMORAL FRACTURES a. Up to 9% of all femoral shaft fractures are associated with ipsilateral femoral neck or intertrochanteric fractures. b. 25 60% of these fractures are minimally displaced and are therefore easily missed. The diagnostic yield of such injuries can be improved by using dedicated internal rotation radiographs of the pelvis or Computed Tomographic Scans with fine cuts. c. The treatment plan is dictated by the femoral neck fracture. Optimal treatment is a must for the femoral neck fracture, though it may not necessarily be dealt with initially. d. Some occult non displaced fractures of the femoral neck can get displaced during IM nailing. Therefore, it is prudent to rule out such

fractures in every case of IM nailing on the image intensifier preoperatively and after the nailing procedure. This practice helps in avoiding the delay in diagnosis of such injuries and prevents the devastating complication of avascular necrosis of the femoral head. e. The different treatment strategies include: i. A retrograde nail or plating for the femoral shaft fracture along with cannulated screws or sliding hip screw for femoral neck fracture. ii. A reconstruction IM nail to address both the fractures simultaneously. iii. In cases of high energy trauma, the femoral neck fractures are vertically oriented midcervial fractures that are inherently unstable. In such cases, a sliding hip screw combined with an antirotation screw is biomechanically better than multiple cannulated screws. 5. OBESE PATIENTS a. The difficulty in obese patients lies in obtaining a proper entry portal through the piriformis fossa. b. IM nailing through the trochanteric entry portal using a nail with a proximal lateral bend can be useful in such cases. Another option is to perform retrograde nailing. COMPLICATIONS OF INTRAMEDULLARY NAILING 1. INTRAOPERATIVE COMPLICATIONS a. Complications related to positioning: i. Compartment Syndrome: occurs in the normal limb when it is placed in the hemilithotomy position for the supine approach. ii. Pudendal Nerve Palsy: can occur due to hip adduction and excessive traction. Most of the cases are transient and show full recovery.

b. Complications related to entry portal: i. With piriformis fossa entry portal: A portal that is too medial or too lateral may cause fracture of the femoral neck or the greater trochanter respectively. A portal that is too anterior will result in excessive hoop stresses and lead to bursting of the proximal fragment. ii. With the trochanteric entry portal: There are chances of iatrogenic comminution and varus malalignment. This can be minimized by using nails with a proximal lateral bend. c. Complications related to reaming & nail insertion: i. Thermal necrosis and fat embolism: Though the risk is theoretical, it can be prevented by using sharp reamers with deep flutes that are passed down the canal in a slow and gradual fashion. ii. Iatrogenic comminution: This can be prevented by choosing a proper sized nail i.e. 1 -1.5 mm less than the largest reamer used. The fracture should be kept well reduced during nail insertion. iii. Malalignment: This can be prevented by ensuring central placement of the guide wire in the distal fragment. d. Complications related to locking: i. Overzealous drilling can lead to vascular injury and pseudoaneurysm formation. ii. Proximal locking screws of the retrograde IM nail can injure branches of the femoral nerve. This complication can be minimized by inserting these screws above the level of the lesser trochanter. 2. POST OPERATIVE COMPLICATIONS a. Malunion i. ANGULAR MALUNION:

 This is most commonly seen in proximal (30%) and distal (10%) femoral fractures. This is because the interference fit of the nail is not good enough in these situations to ensure adequate alignment. It can be prevented by using blocking screws and choosing a nail that is 1 mm smaller than the largest reamer used so as to ensure a snug fit. ii. ROTATIONAL MALUNION: Proper limb rotation can be ascertained by observing the alignment of the anterior superior iliac spine, the patella and the second toe. A comparison with the normal side should also be made. If rotational malalignment is identified per operatively, it can be corrected by removing the distal locking screws, correcting the rotation and reinserting the screws. CT Scan can help in better evaluation of rotational malunions. Symptomatic rotational malunions can be treated by an osteotomy, either open or with an IM saw. b. Nonunion i. The rates of non union with IM nailing are low (<10%), regardless of technique chosen. ii. Deep seated infection should always be ruled out as a cause of non-union and adequately treated prior to surgical treatment for non union. iii. The different treatment modalities include: Dynamization: This is a useful technique for fractures with distraction. Dynamization allows compression at the fracture site. Success rates vary from 54% - 92.3%.

 Exchange Nailing: This may be used for cases of failed dynamization, atrophic changes or bony defects. Success rates vary from 53% - 96%. Plating and bone grafting: This is especially useful for recalcitrant non unions. However, a thorough search must be undertaken to identify and correct any metabolic disturbances prior to such a procedure. c. Infection i. The overall infection rates with IM nailing are low (1% - 3.8%). ii. Infections may be categorised as: Early Infection (< 3 months): Such cases are treated by nail retention, serial debridement and organism specific intravenous antibiotics. Nail removal is indicated only if the infection cannot be controlled. In such cases, external fixation or antibiotic coated cement nails may be used. Antibiotic coated cement nails can be created over guide wires or other suitable substrates. Although the fixation is not as good as an external fixator, the dead space in the medullary cavity is filled up and high concentrations of antibiotic are delivered. Chronic Infection: Is treated along the lines of chronic osteomyelitis. The aim is to eradicate infection prior to definitive fixation. The IM nail is removed and the medullary canal reamed to allow debridement. Organism specific intravenous antibiotics along with local antibiotic therapy, in the form of antibiotic beads or cement spacers are used for 6 weeks. Host factors, such as smoking, malnutrition and any metabolic disorder are addressed. Regular monitoring is done which includes both clinical and laboratory examinations (Complete Blood Count, Erythrocyte Sedimentation Rates, C Reactive Protein). If there is still any doubt, fresh frozen tissue sections can be obtained intra operatively at the time of definitive reconstruction.

d. Leg Length Discrepancy: i. This complication occurs in up to 43% of comminuted femoral shaft fractures. ii. Peroperatively, limb length should be ascertained using a radio opaque ruler and compared with the normal side. In the immediate postoperative period, clinical examination, scanogram or CT Scan can be used to identify leg length discrepancy. iii. If identified per operatively or in the immediate post operative period, the nail should be relocked at the correct length. e. Heterotopic ossification: i. This may occur at the site of nail insertion and is usually of no significance. ii. Large masses can be excised if they are painful and limit motion. f. Hardware Prominence: i. Most commonly seen in case of distal locking screws of the retrograde IM nail. ii. Knee pain may occur with retrograde nails if the nail is not countersunk properly and impinges against the patella in knee flexion. This may warrant removal if the fracture has united or revision if the fracture has not united, to prevent damage to the articular surface of patella. REFERENCES 1) Canale ST, Beaty JH. Fractures of the lower extremity. In: Kay Daugherty LJ, editor. Campbell's Operative Orthopedics. 11th ed. Philadelphia: Elsevier; 2007. p. 3193 - 217. 2) Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. [Review]. 2009 May;17(5):296-305.

3) Ricci WM. Femur: Trauma. In: Berry DJ, Raikin SM, editors. Orthopedic Knowledge Update 8. Rosemont: American Academy of Orthopaedic Surgeons; 2005. p. 425 - 32. 4) Nork SE. Femoral shaft fractures. In: Buchholz RW, Heckman JD, Court-Brown CM, Tornetta P editors. Rockwood and Greens Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 1655 - 1719. Tibial Pilon Fractures-An Update TIBIAL PILON FRACTURES- An Update Siddharth Sharma, Hitesh Gopalan U HISTORY Pilon is a french word meaning pestle and this term was coined by Etienne Destot in 1911 to describe fractures occurring within 5 cm of the ankle joint. Plafond means ceiling. This term was coined by Bonnin in 1950, in allusion to the tibio-talar articular cartilage injury that occurs with these injuries. DEFINITION & RELEVANT ANATOMY Although the common feature of all tibial pilon fractures is involvement of the distal tibial articular surface, two distinct injury patterns can be identified: SNo. FEATURE 1 Mode of injury AXIAL LOAD INJURIES ROTATIONAL INJURIES

High velocity trauma Low velocity with axial rotational forces compression Variable comminution and Minimal or no comminution, no

Tibial fracture

pattern

impaction of the distal tibial articular surface and metaphysis

impaction and no metaphyseal involvement. Variable Lateral displacement

3 4

Fibular fracture Variable pattern Displacement of talus Soft tissue injury Prognosis Proximal displacement Severe Less favourable

5 6

Minimal More favourable

Rotational injuries involving the tibial pilon can be regarded as being a continuum of ankle fractures and are managed as per the principles that guide ankle fracture fixation. EPIDEMIOLOGY 1. INCIDENCE a. Account for less than 10% of all lower extremity fractures. b. Incidence is increasing owing to the use of seatbelts and airbags, which have decreased the incidence of fatal chest and abdominal injuries in high velocity motor vehicle accidents. 2. AGE: average age is 35 40 years. 3. SEX: males are more commonly involved. CLASSIFICATIONS 1. REUDI ALLGOWER CLASSIFICATION CATEGORY DISPLACEMENT COMMINUTION

TYPE I TYPE II TYPE III

Undisplaced Displaced Displaced

Cleavage fracture, no comminution Minimally comminuted Highly comminuted

2. AO/OTA CLASSIFICATION OF TIBIAL PILON FRACTURES TYPE A EXTRA ARTICULAR FRACTURES A1 A2 A3 Metaphyseal Simple Metaphyseal Wedge Metaphyseal Complex

TYPE B PARTIAL ARTICLUAR FRACTURES B1 B2 B3 Pure Split Split Depression Multifragmentary Depression

TYPE C TOTAL ARTICULAR FRACTURES C1 C2 C3 Articular Simple, Metaphyseal Simple Articular Simple, Metaphyseal Multifragmentary Articular Multifragmentary

Inter rater reliability is better with the AO/OTA classification. 3. TSCHERNE & GOETZEN CLASSIFICATION OF SOFT TISSUE INJURY GRADE SKIN INJURY MUSCLE INJURY

GRADE 0 GRADE 1

None Significant abrasion or contusion Deep abrasion with local contusion Extensive contusion or crushing with subcutaneous avulsion

None None

GRADE 2 GRADE 3 (Includes compartment syndrome and arterial injuries) CLINICAL FEATURES 1. MODE OF INJURY:

Mild Severe

a. Axial compression injuries: are high velocity injuries and occur with motor vehicle accidents. There is rapid loading of the bone and release of large amount of energy at failure, which gets disseminated to the soft tissues. b. Rotational injuries: occur as a result of torsional forces applied to the ankle. Loading in these cases is slow and less amount of energy is released at failure, therefore there is minimal soft tissue disruption. 2. ASSOCIATED INJURIES a. Incidence of concomitant injuries: 27 51% b. Incidence of bilateral tibial pilon fractures: 0 8% c. Ipsilateral talus and calcaneal fractures: extremely uncommon with axial loading fracture patterns. This is because most of the energy gets absorbed in the distal tibia and this protects the talus and calcaneum. 3. SOFT TISSUE INJURY

a. Severe soft tissue injury occurs with axial loading fracture patterns. b. Tense soft tissue swelling is palpable and may also be appreciated by absence of wrinkles; conversely the re-appearance of wrinkles indicates healing of the tissues (wrinkle test). c. Blisters indicate soft tissue injury and can be categorized as: i. Clear fluid filled blisters ii. Blood filled blisters Although both types are caused by separations at the dermo epidermal junction, blood filled blisters indicate severe soft tissue injury. 4. NEUROVASCULAR INJURIES a. CT angiography demonstrated vascular injury in 52% of cases in a recent study. b. Tibialis anterior artery is the most commonly involved . DIAGNOSIS 1. RADIOGRAPHS: obtain Antero-posterior, Lateral and Mortise views (AP radiograph with the ankle in 15 degrees internal rotation) in all cases, full leg radiographs to rule out proximal extension, contralateral ankle radiograph as template for preoperative planning. 2. CT SCAN: helps in determining the degree of articular involvement, impaction and comminution and is also a useful adjunct to assess the quality of reduction. GOALS OF TREATMENT 1. To obtain an anatomical articular reduction. 2. Restoration of axial alignment.

3. Maintenance of joint stability. 4. Achieve fracture union. 5. Regain functional and pain-free weight bearing and motion 6. Avoiding infections and wound complications. It may be impossible to achieve all these goals in all cases and therefore treatment should be individualised. EMERGENCY MANAGEMENT 1. Stabilize the patient as per the Advanced Trauma Life Support (ATLS) protocols as most of these injuries are high velocity motor vehicle accidents. 2. Life threatening head, abdominal, chest or other injuries take precedence in management. 3. Talus should be reduced immediately and the ankle should be immobilized in a bivalved cast or slab and elevated. 4. If the talus cannot be reduced, a calcaneal Steinmann pin can be used to deliver 10 pounds (approx. 4.5 kgs) of traction over a Bohler frame. 5. Alternatively, a joint spanning external fixator can be used to achieve and maintain provisional reduction of the fracture as well as talus. INDICATIONS OF CONSERVATIVE TREATMENT The overwhelming majority of Pilon fractures need operative treatment. Indications of conservative management are limited and include: 1. Minimally displaced A or C1 fractures. 2. Moribund and medically unfit patients.

TIMING OF ORIF Open reduction and internal fixation of Pilon fractures should be delayed for several reasons: 1. It has been shown that the trans-cutaneous oxygen concentration at the fracture site drops after injury and remains low up to 10 days after injury. 2. Incisions that are placed through compromised soft tissue envelopes may end up in wound dehiscence, necrosis and infection. 3. Soft tissue swelling may preclude closure of the surgical wound and tightly applied sutures can worsen the soft tissue compromise. SURGICAL APPROACHES FOR PILON FRACTURES APPROACH ANTEROMEDIAL & LATERAL(CLASSICA L) TECHNIQUE Separate incisions for tibial and fibula Both tibia & fibula approached through a single incision centred over posterolater al border of fibula ADVANTAGE Good visualization of fracture site Excellent exposure with fewer wound complication s. Minimal risk of injury to superficial peroneal nerve DISADVANTAG E Wound breakdown, hardware prominence Difficult to address fractures of the posterior aspect of the tibial pilon Difficult to address medial comminution

DIRECT LATERAL

ANTEROLATERAL

Both tibia and fibula can be approached by skin incision centred over anterior border of fibula

Excellent exposure with fewer wound complication s

Iatrogenic damage to superficial peroneal nerve and anterior perforating peroneal artery. Difficult to address medial comminution

POSTEROLATERAL

Utilizes the interval between peroneal tendons and flexor hallucis longus

Provides good exposure for fractures that have posterior displacement & comminution Also useful when skin condition rules out anterior approaches

Difficult to address anterior displacement or comminution Incidence of wound complications is same as with other approaches.

MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS (MIPO)

Limited incisions, indirect reduction techniques, bridge

Minimizes further damage to the compromise d bone & soft

Articular comminution is difficult to address

plating principle used

tissues

The choice of surgical approach is dictated by the soft tissue status, fracture displacement and the location of articular comminution. INITIAL MANAGEMENT It is aimed at reduction of gross displacement of the talus and elevation of the limb. This can be accomplished by: 1. Plaster slab or bivalved cast. 2. Calcaneal pin traction and elevation on a Bohler frame. 3. Spanning external fixator. CHOICE OF OPERATIVE PROCEDURES 1. SINGLE STAGE MANAGEMENT It is preferred for displaced fractures with minimal, closed, soft tissue injury. 2. MULTIPLE STAGE MANAGEMENT Majority of Pilon fractures have moderate severe soft tissue injury, with or without compounding and are best managed by staged treatment protocol, as follows: Stage 1: Closed reduction and external fixation: This may be accomplished by any of the following methods: o Ankle spanning External Fixator: Utilizes pins placed in the tibia and in the calcaneum & /or talus. Advantages: zone of injury is spanned, quick and easy to apply, holds out to talus to length, no further injury to soft tissues and does not preclude other treatments.

 Disadvantage: ankle joint movements are lost, although this may not have much bearing on the final outcome. o Non-spanning External Fixator: Pin fixators, Ilizarov fixators and hybrid fixators (employing pins and wire constructs) Advantage: ankle movements are preserved Disadvantage: at least 2 cm of the distal tibia must be intact to allow such a fixation, safe corridors for the distal tibia are limited and higher incidence of pin, wire and wound complications as the fixation passes through the zone of injury. o Articulated (Hinged) ankle spanning External Fixators: Utilizes a hinge that connects the tibial pins with the hindfoot pins. Advantages: Allows reduction of the displaced talus and also permits limited ankle movements while bridging the zone of injury. Disadvantages: Needs precise pin placement; the hindfoot clamp straddles the neurovascular bundle and the subtalar joint and the calcaneal pin can injure the medial calcaneal branch of the tibial nerve. Stage 2 - Definitive Treatment: is begun when soft tissues have healed and there is no evidence of infection in case of open fractures. The different treatment options include: o Plate Fixation of Tibia: The articular fragments must be reduced under vision anatomically and rigidly fixed with interfragmentary screws. The metaphyseal fractures are dealt with by bridging fixation. Minimal soft tissue dissection, indirect reduction techniques and maintenance of length, alignment and rotation are the goals of treatment.

 Choice of implants: low profile plates that are contoured to the distal tibia are preferred. The use of precontoured angle stable plates (distal tibial locking compression plates) offers several advantages in complex fractures and osteoporotic bone. o External Fixation as a definitive modality of treatment: The most important step is to reduce the articular fracture anatomically and if needed, this can be accomplished by limited open reduction and interfragmentary screw fixation. External fixators can be in the form of Ilizarov fixators, tubular external fixators or modular fixators. o Fibular fixation: Most authors recommend that this should be done at the time of the initial operation. If the fibular fracture pattern is simple, it is fixed first. This permits easy reduction of the tibial fracture. However, in comminuted fibular fracture patterns, the tibia is fixed first. Fixation can be accomplished with one third tubular plates, reconstruction plates or 3.5 mm dynamic compression plates depending on the size of fibula. Surgical Approaches: Although historically a single utilitarian approach was popular in the reconstruction of the tibial plafond, a variety of surgical approaches are currently used to treat these fractures. Less dissection and soft tissue retraction, as well as optimal implant placement, is possible using more direct approaches. As with other complex injuries, the selection of an approach should be based on the personality of fracture and location of major fracture fragments.

 These more customized approaches should adhere to the following principles: - Effective soft tissue handling - Maintenance of a reasonable skin bridge between incisions (especially if these incisions are long or extensile) Placing skin incisions directly over bone should be avoided if possible. Thus, if skin problems occur, resultant tissue defects can be reconstructed with a simple skin graft or fasciocutaneous flap as opposed to a free soft tissue transfer. Howard et al recently reported a series of 46 plafond fractures in 42 patients in which 106 skin incisions were used, creating 60 skin bridges. The mean skin bridge size was 5.9 cm; only 16% were greater than 7 cm. All incisions other than two healed uneventfully, and no deep infections or skin bridge compromises were recorded. COMPLICATIONS 1. WOUND DEHISCENCE & INFECTION i. Incidence was found to be higher in fractures that are managed by single stage open reduction and internal fixation (67% in one series). ii. With the use of staged protocol, this complication occurs in < 10% of all cases. 2. DELAYED UNION & NON UNION i. Incidence is 5% regardless of the modality of treatment used. ii. High energy comminuted fractures, presence of severe soft tissue injury, aggressive soft tissue dissection and infection predispose to these complications. 3. MALUNION

i. Some amount of malunion is expected to occur after high energy comminuted fracture patterns. ii. Reported rates in recent series: 4 25% iii. Angular malunion is most common and incidence is higher in cases treated with external fixation and those where fibula was not fixed. 4. ANKLE ARTHROSIS i. Precise incidence not known, rates up to 50% have been reported. ii. It is thought that the damage to articular cartilage at the time of trauma is the main determinant of arthrosis, although joint incongruity also plays an important role. iii. Avascular necrosis of talus and infection are less common causes of arthrosis. iv. Significant arthrosis develops within 1-2 years of injury and its clinical severity does not correlate with the radiological appearance. REFERENCES 1) Canale ST, Beaty JH. Fractures of the lower extremity. In Campbell's Operative Orthopedics. 11th ed. Philadelphia: Elsevier; 2007. p. 3193 - 217. 2) Reid JS. Pilon fractures update. Current Orthopaedic Practice2009;20(5):527-33 3) Wade AM, Crist BD, Khazzam M, Della Rocca GJ, Calhoun JH. Pilon fractures. Current Orthopaedic Practice2008;19(3):242-8 4) LeBus GF, Collinge C. Vascular abnormalities as assessed with CT angiography in high-energy tibial plafond fractures. J Orthop Trauma. 2008; 22:1622.

5) Barei DP. Pilon fractures. In: Buchholz RW, Heckman JD, CourtBrown CM, Tornetta P editors. Rockwood and Greens Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 1928-71. 6) Howard JL, Agel J, Barei D, et al. Challenging the dogma of the 7cm rule: a prospective study evaluating incision placement and wound healing for tibial plafond fractures. Orthopaedic Trauma Association annual meeting, Phoenix, AZ, October 5-7, 2006 Tibial Pilon Fractures-An Update TIBIAL PILON FRACTURES- An Update Siddharth Sharma, Hitesh Gopalan U HISTORY Pilon is a french word meaning pestle and this term was coined by Etienne Destot in 1911 to describe fractures occurring within 5 cm of the ankle joint. Plafond means ceiling. This term was coined by Bonnin in 1950, in allusion to the tibio-talar articular cartilage injury that occurs with these injuries. DEFINITION & RELEVANT ANATOMY Although the common feature of all tibial pilon fractures is involvement of the distal tibial articular surface, two distinct injury patterns can be identified: SNo. FEATURE 1 Mode of injury AXIAL LOAD INJURIES ROTATIONAL INJURIES

High velocity trauma Low velocity with axial rotational forces

compression 2 Tibial fracture pattern Variable comminution and impaction of the distal tibial articular surface and metaphysis Minimal or no comminution, no impaction and no metaphyseal involvement. Variable Lateral displacement Minimal More favourable

3 4 5 6

Fibular fracture Variable pattern Displacement of talus Soft tissue injury Prognosis Proximal displacement Severe Less favourable

Rotational injuries involving the tibial pilon can be regarded as being a continuum of ankle fractures and are managed as per the principles that guide ankle fracture fixation. EPIDEMIOLOGY 1. INCIDENCE a. Account for less than 10% of all lower extremity fractures. b. Incidence is increasing owing to the use of seatbelts and airbags, which have decreased the incidence of fatal chest and abdominal injuries in high velocity motor vehicle accidents. 2. AGE: average age is 35 40 years. 3. SEX: males are more commonly involved. CLASSIFICATIONS 1. REUDI ALLGOWER CLASSIFICATION

CATEGORY TYPE I TYPE II TYPE III

DISPLACEMENT Undisplaced Displaced Displaced

COMMINUTION Cleavage fracture, no comminution Minimally comminuted Highly comminuted

2. AO/OTA CLASSIFICATION OF TIBIAL PILON FRACTURES TYPE A EXTRA ARTICULAR FRACTURES A1 A2 A3 Metaphyseal Simple Metaphyseal Wedge Metaphyseal Complex

TYPE B PARTIAL ARTICLUAR FRACTURES B1 B2 B3 Pure Split Split Depression Multifragmentary Depression

TYPE C TOTAL ARTICULAR FRACTURES C1 C2 C3 Articular Simple, Metaphyseal Simple Articular Simple, Metaphyseal Multifragmentary Articular Multifragmentary

Inter rater reliability is better with the AO/OTA classification. 3. TSCHERNE & GOETZEN CLASSIFICATION OF SOFT TISSUE INJURY

GRADE GRADE 0 GRADE 1 GRADE 2 GRADE 3 (Includes compartment syndrome and arterial injuries) CLINICAL FEATURES 1. MODE OF INJURY:

SKIN INJURY None Significant abrasion or contusion Deep abrasion with local contusion Extensive contusion or crushing with subcutaneous avulsion

MUSCLE INJURY None None Mild Severe

a. Axial compression injuries: are high velocity injuries and occur with motor vehicle accidents. There is rapid loading of the bone and release of large amount of energy at failure, which gets disseminated to the soft tissues. b. Rotational injuries: occur as a result of torsional forces applied to the ankle. Loading in these cases is slow and less amount of energy is released at failure, therefore there is minimal soft tissue disruption. 2. ASSOCIATED INJURIES a. Incidence of concomitant injuries: 27 51% b. Incidence of bilateral tibial pilon fractures: 0 8% c. Ipsilateral talus and calcaneal fractures: extremely uncommon with axial loading fracture patterns. This is because most of the energy gets absorbed in the distal tibia and this protects the talus and calcaneum.

3. SOFT TISSUE INJURY a. Severe soft tissue injury occurs with axial loading fracture patterns. b. Tense soft tissue swelling is palpable and may also be appreciated by absence of wrinkles; conversely the re-appearance of wrinkles indicates healing of the tissues (wrinkle test). c. Blisters indicate soft tissue injury and can be categorized as: i. Clear fluid filled blisters ii. Blood filled blisters Although both types are caused by separations at the dermo epidermal junction, blood filled blisters indicate severe soft tissue injury. 4. NEUROVASCULAR INJURIES a. CT angiography demonstrated vascular injury in 52% of cases in a recent study. b. Tibialis anterior artery is the most commonly involved . DIAGNOSIS 1. RADIOGRAPHS: obtain Antero-posterior, Lateral and Mortise views (AP radiograph with the ankle in 15 degrees internal rotation) in all cases, full leg radiographs to rule out proximal extension, contralateral ankle radiograph as template for preoperative planning. 2. CT SCAN: helps in determining the degree of articular involvement, impaction and comminution and is also a useful adjunct to assess the quality of reduction. GOALS OF TREATMENT 1. To obtain an anatomical articular reduction.

2. Restoration of axial alignment. 3. Maintenance of joint stability. 4. Achieve fracture union. 5. Regain functional and pain-free weight bearing and motion 6. Avoiding infections and wound complications. It may be impossible to achieve all these goals in all cases and therefore treatment should be individualised. EMERGENCY MANAGEMENT 1. Stabilize the patient as per the Advanced Trauma Life Support (ATLS) protocols as most of these injuries are high velocity motor vehicle accidents. 2. Life threatening head, abdominal, chest or other injuries take precedence in management. 3. Talus should be reduced immediately and the ankle should be immobilized in a bivalved cast or slab and elevated. 4. If the talus cannot be reduced, a calcaneal Steinmann pin can be used to deliver 10 pounds (approx. 4.5 kgs) of traction over a Bohler frame. 5. Alternatively, a joint spanning external fixator can be used to achieve and maintain provisional reduction of the fracture as well as talus. INDICATIONS OF CONSERVATIVE TREATMENT The overwhelming majority of Pilon fractures need operative treatment. Indications of conservative management are limited and include: 1. Minimally displaced A or C1 fractures.

2. Moribund and medically unfit patients. TIMING OF ORIF Open reduction and internal fixation of Pilon fractures should be delayed for several reasons: 1. It has been shown that the trans-cutaneous oxygen concentration at the fracture site drops after injury and remains low up to 10 days after injury. 2. Incisions that are placed through compromised soft tissue envelopes may end up in wound dehiscence, necrosis and infection. 3. Soft tissue swelling may preclude closure of the surgical wound and tightly applied sutures can worsen the soft tissue compromise. SURGICAL APPROACHES FOR PILON FRACTURES APPROACH ANTEROMEDIAL & LATERAL(CLASSICA L) DIRECT LATERAL TECHNIQUE Separate incisions for tibial and fibula Both tibia & fibula approached through a single incision centred over posterolater al border of fibula ADVANTAGE Good visualization of fracture site Excellent exposure with fewer wound complication s. Minimal risk of injury to superficial peroneal DISADVANTAG E Wound breakdown, hardware prominence Difficult to address fractures of the posterior aspect of the tibial pilon Difficult to address medial comminution

nerve ANTEROLATERAL Both tibia and fibula can be approached by skin incision centred over anterior border of fibula Excellent exposure with fewer wound complication s Iatrogenic damage to superficial peroneal nerve and anterior perforating peroneal artery. Difficult to address medial comminution Provides good exposure for fractures that have posterior displacement & comminution Also useful when skin condition rules out anterior approaches MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS (MIPO) Limited incisions, indirect reduction Minimizes further damage to the Difficult to address anterior displacement or comminution Incidence of wound complications is same as with other approaches.

POSTEROLATERAL

Utilizes the interval between peroneal tendons and flexor hallucis longus

Articular comminution is difficult to address

techniques, bridge plating principle used

compromise d bone & soft tissues

The choice of surgical approach is dictated by the soft tissue status, fracture displacement and the location of articular comminution. INITIAL MANAGEMENT It is aimed at reduction of gross displacement of the talus and elevation of the limb. This can be accomplished by: 1. Plaster slab or bivalved cast. 2. Calcaneal pin traction and elevation on a Bohler frame. 3. Spanning external fixator. CHOICE OF OPERATIVE PROCEDURES 1. SINGLE STAGE MANAGEMENT It is preferred for displaced fractures with minimal, closed, soft tissue injury. 2. MULTIPLE STAGE MANAGEMENT Majority of Pilon fractures have moderate severe soft tissue injury, with or without compounding and are best managed by staged treatment protocol, as follows: Stage 1: Closed reduction and external fixation: This may be accomplished by any of the following methods: o Ankle spanning External Fixator: Utilizes pins placed in the tibia and in the calcaneum & /or talus.

 Advantages: zone of injury is spanned, quick and easy to apply, holds out to talus to length, no further injury to soft tissues and does not preclude other treatments. Disadvantage: ankle joint movements are lost, although this may not have much bearing on the final outcome. o Non-spanning External Fixator: Pin fixators, Ilizarov fixators and hybrid fixators (employing pins and wire constructs) Advantage: ankle movements are preserved Disadvantage: at least 2 cm of the distal tibia must be intact to allow such a fixation, safe corridors for the distal tibia are limited and higher incidence of pin, wire and wound complications as the fixation passes through the zone of injury. o Articulated (Hinged) ankle spanning External Fixators: Utilizes a hinge that connects the tibial pins with the hindfoot pins. Advantages: Allows reduction of the displaced talus and also permits limited ankle movements while bridging the zone of injury. Disadvantages: Needs precise pin placement; the hindfoot clamp straddles the neurovascular bundle and the subtalar joint and the calcaneal pin can injure the medial calcaneal branch of the tibial nerve. Stage 2 - Definitive Treatment: is begun when soft tissues have healed and there is no evidence of infection in case of open fractures. The different treatment options include: o Plate Fixation of Tibia: The articular fragments must be reduced under vision anatomically and rigidly fixed with interfragmentary screws.

 The metaphyseal fractures are dealt with by bridging fixation. Minimal soft tissue dissection, indirect reduction techniques and maintenance of length, alignment and rotation are the goals of treatment. Choice of implants: low profile plates that are contoured to the distal tibia are preferred. The use of precontoured angle stable plates (distal tibial locking compression plates) offers several advantages in complex fractures and osteoporotic bone. o External Fixation as a definitive modality of treatment: The most important step is to reduce the articular fracture anatomically and if needed, this can be accomplished by limited open reduction and interfragmentary screw fixation. External fixators can be in the form of Ilizarov fixators, tubular external fixators or modular fixators. o Fibular fixation: Most authors recommend that this should be done at the time of the initial operation. If the fibular fracture pattern is simple, it is fixed first. This permits easy reduction of the tibial fracture. However, in comminuted fibular fracture patterns, the tibia is fixed first. Fixation can be accomplished with one third tubular plates, reconstruction plates or 3.5 mm dynamic compression plates depending on the size of fibula. Surgical Approaches: Although historically a single utilitarian approach was popular in the reconstruction of the tibial plafond, a variety of surgical approaches are currently used to treat these fractures. Less dissection and soft tissue retraction, as well as optimal implant placement, is possible using more direct approaches.

 As with other complex injuries, the selection of an approach should be based on the personality of fracture and location of major fracture fragments. These more customized approaches should adhere to the following principles: - Effective soft tissue handling - Maintenance of a reasonable skin bridge between incisions (especially if these incisions are long or extensile) Placing skin incisions directly over bone should be avoided if possible. Thus, if skin problems occur, resultant tissue defects can be reconstructed with a simple skin graft or fasciocutaneous flap as opposed to a free soft tissue transfer. Howard et al recently reported a series of 46 plafond fractures in 42 patients in which 106 skin incisions were used, creating 60 skin bridges. The mean skin bridge size was 5.9 cm; only 16% were greater than 7 cm. All incisions other than two healed uneventfully, and no deep infections or skin bridge compromises were recorded. COMPLICATIONS 1. WOUND DEHISCENCE & INFECTION i. Incidence was found to be higher in fractures that are managed by single stage open reduction and internal fixation (67% in one series). ii. With the use of staged protocol, this complication occurs in < 10% of all cases. 2. DELAYED UNION & NON UNION i. Incidence is 5% regardless of the modality of treatment used.

ii. High energy comminuted fractures, presence of severe soft tissue injury, aggressive soft tissue dissection and infection predispose to these complications. 3. MALUNION i. Some amount of malunion is expected to occur after high energy comminuted fracture patterns. ii. Reported rates in recent series: 4 25% iii. Angular malunion is most common and incidence is higher in cases treated with external fixation and those where fibula was not fixed. 4. ANKLE ARTHROSIS i. Precise incidence not known, rates up to 50% have been reported. ii. It is thought that the damage to articular cartilage at the time of trauma is the main determinant of arthrosis, although joint incongruity also plays an important role. iii. Avascular necrosis of talus and infection are less common causes of arthrosis. iv. Significant arthrosis develops within 1-2 years of injury and its clinical severity does not correlate with the radiological appearance. REFERENCES 1) Canale ST, Beaty JH. Fractures of the lower extremity. In Campbell's Operative Orthopedics. 11th ed. Philadelphia: Elsevier; 2007. p. 3193 - 217. 2) Reid JS. Pilon fractures update. Current Orthopaedic Practice2009;20(5):527-33 3) Wade AM, Crist BD, Khazzam M, Della Rocca GJ, Calhoun JH. Pilon fractures. Current Orthopaedic Practice2008;19(3):242-8

4) LeBus GF, Collinge C. Vascular abnormalities as assessed with CT angiography in high-energy tibial plafond fractures. J Orthop Trauma. 2008; 22:1622. 5) Barei DP. Pilon fractures. In: Buchholz RW, Heckman JD, CourtBrown CM, Tornetta P editors. Rockwood and Greens Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 1928-71. 6) Howard JL, Agel J, Barei D, et al. Challenging the dogma of the 7cm rule: a prospective study evaluating incision placement and wound healing for tibial plafond fractures. Orthopaedic Trauma Association annual meeting, Phoenix, AZ, October 5-7, 2006 "PRINCIPLES" of Tendon Transfer Surgery principles of tendon tranfers (1) Supple joints before transfer, (2) soft-tissue equilibrium, (3) donor of adequate excursion, (4) donor of adequate strength, (5) expendable donor, (6) Straight line of pull, (7) Synergy, (8) single function per transfer Biomechanics a. Force generating ability, b. Moment arm,

c. Tension of the transfer Indications A peripheral nerve injury that has no potential to improve. root avulsions, nerve injuries that do not recover after direct nerve repair or grafting, failed nerve transfers. loss of muscle or tendon following trauma, central neurologic deficits such as spinal cord injuries and cerebral palsy, tendon ruptures in patients with rheumatoid arthritis, poliomyelitis and leprosy Osteonecrosis of Femoral Head Osteonecrosis of femoral HEAD (Chandlers disease) Aetiology

Atraumatic High-dose corticosteroid use Alcohol abuse: >8 ml of alcohol per day is associated with increased risk Smoking Thrombophilias and hypofibrinolsysis

 Renal osteodystrophy Solid organ transplantation Hemoglobinopathies HIV infection: mainly due to antiretrovirus therapy Gauchers disease Hyperlipidemia Pancreatitis Chemotherapy Radiation therapy Liver disease Gout Systemic lupus erythematosus Caisson disease Idiopathic (most common) Pregnancy Genetic: collagen type II gene mutation Genetic polymorphism such as alcohol metabolizing enzymes and the drug transport protein P-glycoprotein and eNOS polymorphisms Traumatic 1. Displaced femoral neck fractures 2. Fracture dislocation Hip 3. Iatrogenic injury secondary to anterograde medullary nailing (rare)

The treatment of Post- traumatic Osteonecrosis is not included in this review. Theories of Pathogenesis: 1. Direct cellular toxicity: radiation, chemotherapy, or thermal injuries can cause injury to and death of marrow cells and osteocytes 2. Extraosseous arterial: fracture of the femoral neck. Hip dislocations, post surgery, abnormalities in major vessels about the hip, including the retinacular arteries 3. Extraosseous venous 4. Intraosseous extravascular: Hemorrhage: presence of intramedullary hemorrhage in the osteonecrotic lesion of core biopsy specimens is a supporting evidence Elevated Bone Marrow Pressure: This theory proposes that the bone acts like a Starling resistor in which thin-walled vessels traverse the space within a rigid outer cortex. Any increase in the pressure within this compartment causes the vessel walls to collapse, thus leading to decreased blood flow Cellular Hypertrophy and Marrow Infiltration: examples are (a) corticosteroid therapy, (b) Gaucher's disease, (c) leukemia, or (d) caisson disease or dysbarism. 10 to 30% of nontraumatic osteonecrosis is caused by Cortisone administration. Corticostroids may direct bone marrow stromal cells in to the adipocytic pathway as opposed to osteoblastic pathway. Dosages typically considered being associated with the disease are >2 g of

Prednisone, or its equivalent, within a period of two to three months.(Griffith et al..) Bone Marrow Edema 5. Intraosseous intravascular: examples to support this hypothesis are sickle cell disease, lipid emboli, thrombophilias 6. Hypersensitivity reactions: immune complex deposition may lead to vascular damage 7. Multifactorial Current evidence suggests that intravascular coagulation and microcirculatory thrombotic occlusion likely provide a final common pathway for nontraumatic osteonecrosis Pathogenesis: The resultant hypoxia increased cell membrane permeability fluid and electrolytes enter the cell, and the cell swells. Intracellular lysosomal enzymes are released, resulting in autodigestion or coagulation, necrosis and cell rupture Vascular injury tissue edema andHemorrhage inflammatory response, characterised by the appearance of neutrophils and macrophage The hematopoietic elements are the first to undergo anoxic death (in from 6 to 12 hours), followed by bone cells (osteocytes, osteoclasts, and osteoblasts) (in 12 to 48 hours) and, subsequently, marrow fat cells (48 hours to 5 days) Infarcts can be subdivided into four zones: a central zone of cell death surrounded by successive zones of ischemic injury(transition zone, active hyperemia, and finally normal tissue In the periphery of the necrotic area where vascularity is present (called transition zone) an active process of repair occurs. If the lesion is small in the non-weight bearing area it may undergo revascularization and be completely replaced with viable bone or it

may form a sequestrum surrounded by a wall of new bone. This usually does not collapse. In the weight bearing area, the repair process is less effective. Bone resorption is more rapid than formation cancellous bone collapses If the contour of the articular surface remains intact, development of fluid-filled space beneath the cortical subchondral bone. This gives the appearance of a crescent sign in X-rays Clinical Features: Common in young adults between 20 and 40 years Limp Hip pain or vague groin pain groin pain with ROM of the hip (internal rotation), which is not typically tender with direct palpation Bilateral in more than 50 % Positive Sectoral sign: The range of internal rotation is less in hip flexion compared to when in hip extension. Investigations: The investigation of choice for this condition is MRI. It has been found to be 99% sensitive and 98% specific for this disease. The classic appearance of AVN on MRI is that of a focal lesion in the anterosuperior subchondral region of the femoral head . The lesions are non homogenous, segmental and well demarcated, with low SI on T1 and intermediate SI on T2. The T2 WI may show a so called double line sign, which is pathognomonic of AVN. This sign is thought to represent interface between viable and osteonecrotic

bone, and it consists of concentric low and high signal intensity bands. Bone scan has been reported to be insenditive for the diagnosis of ON of femoral head. Classification: 1. Association Research Circulation Osseous (ARCO): This is the Committee on Nomenclature and Staging of Osteonecrosis. The ARCO classification incorporates all the staging systems described below. 2. University of Pennsylvania staging system: 2nd most commonly employed classification 3. Japanese classification (Ohzono et al.. CORR 1992) 4. Ficat and Arlet staging: Most commonly employed The University of Pennsylvania staging is the first to use MRI as specific modality and the first to measure the lesion size and surface involvement Extent of Necrosis: Kerboul et al...(JBJS B1974): determined the extent of necrosis by measuring the arc of articular surface overlying the lesion on both AP and Lateral views. The combined necrotic angle is obtained by adding the angle in AP and lateral views. >250 = large >151-<250= medium <150 = small Koo and Kim et al. used MRI to determine the extent of necrosis(JBJS B 1995; 77)

The combined necrotic angle is a predictor of collapse after core decompression. Combined necrotic angle of less than 190 suggests low risk of collapse, whereas if necrotic angle is more than 240 there is a high risk of collapse Similarly, High fat content and bone marrow edema in the proximal femur appear to predict an increased risk of future collapse. In the University of Pennsylvania staging the angles in AP and lateral are multiplied The Japanese classification and the ARCO suggested the importance of location (anterior, medial, central etc). But this is not found to be important since most lesions are located in the anterosuperior area. Similarly, Steinberg proposed volumetric measurements calculated from coronal and axial images in MRI. Lesions that occupy &<15% of the femoral head are defined as mild, 15% to 30% as moderate or medium, and &>30% of the femoral head as severe lesions. Treatment of Nontraumatic Osteonecrosis of Femoral Head Medical Management: Stanozolol: an anabolic steroid that alters lipoproteins and suppresses clotting factors Lovastatin: agent that lower circulating lipids( associated hypercholesterolemia or hyperlipidemia) Long-term anticoagulation to treat coagulopathies using enoxaparin(for inherited coagulation disorders)

Alendronate: Agarwala et al found improvement in 100 hips after treatment with 10mg/day of alendronate.(4) 1. Published reports justify nonoperative treatment of small precollapse lesions (<10% Size)that are asymptomatic. 2. Extracorporeal shockwave therapy, pulsed electromagnetic fields, hyperbaric oxygen are not currently recommended. Management Guidelines(Based on Ficat and Arlet staging) Stage I and IIA: Normal radiographs, positive MRI, Asymptomatic: Observation, pharmacologic treatment Core decompression and bone grafting: for symptomatic precollapse lesion Decreases intraosseous pressure in the femoral head and may immediately relieve the associated pain Bone grafting allows for removal of weak necrotic bone, decompression of the femoral head, and stimulation of repair and remodeling of subchondral bone. Bone grafting also maintains articular congruity and prevents collapse Indicated for small- to medium-sized precollapse lesion. core decompression involves the use of an 8- to 10-mm trephine or cannula inserted under fluoroscopic guidance to penetrate the lesion Weight-bearing should be protected for 5 weeks after surgery to avoid fracture. Another technique for core decompression is drilling multiple times in to the lesion with a small 3.2 mm diameter pin.

Bone grafting may involve any of the three techniques: 1. Cortical strut grafting through a core track in the femoral head and neck. Vascularised fibular graft is superior to nonvascualrised grafts.Vascularised fibular grafts are a reasonable option for patients younger than 50 years without collapse of the femoral head. 2. Bone grafting through the articular cartilage (the trapdoor procedure), was popularised by dAubigne. An arthrotomy is performed to dislocate the hip anteriorly, the necrotic segment of the head is curetted out, and iliac crest bone graft is packed inside. This is done through a cartilage window of the femoral head. 3. Bone grafting through the femoral neck or femoral head neck junction (light bulb procedure). The Ioannina technique uses serial computed tomography (CT) scans of the proximal femur to identify the configuration of the femur, and the size, location, and configuration of the lesion. This has been developed for accurate graft placement(8) Recent research has focused on development of biologically based therapies that can enhance core decompression with either osteoinductive (BMPs) or osteogenic (mesenchymal cells) agents that have the clinical potential to provide better results for larger lesions(7) The role of use of tantalum rods is being debated and long term outcome studies are not available Stages II B and above: 1. Angular intertrochanteric (varus and valgus) and rotational transtrochanteric (Sugioka): For Stage IIB and Stage III with less than 30 % head involvement and necrotic angle is less than 90

The Sugioka osteotomy is a posterior rotational osteotomy such that the necrotic lesion is shifted posteriorly into the non weight bearing area Good results are obtained in stage II Ficat compared to stage III Good fixation devices like the nail plate device should be used Results are best with patients aged 45 years or younger, with unilateral disease Resurfacing arthroplasty: Hemiresurfacing : should be considered for 1) Ficat stage III disease 2) combined necrotic angle of >200 degrees or >30% involvement 3) femoral head collapse of > 2mm 4) no evidence of damage to acetabular cartilage. Conversion to Total Hip arthroplasty maybe required in the presence of persistent groin pain after hemiresurfacing. Total hip resurfacing can be performed in Ficat stage IV disease without significant deformity or cystic changes in the femoral head. 3. Bipolar hemiarthroplasty: Bipolar hemiarthroplasty has a high failure and complication rate and is associated with a high prevalenece of polythylene wear, so it is not recommended for treatment of osteonecrosis. 4. Total hip replacement: Indicated for patients with femoral head collapse and acetabular involvement. The presence of AVN in the proximal femoral canal may reduce the remodelling capacity of bone at the bonecement interface and impair the establishment of osseointegration and therefore adequate long-term fixation of the prosthesis. Nevertheless, excellent long term results have been obtained using cementless fixation

In the context of radiation induced osteonecrosis, reinforcement rings or highly porous metal socket is recommended The risk of prosthetic joint infection is higher if the underlying aetiological factor is related to immunosupression. Use of corticosteroids, ethanol abuse, systemic lupus erythematosus,or organ transplants negatively affect the prosthetic durability. Ficat and Arlet Staging Stag e 0 Symptom X-rays s None Normal Bone scan Decrease d Uptake? 1 None Mild/Norm al Cold spot Infarction of weight bearing portion of head Abundant dead marrow cells, osteoblasts , osteogenic cells New bone deposited between necrotic trabeculae Pathology Biopsy

Mild

Density change in femoral head Sclerosis or cysts, normal

Increase d uptake

2A

Increase d uptake

joint line, normal head contour 2B Flattening (crescent sign) Mild to moderat e Loss of Increase sphericity, d uptake collapse Subchondral fracture, collapse, compaction and fragmentati on of necrotic segment Dead bone trabeculae and marrow cells on both sides of fracture line

Moderate Joint Increase to severe space d uptake narrowing, acetabular changes

Osteoarthriti acetabular c changes cartilage degeneratio n

University of Pennsylvania Staging: Stage 0: Normal or non-diagnostic X Ray, Bone scan or MRI Stage I: Normal X Ray, Abnormal bone scan or MRI. A: < 15% of head involved (mild) B: 15- 30 % head involved (moderate) C: >30 % of head involved (Severe)

Stage II: Cystic and sclerotic changes in femoral head A:<15% of head involved (mild) B: 15- 30 % head involved (moderate) C: .30 % of head involved (Severe) Stage III: Subchondral collapse without flattening (Crescent sign) A: <15% of articular surface (mild) B: 15- 30 % of articular surface (moderate) C: >30 % of articular surface (Severe) Stage IV: Flattening of femoral head A: <15% of articular surface and <2mm depression (mild) B: 15- 30 of articular surface and 2-4 mm depression (moderate) C: >30 % of articular surface and >4 mm depression (Severe) Stage V: Joint space narrowing and acetabular changes A: Mild Average of femoral head involved as in stage IV B: Moderate and acetabular involvement C: Severe Stage VI: Advanced degenerative changes Treatment Recommendation According to the University of Pennsylvania System of Classification and Staging (Lieberman et al. JBJS 2002; 84-A) I and II (Asymptomatic) Observation, pharmacologic treatment, possible core

decompression bone grafting IA, IB, IC, IIA, IIB, and IIC (Symptomatic) Core decompression bone grafting, vascularised graft IC, IIC, IIIA, IIIB, IIIC, and IVA (Symptomatic) Bone grafting (vascularised or nonvascularised), osteotomy, limited femoral head resurfacing, total hip arthroplasty IVB and IVC (Symptomatic) Limited femoral head resurfacing, total hip arthroplasty V and VI( Symptomatic) Total hip arthroplasty . Ref: 1. Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg 1995;77B:34-41 2. Mont MA, Jones LC, Hungerford DS. Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg 2006;88A: 1117-1132 3. Lieberman JR, Berry DJ, Mont MA, et al. Osteonecrosis of the hip: management in the 21st century. Instr Course Lect 2003;52: 337-355 4. Lai KA, Shen WJ, Yang CY, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg2005;87A:2155-2159 5. Urbaniak JR, Harvey EJ. Revascularization of the femoral head in osteonecrosis. J Am Acad Orthop Surg 1998;6:44-54. 6. Adili A, Trousdale RT. Femoral head resurfacing for the treatment of osteonecrosis in the young patient. Clin Orthop Relat Res 2003;417: 93-101

7. Gangji V, Hauzeur JP, Matos C, De Maertelaer V, Toungouz M, Lambermont M. Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. A pilot study. J Bone Joint Surg Am. 2004;86:11531160. 8. Beris AE, Soucacos PN. Optimizing free fi bular grafting in femoral head osteonecrosis: the Ioannina aiming device. Clin Orthop Relat Res. 2001; (386):64-70. Current Concepts in Intramedullary Nailing of Femoral Shaft fractures CURRENT CONCEPTS IN INTRAMEDULLARY (IM) NAILING OF FEMORAL SHAFT FRACTURES Siddhartha Sharma, Hitesh Gopalan U INTRODUCTION Intramedullary (IM) nailing is one of the preferred methods for treatment of femoral diaphyseal fractures. Successful intramedullary nailing results in a short hospital stay, a rapid return of motion in all joints, prompt return to walking, and a relatively short total disability time. HISTORY & EVOLUTION 1) IM nailing was first described by Gerhard Kuntscher, a German orthopaedist in the 1940s and the device came to be known by his name viz. K Nail. 2) Various generations of nails have been described as follows: a) First Generation Nails i) Have a characteristic longitudinal slot along the entire length of the nail.

ii) Examples: K Nail, Grosse Kempf Nail (has a proximal portion which is tubular and allows better purchase and insertion of proximal locking screws). b) Second Generation Nails i) These are tubular nails without the slot and have provision for proximal and distal locking bolts. ii) Examples: Russel Taylor Nail (has a clover leaf cross section) and Delta Nail (triangular cross section, thicker wall and thinner diameter). c) Third Generation Nails i) Are made from titanium alloys and may be solid or tubular. ii) Examples: Trigen Nail, Universal Femoral Nail (Synthes) INDICATIONS OF IM NAILING: 1) Transverse and short oblique fractures of the femoral shaft. 2) Comminuted Fractures: The nail should always be locked 3) Pathological fractures CONTRAINDICATIONS OF IM NAILING 1. Absolute but correctable contraindications: Hypovolemia, Hypothermia and coagulopathy. 2. Relative Contraindications: presence of previously inserted devices and pre existing deformity. 3. A narrow medullary canal may rule out IM nailing as an operative option. PRE OPERATIVE PLANNING 1. Good quality Anteroposterior and lateral radiographs of the injured extremity should be obtained to know about the fracture

pattern, presence of comminution, medullary canal dimensions and the amount of femoral bow. 2. Length of IM nail: corresponds approximately to the distance between the tip of greater trochanter and the lateral epicondyle of femur. This can be measured directly on the uninjured extremity with a long ruler or on a radiograph, after correcting for magnification. 3. Pre operative skeletal traction is advisable. Many patients can have unpredictable delays in operation and traction maintains femoral length, prevents further soft tissue injury, limits the ongoing blood loss and provides patient comfort. A 2 mm pin inserted through the distal femur adequately tensioned on a traction bow and utilizing approximately 15 20 pounds of weight is recommended. TECHNIQUES OF IM NAILING 1) Antegrade Nailing. 2) Retrograde Nailing. ANTEGRADE IM NAILING 1) Most commonly used technique 2) Can be done via the Piriformis fossa or Trochanteric entry portals 3) Supine or lateral decubitus positions may be employed. ANTEGRADE NAILING - PATIENT POSITIONING: SUPINE VS LATERAL SNo 1. Technique SUPINE POSITION Fracture table used, traction applied to affected limb Normal limb: May be LATERAL POSITION Lateral decubitus position

placed in hemilithotomy position, widely abducted or scissored 2. Advantages A. Ease of access for anaesthesiologist & nursing team B. Ease of imaging the entire femur C. Ideal for bilateral cases, cases with associated acetabular fractures, polytrauma patients and associated spine injuries (radiolucent table should be used instead of fracture table). 3. Disadvantages A. Difficult access to entry A. Difficulty in point in case of obese imaging the patients proximal fragment B. Increased compartment pressures in the normalleg, especially with hemilithotomy position ANTEGRADE NAILING - ENTRY PORTALS SNo 1. Location PIRIFORMIS FOSSA PORTAL In the Piriformis Fossa, at the junction of anterior TROCHANTERIC PORTAL From the Greater B. Difficulty in assessing rotation C. Distal fragment tends to tilt into valgus Improved access to Piriformis fossa (therefore better for obese patients)

2/3rdwith posterior 1/3rd

Trochanter, just lateral to the long axis of the femur A. Technically easier to obtain, especially in obese patients B. It is more forgiving in terms of anterior translation as the bone is cancellous here. Since it is offset, there are higher chances of iatrogenic comminution and varus malalignment.

2.

Advantages

Colinear trajectory with the femoral shaft and therefore decreased risk of iatrogenic comminution & varus malalignment

3.

Disadvantages A. Difficult to obtain in the obese patient B. Sensitive to anteroposterior translation: anterior positioning can cause iatrogenic bursting of proximal fragment due to increased hoop stresses.

RETROGRADE IM NAILING INDICATIONS 1. Difficult access to proximal femur: Obese patients, Pregnant patients 2. Ipsilateral Pelvic fractures, femoral neck fractures, Patellar fractures, or Tibial fractures (floating knee).

3. Associated vascular injury, spinal injury or polytrauma patients: rapid stabilization of the femoral fracture can be achieved with the patient placed in the supine position on a radiolucent fracture table. 4. Distal metaphyseal fractures. DISADVANTAGES 1. Limited knee range of motion 2. Patella baja: inadequate room for the nail between the patella and the tibial condyle with the knee in flexion. 3. Open fractures: risk of septic arthritis of the knee ENTRY PORTAL At the Blumensaat line, 1 cm anterior to the origin of Posterior Cruciate Ligament (PCL). RETROGRADE NAILING - PEARLS & PITFALLS 1. Use of reamed and snug fit locked nails is essential to avoid delayed union and non union. 2. The distal tip of the nail must be countersunk into the subchondral bone of the distal femur. This will prevent its impingement on the patella in knee flexion. 3. The nailed should be locked doubly distally. This prevents telescoping of the nail distally into the knee joint which can occur in cases of comminuted fractures. REAMED Vs UNREAMED NAILING ADVANTAGES OF REAMED NAILING Reamed nailing remains the gold standard for IM nails. Prospective randomized controlled trials have shown reamed IM nailing to have union rates approaching 99% with low complication rates. The overall better healing rates can be attributed to:

1. Increased cortical contact area of the nail & thereby better stability. 2. Beneficial inflammatory response to reaming. 3. Deposition of local bone graft at the fracture site. DISADVANTAGES OF REAMED NAILING These are mainly theoretical and include: 1) Increased marrow pressures, pulmonary artery pressures and higher rates of fat embolism. a) These phenomenon have been demonstrated only in animal studies. b) The phenomenon of embolism is limited & transient. c) The rates of fat embolism in reamed and unreamed nails are similar. d) Fat extravasation is greatest during insertion of nail in the medullary cavity and is not dependent upon increased intra medullary pressure. 2) Endosteal thermal damage & endosteal cortical blood supply disruption. a) The disrupted endosteal blood supply regenerates rapidly and this accounts for high healing rates with reamed nails. b) However, thermal damage should be minimized by using sharp reamers with deep cutting flutes. The process of reaming should be slow and smooth. SPECIAL CASES 1. OPEN FRACTURES

a. These are much less common than in the tibia, and a good soft tissue cover around the femur accounts for the fact that extensive soft tissue injury must occur before the compounding takes place. Small skin wounds may disguise severe underlying muscle and periosteal injury. b. The most important risk factor in the development of infection is the severity of initial trauma rather than the timing of initial debridement. It is therefore prudent to wait for the medical condition of the patient to stabilize before proceeding onto management of the open fracture. c. The principles of treatment are the same as for other open fractures. All non viable tissues should be debrided and thorough lavage done. Debridement should be repeated at 24 48 hours in case of highly contaminated fractures. d. The only contraindication to immediate IM nailing in an open fracture is a case with grossly contaminated medullary canal and severe soft tissue damage. In such cases, provisional external fixation is done to permit serial debridement and thorough lavage. Once the canal has been thoroughly cleansed, conversion to intra medullary nailing may be done. e. Most gunshot injuries need debridement of the entry and exit wounds only. The deeper tissues may be left as such. Exceptions to this rule include close range shotgun injuries and high velocity gunshot injuries, which are managed as other open femoral fractures. 2. POLYTRAUMA a. The timing of IM nailing in polytrauma patients should be optimized to prevent further deterioration of the patients medical status. b. IM nailing is associated with release of inflammatory mediators, surgical blood loss and hypothermia, which may jeopardise

borderline polytrauma patients, especially those with pulmonary compromise. c. It is therefore prudent to follow the principle of damage control orthopaedics. Fracture stabilization can be achieved in a quick and effective manner by using monolateral external fixators. This can be converted to IM nailing once the patients medical condition improves and there are no signs of pin track infection. d. Recently,Unreamed retrograde nailing with or without proximal locking has been advocated as an alternative to external fixation in such cases. 3. VASCULAR & NEUROLOGICAL INJURY a. These are rare injuries and are associated with penetrating trauma. b. Traditionally, treatment protocols center on skeletal stabilization followed by vascular repair. The monolateral external fixator can be applied rapidly and the fixation can be converted to IM nailing within two weeks, having ensured that there are no pin site infections. c. However, recent clinical evidence has shown that vascular repair can be done immediately and definitive skeletal stabilization can be safely accomplished subsequently. Reversing the traditional sequence has the advantage of reducing the ischemia time and avoiding the need for a fasciotomy. Definitive fracture fixation can be performed afterwards without the danger of disrupting the vascular repair. 4. IPSILATERAL FEMORAL SHAFT AND PROXIMAL FEMORAL FRACTURES a. Up to 9% of all femoral shaft fractures are associated with ipsilateral femoral neck or intertrochanteric fractures. b. 25 60% of these fractures are minimally displaced and are therefore easily missed. The diagnostic yield of such injuries can be

improved by using dedicated internal rotation radiographs of the pelvis or Computed Tomographic Scans with fine cuts. c. The treatment plan is dictated by the femoral neck fracture. Optimal treatment is a must for the femoral neck fracture, though it may not necessarily be dealt with initially. d. Some occult non displaced fractures of the femoral neck can get displaced during IM nailing. Therefore, it is prudent to rule out such fractures in every case of IM nailing on the image intensifier preoperatively and after the nailing procedure. This practice helps in avoiding the delay in diagnosis of such injuries and prevents the devastating complication of avascular necrosis of the femoral head. e. The different treatment strategies include: i. A retrograde nail or plating for the femoral shaft fracture along with cannulated screws or sliding hip screw for femoral neck fracture. ii. A reconstruction IM nail to address both the fractures simultaneously. iii. In cases of high energy trauma, the femoral neck fractures are vertically oriented midcervial fractures that are inherently unstable. In such cases, a sliding hip screw combined with an antirotation screw is biomechanically better than multiple cannulated screws. 5. OBESE PATIENTS a. The difficulty in obese patients lies in obtaining a proper entry portal through the piriformis fossa. b. IM nailing through the trochanteric entry portal using a nail with a proximal lateral bend can be useful in such cases. Another option is to perform retrograde nailing. COMPLICATIONS OF INTRAMEDULLARY NAILING 1. INTRAOPERATIVE COMPLICATIONS

a. Complications related to positioning: i. Compartment Syndrome: occurs in the normal limb when it is placed in the hemilithotomy position for the supine approach. ii. Pudendal Nerve Palsy: can occur due to hip adduction and excessive traction. Most of the cases are transient and show full recovery. b. Complications related to entry portal: i. With piriformis fossa entry portal: A portal that is too medial or too lateral may cause fracture of the femoral neck or the greater trochanter respectively. A portal that is too anterior will result in excessive hoop stresses and lead to bursting of the proximal fragment. ii. With the trochanteric entry portal: There are chances of iatrogenic comminution and varus malalignment. This can be minimized by using nails with a proximal lateral bend. c. Complications related to reaming & nail insertion: i. Thermal necrosis and fat embolism: Though the risk is theoretical, it can be prevented by using sharp reamers with deep flutes that are passed down the canal in a slow and gradual fashion. ii. Iatrogenic comminution: This can be prevented by choosing a proper sized nail i.e. 1 -1.5 mm less than the largest reamer used. The fracture should be kept well reduced during nail insertion. iii. Malalignment: This can be prevented by ensuring central placement of the guide wire in the distal fragment. d. Complications related to locking: i. Overzealous drilling can lead to vascular injury and pseudoaneurysm formation.

ii. Proximal locking screws of the retrograde IM nail can injure branches of the femoral nerve. This complication can be minimized by inserting these screws above the level of the lesser trochanter. 2. POST OPERATIVE COMPLICATIONS a. Malunion i. ANGULAR MALUNION: This is most commonly seen in proximal (30%) and distal (10%) femoral fractures. This is because the interference fit of the nail is not good enough in these situations to ensure adequate alignment. It can be prevented by using blocking screws and choosing a nail that is 1 mm smaller than the largest reamer used so as to ensure a snug fit. ii. ROTATIONAL MALUNION: Proper limb rotation can be ascertained by observing the alignment of the anterior superior iliac spine, the patella and the second toe. A comparison with the normal side should also be made. If rotational malalignment is identified per operatively, it can be corrected by removing the distal locking screws, correcting the rotation and reinserting the screws. CT Scan can help in better evaluation of rotational malunions. Symptomatic rotational malunions can be treated by an osteotomy, either open or with an IM saw. b. Nonunion i. The rates of non union with IM nailing are low (<10%), regardless of technique chosen.

ii. Deep seated infection should always be ruled out as a cause of non-union and adequately treated prior to surgical treatment for non union. iii. The different treatment modalities include: Dynamization: This is a useful technique for fractures with distraction. Dynamization allows compression at the fracture site. Success rates vary from 54% - 92.3%. Exchange Nailing: This may be used for cases of failed dynamization, atrophic changes or bony defects. Success rates vary from 53% - 96%. Plating and bone grafting: This is especially useful for recalcitrant non unions. However, a thorough search must be undertaken to identify and correct any metabolic disturbances prior to such a procedure. c. Infection i. The overall infection rates with IM nailing are low (1% - 3.8%). ii. Infections may be categorised as: Early Infection (< 3 months): Such cases are treated by nail retention, serial debridement and organism specific intravenous antibiotics. Nail removal is indicated only if the infection cannot be controlled. In such cases, external fixation or antibiotic coated cement nails may be used. Antibiotic coated cement nails can be created over guide wires or other suitable substrates. Although the fixation is not as good as an external fixator, the dead space in the medullary cavity is filled up and high concentrations of antibiotic are delivered. Chronic Infection: Is treated along the lines of chronic osteomyelitis. The aim is to eradicate infection prior to definitive fixation. The IM nail is removed and the medullary canal reamed to allow debridement. Organism specific intravenous antibiotics along

with local antibiotic therapy, in the form of antibiotic beads or cement spacers are used for 6 weeks. Host factors, such as smoking, malnutrition and any metabolic disorder are addressed. Regular monitoring is done which includes both clinical and laboratory examinations (Complete Blood Count, Erythrocyte Sedimentation Rates, C Reactive Protein). If there is still any doubt, fresh frozen tissue sections can be obtained intra operatively at the time of definitive reconstruction. d. Leg Length Discrepancy: i. This complication occurs in up to 43% of comminuted femoral shaft fractures. ii. Peroperatively, limb length should be ascertained using a radio opaque ruler and compared with the normal side. In the immediate postoperative period, clinical examination, scanogram or CT Scan can be used to identify leg length discrepancy. iii. If identified per operatively or in the immediate post operative period, the nail should be relocked at the correct length. e. Heterotopic ossification: i. This may occur at the site of nail insertion and is usually of no significance. ii. Large masses can be excised if they are painful and limit motion. f. Hardware Prominence: i. Most commonly seen in case of distal locking screws of the retrograde IM nail. ii. Knee pain may occur with retrograde nails if the nail is not countersunk properly and impinges against the patella in knee flexion. This may warrant removal if the fracture has united or revision if the fracture has not united, to prevent damage to the articular surface of patella.

REFERENCES 1) Canale ST, Beaty JH. Fractures of the lower extremity. In: Kay Daugherty LJ, editor. Campbell's Operative Orthopedics. 11th ed. Philadelphia: Elsevier; 2007. p. 3193 - 217. 2) Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: current concepts. J Am Acad Orthop Surg. [Review]. 2009 May;17(5):296-305. 3) Ricci WM. Femur: Trauma. In: Berry DJ, Raikin SM, editors. Orthopedic Knowledge Update 8. Rosemont: American Academy of Orthopaedic Surgeons; 2005. p. 425 - 32. 4) Nork SE. Femoral shaft fractures. In: Buchholz RW, Heckman JD, Court-Brown CM, Tornetta P editors. Rockwood and Greens Fractures in Adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. p. 1655 - 1719. Tibial Plateau Fractures Tibial Plateau Fractures Anatomical Pearls: The articular surface of the lateral tibial plateau is flat or slightly convex in relation to the medial tibial plateau that is concave, which provides greater congruity with the medial femoral condyle than on the lateral side. The lateral plateau is also higher than the medial plateau, accounting for the few degrees of varus of the tibial plateau in relation to the shaft. The most commonly used approaches for surgical fixation of tibial plateau fractures are the anterolateral approach and the posteromedial approach.

Stronger, denser subchondral bone is found on the medial side due to increased load. The posterior cruciate ligament attaches about 1 cm below the joint line on the posterior ridge of the tibial plateau and a few millimeters lateral to the tibial tubercle. Classification Schatzker Classification Type I: Lateral plateau, split fracture Type II: Lateral plateau, split depression fracture Type III: Lateral plateau, depression fracture Type IV: Medial plateau fracture Type V: Bicondylar plateau fracture Type VI: Plateau fracture with metaphyseal diaphyseal dissociation. AO classification A -non articular A1.-avulsions A2 simple metaphyseal A3 comminuted metaphyseal B Partial articular B1 pure split B2 pure depression B3 split depression C complete articular C1- simple C2- articular simple, metaphyseal comminuted C3- articular comminution Biomechanics:

The relative strength of the medial plateau, the valgus anatomic axis of the lower extremity, and the susceptibility of the leg to a medially directed force all lead to a prevalence of lateral-side injuries in lowenergy fractures. Schatzker types I through III are low-energy injuries, whereas types IV through VI involve increasingly higher energy injuries Isolated medial plateau injuries represent more severe injury mechanisms Such injuries typically involve both lateral collateral and anterior cruciate ligament injuries and can result in a fracture dislocation of the knee Clinical Features: Look for associated haemarthrosis An open wound may communicate with the knee joint. This can be identified by injecting 50cc of saline into the joint and looking for its appearance into the wound Watch out for compartment syndrome The anklebrachial index of the extremity, along with ultra-sound examination of the leg, can be helpful in fully evaluating the possibility of vascular injury, Imaging: Knee AP. Lateral, medial and lateral oblique views and 15 caudal view Coronal plane split fractures, which are commonly found within the medial plateau and are difficult to visualize on the anteroposterior projection alone and are best identified in a lateral view

3D CT helps to plan surgery MRI may help in identifying the status of the injured ligaments and menisci, but it doubtful whether this imaging will improve patient outcome. Traction radiographs provide ligamentotaxis to assist in a partial fracture reduction, preventing overlap of fragments and elucidating the fracture pattern. Treatment Types I to III Schatzker: Non operative treatment for fractures, which are minimally displaced (<5 mm) and stable in varus-valgus stress test. Also for nonambulatory patients and surgically unfit patients. Mobilisation is begun on a hinged knee brace. Weight-bearing is delayed for 8- 12 weeks Depression or displacement exceeds 10 mm: surgery to elevate and restore the joint surface is indicated. - When articular depression is between 5-10 mm, other factors like age, activity of the patient, associated injuries should be taken into account A fracture that is undisplaced initially and later gets displaced also needs surgery Also fracture with injury to collateral ligament which requires surgery needs ORIF. Similarly varus-valgus instability that exceeds 10 needs operative stabilisation Type IV to VI: Use of MIPPO (Minimally Invasive Percutaneous Plate Osteosynthesis) technique. In high energy injuries with significant soft tissue injuries, a temporary spanning external fixation maybe used initially and definitive fixation maybe delayed until the soft tissues heal (Anglen JO et al..)

In high energy injuries, it is more important to restore overall joint congruity, coronal and sagittal plane alignment than obtaining perfect anatomical reduction of joint depression(Kettelkamp DB et al..) Limited ORIF uses Ligamentotaxis, to show which fragments can be restored without direct surgical intervention. Indirect reduction is achieved by Ligamentotaxis by external fixation or a femoral distractor or simple traction on the lower extremity. The two most commonly used approached are the anterolateral approach and the posteromedial approach - A submeniscal arthrotomy maybe done by incising the coronary ligament to evaluate the menisci and repair them - The posteromedial approach is through the interval between the medial head of gastrocnemius and the pes anserinus tendons - The posteromedial approach is used to reduce and fix the posteromedial fragment - Extensile approaches through the anterior aspect of the knee(similar to TKA exposure) are less favoured for dual plating Partial incision of IT band will help to visualize further the lateral tibial plateau. Most of the meniscal injuries are peripheral rim tears and may be repaired in a horizontal mattress fashion to the capsule After reduction is achieved periarticular reduction clamps can be used to close the unicondylar or bicondylar fragments. Direct elevation of the depressed fragment may also be done The bone void that is created is restored with bone grafts or bone graft substitutes (calcium sulphate or calcium phosphate bone cements). Care must be taken not to allow extravasation of cement into the articular surface, hence screws must be placed before cement injection or when cement is in the moldable phase

A periarticular plate (LCP) construct is used to fix the fragments An LCP may help avoid dual plating that is often done for Schatzker V and VI fracture subtypes. - The medial condyle can be stabilized with lateral locking plates, provided multiple locking screws engage the medial fragment - When compression is required between the medial and lateral fragment, nonlocked lag screws should be used before placing locked screws across the fracture line. - But in the presence of a posteromedial fragment it will need fixation via an additional posteromedial approach. - A minority of fractures, those with a bicondylar posterior shearing injury pattern, may benefit from a direct posterior exposure. Loss of articular reduction can be prevented by using multiple parallel screws in the subchondral area, these screws have been termed raft screws MIPPO: medial or lateral plating can be done depending on the type of injury. Plating is easier on the medial surface since the medial tibia is subcutaneous. On the lateral surface, the submuscular plane is identified and the plate is slid. Associated Ligament Injuries: Most authors agree that ligament(MCL/LCL) repair is not necessary in the acute setting Arthroscopically assisted reduction: advantages are treatment of associated ligament injuries and meniscal injuries. A potential complication of this technique is extravasation of arthroscopy fluid into the lower extremity compartment and risk for compartment syndrome.

The risk of fluid extravasation can be minimized by going dry during the reduction stage and by making an incision where the plate or screws will be placed to allow the fluid to escape References: Anglen JO, Aleto T: Temporary transarticular external fixation of the knee and ankle. J Orthop Trauma 1998; 12: 431-434. Kettelkamp DB, Hillberry BM, Murrish DE, Heck DA: Degenerative arthritis of the knee secondary to fracture malunion. Clin Orthop 1988; 234:159-169. Mueller KL, Karunakar MA, Frankenburg EP, Scott DS: Bicondylar tibial plateau fractures: A biomechanical study. Clin Orthop 2003;412:189- 195. Goesling T, Frenk A, Appenzeller A, Garapati R, Marti A, Krettek C: LISS PLT: Design, mechanical and biomechanical characteristics. Injury 2003; 34(suppl 1):A11-A15 DNB December 2010 Theory papers Paper 1 1. Define neuropathic joint. List the causes of neuropathic joint. Mention in brief the clinical features, diagnosis and treatment of neuropathic joint. 2. Define gout. Describe in brief its clinical features, diagnosis and treatment.? 3. Describe the broad principles of tendon transfer. Enumerate the tendon transfer for high radial nerve palsy. 4. Discuss the indications of surgery in TB spine with or without neurological complications. 5. Draw a labeled diagram of brachial plexus. Classify brachial plexus injury. Describe the clinical features and management of lower brachial plexus injury.

6. Describe various types of lumbar root anomalies. List the complications of lumbar disc surgery. 7. Define "Fat Embolism Syndrome". Describe in brief the clinical features, diagnosis and management of "Fat Embolism Syndrome". 8. Define Giant Cell Tumor (GCT) of bone. Describe in brief clinical features, diagnosis and management principles of GCT of upper end of tibia. 9. Describe aetiopathogenesis of avascular necrosis of hip. Classify avascular necrosis of hip. Comment on broad principles of its management. 10. Define ochronotic arthropathy. Describe its clinical features, diagnosis and management. Paper 2

1. Define congenital muscular torticollis. List the differential diagnosis and outline the management of congenital muscular torticollis. 2. Describe the blood supply of scaphoid. Describe the clinical features, diagnosis and management of nonunion of scaphoid. 3. Define ulnar claw hand. Enumerate the causes of ulnar claw hand. Discuss its management. 4. Describe Dupuytren disease and its characteristic f,eatures. Describe in brief its pathogenesis prognosis and management. 5. Describe the hand deformities in rheumatoid arthritis. Describe in brief the Patho-anatomy and treatment of Boutonneire deformity. 6. Define pseudoarthrosis of tibia. Describe its pathogenesis, diagnosis, classification and management 7. Define Legg Calves Perthes disease. Describe its clinical features, diagnosis and management 8. Classify physeal injuries. Describe the management and complications of various types of physeal injuries. 9. List the causes of limp in a child.

10. Describe the Pathology and radiological signs in rickets and scurvy. Paper 3 I. Classify proximal humerus fracture. Discuss the management options for various types. Outline the management for type IV fracture in elderly females. 2. Describe pitfalls in using the Locking Compression Plate. 3. Classify open fractures of tibia. Describe the management of type 3 b open fracture of tibia. 4. Describe briefly the etiology, clinical features, diagnosis, investigations and treatment of painful elbow following injury around elbow. 5. Describe classification of Monteggia fracture dislocation and its management. 6. Define nonunion. Describe the classification and broad principles of management of diaphyseal nonunion. 7. Define Tension Band principle. Describe the use of Tension Band principle in fracture surgery. 8. Define external fixation. Classify the external fixators. Describe the advantages and disadvantages of external fixation. 9. Classify thoracolumbar spine injuries. Give radiological classification of burst fracture. Outline the management of burst fracture of LI vertebra. 10. Describe various methods of treatment of distal radius fracture with their principles.

Paper 4 1. Describe different types of bone grafts along with their properties. 2. Describe the phases of normal gait and the types of muscle contractions in gait cycle. 3. Write short note on Nuclear medicine and its applications in

Orthopedics. 4. What is flap reconstruction? Write its classification. 5. What are the types of epiphysis? Describe the types, various methods and indications of epiphysiodesis. 6. Write short note on Coxa Vara. 7. Describe pathogenesis of acute compartment syndrome and its diagnosis. 8. Name biomaterials used in orthopedics. Describe in brief their features. 9. Describe nerve injuries, Sunderland Classification, outcome expected and basis of repair. 10. Describe the various foot and ankle deformities in cerebral palsy and their management. Anterior Shoulder Instability Definition Stabilizing Factors Tests - LAXITY TESTS, INSTABILITY TESTS Imaging Radiographs, CT, MRI, MR arthrography Classification, Matsens TUBS & AMBRII Surgical options: Anatomic Reconstruction (Bankart Repair and Montgomery and Jobe modification); Non-Anatomic Reconstruction (Bristow Latarjet Procedure, PuttiPlatt Procedure, Magnuson Stack Procedure, Neers, OBrien) Current Recommendations Clinical Scenarios Definition of Shoulder Instability:- Abnormal symptomatic motion of the humeral head relative to the glenoid during active shoulder motion.

Stabilizing Factors: The mechanisms providing stability can be categorized as static

and dynamic. The rotator cuff muscles form the dynamic stabilizers whereas the articular anatomy and the capsuloligamentous complex form the static stabilizers. In all, the glenohumeral joint is stabilized by following key elements: 1. Concavity of the glenoid 2. The muscles that compress the humeral head into the glenoid. 3. The coracoacromial arch 4. The capsuloligamentous restraints 5. Adhesion-cohesion of the articular surfaces The above mentioned elements function inter-dependently to keep the humeral head stable in the glenoid cup. Deficiencies or defects in any of these structures or incoordination between the structures can lead to instability. Factors influencing probability of recurrent dislocation: 1. Age, 2. return to contact/collision sports, 3. bony defect (glenoid /humeral head) Glenoid Concavity The glenoid concavity is formed by three components: 1. the osseous glenoid - slightly concave 2. the articular cartilage - thicker at the periphery and thinner in the center making the concavity deeper and 3. the glenoid labrum - further deepens the glenoid concavity by 50% The concavity of the glenoid provides stability to the humeral head similar to a ball which sits at the centre of a concave surface. The adequacy of the glenoid concavity in different directions can be assessed clinically by the load-and-shift test.

Muscles that compress the humeral head The humeral head is compressed into the glenoid by the muscles of the rotator cuff and other scapulohumeral and thoracohumeral

muscles. Subscapularis - primary anterior compressor Supraspinatus - primary superior compressor Infraspinatus primary posterior compressor (assisted by teres minor) The rotator cuff muscles function as head compressors in almost any position of the glenohumeral joint, except the terminal range. Other muscles, such as deltoid, long head of the biceps, pectoralis, latissimus, teres major and pectoralis major contribute to humeroglenoid compression in certain other positions. For example, deltoid becomes a strong compressor of the head into the glenoid when the arm is abducted 90. Paralysis, detachment, or dysfunction of any of the rotator cuff muscles results in loss of humeral head compression.

The Glenohumeral Ligaments and Capsule During rotation of the arm, the glenohumeral ligaments and capsule tighten and loosen reciprocally, thus limiting translations and rotations in a load-sharing fashion. The glenohumeral capsule and its associated ligaments are lax and do not exert a centering effect in mid-range positions (Compare muscular stabilizers). However at the extremes of motion, these structures become important contributors to humeral centering. They prevent humeral rotation beyond the point where the muscles are effective. Adhesion-Cohesion The surfaces of the humeral and glenoid cartilage and the surfaces of the coracoacromial arch and the proximal humeral convexity adhere to each other because of the adhesive and cohesive properties of water molecules giving a smooth glide for the surfaces while simultaneously preventing them from separating.

The Suction Cup Mechanism The negative intra-articular pressure in the joint makes the pliable labrum centered by a non-compliant osseous glenoid stick to the humeral head like a suction cup. Both the adhesion-cohesion and the suction-cup mechanism are non-energy- consuming. Conditions where these mechanisms are lost: 1) fracture of the glenoid lip, 2) when the joint surfaces are not covered with smooth wettable hyaline cartilage eg. Glenohumeral arthritis or following total shoulder replacement, 3) both are also lost when there is joint effusion or hemarthrosis. Evaluation of Glenohumeral Instability: Patient History Age of 1st dislocation event or instability- Younger the age, higher is the chance of recurrent instability. <20yrs->40yrs 10%,but more tendency to fracture with dislocation Onset- Traumatic or Atraumatic o History of trauma? o Frank dislocation that required manual reduction or a subjective feeling of instability of the shoulder (subluxation)? Position of the arm at the time of instability- To know if the dislocation was anterior or posterior Any particular position or movement exaggerating the pain or produces sense of instability? The number of discrete instability events and the degree of disability? The ability to voluntarily dislocate the joint? Surgical management of instability in this patient population may result in high rates of recurrence. Physical examination Physical examination for shoulder instability can be divided into two main groups:

(1) tests for glenohumeral laxity and (2) tests for glenohumeral instability. (3) tests for generalized ligamentous laxity Laxity Tests: Anterior Drawer Test Quantifies the amount of anterior translation. Patient lying supine, examiner stands at the ipsilateral side of the affected extremity. The patients hand is positioned in the examiners axilla. The shoulder is in 80o to 120o of abduction, 0o to 20o of forward flexion, and 0o to 30o of external rotation. The scapula is stabilized with one hand. The other hand grasps the proximal humeral shaft and exerts an anterior force. The amount of translation is quantified. Posterior Drawer Patient in supine position. For left shoulder, the patients left wrist and forearm is held with the elbow flexed to 120o. With the shoulder in 80o to 120o of abduction and 60o to 80o of forward flexion and internal rotation, a posterior force is applied on the arm. The amount of posterior translation is assessed by the hand stabilizing the scapula. Lachman test Patient supine, extremity in various degrees of abduction and external rotation in the plane of the scapula. Anterior stress is applied to proximal humerus. The amount of translation and the end point are evaluated. Anterior and Posterior Load and Shift Test Supine position with arm in 20o of abduction, 20o of forward flexion and neutral rotation or upright position with arm by the side of torso. The examiner grasps upper arm and applies an axial load perpendicular to the articular surface of the glenoid. Anterior or posterior-directed forces are then applied the humeral head and translation relative to the glenoid is measured. Gage Hyperabduction Test

 It is a measure of laxity of the inferior glenohumeral ligament complex. The test is performed with the patient sitting and the examiner standing behind. With one hand stabilizing the scapula, the other hand is used to abduct the affected shoulder. The amount of abduction measured before the initiation of scapula motion is recorded. The amount of abduction where glenohumeral motion ends and scapulothoracic motion begins is the passive motion of the shoulder in abduction. A value greater than 105o is suggestive of inferior glenohumeral ligament laxity. Sulcus Sign It is positive when there is increased inferior translation of the humeral head relative to the glenoid with applied downward traction in patients with inferior and multidirectional instability. The sulcus should be measured at both neutral and 30o of external rotation. Elimination of the sulcus sign with external rotation suggests competency of the rotator interval; persistence of sulcus sign at 30o of external rotation suggests a lax rotator interval. Grading of Humeral Translation grade 0 - Minimal inferior translation grade I 0 to 1 cm translation (or) greater than the opposite uninvolved extremity grade II - 1 to 2 cm translation (or) humeral head translation to the glenoid rim grade III - greater than 2.0 cm translation (or) translation over the glenoid rim grade IV - indicates dislocation during testing Instability Tests: Apprehension Test Patient in supine or upright position. Anterior apprehension test:

 Affected shoulder is passively moved to abduction and maximum external rotation and a gentle anterior force is placed on the posterior humeral head. Test is positive when the patient becomes apprehensive and experiences pain. Posterior apprehension test The affected shoulder is adducted and internally rotated. Apprehension-Relocation Test: After apprehension test, a posterior-directed force is applied to the anterior humeral head. There is relief of apprehension. This is also called Fowlers sign. Anterior Release and Surprise Test The patient is in the supine position. The affected shoulder is held over the edge of the examiners table. The arm is positioned in 90o of abduction. A posterior directed force is applied to the anterior humeral head while simultaneously moving the shoulder to maximum external rotation. The posterior force is then released. The test is positive when the patient experiences pain and apprehension. Imaging: Radiographs: Basic Views True anteroposterior (AP) view of the G-H joint Supraspinatous Outlet View (SSOV) also called lateral or Y view in the scapular plane and an Axillary view Special Views Stryker-notch view: For Hillsachs Lesion Patient lying supine with the cassette placed posterior to the shoulder. The hand of the affected extremity is placed on top of the head with the elbow pointing straight upward. The radiograph beam is directed 10o cephalad and centered over the coracoid process. West Point axillary view:

 For Bony Bankart or Glenoid fracture. Patient lying prone with the affected shoulder resting on a pad. The radiograph beam is aimed 25o from the horizontal plane (angled toward the table surface) and 25o toward the patients midline. CT scan Useful for assessing bone defects on humeral or glenoid side. CT scan should be considered if patient reports instability at low abduction angles or has marked apprehension at low abduction/external rotation during provocative testing To determine the percentage of defect, the area of bone loss is divided by the area of a circle based on the inferior glenoid and the quotient is multiplied by 100% MRI and MR arthrography Gold standard for evaluating the capsulolabral structures especially the Bankarts lesion (Detachment of anterioinferior glenoid labrum and the inferior gleno-humeral ligament from the glenoid). The addition of contrast can improve the ability of MRI to show rotator cuff pathology, humeral avulsion of glenohumeral ligament(HAGL), capsular tears Examination under anesthesia confirms laxity but not instability. Arthroscopy is an excellent technique for confirming shoulder instability. Classification: Shoulder instability can be classified based on the direction, degree, and duration of symptoms and direction of instability should be categorized as unidirectional, bidirectional, or multidirectional. Matsens Classification TUBS: Traumatic, Unidirectional , with a Bankarts lesion, requires Surgery and AMBRII: Atraumatic, Multidirectional and Bilateral, responds to

Rehabilitation, occasionally requires an Inferior capsular shift and Internal closure. Surgical options: Checklist for treating Shoulder Instability 1. Unidirectional/ Multidirectional. 2. Status of Dynamic stabilizers (Rotator cuff and Long head of Biceps). 3. Status of Capsuloligamentous structures (Glenohumeral ligaments/ Capsule). 4. Status of articulating bones (Humeral head defect/ Glenoid bone deficiency). Anatomic Reconstruction Bankart Repair Principle: Reattachment of the antero-inferior glenoid labrum and the IGHL back to the glenoid anatomically. Procedure: Open/ Arthroscopic Subscapularis and anterior capsule are opened vertically. Lateral leaf of capsule is attached to anterior glenoid rim. Medial leaf is imbricated and subscapularis is approximated. Adv: Corrects labral defect, no metallic internal fixation device required. Disadv: Technical difficulty, restriction of external rotation. Modified Bankart repair: Modified by Montgomery and Jobe. Anterior capsule imbricated in north-south direction. Hence external rotation not lost. Keys to success of Bankart surgery 1. Abrading the scapular neck 2. Restoring glenoid concavity 3. Anatomical capsular fixation at the edge of glenoid 4. Superior and inferior capsular advancement and imbrication 5. Goal oriented rehabilitation

Non-Anatomic Reconstruction Bristow Latarjet Procedure- Transfer of coracoid to anterior glenoid rim Putti- Platt Procedure- Reefing the subscapularis and anterior capsule of the shoulder joint. Magnuson Stack Procedure- Lateral transfer of the subscapularis tendon attachment. Inferior Capsular Shift (Neers procedure)- Described for Multidirectional instability to reduce the volume of the joint. T shaped incision starting from the glenoid neck. Obliterates the capsular redundancy on the side of surgery and also on the opposite side. OBrien modification of Neer procedure: Capsular shift procedure with the T portion of the incision starting adjacent to the glenoid. Allows much easier repair of a detached glenoid labrum if present. - Weber osteotomy: Subcapital rotational osteotomy of proximal humerus for large humeral defects. The procedure rotates the defect to a more posterolateral position to avoid levering of the humeral head on the glenoid at the Hill-Sachs lesion. Anterior instability without bony defect - Anatomic reconstruction (Bankart repair) Anterior instability with humeral head defect of <20% - Reduction + Immobilisation/ Bankart anterior stabilisation 20-30%: Acute-Disimpaction; Old-Bankart repair 30-45% - As above/ Bone graft/ Weber osteotomy >45% - Prosthetic replacement Anterior instability with anteroinferior glenoid defect of <20% - Bankart repair >20% - Bone graft/ Corocoid transfer

SCHEUERMANN's DISEASE SCHEUERMANN DISEASE Hitesh Gopalan U, MS, Senthilnathan MS MD. Theories of Origin  Scheuermann proposed that the kyphosis resulted from avascular necrosis of the ring apophysis of the vertebral body.  Schmorl suggested that the vertebral wedging was caused by herniation of disc material into the vertebral body.  Ferguson implicated the persistence of anterior vascular grooves in the vertebral bodies, which create a point of structural weakness in the vertebral body, which leads to wedging and kyphosis.  Bradford et al suggested that osteoporosis may be responsible for the development of Scheuermann disease.  Mechanical factors: Common in patients who do heavy lifting or

manual labour.  Ippolito and Ponseti suggested that a biochemical abnormality of the collagen and matrix of the vertebral endplate cartilage. Criteria for Diagnosis (Sorenson criteria) More than 5 degrees of anterior wedging of at least three consecutive vertebrae at the apex of the kyphosis and vertebral endplate irregularities. Thoracic kyphosis of more than 45 degrees.

Natural history of the disease: Adult patients with mild deformity( Mean 71 degrees) present with chronic back pain. More severe defomities cause severe chronic back pain. Pulmonary compromise generally occurs if the curve is more than 100 degrees. Patients with type II Scheuermann's kyphosis almost never require surgery Classification There are two forms of Scheuermann's kyphosistype I and type II. The classic thoracic type (type I) has an apex between T7 and T9 and is associated with increased lumbar lordosis. Type I (typical) again divided into 2 types Type a(thoracic) extends from T1-2 to T12-L1 and apex at T6-T8 and type b(thoracolumbar) extends from T4-5 to L2-3 and has apex at Thoracolumbar junction. The thoracolumbar or lumbar type (type II) has a lower apex, which frequently is associated with reduced upper thoracic kyphosis or thoracic lordosis.

 Type II Scheuermann's kyphosis occurs more frequently in males in a slightly older age group (15 to 18 years). This form tends to be more painful but rarely leads to progressive deformity Clinical Features: * In Scheuermanns disease the deformity does not disappear on lying supine or with hyperextension manouevre. * Pain is usually at the apex of the deformity * Kyphosis is often rigid and cannot be corrected by hyper extension * Neurological examination is often normal, because kyphosis occurs gradually and over several segments * The onset is often after lifting heavy weight from a flexed position. * Lumbar Scheuermann is less common and the deformity is often minimal. * Rarely, thoracic disc herniation, epidural cysts, or a severe kyphosis (>100 degrees) can cause neurologic deficit in patients (usually adults) with Scheuermann's kyphosis Imaging: lateral x-rays: to measure vertebral wedging and measure Cobbs angle of deformity May also reveal vertebral end plate irregularities, narrow disc spaces and Schmorls nodes In 20% to 30% of patients, the posteroanterior x-ray shows associated mild scoliosis in the area of the kyphosis. The scoliotic apex usually corresponds with the kyphotic apex. A lateral x-ray should be examined for spondylolisthesis in addition to kyphosis. In the later stages of Scheuermann's kyphosis, x-rays may show changes of degenerative arthritis, including decreased intervertebral disc spaces, marginal osteophytes, and ankylosis

 MRI: to rule out disc herniation if patient is planned for posterior surgery Differential Diagnosis: 1. Postural kyphosis: In a forward bending test, the kyphotic deformity is accentuated, and the apex appears as a sharp angulation, in contrast to the smooth curve of a patient with postural kyphosis. A forward bending test also exposes any associated scoliosis. The hyperextension test helps the examiner understand the rigidity of the curve. A curve that is flexible or reduces significantly with hyperextension is typically postural and not Scheuermann's kyphosis, although in younger children a flexible round-back deformity may be the first sign of evolution to true Scheuermann's kyphosis. Treatment: Conservative: Bracing - effective in controlling the progression of deformity.  Indicated in patients with kyphosis less than 1year of onset, curves between 50-70 degrees and apex below T7.  Bracing is continued for at least 18 months.  Acute application of a brace can influence the deformity and improve kyphosis by 40% to 50%; however, several articles have shown at least partial loss of this correction when brace wear is stopped.  All kyphosis braces require careful orthotist attention to ensure fit and to recontour the posterior bars and pads every 2 months to gain further correction progressively. Pain usually responds to NSAID's and physical therapy.

 Surgical: i Posterior correction with or without osteotomy and fusion. i Anterior release has been recommended for deformities that do not correct to 50 degrees on stress views. i Fusion level: Current recommendations are to include the proximal end vertebra (determined by the modified Cobb method) and to extend the fusion past the transitional zone to the first lordotic disc distally i Traditional teaching is to restrict the correction to 40 degrees to prevent proximal or distal junctional kyphosis and implant pull out. i Intraoperative neurologic monitoring is crucial during any surgery to correct kyphosis because the thoracic cord is at risk during correction and instrumentation. NMEPs and SSEPs are used for this. i postoperative bracing for approximately 3 to 6 months Relative indications for surgery: Kyphosis more than 70 deg, Deformity progression despite bracing, cosmesis, neurologic deficits and failure of conservative treatment for pain. Contraindications: Asymptomatic patient without cosmetic concerns. Ref: 1. Papagelopoulos PJ, Klassen RA, Peterson HA, et al. Surgical treatment of Scheuermann's disease with segmental compression instrumentation. Clin Orthop 2001;386:139-149. 2. Otsuka NY, Hall JE, Mah JY. Posterior fusion for Scheuermann's kyphosis. Clin Orthop 1990;251:134-139. 3. Tribus CB. Scheuermann's kyphosis in adolescents and adults: diagnosis and management. J Am Acad Orthop Surg 1998;6:36-43. 4. Wenger DR, Frick SL. Scheuermann kyphosis. Spine 1999;24: 2630-2639. Intercondylar Fractures of the Elbow

INTERCONDYLAR FRACTURES Mechanism of injury: Is by a force directed towards an elbow which is flexed > 90 which causes the ulna to drive against the trochlea Riseborough and Radin Classification Type I: Nondisplaced Type II: Slight displacement with no rotation between the condylar fragment. Type III: Displacement with rotation Type IV: Severe comminution of the articular surface. Classification of Mehne and Matta: 1. High T. 2. Low T 3. Y-type 4. H-type. 5. Medial. 6. Lateral The Mehne and Matta classification describes the most often encountered fracture patterns intraoperatively. Clinical Features: 1. The elbow maybe held in 90 flexion and forearm is kept pronated 2. Crepitus may be elicited 3. Independent mobility of the medial and lateral condyle can be elicited 4. The normal 3 point bony relationship between the olecranon, medial epicondyle and lateral epicondyle is lost X-Rays: Standard AP and lateral views are obtained

CT scan is helpful to further delineate the fracture pattern Nonoperative Treatment Elderly patients with severe osteopenia and comminution or Patients with significant comorbid conditions precluding operative management. Operative Treatment Open reduction and internal fixation: Restores articular congruity Interfragmentary screws and dual-plate fixation: One plate is placed medially and another plate posterolaterally. Reconstruction plate and one-third plate are used commonly. Total elbow arthroplasty (semi constrained): May be considered in markedly comminuted fractures and in fractures with osteoporotic bone. Pearls of Internal fixation for distal humerus fractures (ODriscoll et al..) 1. olecranon osteotomy provides the best exposure of the articular surface of the distal humerus (1), but problems due to non union and symptomatic implants maybe seen 2. Alternative approaches include the triceps reflecting, anconeus pedicle, or TRAP exposure described by O'Driscoll or elevating the triceps from the posterior humerus, but leaving it attached to the olecranon(Allonso Llamas) approach(2) 3. Identify the ulnar nerve and protect it throughout the procedure. 4. Transpose the ulnar nerve if hardware is placed medially to prevent irritation from the hardware 5. Perform the olecranon osteotomy in the area of the olecranon that is normally devoid of articular cartilage. 6. Drill and tap olecranon prior to performing the osteotomy.

7. When performing the olecranon osteotomy, remember that the semilunar notch is V-shaped with the central area being the thickest (the site for the osteotomyabout 2 cm distal to the olecranon tip) 8. Create a chevron osteotomy with the apex pointing distally. 9. Anatomic reduction and preliminary fixation with Kirschner wires or interfragmentary lag screw fixation of the articular condyles 10. Fixation of the lateral column with a well-molded posterior plate 11. Fixation of the medial column with a medial plate extending down to, and on occasion wrapping around, the medial epicondyle 12. Multiple interfragmentary screws, usually through the plates or independent of the plates, to secure the fracture construct together 13. If one large fragment of the joint surface can be reduced to either medial or lateral column, it can be used to surgeons advantage. Once this stable construct has been established other fragments can be added 14. Try to place every screw in a fragment through the plate 15. If the fracture extends distally, the plates should be contoured over the respective epicondyles and placed adjacent to the articular margin 16. Distal plate placement may result in impingement during terminal elbow extension therefore, before definitive plate fixation the elbow should be examined to ensure an acceptable ROM with absent bony or soft tissue impingement 17. Some surgeons prefer cannulated screws because these can be placed over the preliminary K- wires 18. Avoid injury to the radial nerve by identifying the nerve if proximal exposure is necessary. 19. Avoid narrowing the trochlea with lag fixation in cases with articular comminution. Ref: 1. Wilkinson JM, Stanley D. Posterior surgical approaches to the

elbow: a comparative anatomic study. J Should Elbow Surg 2001;10:380-382. 2. Alonso-Llames M. Bilaterotricipital approach to the elbow. Acta Orthop Scand 1972;43:479-490. 3. Muller ME, Allgower M, Schneider R, et al. Manual of internal fixation. Techniques recommended by the AO-ASIF Group. 3rd ed. Berlin: Springer-Verlag; 1991. 4. ODriscoll SW, Jupiter JB, Cohen MS, Ring D, McKee MD: Difficult elbow fractures: Pearls and pitfalls. Instr Course Lect 2003;52:113-134. Os Trigonum Syndrome Is a cause of posterior ankle pain. The lateral (posterior) tubercle of the talus has a separate center of ossification, which appears from ages 7 to 13 years. When this fails to fuse with the body of the talus, it is called os trigonum It lies lateral to the groove for the flexor hallucis longus (FHL) tendon A cartilage connection may or may not attach the os trigonum to the talus. The os trigonum has been reported to be present in 1.7% to 7% of normal, asymptomatic feet Clinical features: gradual onset of pain, especially in the anterior aspect of the retrocalcaneal space Pain is recreated by forced plantar flexion of the ankle pain may be elicited by direct pressure over the posterior lip of the talus Imaging: May be visible on plain radiographs. Stress views with the ankle in plantar flexion can show the posterior

impingement. Three-phase bone scanning may show increased radioactivity in the case of a symptomatic nonunion. However, not all os trigonum with positive bone scans are symptomatic. CT scan: can provide detailed visualization, especially of a fibrous union or nonunion. MRI: may show edema within the os trigonum fragment, as well as fluid around it. Treatment: Nonoperative treatment consists of NSAIDs, activity modification, and occasionally immobilization. Surgical treatment may be indicated if nonsurgical management fails. Excision can be performed arthroscopically. The os trigonum is visualized through the anterolateral portal, and working portal is the posterolateral portal. Excision is performed using arthroscopic banana knives, curettes, and graspers. Care should be taken to avoid injury to the FHL tendon and the posteromedial neurovascular structures. Cure rates with surgery are high ACROMIOCLAVICULAR JOINT INJURIES ACROMIOCLAVICULAR JOINT INJURIES Mechanism of Injury: 1. Direct force is the commonest cause due to fall on the shoulder with arm adducted 2. It can also occur with indirect force due to fall on the outstretched hand Features of Acromioclavicular joint:

 Is a diarthrodal (synovial) joint Horizontal stability is provided by the acromioclavicular ligaments The AC joint has a thin capsule that is stabilized by anterior, posterior, superior, and inferior AC ligaments. Superior AC ligament is the most important of all ligaments A fibrocartilaginous disk of varying size and shape exists inside the joint Vertical stability is by the coracoclavicular ligaments Normal coracoclavicular distance is 1.1 to 1.3 cm Rockwood Classification Type I: Sprain of the AC ligament Normal radiograph Type II: AC ligament tear, coracoclavicular ligaments sprained Radiograph demonstrates AC joint widening (normal AC joint distance is 1 to 3mm). Stress views show identical coracoclavicular distance compared to uninvolved side Type III: AC and coracoclavicular ligament torn. Radiograph demonstrates loss of AC joint relationship and increased coracoclavicular distance in stress view (25% to 100% greater than the normal side.). Type IV: Type III with distal clavicle displaced posteriorly into or through the trapezius Type V: Type III with the distal clavicle grossly displaced superiorly. Type VI: AC dislocated with the clavicle displaced inferior to the acromion or the coracoid. Clinical Features: As in all fractures pain, tenderness and difficulty in moving the affected part is seen. An apparent step-off deformity is seen at the AC joint There may tenting of the skin over the distal clavicle X Rays:

 AP view of the shoulder, scapular Y view and axillary views Zanca view: A 15 degree upward tilt view best visualizes the AC joint Stress views of the AC joint are obtained by tying 10 to 15 lb weight to the wrists and taking an AP view. The Acromioclavicular and coracoclavicular distances are compared with the normal shoulder. Stryker notch view: will rule out an associated coracoid fracture. A coracoid fracture is suspected when there is an AC joint dislocation on the AP projection but the coracoclavicular distance is normal, or equal to that on the opposite, uninvolved side Treatment Type I: Sling immobilisation Type II: Sling immobilisation Type III: Inactive, non-labouring patient: -nonoperative treatment with sling. Operative treatment in heavy labourers. Type IV, V, VI: Open reduction and surgical repair of coracoclavicular ligaments. When surgical repair is done, open reduction is performed and acromioclavicular joint is fixed with K wires or indirect fixation is achieved by coracoclavicular fixation with a Bosworth screw. Reconstruction of the coracoclavicular ligaments is performed by using the coracoacromial ligament as a substitute, and by the placement of a synthetic augmentation device (such as a band made of absorbable braid or ribbon, Dacron tape) between the coracoid and clavicle Clavicular HOOK PLATE: The clavicular hook plate was developed for treatment of AC joint dislocations and claviCLe fractures in which the distal fragment is too small to allow conventional plate fixation . The plate has an offset lateral hook, designed to engage distal to

the posterior aspect of the acromion. It has been used with some success for displaced lateral-end clavicular fractures, but there are concerns that the plate may induce shoulder stiffness and osteoarthritis of the acromioclavicular joint, and there is also a risk of skin slough and infection. Improper positioning of the hook may lead to inadequate fixation. Osteolysis has been noted around the hole for the hook as shoulder movement increases, and most surgeons advise routine plate removal at three months after implantation, which necessitates a second operation. The timing of plate removal is critical, as early removal may result in nonunion or refracture due to instability at the fracture site, whereas delayed removal can lead to shoulder stiffness or even fracture medial to the plate

Advantages and disadvantages of AC joint dislocation fixation methods: a)Intra-articular AC fixation Adv: Anatomic reduction Disadv: Hardware failure or migration Distal clavicle osteolysis b)Extra-articular coracoclavicular repairs Adv: Superior strength of initial fixation (screw) Disadv: Screw failure Bone resorption secondary to hardware Does not address soft tissue injury c)Ligament reconstruction Adv: Anatomic repair No risk of metallic hardware failure or retention Disadv: Less initial fixation strength Harvest coracoacromial ligament

Chronic AC joint dislocations: Type 1: nonoperative treatment will suffice Type 2: initial conservative, on failure surgery. Surgery involves distal clavicle excision combined with AC joint capsule reconstruction with CA ligament transfer Type 3 to 6: Surgical treatment, distal clavicle excision with CA(coracoacromial) ligament transfer. The acromial attachment is detached and transferred to the resected end of clavicle

Complications: 1. Pneumothorax and pulmonary contusion are common with type VI injuries 2. Osteolysis of distal clavicle 3. Coracoclavicular ossification (disability is minimal) 4. AC joint arthritis is treated by Weaver Dunn technique: distal clavicle excision with CA(coracoacromial) ligament transfer 5. Complications of surgery include migration of pins as far as posterior mediastinal vessels and even carotids. 6. Failure of fixation is common Role of Arthroscopy: The CA ligament can be released from the acromion during routine subacromial decompression and this will facilitate AC ligament reconstruction, including transfer of the coracoacromial ligament by decreasing the necessary size of the incision in the deltotrapezial fascia Wolf and Pennington described an all-arthroscopic technique of AC joint reconstruction(7)

Ref: 1. Nuber GW, Bowen MK. Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5:1118. 2. Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med 1998;26:137 144 3. Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg [Am] 1972;54:1187-1194 4. Galatz LM, Williams GR, .Injuries to the acromioclavicular joint. In Rockwood and Greens Fractures in adults, 6th Ed. 5. Kumar S, Sethi A, Jain AK. Surgical treatment of complete acromioclavicular dislocation using the coracoacromial ligament and coracoclavicular fixation: report of a technique in 14 patients. J Orthop Trauma 1995;9:507-510 6. Snyder S, Banas M, Karzel R. The arthroscopic Mumford procedure: an analysis of results. Arthroscopy 1995;11:157-164 7. Wolf EM, Pennington WT. Arthroscopic reconstruction for acromioclavicular joint dislocation. Arthroscopy 2001;17(5):558-563 Madelung's deformity CONGENITAL SUBLUXATION OF THE WRIST (MADELUNGS DEFORMITY) Pathogenesis (Brailsford):  Stunted development of inner third of the growth cartilage at the lower end of the radius, due to still unknown cause.  Growth of the outer two-thirds continues and, as a result, the radial shaft is bowed backwards, the interosseous space is increased, there is overgrowth of lower end of ulna and is subluxated backwards. Soft tissue changes: Abnormal tethering of soft tissues from the

distal radius to the carpus and ulna. These have included aberrant ligaments and pronator quadratus muscle insertions Hypertrophy of the palmar ligaments, including the radiotriquetral and the short radiolunate ligaments and an anomalous volar ligament(Vickers ligament) Clinical Features:  Often bilateral, hence disability may not be identified early and hence late presentation is common  Often seen for the first time in adolescence.  Females>males.  Early cases: mild symptoms of ulnocarpal impaction with power grip activities, and distal radioulnar joint incongruity with forearm rotation  Flexion may be increased; other movements are restricted and may be painful.  May be associated with Dyschondrosteosis (Leri Weil syndrome), Turners syndrome, Achondroplasia, Olliers disease Vender and Watson Classification: a) Post traumatic b) Dysplastic c) Genetic d) Idiopathic

X-ray: i Steep ulnar slope and deficient ulnar margin of radius i Lunate uncovered. i The carpus subluxates ulnar and palmarward and appears wedge shaped (lunate lies at the apex of the wedge)

i Increased width between the distal radius and ulna. i Relatively long ulna compared to radius (positive ulnar variance). i Decreased carpal angle. i Triangularization of the distal radial epiphysis. i Carpus migrates more proximal into the increasing diastasis between the radius and the ulna Treatment In recent or acute cases, dorsiflexion of the wrist-maintained by a full arm plaster for 4 weeks. Indications for surgery: Acute pain and deformity Early presentation: In early-detected cases distal radial epiphysiolysis is done (Vickers and Nielsen et al.) Epiphysiolysis involves resection of the abnormal volar, ulnar physeal region of the radius and fat interposition. At the same time, any aberrant, tethering anatomic structures are excised Early presentation with marked deformity and complete lack of a lunate fossa for carpal support, needs combined radial and ulnar osteotomies. Alternatively ulnar and radial epiphysiodesis maybe done Late presentation: Osteotomy of the lower end of the radius may be done. Options include dome osteotomy, dorsal radial closing-wedge osteotomy, or volar opening-wedge radial osteotomy and bone grafting Ulnar shortening procedure like the Suave-kapandji maybe useful, though there may already be deterioration of the articular cartilage, wrist ligaments, or triangular fibrocartilage, resulting in continued pain and limitation of motion postoperatively..

Ref: 1. Vickers D, Nielsen G. Madelung's deformity: treatment by osteotomy of the radius and Lauenstein procedure. J Hand Surg [Am] 1987;12(2):202-204 2. Ranawat CS, DeFiore J, Straub LR. Madelung's deformity. An endresult study of surgical treatment. J Bone Joint Surg Am 1975;57(6):772-775 Pigmented villonodular synovitis PIGMENTED VILLONODULAR SYNOVITIS (PVNS) Definition: Pigmented villonodular synovitis (PVNS) is a slow growing lesion of uncertain etiology arising from the synovial membrane, characterized by villous and nodular overgrowths of the synovial membrane of the bursa or the tendon sheath. The appendicular skeleton, especially large joints such as the knee and hip joints are frequently involved. Synonyms: Until Jaffe in 1941 proposed the term pigmented villonodular synovitis this condition has been known as synovial xanthoma, synovial endothelioma/ fibroendothelioma, Benign fibrous histiocytoma, xanthomatous GCT, Myeloplaxoma, fibrohemosideric sarcoma , Sarcoma fusigigantocellulare. History: 1852: 1st described as neoplastic process due to unrelenting growth pattern, by Chassaignac, eroding surrounding bone and joint tissue, & high recurrence rate post-resection. 1865: Simon described a focal form of PVNS 1909: Moser described a diffuse PVNS 1941: 1st reported & coined by Jaffe et al. as synovitis, shifting from neoplastic to inflammatory foci. Prevalance:

 Age: 3rd-4th decades of life, rare in children Sex: no sex based predilection Incidence: 1.8 per million population no predilection for any laterality Etiopathogenesis: repetitive trauma (50%) causing recurrent local hemorrhage to affected joint (cf:hemophilics show progressive erosive arthropathies). proliferation of the synovium of joints, tendon sheaths or bursae. It is a reactive condition, and not a true neoplasm. PVNS classically presents as a monoarticular disease, mimicking arthritis. Recurrent atraumatic haemarthrosis is a characteristic feature. Often aggressive, with marked extra-articular extension. Types: Monoarticular involvement (most common), occurs in two forms: localized and diffuse. Two variants as described by Granowitz a. Localized form (LPVNS): focal involvement of the synovium - Nodular / Sessile or Pedunculated masses. - Hands & feet b. Diffuse form (DPVNS) (more common): affects virtually the entire synovium, eg. - Intra-articular PVNS tends to be of the diffuse form. - Tendon sheath PVNS (Giant cell tumour of tendon sheath[GCCTS]), the nodular form. Sites: MC site: knee joint, followed by the hip and shoulder. Knee:

- anterior compartment common - mostly at meniscocapsular junction - synovium in the region of the anterior horn of the medial meniscus is the most common site - infrapatellar fat pad, suprapatellar pouch, intercondylar notch, anterior horn of the lateral meniscus, and the medial and lateral recesses of the knee have been reported. Uncommon : elbow, ankle, shoulder, foot, wrist Rare : spine, cervical involvement commoner than thoracic and lumbar Clinical features: o Pain (80%) o Swelling(76%) o Reduced range of movement(52%) o Locking(16%) o Instability/palpable mass(12%) Type specific features: LPVNS: - if untreated, causes continuous pain and discomfort, limiting ADLs - at knee often present with signs and symptoms of meniscal pathology (locking, catching, and instability) - episodic character of joint effusionthe patient may have completely symptom-free periods between exacerbations DPVNS: - Slow, insidious onset of pain, swelling, and - stiffness in the involved joint - most or all joints involved - swelling and pain more pronounced - decreased range of motion of the affected joint - poorly localized - with sometimes extra-articular extension, either primary or

recurrent. - may encroach on major neurovascular structures. - Osteoarthritis- continued inflammation and joint erosions lead to articular cartilage destruction, may finally need total joint arthroplasty. Investigation: Aspiration of joint: characteristically reveals a blood tinged brownish-stained aspirate. X-ray: Soft tissue swelling will be marked due to haemorrhage and lobulated synovial tissue. May reveal cysts or erosions in the joint mimicking gout. Bony erosions are usually from without, especially in the hip periarticular erosions, with a thin rim of reactive bone Osteoporosis is characteristically absent Can affect the epiphysis Reciprocal bony lesions on opposite sides of the joint, despite articular preservation, are highly suggestive of PVNS Late feature of joint space narrowing indicates articular cartilage loss, is difficult to distinguish from primary OA. MRI: ideal investigation nodular mass (periarticular or synovial) with bone erosion MRI is invaluable in early diagnosis and evaluating extent. Nodular synovial masses -low signal on T1/T2 sequences dark on dark on T1- and T2-weighted images Sonography: Loculated joint effusions, Complex heterogeneous echogenic masses and markedly thickened synovium

Arthroscopy: direct visualisation of synovium Has both diagnostic and therapeutic value in resection of tumours Normal arthroscopic findings however does not exclude PVNS (Klompmaker et al) Histolopathology: Synovium looks like a shaggy carpet. LPVNS is pedunculated, lobular lesion localized to one area of the synovium. On microscopy, Histiocytes, lipid laden macrophages, hemosiderin containing cells and frequent giant cells are seen. Subsynovial nodular proliferation of large round, polyhedral or spindle cells with prominent cytoplasm and pale nuclei. Differential diagnosis Hemophiliac lobular synovitis ( hemosiderin deposition, lacks lipidladen histiocytes and giant cells, which is classic indications of PVNS) Osteoarthritis Rheumatoid arthritis, Meniscal tear, or other ligamentous injury Treatment: Synovectomy: o Total synovectomy (open or arthroscopic): - Open (anterior approach midline incision or medial parapatellar arthrotomy) for the diffuse form for the intraarticular component - Arthroscopic synovectomy, has gained popularity, has several advantages over the open technique, preferred for LPVNS, shows higher recurrence in DPVNS. - The standard anterior portals are not effective, whereas the accessory posterior portals are necessary to accomplish total posterior synovectomy

o Vascular or neurologic injury may occur during this procedure, especially if there is posterior extra-articular extension of the lesion or fibrosis after irradiation. Open synovectomy should be preferred in such cases o Open posterior synovectomy (lazy S-shaped incision): done subsequently for extensions into the popliteal fossa. Local excision: for the nodular form (recurrence rare). Radiotherapy (3500- 4000 cGy) (Radiation induced synovectomy/ intra-articular radiation synovectomy using yttrium Y-90) has been used in the management of recurrences with varying success; side effect is soft tissue radionecrosis Advanced cases with secondary arthritis should be addressed with arthroplasty plus extensive synovectomy to decrease recurrence. Prognosis: LPVNS: excellent prognosis, low recurrence rate if managed surgically, recurrence 8%. DPVNS: surgical excision difficult, recurrence rate of up to 46%. The debate continutes: malignant or inflammatory- Rare reports describe malignant transformation and metastasis, (presence of trisomy 7 and clonal DNA rearrangements reported). - Bertoni et al reported eight patients with malignant PVNS; mortality rate was 50%. - Oehler et al found strong support for its being a chronic inflammatory process and not noeplastic. - Currently, data are inconclusive to prove PVNS as either malignant or inflammatory process. - It shows neither cellular atypia nor abnormal mitosis, recent cytogenetic studies say that pathogenesis remains unresolved. References: 1. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented villonodular synovitis, bursitis and tenosynovitis. Arch Pathol 1941;31:73165. 2. Granowitz SP, DAntonio J, Mankin HL. The pathogenesis and

long-term end results of pigmented villonodular synovitis. Clin Orthop Relat Res 1976;114:33551. 3. Oehler S, Fassbender HG, Neureiter D, Meyer-Scholten C, Kirchner T, Aigner T: Cell populations involved in pigmented villonodular synovitis of the knee. J Rheumatol 2000;27: 463-470. 4. Bertoni F, Unni KK, Beabout JW, Sim FH: Malignant giant cell tumor of the tendon sheaths and joints (malignant pigmented villonodular synovitis). Am J Surg Pathol 1997;21:153163. Osteoid Osteoma Osteoid Osteoma i Most commonly involves the diaphysis of long bones especially femur and tibia, and the proximal femur is the most common site. i 50% of tumours involve the lower extremity i Osteoid osteoma may have a unique pathogenic nerve supply i Three types have been described: Intracortical (80%), cancellous and subperiosteal i The pain may be referred to an adjacent joint and when the lesion is intracapsular it may simulate arthritis with effusions ,spasms and contractures i Occasionally pain precedes the appearance of radiographic changes, and leads to multiple incorrect diagnoses including neurosis i In the spine, posterior elements of the lumbar spine is most commonly involved (next common thoracic spine). An associated scoliosis is often present i If the nidus is in proximity to a nerve root, root irritation can develop. i In the lumbar spine, this pain can present as sciatica and suggest the diagnosis of a herniated intervertebral disc i Torticollis may be seen if the cervical spine is involved. i Aspirin or nonsteroidal anti-inflammatory agents relieves pain

secondary to a high concentration of prostaglandins in the nidus Histology: There is a distinct demarcation between the nidus and the reactive bone The nidus consists of an interlacing network of osteoid trabeculae with variable mineralisation. The trabecular organization is haphazard and the greatest degree of mineralisation is in the centre of the lesion Investigation: X rays: Central lytic nidus with extensive reactive sclerosis. The nidus is always less than 1.5 cm although the area of the reactive bone sclerosis may be larger. The radiolucent nidus may be obscured by dense sclerotic bone When the lesion is intramedullary there is less sclerotic bone CT scan is the investigation of choice Double density sign on bone scan (Focal areas of increased uptake with a second smaller area of increased uptake) MRI scans will show extensive edema, which may be confused with a marrow-replacing neoplasm and is therefore not recommended if osteoid osteoma is the suspected lesion DD: Bone island (enostoses): Mimic osteoid osteoma on X-rays but MRI changes are different from an Osteoid osteoma. Treatment:i If surgery is undertaken, it is important to eradicate the entire symptomatic nidus. i Removal of a large amount of the surrounding sclerotic bone should be avoided because it can severely weaken the bone and may result in a pathologic fracture i Intralesional resection by simple curettage of the nidus followed by

high-speed burring is done often (Burr down technique). i Intraoperative localization of the lesion may be done by technetium labeled methylene diphosphonate and detection by a Geiger counter i If block excision is performed, intraoperative roentgenograms of the specimen are advised to document complete removal of the nidus i CT-guided percutaneous resection for small tumours is becoming popular. i Percutaneous Radiofrequency ablation is being tried. Under CT Guidance a radiofrequency probe is placed into the lesion and the nidus is heated upto 80degree C. This induces ionic agitation and frictional heat to cause tumor necrosis i The patient may be also treated nonoperatively using NSAIDS. About 50% of the patients treated with NSAIDs will have their lesions burnt out with no further medical or surgical treatment necessary Ref: 1. Cantwell CP et al: Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol 2004; 14(4):607. Metal on Metal Bearing in Hip Arthroplasty Metal on Metal (MoM) - Are associated with decreased wear rate compared to conventional polyethylene - Mixed film lubrication appears to be the operative mechanism in most metal-on-metal hip joints - With metal-on-metal bearings, in contrast to polyethylene bearings, a larger-diameter bearing actually produces lower wear rates than does a smaller-diameter bearing - Larger-diameter bearings have a greater arc of motion(and thus better ROM), which decreases the risk of impingement and also lessens the incidence of dislocation

- Alloys of cobalt (Co) and chromium (Cr) have been preferred for MOM bearings in THR because of their hardness. - High chromium content provides good corrosion resistance - There are two types of wear particles with MoM bearings: Co-Cr-Mo particles and chromium oxide particles - It has been hypothesized that the Co-Cr-Mo particles are produced by the wear of the carbides on the bearing surfaces and the prosthesis matrix, and that the chromium oxide particles come from the passivation layer on the implant surface and possibly from oxidized chromium carbides Metal hypersensitivity: - all metals in a biological environment corrode; the ions released can combine with proteins and activate the immune system as antigens and elicit hypersensitivity responses - the incidence of hypersensitivity is approximately 2 per 10,000 - are generally delayed cell-mediated responses - ALVAL: are Lymphocytic infiltrations in the subsurface layer of the lining tissues, which were either diffuse or aggregated around small postcapillary vessels - delayed type hypersensitivity should be considered when a patient with a well-fixed implant experiences chronic, aching pain with evidence of synovitis (an irritable range of motion) but has no objective evidence of infection - If a modular MOM bearing is being considered, the use of substrates without Co-Cr (e.g., titanium) will allow revision of only the bearings in cases were hypersensitivity develops What is New in Hip Resurfacing(Metal on Metal)? -S. Glyn-Jones and H. Pandit reported in Dec 2009 JBJS B that incidence of ALVAL is higher in women especially if performed under 40 years of age.

-Factors significantly associated with an increase in revision rate were female gender, age under 40, dysplasia and small components. -the higher revision rates in women could be due to increased prevalence of allergy in women because of wearing jewellery, increased ROM, which would be more likely to cause impingement, edge loading or different gait patterns Floor Reaction Orthosis FLOOR REACTION ORTHOSIS (FRO)

n Revolutionary orthoses: Custom fabricated, moulded plastic device that supports the ankle and foot area of the body and extends from below the knee down to and including the foot. It was described by Saltiel for the use of weak quadriceps or plantar flexors in 1969 n It holds the ankle in equinus to prevent the heel from touching the ground. As the body weight brings the heel downwards, the suprapatellar band will press the knee back preventing knee from buckling during stance phase n It allows the knee to flex during swing phase when the foot is off the ground Use: n It can be used in lower limb paralyses with weak quadriceps like post polio residual paralysis

Advantages over other AK Orthosis: n Light weight-300gms

n Swing phase is not laboured n Floor reaction prevents knee from buckling n 2 weeks training is enough to use it. n Stabilises knee without muscle action n Ground clearance is easier n Good patient compliance n Cosmetically acceptable-can be worn under shoe Disadvantages: n Must be correct fitting or else it wont function n Has to be custom made DNB Theory Paper 2009 December DNB Orthopaedics Theory December 2009 Paper 1 1. Post-operative pain management. Describe patient control analgesia. 2. Clinical features and management of stove in chest. 3. Indications of Limb salvage surgery in malignant bone tumors. Describe the techniques of limb salvage in osteosarcoma. 4. Uses of botulinum neurotoxin in Orthopaedic surgery. 5. Define pigmented villonodular synovitis. Describe pathology, clinical features, diagnosis & its treatment. 6. Give a functional classification of muscles around the shoulder. Enumerate the indications for shoulder arthrodesis. What are the pre-requisites for a good result? Describe any one technique of shoulder arthrodesis. 7. Describe pathophysiology of nerve compression (entrapment) syndromes. Enumerate various syndromes of nerve entrapment. Give an outline of the management of Tarsal Tunnel Syndrome. 8. What is traumatic arthrotomy of the knee joint? What is fluid challenge test to confirm the diagnosis in doubtful cases? Outline the principles of management.

9. What are the various causes of late onset paraplegia in tuberculosis of spine? Describe the investigative modalities and outline the principles of management. 10. Describe the management of unicompartmental osteoarthrosis knee. Paper 2 1. Management of septic arthritis in children, 2. Pathophysiology, types and clinical features of Osteogenesis Imperfecta 3. Prognostic factors and outcome in the treatment of Perthes disease 4. Describe Madelung deformity, classification, clinical features and management of madelung's deformity 5. Classify congenital dislocation of knee. Comment on differential diagnosis and management 6. Draw a diagram of Floor Reaction Orthosis, What is a good indication for its use. Describe mechanism of action 7. Orthopaedic manifestation of neurofibromatosis 8. Describe muscular dynamics in calcaneovalgus deformity. Describe management in patients before and after attaining skeletal maturity 9. Classification of neurogenic bladder and management 10. What are closed chain and open chain exercises and discuss ACL rehabilitation protocol

Paper 3 1. Classification, management and complication of fractures of the femoral head and neck in children 2. What are Monteggia equivalents, discuss the principles of management of Monteggia fracture dislocation in children 3. Principles of management of a pulseless hand after supracondylar fractures in children

4. Role of ultrasound in fracture healing 5. Subacromial impingement syndrome 6. Describe indications for amputation, Principles of lower limb amputation in children 7. What is Mangled Extremity severity score(MESS), describe principles of flap coverage in proximal one third of tibia 8. Classify ankle fractures, which pattern has syndesmotic instability, what is their management? 9. What are biodegradable implants, what is their chemical composition? Mention the indications of their use, advantage and disadvantage of their use 10. What is central cord syndrome, describe its clinical presentation. How will you manage such a case? Paper 4 1. Osteochondral allograft transplantation. Mention indications for the procedure 2. Role of Pamidronate in bone metastasis 3. What do you understand by patellar instability, describe the principles of management, before and after skeletal maturity? 4. Enumerate modalities leading to biological enhancement of fracture healing. Mention the methods of preservation of allogenic bone grafts. Comment on mode of action, advantages and disadvantages 5. Describe the pathogenesis of hallux valgus deformity; describe the role of metatarsus primary varus in the pathogenesis. How will you manage an adolescent girl with severe hallux valgus? 6. Describe various types of rickets; describe biochemical changes and clinical presentation of various types of rickets! 7. Define osteoporosis. Comment on types, causes and management 8. What is highly cross linked polyethylene? How is it manufactured? How has it affected modern total hip arthroplasty? 9. Anatomy of Lisfranc joint, and management of injuries around the joint

10. Describe gate control theory of pain. What is transcutaneous nerve stimulation and its indications? Parathormone(PTH) Composition and Mechanism of action: Endogenous PTH is an 84-amino-acid peptide that is largely responsible for calcium homeostasis Although chronic elevation of PTH, as occurs in hyperparathyroidism, is associated with bone loss (particularly cortical bone), PTH can also exert anabolic effects on bone Unlike antiresorptive therapies that reduce bone resorption, parathyroid hormone (PTH) is an anabolic agent that enhances osteoblastic bone formation. Biologic activity of the intact hormone resides within the N-terminal 1-34 fragment; fragments from the mid- and C-terminal regions lack biologic activity. Teriparatide is a synthetic polypeptide hormone that contains the 134 amino acid fragment of recombinant human PTH (rhPTH [1-34]), a sequence identical to the biologically active N-terminal region of the 84-amino acid human PTH. They bind to specific cell-surface receptors on target cells in bone and kidney with high affinity. Daily single-dose administration causes a transient increase in serum PTH concentration, promoting new bone formation on both cancellous and cortical bone surfaces by preferential stimulation of osteoblastic activity over osteoclastic activity Continuous infusions, which result in a persistent elevation of PTH, lead to greater bone resorption than daily injections. Whereas daily injections of PTH increase bone volume, the net effect of continuous infusions is a decrease in bone volume. Daily PTH injections build bone by uncoupling bone turnover as the serum PTH level rises above normal for several hours, then falls below normal for many hours.

 The pattern of changes in serum PTH, combined with the pattern of elevation in biochemical markers of bone remodeling (increases in bone formation markers followed by increases in bone resorption markers), suggests a pathway through which daily PTH injection may temporarily uncouple bone turnover Teriparatide produces increases in bone mass and mediates architectural improvements in skeletal system These effects are lower when patients have been previously exposed to bisphosphonates, possibly in proportion to the potency of the antiresorptive effect Dosage and uses: 20 microgm PTH exogenous PTH analogue (1-34hPTH; teriparatide) is used as a single daily SC injection for the treatment of postmenopausal osteoporosis in women with a high risk of fracture. These patients include women with a history of osteoporotic fracture, multiple risk factors for fracture, intolerance with osteoporosis therapy, or failure with therapy Teriparatide is also FDA-approved for the treatment of men with primary or secondary hypogonadal osteoporosis who are at high risk of fracture. After a 20- g SC injection, PTH reaches peak serum concentration in approximately 30 minutes and declines to nondetectable levels within 3 hours. Combining PTH with antiresorptives has demonstrated even greater improvements in BMD that persist for at least 1 year after PTH is discontinued. Adverse effects and Special Precautions: Side effects of teriparatide are generally mild and can include muscle pain, weakness, dizziness, headache, and nausea. Hypercalcemia can occur and symptoms typically appear 4 to 6

hours after injection Orthostatic hypotension can occur PTH should be used with caution in patients with urolithiasis and dose reduction is necessary in patients with renal insufficiency Teriparatide is not recommended for women who are pregnant or nursing. Teriparatide should not be prescribed for patients at increased risk for osteosarcomas, including patients with Pagets disease of bone or unexplained elevations of alkaline phosphatase, children or young adults with open epiphyses, or patients who have undergone prior radiation therapy of the skeleton. In addition, teriparatide should not be administered to patients with preexisting hypercalcemia, bone metastases, or a history of skeletal malignancies or metabolic bone diseases other than osteoporosis DEVELOPMENTAL COXA VARA DEVELOPMENTAL COXA VARA Aetiology: primary defect in endochondral ossification of the medial part of the femoral neck. Other theories regarding aetiology: Excessive intrauterine pressure on the developing fetal hip Vascular insult Faulty maturation of the cartilage and metaphyseal bone of the femoral neck Bilateral in 30% to 50% of patients Clinical Features: Present after they have started walking, but before 6 years of age. Painless limp due to a mild abductor weakness and mild limb length discrepancy If bilateral, the child presents with a waddling gait and increased lumbar lordosis

 The greater trochanter will be more prominent and proximal decreased ROM with maximum restriction in abduction and internal rotation. X-Rays: Decreased femoral neck-shaft angle Vertical position of physeal plate Triangular metaphyseal fragment in inferior femoral neck with associated inverted Y appearance, which is pathognomonic. Shortened femoral neck Decrease in normal anteversion

Hilgenrieners epiphyseal angle (H-E angle): Angle subtended by the horizontal line connecting the tri-radiate cartilage and the physeal line. Normal angle: <30 Treatment HE Angle 45-60: Observation and periodic follow up Indications for surgery: HE angle> 60, progressive deformity, femoral neck shaft angle< 90, development of trendelenburg gait Subtrochanteric valgus osteotomy. Adequate internal rotation of the distal fragment should be done to restore the femoral anteversion. Intertrochanteric osteotomy (Langenskolds and Pauwels) is an alternative If the H-E angle is reduced to less than 38 degrees, 95% of the patients showed no evidence of recurrence Blade plate or a sliding hip screw is often used. An adductor tenotomy is frequently done. Spica cast immobilization is used, in addition, for 6 to 8 weeks in most patients.

Complications: i Premature physeal closure may occur in the first 1-2 years after surgery. i This can cause recurrence of the deformity i Trochanteric apophysiodesis or a trochanteric advancement is done to prevent recurrence once physeal closure is documented. i In case of recurrence of varus deformity a repeat valgus osteotomy is done Ganglion Cyst a) Ganglions, Ganglion Cysts i Account for 60-70% of soft-tissue tumours of the hand. i The disease is common in females in their third and fourth decades. i Usually arise adjacent to tendons. May also be intraosseous or intratendinous

Aetiology (theories): Formed by herniation of the synovial lining in which a one-way valve mechanism is created benign tumors of synovial origin A rent in the joint capsule or tendon sheath allows leakage of synovial fluid, which irritates surrounding tissue. This local tissue reacts by forming a pseudocapsule and subsequent ganglion Mucoid degeneration of connective tissue, with breakdown products of collagen collecting in pools, which coalesce to form large cysts. Usual Sites Dorsum of the wrist (70%): in this location the origin is Scapholunate ligament. The dorsal ganglia are usually painless and

they are found between the EDC and the EPL tendons. Volar wrist (20%): Deriving their origin from the radiocarpal (2/3rd) or STT (1/3rd) joints. Dorsum of the distal interphalangeal (DIP) joint-mucous cyst Volar aspect of a digit at the metacarpal phalangeal flexion crease (volar retinacular ganglion cyst). Arise from the A1 or A2 pulley of the flexor tendon sheath Cyst fluid is gelatinous (apple jelly-like) with a high concentration of hyaluronic acid. Microscopy: ganglia develop in stages as follows 1. First stage characterised by large number of spheroidal cells that are closely packed with a periphery of spindle cells 2. The second stage consists of spheroidal cells and spindle cells but with a central cavity filled partly with secretion from the spheroid cells. 3. Third stage, here the ganglion is well developed with a smooth wall resembling synovial membrane of joints. The walls of the larger cyst are poorly vascularised and the vessels show fibrosis of their wall suggesting a vascular aetiology for the development of these cysts. Clinical Features: Dorsal ganglion The mass is compressible, subcutaneous, transilluminating, slightly mobile, and without skin changes. Wrist extension often elicits pain at the site. Small dorsal ganglions may be palpable only in full wrist flexion. Occult ganglions are not palpable but may be quite painful. wrist pain, tenderness, and interference with activity Volar ganglion: The mass is usually palpable between the radial artery and the flexor carpi radialis (FCR) tendon, or

 Adjacent to the scaphoid tubercle in the anatomic snuffbox or more distal in the palm. May arise ulnarly from the pisotriquetral joint and are palpable adjacent to the flexor carpi ulnaris (FCU) tendon. May compress the palmar cutaneous branch of the median nerve, median nerve or the deep branch of the ulnar nerve Volar Retinacular Ganglion Cyst: Present as a small, very firm, minimally mobile mass near the proximal digital crease or metacarpophalangeal joint. do not move with flexor tendon excursion They are painful only when gripping a firm surface. Volar retinacular ganglions do not cause digital triggering, nor are they associated with trigger digits Can compress the digital nerve causing sensory disturbance. Mucous Cyst: Gradually enlarging subcutaneous mass develops over the dorsal DIP joint. The lesion is firm and minimally mobile and can be transilluminated Lies typically lateral to midline, being displaced by the extensor tendon. Associated with osteoarthritis May rupture and get infected Nail deformity may develop from pressure on the germinal matrix. Ganglions maybe associated with tendons, they are typically located in the dorsal wrist, extensor apparatus or the FCR in the volar wrist Intraosseous ganglions of the hand and wrist: most common in the scaphoid and lunate. On X-rays: The lesions appear radiolucent with a sclerotic border and frequently contact a joint surface without causing cortical expansion. Diagnosis is mainly of exclusion.

DD for dorsal wrist ganglion: 1. Ganglion of tendon sheath, giant cell tumor of tendon sheath, tenosynovitis of inflammatory or infectious origin, or an extensor digitorum brevis manus muscle belly. 2. The proximal pole of the scaphoid may be prominent dorsally in cases of dorsal intercalated segment instability, 3. The proximal pole of the lunate may be prominent in volar intercalated segment instability. 4. A firm mass more radial and slightly more distal may be an osteophyte from scaphotrapezial arthritis. 5. A compressible mass that decreases in size with elevation of the wrist may be a venous aneurysm DD for volar ganglion: 1. Aneurysms of the radial or ulnar arteries 2. Intraneural cysts. DD for volar retinacular ganglion cyst: 1. epidermoid inclusion cyst, 2. giant cell tumor of tendon sheath, 3. foreign body granuloma, 4. lipoma 5. Neurilemoma. DD for mucous cyst: 1. Heberdens node 2. Gout 3. Giant cell tumor of tendon sheath. Diagnosis: is mainly clinical. USG and MRI also help in establishing a

diagnosis Wrist Arthroscopy has potential advantages in both diagnosing and treating an occult dorsal ganglion that is intra-articular and therefore visible from within the radiocarpal joint, and also provides information about other causes of dorsal wrist pain, such as synovitis, chondromalacia, and scapholunate ligament tears

Treatment Historical folk medicine has mentioned rupture with a mallet or Bible, methods that need not be considered except for their historical interest i. cyst puncture and aspiration (High recurrence) ii. Excision Dorsal ganglia:

Surgical treatment can be performed with the use of intravenous regional (Bier block) anesthesia, A transverse incision in Langers lines leaves a less noticeable scar than a longitudinal one The ganglion lies between the second and fourth dorsal extensor compartment Dissection is carried down to the joint capsule. When they are properly excised with a swath of joint capsule surrounding the stalk of the cyst, recurrence rates are less than 10% for dorsal cysts, and as high as 20% for volar cysts. It is important to maintain the overall integrity of the capsule and to not create secondary instability

 This lower recurrence rate may be due to the removal of a valvular mechanism or microcysts in the surrounding capsular tissue. Volar Ganglia: Cyst puncture and aspiration is not recommended due to proximity to radial artery Surgical excision is preferred: Longitudinal incision just radial to the FCR tendon Branches of the lateral antebrachial cutaneous nerve and superficial radial nerve must be protected. The radial artery is carefully dissected free and gently retracted radially. If this dissection is difficult due to adherence of the cyst wall to the artery the technique of Lister and Smith maybe used According to Lister and Smith: one wall of the cyst is left attached to the artery while the remainder of the cyst and the stalk are excised. Ulnar sided volar ganglions are approached with a longitudinal incision along the radial border of the FCU tendon.

Volar Retinacular Ganglion Cyst: The mass is excised with a small window of tendon sheath, which is not repaired The neurovascular bundle is preserved. Mucous cyst: Excision of the stalk of the cyst, removal of the dorsal capsule and synovium, and debridement of dorsal osteophytes to minimize the risk of recurrence. An H-shaped incision with the transverse limb over the DIP joint and the longitudinal limbs in the midaxillary line In an open draining sinus, a rotational flap is done by triangulating

the cyst into the incision. Curettage and bone grafting is done for established ganglion cyst of bone. Complications: Recurrence Painful neuroma if the superficial branch of the radial nerve or palmar cutaneous branch of the median nerve is involved Intercarpal instability if the intercarpal ligaments are accidentally excised Injury to radial artery in the volar radial wrist, ulnar neurovascular injury in the ulnar volar wrist, and digital neurovascular injury in the region of the palmar digital crease. NB: Turret exostosis Traumatic subperiosteal haemorrhage in the phalangeal bones that leads to extraperiosteal new bone formation. Excision after the bone matures is curative. The inspiring story of GERHARD KUNTSCHER GERHARD KUNTSCHER (1900-1972)

- Served in the German army during the Second World War. - Kuntscher was prejudiced academically and was never offered a chair. - Developed the Kuntscher nail for the treatment of femur fractures - The first intramedullary nailing was performed in 1939 University of Hamburgs Department of Surgery - German military initially disapproved of Kuntschers IM nailing technique - The German military had the upper hand on treating soldiers with the IM nail and having them return to fighting status in just a few

weeks. - Worldwide knowledge was not established until the Prisoners of War (POWs) returned to their home countries carrying Kuntschers legacy in the form of steel nails in their legs - 'The war and the post-war period' produced unfavorable conditions that severely limited and hampered his creative activities

- Kntscher published his first book on intramedullary nailing at the end of World War II. - Although it was written in 1942, the illustrations for it were destroyed in the air raids on Leipzig, so the book was not published until 1945. - In 1945, the Germans understood Kuntscher's technique when the book was published. - Kntscher developed femoral and tibial nails, an intramedullary bone saw for endosteal osteotomy, the distractor to align the fractures, an expanding nail for the distal tibia, the signal arm nail for Trochanteric fractures, cannulated flexible powered intramedullary reamers, and an intramedullary nail to apply compression across fracture sites. - All this was done in collaboration with his engineer, Ernst Pohl, and his lifetime technical assistant, Gerhardt Breske. - Of Kntscher's invention, A. W. Fischer said in 1944: "This practical treatment of fractures using a nail, the Kntscher procedure, is, in my eyes, a great revolution that will conquer the world." - Kntscher was a great lover of life: he swam every day; he enjoyed humor and parties and was a great practical joker, but never married, according to Herr Breske, because he was far too busy. - Unfortunately, only in his very late years did Kntschers accomplishments and work earn widespread recognition and respect. It disappointed him that his operative methods were regarded sceptically at first.

- Gerhardt Kntscher died in 1972 at his desk, working on yet a further edition of his book on intramedullary nailing. - He was found slumped over his final manuscript on Practice of Medullary Nailing by Dr. Wolfgang Wolfers, chief of surgery at the St. Franziskus Hospital of Flensberg, where from 1965 onward Kntscher had worked as a guest surgeon Ref: 1. M S. and Siegfried Fischer et al..Gerhard kntscher 1900-1972 J Bone Joint Surg Am. 1974; 56:208-209. 2. Seyed Behrooz Mostofi in 'Who's who in Orthopaedics', 2005, Springer verlag, United States of America Musculoskeletal Manifestations of HIV infection MUSCULOSKELTAL MANIFESTATIONS OF HIV INFECTION The etiologic agent of AIDS is HIV, which belongs to the family of human retroviruses (Retroviridae) and the subfamily of lentiviruses The most common signs and symptoms are fever, fatigue, and a maculopapular skin rash and seen in 90 % patients with acute infection Around 50% to 70% also complain of myalgias, arthralgias, and paresthesias, which may be the only symptoms of the acute infection. Acute HIV infection should be included in the differential diagnosis of sudden onset of arthralgias and myalgias with a compatible history of exposure.

Myopathies a) Pyomyositis :maybe misdiagnosed as muscle strain, contusion,

hematoma, cellulitis, deep vein thrombosis, osteomyelitis, septic arthritis, or neoplasm Staphylococcus aureus is the most common pathogen (90% of cases) but Streptococcus pyogenes, Mycobacterium tuberculosis, Nocardia asteroides, and Cryptococcus neoformans is also found. Pyomyositis develops in patients with preexisting muscle damage who experience transient bacteremia. Muscle injury maybe due to nutritional deficiencies, azidothymidine (AZT)-induced mitochondrial injury, opportunistic infections, or direct viral invasion of muscle tissue in HIV-infected patients. Aggressive management with i.v antibiotics and surgical drainage should be done. b) Polymyositis: - bilateral, symmetrical proximal muscle weakness associated with elevated serum CK levels. Cause: direct muscle injury by the virus or immunogenic reaction MRI, EMG or muscle biopsy will confirm the diagnosis. In MRI, Unlike pyomyositis, rim enhancement is not present NSAIDs, oral prednisolone(upto 60mg/day) c) AZT Myopathy Reversible toxic mitochondrial myopathy that mimics polymyositis clinically. Patients usually present with myalgia, fatigue, proximal muscle weakness, and elevated serum CK levels. EMG shows myopathy Treatment is withdrawal of AZT and institution of another antiviral agent. Infections a) Tuberculous Osteomyelitis Commonly affects the spine

 The thoracic and lumbar (especially L1) regions are most commonly affected; Infection usually begins in the vertebral body and spreads to adjacent disc. The duration of antibiotic tuberculosis therapy usually is longer in HIV-infected patients(1 year) b) Bacillary Angiomatosis Caused by bartonella henselae(formerly Rochalimaea henselae) Cat bite and cat scratch are strong risk factors. Multiorgan involvement may include adenitis, intracerebral mass lesions, aseptic meningitis, peliosis hepatis, and osteomyelitis. Cutaneous lesions are characterised by friable angiomatous papules, which resemble Kaposis sarcoma lesions. The presence of osseous lesions, which are not typically seen with Kaposis sarcoma, may help differentiate this disease Osseous lesions are lytic and can be associated with periostitis and a soft-tissue mass Extensive cortical damage and medullary permeation are seen, often preceding the cutaneous lesions by many months. The overlying skin changes mimic cellulitis. Increased uptake on technetium 99m bone scan; MRI shows the nonspecific changes of osteomyelitis. Warthin- Starry silver staining is used to identify the bacillary organism. Early treatment with erythromycin should be instituted when an osteolytic lesion in present Neoplasms a) Non-Hodgkins Lymphoma It is the second most common type of tumor in HIV-infected persons after Kaposis sarcoma Extranodal involvement, including the central nervous system, bone

marrow, abdominal organs, and mucocutaneous sites, is common Patients may present with pain, fever, weight loss and pathologic fracture. On X-rays it is commonly osteolytic with cortical destruction and permeation. Sclerotic and mixed appearance may also be seen. DD includes osteomyelitis Treatment is by chemotherapy, radiotherapy and surgical debulking in selected patients b) Kaposis sarcoma Is seen in 20% of patients with HIV Osseous lesions range from erosions to discrete osteopenia or cortical destruction Treatment consists of chemotherapy and radiation Inflammatory arthropathy a) Reiters syndrome Is 100 to 200 times more frequent in the HIV infected population than in the noninfected. Commonly oligoarticular, predominantly involving the lower extremities. Enthesopathy is common, which frequently involves the Achilles tendon, plantar fascia, and extensor tendons, as well as anterior and posterior tibial tendons. This is called AIDS foot and presents as a broad-based gait with weight bearing through the lateral margins of the feet to protect the painful heel. It can be extremely disabling, some patients become wheelchair bound, and may mimic a peripheral neuropathy. Upper extremity enthesopathy may include medial or lateral epicondylitis, rotator cuff tendinitis, de Quervains tenosynovitis, or flexor tendinitis. Associated with HLA- B27

 Is usually refractory to treatment with NSAIDs, but possibly responds to second line drugs like phenyl butazone and sulphasalazine Cyclosporine and prednisone may be used in refractory cases But methotrexate is contraindicated since it may precipitate full blown AIDS and Kaposis sarcoma b. Psoriatic Arthritis Typical cutaneous manifestations include circumscribed, discrete, and confluent red, silvery scaled maculopapules that occur predominantly on the elbow, knee, scalp, and trunk. Treatment is similar to Reiters syndrome c. HIV associated arthritis - Usually involves the knees and ankle - X-rays show non specific changes - Synovial biopsy shows a chronic process with a predominantly mononuclear cell infiltrate. - Rheumatoid factor and HLA B 27 are characteristically negative - Treatment is by administering intra articular steroid injections d. Painful articular syndrome The hallmark of this arthritis is a sharp, severe arthralgia of acute onset that often simulates a septic joint MC site: knee> elbow> shoulder Differentiated from a septic joint by its intermittent pain pattern and lack of effusion or synovitis on physical examination. X-rays are non specific This self-limited condition lasts from 2 to 24 hours and responds well to narcotics and anti-inflammatory medications. e. Acute symmetric polyarthritis . is unique to HIV-infected patients and resembles rheumatoid

arthritis both clinically and radiographically Rheumatoid factor is usually negative Gold is used for treatment f. Hypertrophic Osteo arthropathy: - Severe pain in the lower extremity is typical, and clinical manifestations include arthralgias, nonpitting edema, digital clubbing, and periarticular soft-tissue involvement of the ankle, knee, and elbow Extensive periosteal reaction and subperiosteal proliferative changes of the long bones Surgical or chemical vagotomy or radiation therapy has been used to relieve bone pain in refractory cases g. Osteonecrosis: Embolic phenomena secondary to the formation of antiphospholipid antibodies and immune complexes, protein S deficiency, and hypergammaglobulinemia also have been proposed as etiologies There is a strong correlation between protease inhibitor use and osteonecrosis of the femoral head. Ref: 1. Rodgers WB, Yodlowski ML, Mintzer CM: Pyomyositis in patients who have the human immunodeficiency virus: Case report and review of the literature. J Bone Joint Surg Am 1993;75:588-592. 2. Luck JV Jr, Logan LR, Benson DR, Glasser DB: Human immunodeficiency virus infection: Complications and outcome of orthopaedic surgery. J Am Acad Orthop Surg 1996;4:297-304. 3. Paiement GD, Hymes RA, LaDouceur MS, Gosselin RA, Green HD: Postoperative infections in asymptomatic HIV-seropositive orthopedic trauma patients. J Trauma 1994;37:545-551. 4. Ragni MV, Crossett LS, Herndon JH: Postoperative infection following orthopaedic surgery in human immunodeficiency virusinfected hemophiliacs with CD4 counts < or = 200/mm3. J

Arthroplasty 1995;10:716-721. 5. Ayaz A. Biviji,, Guy D. Paiement, Lynne S. Steinbach : Musculoskeletal Manifestations of Human Immunodeficiency Virus Infection J Am Acad Orthop Surg 2002;10:312-320 Calcaneal Fractures CALCANEUM fractures Mechanism of Injury: fall from height or motor vehicle accident Classification: a. Extra Articular Fractures Anterior process fractures Tuberosity fractures Medial process fractures Sustentacular fractures Body fractures not involving the subtalar articulation b. Intra Articular Fractures (Essex Lopresti Classification) Intra- articular fractures involve the subtalar joint. They have primary and secondary fracture lines. Intra articular fractures are more common (75%) Primary Fracture Line Producing two main fragments: i Sustentacular (anteromedial) and the tuberosity (posterolateral) fragments. i The anteromedial sustentacular fragment is also called the constant fragment because of its resistance to significant displacements. i The anteromedial fragment consists of part of the posterior facet, anterior process, middle and anterior facets, supported by the sustentaculum tali. i The posterolateral fragment consists of the tuberosity and lateral wall along with a variable portion of the posterior facet.

Secondary Fracture Line Tongue fracture. Secondary fracture line appears beneath the facet and exits posteriorly. The relationship of the lateral posterior facet and the superior aspect of the tuberosity remain intact. Joint depression fracture: Secondary fracture line exits just behind the posterior facet. Joint depression fractures are those in which the secondary fracture line separates the lateral posterior facet from the body and tuberosity of the calcaneus. Sanders Classification Describes comminution and displacement of the posterior facet by computed tomography. CT scan is essential if surgical treatment is being planned. Type I: All Nondisplaced fractures regardless of the number of fracture lines Type II: Two-part fractures of the posterior facet; subtypes IIA, IIB, IIC based on the location of the primary fracture line Type III: Three-part fractures in which a centrally depressed fragment exists; subtypes IIIAB, IIIAC, IIIBC Type IV: Four-part articular fractures; highly comminuted  Bohlers tuber joint angle :( 25 to 40 degree normal). Decreased in intra-articular calcaneal fractures.  Crucial angle of Gissane: Angle formed between the posterior facet and the anterior facet. Normal angle is 110 to 130. Increased in intra-articular calcaneal fractures.

 Harris axial view is used to assess varus or Valgus position and

width of the heel.  Brodn view, obtained by internally rotating the leg 40 degrees with the ankle in neutral, then angling the beam 10 to 15 degrees cephalad, helps to evaluate congruency of the posterior facet Treatment Extra-articular fractures of the calcaneum can be treated conservatively. Displaced tuberosity avulsion fracture, which serves as the attachment of the tendo calcaneus should be internally fixed with a screw to restore the power of the tendo calcaneus and prevent a wide heel with the ensuing difficulties of shoe-fitting Intra-articular fractures: Should be treated with ORIF with plates and screws (Reconstruction plate) in order to reconstruct the articular surface. Axial fixation using the Gissane spike has been popularized by Essex Lopressti Patients with increasing physiological age, male gender, tobacco use, a pending workers compensation claim, heavy laborers, bilateral injuries and increasing comminution of posterior facet may not have significant improvement in function with surgery as compared to nonsurgical treatment(1,2) Anatomic surgical reduction of posterior facet results in improved outcomes compared with those achieved reduction with residual steps, gaps or comminution. Surgical Pearls: Reconstruction of the calcaneus: i Surgical reconstruction maybe delayed for 7 to 10 days for optimization of soft tissue status i Performed through a lateral L incision, with the vertical limb just

posterior to the midpoint between lateral border of Achilles tendon and posterior aspect of fibula, posterior to sural nerve. i The lateral border of the calcaneus is exposed subperiosteally by elevating a full thickness flap. Peroneal tendons, sural nerve and calcaneofibular ligament are reflected en masse in the flap. i Vascularity of flap is based on peroneal artery blood supply which remains protected within substance of flap i Reduction typically proceeds from anteromedial to posterolateral, effectively decompressing central portion of calcaneus to allow accurate reduction of posterior facet fragments i A pin is placed in the posterior fragment to improve exposure of the fracture and to facilitate reduction. i A plate (reconstruction plates, precontoured periarticular multiple limbed plates or LCP) is placed laterally after the fracture has been reduced, and fixation is provided by placing screws into a stable fragment, commonly the sustentaculum tali. i Principles of reconstruction include restoration of calcaneal height (Bohlers angle), heel width (as in axial view), posterior facet alignment, and anatomic realignment of the three superior facets to each other. i The sural nerve is preserved and the peroneal tendons reflected en masse to expose the sub-talar joint. i Large Bony defects may require bone grafting. i The incision is closed primarily, using a two layered closure. There should be a deep interrupted absorbable periosteal suture followed by a separate nylon modified Allgower-Donati flap stitch to minimise tension along the skin incision. i posterior splint is applied Complications of Calcaneal Fractures: Wound Necrosis, Dehiscence, and Infection: Carefully retracting the soft tissues and maintaining a full-thickness flap during open reduction are crucial. Lateral fibular impingement: This is treated by lateral

decompression. Post traumatic arthrosis of subtalar joint: Treated by subtalar arthrodesis. Open calcaneal fractures: 5- 10% calcaneal fractures are open Most of the wounds occur in the medial aspect of foot They are prone for wound complications like osteomyelitis, poor functional outcome and amputation Gustilo I and II open fractures on medial side can be treated with ORIF with results similar to closed fracture. With more extensive soft tissue compromise or type II non medial wounds, external fixation and/or percutaneous screw fixation should be considered. Alternative treatment methods for open calcaneal fractures like percutaneous limited approaches, arthroscopy assisted techniques and ring fixators.

Further Reading: 1. Buckley RE, Tough S. Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg 2004;12:172178 2. Buckley R, Tough S, McCormack R et al.. Operative compared with nonoperative management of displaced intraarticular fractures. A prospective RCT. JBJS 2003;84-A, 1733-1744 TIBIA VARA (BLOUNT DISEASE) TIBIA VARA (BLOUNT DISEASE) Classification: - Infantile form: Presents in children 04 years old  Juvenile form: Presents at >49 years of age in obese children  Adolescent form: Presents in children >10 years old; has excellent prognosis with surgery

Aetiology: Abnormal compression on the posteromedial aspect of the proximal tibial physis, causing retardation of growth from that area Or increased growth from the proximal aspect of the fibula and the lateral aspect of the proximal part of the tibia, or both. This multiplanar deformity consists of varus, procurvatum and internal tibial torsion. Additionally, distal femoral varus is commonly noted in the lateonset form. Blounts disease is the most common cause of pathologic genu varum The Hueter Volkmann law probably explains the aetiology: Compressive forces inhibit bone growth and tensile forces stimulate bone growth at physis. NB: Normal knee alignment progresses from 10 to 15 degrees of varus at birth to a maximum or peak valgus angulation of 10 to 15 degrees at the age of three to three and half years. Neutral femorotibial alignment is achieved when child is 14 months to 20 months old Risk factors: African American ethnicity Obesity Early age of walking Varus greater on the tibial than the femoral side is a risk factor for infantile and juvenile Blount disease Clinical features: Generally present at fourteen to thirty-six months old for evaluation of bowlegs. Infantile tibia vara is found more frequently in children who are black, female, and obese and who started walking at an early age The infantile form is more common in girls. The juvenile or adolescent form is more common in boys.

 Progression to severe form is more common in infantile variety compared to juvenile and adolescent forms The finding of short stature suggests rickets or a skeletal dysplasia Differential diagnosis: Physiological bowlegs 1. The most common cause of genu varum in this age group. 2. Their bowlegs will spontaneously resolve before the age of three. Hypophosphatemic rickets: 1. Short stature and genu varum are features. 2. X-rays show widening or rachitic-like changes at the physis. 3. Serum Phosphorus is low Metaphyseal chondrodysplasia, Focal fibrocartilaginous dysplasia.

Langenskold Classification Stage I: Irregularity of medial proximal tibial physis with varus deformity. Stage II: Medial tapering of epiphysis, metaphysis and slight step in the physis. Stage III: Sharp angular step in the medial proximal tibial metaphysis. Stage IV: Ossification of epiphysis into the metaphyseal step. Stage V: Appearance of separate medial fragment. Stage VI: Bony bridge formation.

This is still the most commonly employed classification system though significant interoberver variability is seen in the intermediate

stages. X-ray A standing full-length anteroposterior radiograph (teleoroentgenogram) of the entire length of both lower extremities with the patellae forward is crucial for a detailed analysis of frontal plane alignment To obtain a true AP view: no more than 60% of the proximal part of the fibula should be seen to overlap the adjacent tibia on a true anteroposterior radiograph centered at the knee, irrespective of the patients age

Drennans metaphyseal-diaphyseal angle of more than 11 degrees warrants close observation >16 degree: Diagnostic The medial physeal slope: an angle formed by the intersection of a line through the lateral aspect of the tibial physis and a line through the medial aspect of the physis . The medial physeal slope is a better radiographic predictor of recurrent varus deformity following osteotomy. A medial physeal slope greater than 60 degrees is always associated with recurrent varus deformity after tibial osteotomy CT scan: i Can be useful in delineating the physeal damage that later may form a bar i A physeal bar is not common in adolescent variety, but the deformity maybe present in both the femur and tibia 3-D CT scan: helpful for preoperative planning in children with earlyonset Blount disease who present with recurrent deformities

An intraoperative arthrogram is helpful for delineating the articular surface and for evaluating dynamic instability of the knee MRI to define intra-articular changes such as posteromedial depression of the tibial plateau and hypertrophy of the medial meniscus in children with early-onset disease detecting growth plate irregularities and early physeal bar formation Treatment Lower stages:  Brace (KAFO) with a medial upright and droplock hinges to unload the medial compartment of the knee for children younger than thirtysix months of age with early-stage(Langenskiold stage-I or II) Blount disease  Full-time bracing (22 hours a day) puts a corrective valgus stress on the knee (more knock-kneed) and decreases the stress on the medial physis  Risk factors for failure of brace treatment include: a weight greater than the 90th percentile, varus thrust and bilateral disease Proximal tibial valgus osteotomy may be done if patient presents between 3 and 4 years of age and stage III or IV:  10 degree overcorrection is recommended.  Elevation of depressed tibial plateau must be done.  Chemoprophylaxis with LMW Heparin maybe given if children are obese Stage V, VI: Excision of bar and insertion of free fat graft. An osteotomy often is combined with completion of the closure of the proximal tibial physis. Lengthening maybe performed later. Adolescent form: Osteotomy may be combined with hemiepiphysiodesis on the lateral side, and later lengthening of necessary Tumour Biopsy Principles

PRINCIPLES OF TUMOUR BIOPSY: 1. Biopsy should be done only after clinical, laboratory, and roentgenographic examinations are complete. This will help in planning the placement of the biopsy incision. It will also help to make an accurate diagnosis 2. Place small incisions whenever possible, also use small capsular incisions over the tumour thus reducing bleeding 3. The biopsy track should be considered contaminated with tumor cells. Placement of the biopsy incision therefore is important because the biopsy track should also be excised en bloc with the tumor subsequently. 4. The surgeon should be familiar with incisions for limb salvage surgery, and also with standard and nonstandard amputation flaps. 5. If a tourniquet is used, the limb is elevated before inflation but should not be exsanguinated by compression because the latter may cause tumour spread. 6. Care should be taken to contaminate as little tissue as possible. Transverse incisions should be avoided since they are extremely difficult or impossible to excise with the specimen. The deep incision should go through a single muscle compartment (muscle belly) rather than through an intermuscular plane. Major neurovascular structures should be avoided. Care should be taken not to contaminate flaps. Minimal retraction should be utilized to limit soft tissue contamination. 7. If possible soft tissue extension of a bone lesion should be sampled 8. If a hole must be made in the bone, it should be round or longitudinally oval to minimize stress concentration and prevent a subsequent fracture. A fracture may preclude a subsequent limb salvage surgery. PMMA is plugged into the hole to contain a hematoma. Only minimal amount of PMMA needed to plug the hole should be used because excessive amounts will push the tumor up and down the bone.

9. Biopsy should be taken from the periphery of the lesion, which contains the most viable tissue. Biopsy material may be sent for culture and sensitivity if there is a doubt regarding infection 10. A frozen section should be sent intraoperatively to ensure that diagnostic tissue has been obtained. If a tourniquet has been used it should be deflated and meticulous haemostasis ensured before closure, since a hematoma would be contaminated with tumor cells. 11. Drains should not be used routinely. If a drain is used, it should exit in line with the incision so that the drain track also can be easily excised en bloc with the tumor. The wound should be closed tightly in layers. 12. When performing an open biopsy the operating surgeon should accompany the specimen to the pathologist if feasible and should discuss with the pathologist about clinical findings, imaging, intraoperative findings and the specimen. Ref: 1. Mankin HJ, Mankin CJ, Simon MA: The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg 1996; 78A:656.

IMMUNOHISTOCHEMISTRY: i Immunohistochemical stains are used to identify certain specific intermediate filament proteins like desmin, vimentin, keratins, neurofilament, glial, fibrillary and lamin filament proteins. i These can be appreciated in light microscopy after appropriate staining of the biopsy tissue i Certain tumours have specific Immunohistochemical profiles that help in their identification i Keratins (epithelial origin) are classically found in metastatic carcinomas. They are also seen in tumours containing epithelial elements like adamantinoma, synovial sarcoma, and epithelioid

sarcoma. i Vimentin (mesothelial origin) is positive in all sarcomas but occasionally negative in carcinomas i Desmin and actin (muscle origin) is positive in tumours with myodifferentiation like rhabdomyomas, Rhabdomyosarcoma, leiomyomas and leiomyosarcomas. May also be present in desmoid tumours and primitive neuroectodermal tumours i S- 100: the name of this protein is derived from the fact that it is soluble in 100% ammonium sulfate. It is positive in Histiocytosis-X i Factor VIII related antigen (von Willebrands factor): these are positive in low-grade vascular lesion like hemangiomas and hemangioendotheliomas. But negative in high grade angiosarcomas FIBROUS DYSPLASIA Fibrous Dysplasia originally described by Lichtenstein in 1938 and by Lichtenstein and Jaffe in 1942 represent approximately 5% to 7% of benign bone tumors A sporadic disorder of osseous and fibrous tissue development characterised by postzygotic mutation of GNAS1 gene coding for stimulatory G protein. Analysis of the Gs subunit in patients with fibrous dysplasia, as well as in those with McCune-Albright syndrome, reveals a missense point mutation at the arginine 201 codon, which results in an arginine-to-histidine or arginine-to-cysteine substitution in the end protein product This result in autonomous function in bone, skin and various endocrine glands dependent on c-AMP -protein kinase, a signal transduction pathway. It is postulated that elevated levels of cAMP could then lead to the expression of proto-onco genes such as c-fos in affected osteoblasts. The proto-onco gene c-fos has been implicated in the process of

osteoblastic differentiation and proliferation that may lead to the formation of fibrous dysplasia lesions In bones areas of trabecular origin, bone is replaced by cellular fibrous tissue containing flecks of osteoid and woven bone. Tumour progression occurs during pregnancy indicating the presence of oestrogen receptors It can be monostotic, polyostotic or monomelic. McCune-Albright syndrome-polyostotic fibrous dysplasia plus cafau-lait spots (Coast of Maine appearance) and hyperfunction of endocrine systems like precocious puberty. Mazabrauds syndrome: in this syndrome skeletal lesions of fibrous dysplasia are combined with intramuscular myxomas. Clinical features: Pain and deformity are signs that microfractures are developing in a lesion and should be addressed. Localized pain may be the presenting symptom in patients with fatigue fractures in high-stress areas in dysplastic bone, especially in the femoral neck. Can occur at any age but mostly seen around the age of 30. Female patients can experience an increase in the pain level during pregnancy and at particular times during their menstrual cycle because of estrogen receptor Polyostotic form involves maxilla and other craniofacial bones, ribs, metaphyseal or diaphyseal portions of proximal femur and tibia (MC site: proximal femur). Weight bearing bones may be deformed, e.g. shepherds crook deformity of proximal femur. Pathological fractures may occur and are more frequently seen in polyostotic disease Sarcomatous degeneration (osteosarcoma) of femur or facial bone

is a rare complication. Rarely renal wasting of phosphate leading onto rickets coexists. In McCune Albright syndrome the lesion tend to be larger, more persistent, and associated with more complications Polyostotic disease may have deformities, which include: coxa vara, the shepherds crook deformity, bowing of the tibia, the Harrison groove (a horizontal depression along the lower border of the thorax, corresponding to the costal insertion of the diaphragm), and protrusio acetabuli Malignant transformation is seen in 0.4 to 4 % of tumors and includes osteosarcoma, fibrosarcoma, and chondrosarcoma.(3) Malignant transformation is seen in adults over 30 years of age and the most common site of involvement is the craniofacial area, followed by femur, tibia and pelvis and also tends to occur more frequently in Mazabrauds syndrome(1,2). Gross pathology: Yellowish white tissue with a distinctive gritty feel, imparted by the small trabeculae of bone scattered throughout the lesion The lesion can be easily peeled away from the encircling shell of reactive bone by blunt dissection The tissue can be cut with a scalpel and may bleed briskly when cut, as a result of its concentration of small vessels. Histology: there is fibroblast proliferation that produces collagen matrix along with metaplastic woven bone. The woven trabeculae are disorganized and have been described as having a Chinese letter appearance. Areas of cartilage formation are commonly present X-ray: Radiolucent cystic areas, which are expansile with deep endosteal scalloping and ground glass appearance or shower door glass appearance in the metaphysis or shaft with medullary calcification. Lesion is bounded by a distinct rim or shell of reactive bone that is

defined more sharply on its inner border than on its outer border, where it may fade gradually into normal cancellous bone Can grow eccentrically or concentrically and can resemble simple bone cyst. Endosteal scalloping maybe present, the periosteal surface is smooth and without reaction. Monostotic lesions mature after skeletal growth ceases., whereas polyostotic lesions continue to grow A well-defined sclerotic rim is usually seen. Radiologically facial bone involvement present as radiodense lesions (leonine ossea- leonine appearance) When a fatigue fracture is present in the proximal femur there are two humps of reactive bone on the medial cortex separated by a thin radiolucent line resembling a parrots beak Bone scans are useful to evaluate the extent of the disease. A bone scan that does not show increased uptake does not exclude the diagnosis of fibrous dysplasia CT scans are useful to evaluate the thickness and extent of lesion, also endosteal reaction, periosteal new bone reaction, and homogeneity of the poorly mineralized lesional tissue MRI: T1-images show low signal intensity, T2-weighted images have a higher-intensity signal that is not as bright as the signal of malignant tissue, fat, or fluid. Cysts demonstrate high signal intensity on T2-weighted images secondary to high water content. It is also useful in evaluating suspected malignant degeneration of known fibrous dysplasia lesions by showing the extent of the lesion and/or the surrounding soft tissues and its soft-tissue extension, if present. Treatment

No effective treatment is available. 1. Monostotic asymptomatic small lesions require no surgery especially in patients who have attained skeletal maturity. In newly identified cases, a bone scan is needed to exclude a diagnosis of polyostotic disease. When polyostotic disease is found, a referral to an endocrinologist for endocrine and metabolic testing is paramount 2. I.v pamidronate therapy may cause radiographic resolution in polyostotic disease (4). Dose: 60mg/day for 3 days, which is repeated every 6 months, supplemented with calcium (500 to 1500 mg/day) and vitamin D (800 to 1200 IU/ day). Monitoring markers of bone turnover (N-telopeptide and alkaline phosphatase) at six-month intervals and bone mineral density yearly during treatment is a means of assessing the efficacy of bisphosphonate therapy. 3. Large painful, fracture prone lesions can be curetted and grafted. A cortical graft may be useful to bridge the defect, especially a cortical allograft since it is reabsorbed slowly. Suitable osteotomies to correct deformities may be employed. Treatment may be postponed until skeletal maturity since recurrence is very common Fixed-angled internal-fixation devices, like intramedullary nails should be employed to correct the deformity. Collins et al devised an insturment for measuring the skeletal burden of fibrous dysplasia and predicting the functional outcome (5). Decision and type of surgery can be attained from this score. Irradiation is contraindicated because of the risk of radiation induced sarcoma later in life Ref: 1. Yabut SM Jr, Kenan S, Sissons HA, Lewis MM. Malignant transformation of fibrous dysplasia. A case report and review of the literature. Clin Orthop Relat Res.

1988;228:281-9. 2. Lopez-Ben R, Pitt MJ, Jaffe KA, Siegal GP. Osteosarcoma in a patient with Mc-Cune-Albright syndrome and Mazabrauds syndrome. Skeletal Radiol. 1999;28:522-6. 3. Harris WH, Dudley HR Jr, Barry RJ. The natural history of fibrous dysplasia. An orthopaedic, pathological, and roentgenographic study. Am J Orthop. 1962; 44:207-33. 4. Chapurlat RD, Delmas PD, Liens D, Meunier PJ. Long-term effects of intravenous pamidronate in fibrous dysplasia of bone. J Bone Miner Res. 1997;12:1746-52. 5. Collins MT, Kushner H, Reynolds JC, Chebli C, Kelly MH, Gupta A, Brillante B, Leet AI, Riminucci M, Robey PG, Bianco P, Wientroub S, Chen CC. An instrument to measure skeletal burden and predict functional outcome in fibrous dysplasia of bone. J Bone Miner Res. 2005;20:219-26. Stem cells in Orthopaedic Surgery STEM CELLS IN ORTHOPAEDIC SURGERY

i A stem cell is an immature or undifferentiated cell which is capable of producing an identical daughter cell. i Stem cells must have a capacity for self-renewal giving rise to more stem cells, and the ability to differentiate into tissues of various lineages under appropriate conditions i They may be totipotent, pluripotent or multipotent, depending on type i Totipotent: Cells which can form all the cells and tissues that contribute to the formation of an organism i Embryonic stem cells (ESCs) are pluripotent, which can form most, but not all cells or tissues of an organism

i Differentiation of adult stem cells is generally restricted to the tissue in which they reside. Under appropriate conditions some can differentiate into multilineages, becoming multipotent. Eg., mesenchymal stem cells (MSCs) which are found in bone marrow, skin, adipose tissue i These cells are capable of differentiating into bone, cartilage, tendon, ligament, fat and other tissues of mesenchymal origin i The phenomenon of transdifferentiation: Here cells from one lineage dedifferentiate, giving rise to an intermediate cell type, before redifferentiating into cells of another lineage i MSCs as progenitor cells, injected directly into tissues to enhance the process of repair, or by using them as a vehicle for gene delivery. i Articular cartilage is vulnerable to injury and has poor potential for repair i Procedures directed at the recruitment of stem cells from the marrow by penetration of the subchondral bone have been widely used to treat localised cartilage defects (autologous chondrocyte implantation) i Attempts to 'regenerate' normal articular cartilage have been introduced in clinical practice with autologous chondrocyte implantation. Lesions of osteochondritis dissecans or traumatic osteochondritis can be treated with this technique Bone i Trauma and some pathological conditions may lead to extensive loss of bone, which requires transplantation of bone tissue i Mesenchymal stem cells derived from bone marrow have been used to treat segmental bone defects (Quarto et al)

i Successful tissue engineering of bone requires osteoproduction, osteoinduction, Osteoconduction and mechanical stimulation i Bone induction to assist and enhance bone deposition and repair was introduced by Urist in 1965 and led to the isolation of the BMPs, which could stimulate osteogenic precursor MSCs to form bone. i A number of studies have shown the potential for BMP-2, BMP-3 and BMP-4 in the healing of fractures and segmental bone defects, and in the fixation of prosthetic implants i BMP regulates chemotaxis, mitosis and differentiation, and is fundamental in initiating fracture repair i TGF- and IGF may stimulate fracture repair and minimise the rate of nonunion i In order for BMP to induce bone formation effectively, its dose must be of sufficient concentration for a sustained period. i However, these proteins have short biological half-lives and must be maintained at therapeutic concentrations at the fracture site to be effective Tendons and ligaments i In rabbits tendoachilles tears and patellar tendon defects have been successfully been treated by MSC.( Young et al) i Key to success in surgical reconstruction of the anterior cruciate ligament (ACI.) is the healing of the tendon graft to the bone. i The normal anatomy of the insertion site of the ACL is fibrocartilaginous and consists of four distinct zones: ligament substance, unmineralised fibrocartilage, mineralised fibrocartilage

and bone i Conventional free tendon transfers are unable to restore this complex anatomy within the first six months i By applying MSCs to tendon grafts at the tendon-bone junction results in a zone of fibrocartilage at the junction which more closely resembled that of the normal ACL (Lim et al) Meniscus i Tears in the avascular inner third of the meniscus have limited or no potential for repair as the reparative process cannot occur without the presence of bleeding i Dutton et al assessed the capability of autologous seeded BMSCs to repair an avascular meniscal lesion in the pig. i They showed that a meniscal lesion involving the inner, avascular, one-third of the meniscus benefited from the bonding capabilities of the transplant. i This study raises the potential of cell-based therapy to repair a tear in the avascular inner third of the meniscus rather than proceeding to surgical resection. Spine i Degeneration of the intervertebral disc is a leading cause of back pain and morbidity i Most commonly, fusion with or without discectomy is performed, although more recently disc replacement has received some attention i Cell transplantation can potentially increase proteoglycan production, induce disc regeneration or slow the process of degeneration (Crevenstcn et al) i Spinal fusion: a novel approach to create a hybrid graft by combining cultured MSCs with a ceramic scaffold (Cinotti et al)

Spinal cord i Stem cell therapy has therapeutic potential for spinal cord injuries because of the ability of pluripotent cells to differentiate into neural tissue i But, repair of the spinal cord is very complex. It includes restoring or enhancing local spinal reflex arcs and reconnecting regenerating axons from above. i Gliosis may block the outgrowth of axons i MSCs isolated in culture from the mononuclear layer of bone marrow can remyelinate demyelinated spinal cord axons after direct injection into the lesion (Akiyama et al) Paediatric Orthopaedicsi - Deformity correction in children sometimes include excision of a preexisting bony bridge and the insertion of fat, polymeric silicone or muscle as an interpositional material i Cultured chondrocytes have been transferred into physeal defects for the correction of established growth arrest in animal models i Attention has turned to the use of MSCs from bone marrow to repair physeal defects i Duchennes Muscular dystrophy: An encouraging and pioneering experiment in mouse models of DMD demonstrated that myoblasts could be transplanted into dystrophic muscle and repaired a small proportion of damaged myofibres i Other diseases where stem cells are being tried are Osteogenesis imperfecta and Juvenile rheumatoid arthritis. Ref: 1. Urist MR. Bone formation by autoinduction. Science 1965;150:8939. 2. Young RG, Butler DL, Weber W, et al. Use of mesenchymal stem cells in a collagen matrix for Achilles tendon repair. J Orthop Res 1998;16:406-13. 3. Lim JK. Hui J, Li L, et al. Enhancement of tendon graft

osteointegration using mesenchymal stem cells in a rabbit model of anterior cruciate ligament reconstruction. Arthroscopy 2004;20:899910 4. Dutton A, Hui JPP, Lee EH, Goh J. Enhancement of meniscal repair using mesenchymal stem cells in a porcine model. Procs 5th Combined Meeting of the Orthopaedic Research Societies of USA, Canada, Japan & Europe. 2004 5. Crevensten G, Walsh AJ, Ananthakrishnan D, et al. Intervertebral disc cell therapy for regeneration: mesenchymal stem cell implantation in rat intervertebral discs. Ann Biomed Eng 2004;32:430-4. 6. Cinotti G, Patti AM, Vulcano A, et al. Experimental posterolateral spinal fusion with porous ceramics and mesenchymal stem cells. J Bone Joint Surg 2004;86-B: 135-42 7. Akiyama Y, Radtke C, Honmou O, Kocsis JD. Remyelination of the spinal cord following intravenous delivery of bone marrow cells. Glia 2002;39:229-36. 8. Chen F, Hui JH, Chan WK, Lee EH. Cultured mesenchymal stem cell transfers in the treatment of partial growth arrest. J Pediatr Orthop 2003;23:425-9 9. Gussoni E, Soneoka Y, Strickland CD, et al. Dystrophin expression in the MDX mouse restored by stem cell transplantation. Nature 1999;401:390-4 Acetabulum fractures FRACTURES OF THE ACETABULUM Letournel and Judet Classification Letournel and Judet devised the column concept where the anterior column was formed by the iliopectineal component and the posterior column was formed by the ilioischial component. The acetabular dome is formed the junction of the two columns. Both the columns have an inverted Y shaped construct Based on degree of columnar damage, 10 fracture patterns occur5 elementary and 5 associated.

Elementary Patterns 1. Posterior wall # 2. Posterior column # 3. Anterior wall # 4. Anterior column # 5. Transverse # Associated Patterns 1. T-shaped # 2. Posterior column and posterior wall # 3. Transverse and posterior wall # 4. Anterior column/Posterior hemitransverse # 5. Both columns # Mechanism of Injury: a) Direct trauma: Direct impact to the greater trochanter forms a transverse fracture when the hip is in neutral position Direct impact to the greater trochanter forms an anterior column fracture when the hip is externally rotated. Direct impact to the greater trochanter forms a posterior column fracture when the hip is internally rotated. b) Indirect trauma: As in a dash type of injury with a flexed knee. Clinical Features: Airway, breathing and circulation should be assessed. Look for sciatic nerve injury (common peroneal nerve component) especially in posterior column fractures. Morel-Lavalle lesion: It is a localised area of subcutaneous fat necrosis over the lateral aspect of the hip caused by the same trauma that causes the acetabular fracture.

X-ray AP view The obturator oblique view evaluates the anterior column (iliopectineal line) and posterior wall of the acetabulum. The obturator oblique view is obtained when the pelvis is rotated 45 degrees with the inured side up The iliac oblique radiograph posterior column (ilioischial line or Kohlers line), anterior wall of the acetabulum. Roof arc angle of Matta is calculated by drawing 2 lines, one vertical line along the geometric centre of the acetabulum and the other from the fracture line to the geometric centre. The medial, anterior and posterior roof arcs are calculated.

CT scans including 3-D CT: 3D CT helps in a better understanding of the fracture but may not clearly identify fractures with minimal displacement due to averaging phenomena Treatment Non-operative Treatment (Indications) 1. Minimally displaced fractures (<2 mm) in the weight-bearing dome. 2. Roof arc angle> 45 degrees. 3. Secondary congruence in both column fractures where the ball and socket configuration of hip is maintained. 4. No femoral head subluxation on three x-rays, taken out of traction 5. For posterior wall fractures: less than 40% of width of wall on CT Roof arc angles are not used in posterior wall fractures. Operative Treatment (Indications) 1. Mainly for displaced fractures in the weight bearing area. 2. Mattas roof arc angle <45 degrees. 3. Inability to maintain a congruent joint out of traction

4. Cranial 10 mm of the acetabulum on the CT scan corresponds to the area defined as the weight-bearing dome by roof arcs. Fractures involving area in the upper 10 mm of acetabulum are treated operatively. Applied anatomy: Corona mortis: is a vascular communication between external iliac and deep inferior epigastric artery and the obturator artery. May extend over the superior pubic ramus; average distance from the symphysis to corona, 6 cm The ascending branch of MCFA contributes to vascularity of femoral head; hence preservation of this artery while dissecting near the quadratus femoris is important. The superior gluteal neurovascular bundle exists through the greater sciatic notch, damage of this bundle can occur when the fracture line exits the greater sciatic notch. Factors predicting a good outcome in acetabular fracture fixation: Injury to cartilage or bone of femoral head Damage: 60% good/excellent result No damage: 80% good/excellent result Anatomic reduction Age of patient: predictive of the ability to achieve an anatomic reduction

Posterior wall fracture: - Maybe single or multifragmentary Marginal impactions maybe present: This is a rotated and impacted osteochondral fragment that is displaced as the femoral head dislocates and the wall fractures CT scan helps to evaluate marginal impaction, loose fragments in the joint, evaluation of joint concentricity and estimation of size of

posterior wall fragment. Kocher Langenback approach is used for fixation Posterior column fracture: Usually fractures the greater sciatic notch at or above the location of the superior gluteal neurovascular bundle, extends inferiorly through the roof of the weight bearing dome and exists through the obturator foramen Neurovascular bundle maybe entrapped in the fracture if the posterior column is widely displaced. It should be extracted prior to reduction of the fracture dislocation Letournels gull sign: the articular cartilage accompanying the displaced posterior acetabular segment hinges inward creating an image with the intact portion of the roof that looks like a bird in flight. Kocher Langenback approach is used for fixation Anterior wall fractures: May be associated with thinning or reduplication of the ilioischial line The teardrop is often displaced medially with respect to the ilioischial line. Ilioinguinal approach is used for fixation Anterior column fracture: High anterior column fractures exit the iliac crest, intermediate fractures exit the anterior superior iliac spine (ASIS), low fractures exit the psoas gutter just below the AIIS, and very low anterior column fractures exit the bone at the iliopectineal eminence The roof or portion of it can be displaced medially as seen in high or intermediate anterior column fractures. This pattern may also be seen in anterior column-posterior hemitransverse fractures or both column fractures of the acetabulum. The more superiorly the fracture line ascends, the greater the involvement of the weight-bearing aspect of the acetabulum. Ilioinguinal approach is used for fixation

Transverse fractures: breaks both the anterior and posterior border of the innominate bone separates the innominate bone into two pieces: the upper iliac piece and the lower ischiopubic segment subdivided by where the fracture crosses the articular surface:  Transtectal fractures cross the weight bearing dome of the acetabulum.  Juxtatectal fractures cross the articular surface at the level of the top of the cotyloid fossa.  Infratectal fractures cross the cotyloid fossa Transtectal fractures maybe fixed with extended iliofemoral approach or Kocher langenback approach Infratectal or Juxtatectal fractures are approached through the Kocher Langenback approach Complications: 1. Nerve injury: Sciatic nerve injury is associated with posterior column fractures. 2. Surgical wound infection: abdominal and pelvic visceral injuries predispose to increased incidence of surgical wound infection. 3. Heterotopic ossification: the incidence is highest with the extended iliofemoral approach and second highest with the KocherLangenback. indomethacin or low-dose radiation are sued for prophylaxis 4. Avascular Necrosis 5. Chondrolysis Osteosarcoma These are spindle cell neoplasms that produce Osteoid It is the second most common primary malignancy of bone behind multiple myeloma. OSTEOSARCOMA CLASSIFICATION

 High grade Intramedullary Osteosarcoma Low Grade Telengiectatic Osteosarcoma Surface Osteosarcoma 1. Paraosteal 2. Periosteal 3. High Grade Surface Osteosarcoma Osteosarcoma of the Jaw Multicentric osteosarcoma Secondary osteosarcoma Irradiation induced Osteosarcoma Dedifferentiated Chondrosarcoma Osteosarcoma derived from benign precursors Osteosarcoma may be also classified based on prognostic importance Low Grade Parosteal Low-grade central Intermediate Grade Periosteal High Grade Conventional Telangiectatic Small cell Postradiation Pagetoid High-grade surface

Aetiology: Genetic abnormalities: p53 suppressor genes, Rb gene, F33 isoform, ErbB-2 (Her 2neu), transforming growth factor beta,

isoform 3 expression Associations: Retinoblastoma (Rb gene), Rothmund-Thomson syndrome, and Li-Fraumeni syndrome (p53 gene) Li-Fraumeni syndrome: sarcomas in young patients and premenopausal breast cancer in the mothers of the young patients Rothmund Thomson syndrome: rare genodermatosis that features a progressive, early-onset poikiloderma, a high incidence of juvenile cataracts, stunted growth, and a wide range of skeletal abnormalities. Osteosarcoma is the most common type of bone sarcoma(The most common primary bone malignancy is multiple myeloma, and the most common malignancy affecting bone is metastatic carcinoma) Bimodal peak age incidence Majority occur within the second decade (~60%) Second peak age >55; often secondary osteosarcomas Incidence: 0.3 per 100,000 per year Local Growth:  Osteosarcomas usually arise within the metaphyseal region of long bones.  They may be located within the bone or on the surface of the bone.  If untreated, osteosarcomas will continue to grow, with local destruction of bone and extension outside the bone into the surrounding soft tissues.  The physis and articular cartilage may act as a relative barrier to tumor extension, but epiphyseal or intra-articular extension is still seen frequently. Metastases  Osteosarcomas, as with all sarcomas, usually metastasize hematogenously.  Lymph node metastases are not common and usually present only very late in the course of metastatic disease.

 15% to 20% of patients present with metastases at time of diagnosis.  Most common site of metastasis: lungs  Second most common: bone  Skip lesions: distinct smaller areas apart from primary tumor within same bone  Prognosis: same as or worse than distant metastases (lung or bone)

a) Classic Osteosarcoma (High Grade Intramedullary osteosarcoma) i Most common in second or third decade. i Fifty percent of lesions seen about the knee joint. i Histological cell types are osteoblastic, chondroblastic, fibroblastic and small cell i Arises from the medullary canal i MC location: distal femur > proximal tibia >proximal humerus i Can occur in any bone CF: i Pain before a tumour mass is noticeable. i Pain is due to microinfarctions occurring in the bone. i Night pain is an important symptom but is seen in only 25% of patients. i Pain gradually worsening, though may be intermittent or increase with activity i Pain is usually present for weeks to months, not acutely i Dilated veins over swelling. i Fusiform swelling, fixed to bone, firm and immobile i Tenderness is usually present to palpation, with range of motion, and with weight bearing i About 10- 20% patients have pulmonary metastasis at presentation

i Metastasize in 80% patients treated by surgery alone Investigations: X-ray:  Permeated lytic destruction of metaphyseal bone  Codmans reactive triangle  Sunburst pattern or hair on end appearance.  Areas of bone formation maybe present  Occasionally the lesion is pure sclerotic or lytic.  There is usually some cortical destruction with extension of a soft tissue mass  Associated higher-level lesion in the femur- skip lesion MRI: identifies i Extent of soft tissue involvement i Intramedullary spread i Neurovascular involvement At least one sequence of entire bone (preferably coronal T1 images) to rule out skip lesion in same bone (metastasis) is essential Whole-body bone scan:i Uptake on scan of primary lesion is almost always present, but scan is to rule out other sites of disease. i May detect other sites of disease i May also show skip lesion in same bone Biopsy: Periphery of the tumour is the best tissue for a biopsy because It is easy to reach. Soft enough for a diagnostic frozen section, and Representative of the most aggressive portion. CT chest to detect any pulmonary metastasis Pathology:

 Osteosarcoma produces high-grade spindle cell sarcomatous stroma with malignant osteoblasts that produce malignant osteoid or bone.  Tumor cells are typically anaplastic (less differentiated), may show marked atypia and pleomorphic (widely variable) nuclei, and may show many and/or bizarre mitoses.  There may be areas of osteoblastic (osseous), fibroblastic (fibrous), or chondroblastic (cartilage) appearance, but if there is the presence of malignant osteoid (wavy, lace-like, uncalcified bone matrix produced by malignant osteoblasts), the diagnosis of osteosarcoma is made regardless of the associated areas. Grading:  Helps to assess prognosis  Low grade tumours do not require chemotherapy and are less likely to develop metastasis  Most osteosarcomas are high-grade tumors( mostly IIB Enneking)

Poor prognostic factors in osteosarcoma are:a. Metastases to lung, bone and lymph nodes b. Expression of P glycoprotein in the cells c. High Alkaline phosphatase d. High Lactate dehydrogenase e. Vascular Invasion f. Large tumour size g. No alteration in DNA ploidy after chemotherapy h. Absence of anti heat shock protein 90 antibody after chemotherapy Treatment: Neoadjuvant chemotherapy, Surgery In extremity osteosarcoma, limb-sparing surgery, with wide resection of the tumour, is the standard approach.

Chemo for osteosarcoma: Methotrexate, Adriamycin, cisplatin, and ifosfomide. Neoadjuvant chemotherapy is delivered for 8- 12 weeks followed by resection of the tumour. Maintenance chemotherapy is given for 6- 12 months. Neoadjuvant chemotherapy: i Neoadjuvant chemotherapy may shrink the primary tumor and sterilize microscopic tumor foci in the reactive zone around it, facilitating resection and increasing the chance for limb-sparing surgery. i Neoadjuvant chemotherapy also allows time for surgical planning, the fabrication of a custom tumor prosthesis, or the procurement of allograft tissue for implantation. i Finally, neoadjuvant chemotherapy induces necrosis in the primary tumor, and the amount of this necrosis serves as an extremely important prognostic indicator for long-term survival i Thallium 201 is used to assess tumour response after chemotherapy Side effects of these medications can be severe, and toxicities can occur. These include mucositis, cardiomyopathy (doxorubicin), alopecia, myelosuppression, nausea/vomiting, and relative immunocompromise, sepsis, and rarely even death. Medications used during chemotherapy treatment to minimize side effects i Granulocyte colony-stimulating factor (G-CSF;):Improves neutropenia by stimulating neutrophil production by marrow, decreases infections and febrile neutropenias i Erythropoietin stimulates red blood cell production. i Dexrazoxane protects against cardiomyopathy of doxorubicin. i Leucovorin rescues normal cells from effects of high-dose methotrexate and decreases myelosuppression and mucositis

Limb sparing Surgeryi Limb-sparing surgery is indicated for patients in whom wide margins can be obtained without sacrificing so much tissue that the remaining limb is nonfunctional. i Usually, the determining factor is the ability to spare major nerves. Major vessels need to be preserved or reconstructed. Role of radiation therapy: i Mainly for palliation i may be the safest oncologic treatment following initial resection with positive margins(margins containing malignant cells) b) HAEMORRHAGIC or Telengiectatic Osteosarcoma i High-grade, purely lytic tumour, incidence of pathologic fracture is high. i 0.4% to 12% of all osteosarcomas i Histology: Bag of blood with few cellular elements, cellular elements have highly malignant appearance i X ray: Permeative or ballooned out appearance resembling aneurysmal bone cyst with little bone production i A pathologic fracture may necessitate amputation rather than limb salvage. i Impending lesions should be either immobilized to prevent pathological fracture or treated with early surgery. i Treatment is by multi agent chemotherapy and surgery c) PARAOSTEAL OSTEOSARCOMA i More common in females, slightly older age group(2nd and 3rd decades) i Most common surface osteosarcoma. Other surface osteosarcomas include periosteal osteosarcoma and high grade surface osteosarcoma i 5% of osteosarcomas

i MC sites: distal femur>proximal humerus i Patients usually complain of a painless mass, dull aching type of pain may also be a presenting complaint i Slow growing low-grade tumour usually appearing in posterior aspect (surface) of the distal femur (over the external aspect of bone) X-rays reveal dense mineral deposits within the tumour DD on X-ray: Myositis ossificans. The ossification in myositis ossificans is more mature at the periphery of the lesion, whereas the center of a periosteal osteosarcoma is more heavily ossified and lobulated. Differentiated from osteochondroma that it lacks the corticomedullary trabecular continuity Cleavage plane or a radiolucent line between tumour and cortex Has a stuck on appearance. It may wrap around cortex, with invasion into bone later Histology: The osseous trabeculae are regularly arranged. Between the normal trabeculae are atypical spindle cells. Cartilage is frequently present and is arranged as a cap over the lesion In around 1/6th of the lesions that appear in X-rays as Paraosteal osteosarcoma there is a high grade element. In this circumstance the lesion is termed a Dedifferentiated Osteosarcoma, for which the prognosis is worse. Treatment: It does not respond well to either chemotherapy or radiation therapy. Wide surgical resection is the treatment of choice. Dedifferentiated form: responds to multiagent chemotherapy. d) PERIOSTEAL OSTEOSARCOMA

i More common in females in the second decade of life. i 1-2% of all osteosarcomas i Common in the diaphysis of femur and tibia(anterior surface) i X rays: i Radiographically, a fusiform mass with lucency and ossification i A sunburst appearance is seen resting on a saucerised cortical depression. i Cortical depression can mimic a periosteal chondroma, but periosteal osteosarcoma is associated with a larger size (>4 cm) and irregular margins i Histologically the lesion is more chondroblastic. i Wide surgical resection is the modality of choice. This is combined with chemotherapy. i The prognosis is intermediate between High grade intramedullary osteosarcoma and paraosteal osteosarcoma e) SECONDARY OSTEOSARCOMA i May arise in Pagets disease, osteoblastoma, fibrous dysplasia, benign giant cell tumour, osteochondroma, Melorheostosis, osteogenesis imperfecta, bone infarction, and chronic osteomyelitis. i Most common of the secondary osteosarcomas-Pagetic osteosarcoma i The most frequent location for pagetic osteosarcoma is the humerus, followed next by the pelvis and femur. i Several thousand-fold increased risk of osteosarcoma in patients with Paget's disease compared to the general population i Occur in an older population (55 to 85 years old) i Increasingly painful mass is most common presentation. i Occur in Flat bones, unlike conventional osteosarcoma due to frequent involvement of pelvis and scapula with Paget's disease i X-rays: reveal destructive mass, usually with soft tissue extension in bone with Paget's disease.

i The prognosis for patients with pagetic osteosarcoma is extremely poor. i Occur in 5% of patients with polyostotic Pagets disease f) LOWGRADE INTRAMEDULLARY OSTEOSARCOMA i 1 to 2% of all osteosarcomas i Older, typically third decade i Radiographically, sclerotic density in metaphyseal bone. i Often confused with fibrous dysplasia or by progression or recurrence after treatment for suspected benign disease i Prognosis is similar to paraosteal sarcoma i Wide resection is the treatment of choice. g) IRRADIATION INDUCED OSTEOSARCOMA Usually with >4000 cGy radiation dosage Usually appears after 3- 15 years from the time of radiation insult. Common in flat bones like scapula, pelvis and rib h) MULTICENTRIC OSTEOSARCOMA a. Synchronousoccurring in childhood and adolescents and b. Metachronous occurring in adults. Prognosis is poor for both types. i) Soft -Tissue Osteosarcoma (extra osseous osteosarcoma) Can occur in muscle tissue (4% of all osteosarcomas) Tumour is usually seen in large muscle groups of the pelvis, thigh areas or the shoulder. DD: Myositis ossificans. Myositis ossificans has a zonal pattern of ossification (Ackermann zone phenomenon) with the mature dense ossification concentrating at the periphery of the lesion. Treatment: Wide resection, +/- adjuvant chemotherapy and radiotherapy j) HIGH GRADE SURFACE OSTEOSARCOMA

i Up to 1% of osteosarcomas i Located on surface of bone i Otherwise identical to conventional osteosarcoma in histology, treatment, and prognosis k) SMALL CELL OSTEOSARCOMA i Rare; about 1% to 4% of all osteosarcomas i Controversy: Are these atypical Ewing sarcoma? i Age, location, and radiographic picture similar to conventional osteosarcoma i Typically has a destructive, permeative pattern, sometimes extends into diaphysis i Histology: there is often difficulty in distinguishing this tumor from Ewing sarcoma and other small round cell tumors if no osteoid is seen on biopsy. i Usually has areas of osteoblastic activity, which helps distinguish it from Ewing sarcoma Perthes DIsease Current Concepts Perthe's disease- aetiology: G. C. Perthes in Germany, J. Calv in France and A.T. Legg in America described the disease almost simultaneously, in 1910. Synonyms: Coxa Plana; osteochondritis deformans juvenilis Aetiology: Theories and Supporting Evidence 1. Compromised Vascular supply: Angiograms and laser Doppler flow studies showing that the medial circumflex artery is missing or obliterated in many cases and that the obturator artery or the lateral epiphyseal artery are also affected in some cases. 2. Increased intra-articular pressure:

Animal experiments have shown that an ischemia similar to that in LeggCalv-Perthes disease can be generated by increasing the intraarticular pressure 3. Raised Intraosseous pressure The venous drainage in the femoral head is impaired, causing an increase in intraosseous pressure 4. Coagulation disorder Association with Protein C or S deficiency. These factors normally inhibit coagulation 5. A maturation disorder Legg- Calv- Perthes disease patients are shorter, on average, than their peers of the same age and show a retarded skeletal age 6. Social conditions: Studies in the UK have shown that Legg- CalvPerthes disease is more common in the lower social strata 7.Genetic factors: Genetic studies have shown that first degree relatives of children with Perthes disease are 35 times more likely to suffer from the condition than the normal population. Classifications Catteralls Head-at-risk Signs 1. Lateral subluxation of the femoral head from the acetabulum. 2. Speckled calcification lateral to the capital epiphysis. 3. Diffuse metaphyseal reaction (metaphyseal cysts). 4. A horizontal physis, and 5. Gage sign: A radiolucent V-shaped defect in the lateral epiphysis and adjacent metaphysis. Salter Thompson Classification

 Type A: Extent of the fracture is less than 50% of the superior dome of the femoral head. Good results. Type B: Extent of the fracture is more than 50% of the dome. Fair or poor results. Herring Lateral Pillar Classification Group A: No involvement of the lateral pillar. Group B: At least 50% of lateral pillar height maintained. Group C: Less than 50% of lateral pillar height maintained. The lateral pillar consists of the lateral most 30% of the femoral head in an AP projection. To designate borderline groups between B and C the B/C border group was included. B/C1: lateral pillar more than 50% width, but < 2 to 3 mm width B/C2: lateral pillar more than 50% width, but little ossification B/C3: lateral pillar more than 50% width, but depressed relative to central column. Catterall Classification Group I: Anterior part of head involved. Group II: Anterior and partial lateral involvement. Sequestrum+ Mild metaphyseal changes Group III: Anterior and lateral head involvement Sequestrum + Diffuse metaphyseal changes + Coxa magna Group IV: Complete head involvement Collapse of head

stages Stages of Perthes Disease (Waldenstrm Staging) Stage and Characteristics 1. Avascular stage. The femoral head appears slightly denser than

normal on the x-ray and is slightly flattened; the joint space is widened (Waldenstrm sign). Lateralisation of the femoral head. 2. Stage of resorption (Fragmentation). Femoral head breaks up into fragments Lucent areas appear in the femoral head Increased density resolves Acetabular contour is more irregular 3. Stage of reossification. The femoral head is rebuilt New bone formation occurs in the femoral head 4. Healing stage. End stage with or without defect healing (normal hip, coxa magna, coxa parva, flattened head etc.)

Clinical Features: Limp and mild to moderate hip pain The ROM of the hip is restricted, in particular abduction and internal rotation. Prognostic Features: Deformity of femoral head, Age, subluxation, lateral calcification, mobility and sex in decreasing order of significance Herring lateral pillar classification has the best prognostic significance Gage sign and Horizontal growth plate as originally described by Caterall have no prognostic significance Differential Diagnosis: 1. Epiphyseal dysplasia: The following are features Bilaterali involvement

Largely symmetrical findingsi Possible involvement of otheri joints or the spine Possible involvement of the acetabulumi Fewi sclerotic or cystic changes in the femoral head Little tendency towardi lateral calcification or subluxation Typical stages of LCPD like sclerosis,i collapse, fragmentation and reossification are not apparent 2. Osteochondritis dissecans of the femoral head 3. Chondroblastoma of the femoral head The height of the femoral head is not initially reduced, nor is the cartilage thickened. The presence of non-load-related pain Stages of radiological changes in Perthe's disease: Early Joint space widening(waldenstrom's sign) Increased density of femoral epiphysis Subchondral fracture, or crescent sign, seen on lateral radiograph Midstage Fragmentation and flattening of head Widening of the physis Femoral neck cysts Extrusion of the femoral head Late Coxa magna High-riding trochanter Flattened femoral head Irregular articular surface Perthes disease features: Unilateral involvement,i If bilaterali involvement is present: pronounced asymmetry, disease

in differing stages, possibly also of differing severity, No involvement of other joints or thei spine, No involvement of the acetabulum,i Sclerotic and cystic changesi in the femoral head, Cystic changes in the metaphysis,i Tendency towardi lateral calcification and subluxation

DD Other disorders associated with Avascular Necrosis of the femoral head in children: Sickle cell anemiai Thalassemia ((highi incidence (25%) of avascular femoral head necrosis )) Trichorhinophalangeali syndrome Klinefelter syndromei Morquios syndromei Down syndromei (trisomy 21) Achondroplasiai Gauchers diseasei i Myelomeningocoele Hemophilia (the incidence in hemophilia is 7%)i i Congenital tibial pseudoarthrosis

Treatment Treatment is guided my dividing the patient into three groups. Poor prognosis group: Treatment indicated: Catterall 3 and 4 Salter-Thompson Lateral pillar C

 At risk clinically At risk radiographically, regardless of the disease extent Age<8yrwithdeformity Age >8 yr (Catterall group 2, 3, and 4, with or without at-risk signs; lateral pillar B and C; Salter-Thompson B), with or without head deformity Good prognosis group: no treatment necessary: Catterall 1 and 2(generally good prognosis in 90% of cases) Salter-Thompson A Lateral pillar A If disease is in reossification stage Indeterminate prognosis group: may require treatment if head at risk signs is present. Otherwise no treatment is indicated. Catterall 2 Lateral pillar B Principles of treatment The first principle regardless of the method of treatment is restoration of motion. Restoration of motion can be accomplished by bed rest alone, or with skin traction and progressive abduction to relieve the muscle spasms Reassessment is done in 1 week to assure that range of motion has considerably improved (to at least 45 degrees of abduction The cornerstone of treatment for Legg-Calve-Perthes syndrome is referred to as containment The essence of containment is that, in order to prevent deformities of the diseased epiphysis, the femoral head must be contained within the depths of the acetabulum Arthrography is a useful adjunct in determining whether the femoral head actually can be contained and, if so, in what position this is best accomplished. It is essential to regain range of motion before instituting

containment treatment Hinged abduction: This is a condition in which the head levers out of the acetabulum with abduction instead of moving within the socket Demonstration of the hinge abduction phenomenon is a contraindication to any type of containment treatment Surgical containment (Varus Derotational Osteotomy / Innominate Osteotomy/ Lateral Shelf acetabuloplasty) is the most popular method of treatment Abduction brace like the Atlanta Scottish Rite orthosis are used by surgeons who prefer nonsurgical containment The requisites for an varus derotation intertrochanteric osteotomy are: 1. Epiphyseal plate not too steep, 2. No major leg shortening, 3. Congruency between the femoral head and the acetabulum, 4. Ability to contain the femoral head in the acetabulum in abduction and internal rotation 5. Only slight restriction of abduction

Pre requisites for an innominate osteotomy (Salters osteotomy) include: 1. Restoration of a full range of motion, 2. A round or almost round femoral head, and congruency of the joint, demonstrated arthrographically. 3. The head must be well seated in flexion, abduction. Combined varus derotation and innominate osteotomies are being evaluated for Caterall 3 and 4 stage disease Shelf Arthroplasty: is becoming popular as a method of containment Prerequisites-

1. Children older than 8 years with Catterall group 2, 3, or 4 disease with or without at-risk signs, 2. Lateral pillar type B or C disease, and 3. Salter-Thompson type B disease; 4. If subluxation is present, it must be reducible on a dynamic arthrogram Risk factors for poor results with this technique are age older than 11 years, female gender, and Catterall group 4 disease. Triple Innominate osteotomy as a method of containment is being investigated Arthrodiastasis: the use of hip distraction for periods of 4 to 5 months, with or without soft tissue release, in older children with Perthes disease is also being investigated

Management of the Noncontainable Hip Management of the Noncontainable Hip and the Late-presenting Patient with Deformity: These include patients in later stages (reossification) of the disease, those with noncontainable deformities, and those who have lost containment after undergoing either surgical or nonsurgical containment These patients usually demonstrate hinge abduction on arthrography. The salvage procedures to be considered at this point include abduction extension osteotomy, lateral shelf arthroplasty, Chiari osteotomy, and cheilectomy These salvage procedures are done with limited aims of pain relief, correction of limb length inequality and improvement of movement and abductor weakness Cheilectomy removes the anterolateral part of the head that impinges on the acetabulum in abduction

Cheilectomy does not correct any residual shortening or abductor weakness This procedure should only be done after the physis has closed, otherwise an SCFE may ensue. Chiari Osteotomy improves the lateral coverage of the head, but does not give coverage to the deformed head in abduction and it may exacerbate abductor weakness Abduction extension osteotomy is indicated when arthrography demonstrates joint congruency in extended and adducted position This osteotomy improves the limb length, decreases limp and improves function and range of motion Femoroacetabular Impingement Femoroacetabular impingement aetiology The presence of aberrant morphology involving the proximal femur and/or the acetabulum results in abnormal contact between the femoral neck and the acetabular rim during terminal motion of the hip. Ganz described two types of FAI: cam impingement and pincer impingement. Cam impingement: Cam impingement occurs when an abnormally shaped (ie, nonspherical) femoral head with increased radius is jammed into the acetabulum during normal motion, especially flexion. The prominence on the femoral neck is forced into the acetabulum and results in tearing of the labrum and/or its avulsion from the rim. The pincer impingement: is the result of abnormal contact between the acetabular rim and the femoral neck. The femoral head in this situation may be normal, and the abutment is mostly a result of overcoverage of the femoral head in conditions such as coxa profunda or acetabular retroversion.

Both mechanisms lead to cartilage wear and eventually osteoarthritis clinical features Presents in active young adults with slow onset of groin pain that may start after a minor trauma Hip or groin pain on prolonged standing or sitting or athletic activities. Anteroposterior impingement test(fig a). The patient is placed supine with the hip in 90 of flexion. Internal rotation of the hip and adduction recreates the symptoms. Posteroinferior impingement test(fig b) is performed by having the patient lie supine on the edge of the bed and having the legs hang free from the end of the bed in order to produce maximum hip extension. External rotation with the hip in extension that gives rise to severe, deep-seated groin pain is indicative of posteroinferior impingement

x-rays:

Following X-rays are required , 1. True AP view of pelvis- A true X-ray is one in which the coccyx points toward the symphysis pubis with a distance of 1 to 2 cm between them 2. Cross table lateral view with hip in 10 deg of Internal Rotation. 3. Dunn View- An anteroposterior radiograph of the hip in neutral rotation, 20deg of abduction, and 90deg of flexion. Differentiating b/n Cam and Pincer type impingement is important as

the treatment varies. Common Features-Pitts pit - Fibrocystic changes at the femoral head-neck junction seen on X-ray but more clear in CT/MRI scan - 91% specific & positive predictive value of 71% Features of Pincer Impingement- True AP View of Pelvis , , a Retroverted Acetabulum, 1.The Crossover sign- Anterior wall of the acetabulum crossing the posterior wall. 2. The Posterior Wall sign- Center of the femoral head lying lateral to the posterior wall. 3. The Ischial Sign- Ischial spine projecting into the pelvic cavity on the AP pelvic radiograph. b. Coxa Profunda: 1. The medial wall of the acetabulum lies on or medial to the ilioischial line. 2. Protrusio, which represents the more severe form of coxa profunda, is diagnosed when the femoral head crosses the ilioischial line. Features of Cam type Impingement- Cross Table Lateral/ Dunn View, 1. Asphericity of femoral head. 2. Alpha Angle > 50.5 degrees ( The angle between the axis of the neck and

the point where the bone of the head-neck junction crosses outside the radius of curvature of the head) 3. The Head-Neck Offset Ratio measured by dividing the anterior offset by the femoral head diameter)

Treatment Non operative Treatment: NSAIDs, activity modification, restriction of athletic activities Operative: Surgical Dislocation of the Hip (Ganz et al) Involves dislocation of the hip, with preservation of the blood supply to the femoral head, and femoroacetabular osteoplasty After crossing the obturator externus muscle posteriorly, the MFCA runs anteriorly toward the short rotators and crosses the femoral neck anteriorly to become the retinacular vessels penetrating the femoral neck Preservation of the short posterior rotators of the hip ensures that the MFCA is not damaged during surgical dislocation of the hip. Involves a trochanteric flip osteotomy through a lateral incision and a lazy Sshaped capsulotomy Osteoplasty of the femoral neck is then carried out. The torn labrum is dbrided, and osteotomy is performed of the acetabular rim to remove the chondral lesion The remaining labrum is reattached using nonabsorbable anchor sutures.

Hip arthroscopy: Is both diagnostic as well as therapeutic Maybe useful for simple cam type impingement.

The disadvantage of hip arthroscopy is in the fact that, it is difficult to address posterior labral lesions, inability to guide the extent of resection of the femoral neck prominence and inadequate treatment of an associated chondral lesion Aneurysmal Bone Cyst Aneurysmal Bone Cyst Nonneoplastic vasocystic tumour Age group: 10-20 years old(peak age: 11 years) Can occur in any decade of adult life, but nearly 80% occur in the 2nd decade Represent 1.5% of all primary bone tumors Maybe primary or secondary( arising in other tumours) Frequency: distal femur> proximal tibia> proximal humerus> distal radius. The vertebrae are involved in 12% to 27% of patients Primary ABC maybe neoplastic. Chromosomal rearrangements suggestive of cancer like the USP6 and CDH11 are seen. Spontaneous regression may be seen in active primary ABCs. But rare in aggressive or secondary lesions May be of hydraulic pressure origin, secondary to haemorrhage and could be traumatically induced. Are not true cysts but rather sponge-like collections of interconnected fibrous tissue and blood-filled spaces Are destructive lesions and replace bone and thin the cortices of the host bone. In the spine, two-thirds of aneurysmal bone cysts will arise from posterior elements and one-third will arise from the vertebral body and present as an aggressive osteolytic lesion with extensive permeative cortical destruction. Children with open physes are much more prone to local recurrence (up to 50%) Pathological fractures are common and more frequent in humerus and femur

histology and classification Campanaccis classification of ABC (1) 1. Aggressive cyst: signs of reparative osteogenesis with ill-defined margins and no periosteal shell. 2. Active cyst: has an incomplete periosteal shell and a defined margin between the lesion and the host bone. 3. Inactive cyst: has a complete periosteal shell and a sclerotic margin between the cyst and the long bone.

Histology: Composed of blood filled spaces with intervening fibrous septae. True endothelial cells are not found. The tissue is sponge like with cavernous spaces filled with blood. Cavities surrounded by gray or brownish tissue with an osseous component At the periphery of the lesion is an eggshell-like layer of periosteal bone around the lesion Solid variant of ABC consist of fibrous or granular tissue with local haemorrhages and a layer of reactive bone. There are skeletal tumours that may demonstrate an aneurysmal component: Giant cell tumour, chondroblastoma, osteoblastoma, chondromyxoid fibroma, fibrous dysplasia, and malignant haemorrhagic osteosarcoma Imaging X rays: Eccentrically (maybe central also) located lytic lesion, expansile with septations. Classically, blown out cortex with egg-shell thin rim of reactive

bone Sites: metaphysis of long bone, posterior elements of spine, distal phalanx of fingers Fluid levels can be seen on MRI /CT scans, which may also be seen with telengiectatic osteosarcoma CT: Useful to assess lesions of the pelvis or vertebral column more precisely than radiography Helps to assess carefully the presence of the periosteal rim of bone around a lesion MRI can evaluate soft tissue involvement On T2-weighted images, the lesions have high signal levels, and layering in the blood (fluid-fluid levels) often can be seen more accurate assessment than CT or radiography of the extent of an aneurysmal bone cyst DD Differential Diagnosis for Holes in Bone: (Mnemonic: FOGMACHINE) Fibrous dysplasia Osteoid osteoma, Osteoblastoma,Osteosarcoma, Osteofibrous dysplasia Giant cell tumor Myeloma Aneurysmal bone cyst, adamantinoma Chondromyxoid fibroma, chondroblastoma, chondrosarcoma Histiocytosis Infection Nonossifying fibroma Enchondroma, Ewing sarcoma

Treatment Augmented curettage and bone grafting. Repeated embolisation to reduce the rate of haemorrhagic expansion especially in difficult areas like the pelvis Pathologic fractures: require curettage , bone grafting +/stabilisation Pelvic ABCs: spontaneous regression after biopsy has been noted. Consider observation after biopsy. If regression occurs no need for further surgery. If progression occurs, perform curettage Spinal ABCs: preoperative selective arterial embolisation, extended intralesional curettage with grafting +/- limited fusion. Embolisation though poses risk of cerebral emboli and also ischemic damage to the cord Incompletely resectable, recurrent or aggressive ABCs: low dose radiation(26 to 30 cGy) If a patient does have a local recurrence, repeat surgical excision can be performed. Selective arterial embolisation as a definitive procedure can be used in locations where a tourniquet cannot be used and control of bleeding can become difficult (e.g., spine, pelvis, and the proximal portions of the extremities)(2)

Ref: 1. Campanacci M, Capanna R, Picci P. Unicameral and aneurysmal bone cysts. Clin Orthop 1986; 204:25-36. 2. Green JA, Bellemore MC, Marsden FW. Embolization in the treatment of aneurysmal bone cysts. J Pediatr Orthop 1997;17(4):440-443. PROTRUSIO ACETABULI (OTTO PELVIS) The German pathologist Otto first described Protrusio acetabuli, (also known as arthrokatadysis,) in 1824. Hence also known as Otto

Pelvis Aetiology: Idiopathic, or primary protrusio acetabuli: no causative factors are found in this group Secondary protrusio acetabuli: The causes are as follows Infectious Gonococcus Echinococcus Staphylococcus Streptococcus Mycobacterium tuberculosis Neoplastic Hemangioma Metastatic carcinoma (breast, prostate most common) Neurofibromatosis Radiation-induced osteonecrosis Inflammatory Rheumatoid arthritis Ankylosing spondylitis Juvenile rheumatoid arthritis Psoriatic arthritis Acute idiopathic chondrolysis Reiters syndrome Osteolysis following hip Replacement Metabolic Pagets disease Osteogenesis imperfecta Ochronosis

 Acrodysostosis Osteomalacia (very high incidence 50%) Hyperparathyroidism Traumatic Sequalae of acetabular fracture Surgical error during hip Replacement Genetic Trichorhinophalangeal syndrome Stickler syndrome Trisomy 18 Ehler-Danlos syndrome Marfans syndrome Sickle cell disease Pathomechanics . The typical orientation for the joint reaction force is 69 degrees from horizontal during the stance phase of gait. . McCollum et al.. found that protrusio acetabuli occurs at 65 degrees from the horizontal and concluded that the axis of migration was nearly the same as that of the joint-reaction force during stance(1) . Eppingers theory: the condition is secondary to a chondrodystrophy wherein the three plates of the triradiate cartilage remain unfused, allowing protrusion of the femoral head medially into the pelvis . Inflammatory causes lead to destruction and weakening of the bone surrounding the hip with resultant migration along the joint-reaction vector The deformity may progress until the greater trochanter impinges on

the side of the pelvis An associated varus deformity of the femoral neck is often seen CF: -Idiopathic protrusio presents in early adolescence, hence should be kept in the differential diagnosis of hip pain in a teenager -Common in younger women -Present with pain and stiffness, rarely with knee pain -Arising from a seated position is a frequent cause of exacerbation X-Rays: . -The Wibergs center-edge angle over 40 degrees is diagnostic of protrusio acetabuli -Normally on an AP radiograph the medial wall of the acetabulum lies 2 mm lateral to the ilioischial line in a male and 1 mm medial to this line in a female. -If the medial wall of the acetabulum protruded medial to the ilioischial line (Kohlers line) by 3 mm in males or 6 mm in females it favours the diagnosis of protrusio. -May be graded as mild (1 to 5 mm), moderate (6 to 15 mm), or severe (>15 mm), with reference from the ilioischial line. Treatment: In skeletally immature patients, with an open triradiate cartilage: surgical closure of the triradiate cartilage is done. A valgus intertrochanteric osteotomy may be combined In adolescent or skeletally mature patients: Valgus intertrochanteric osteotomy (VITO). This lateralises the mechanical axis of the limb. Soft tissue releases of the psoas tendon may be done.

 VITO procedure should not be performed on patients who are over age 40 years or whom have significant degenerative changes visualized on plain radiographs. Older Adult Patients: Total hip Arthroplasty is the treatment of choice The principles of THA in protrusio acetabuli are: -Restoration of hip center at its anatomical location for proper joint biomechanics -The intact peripheral rim of the acetabulum should be used to support the acetabular component -Cavitary and segmental defects in the medial wall must be reconstructed with bone grafting Surgical pearls: -The sciatic nerve will lie near the joint compared to normal patients, and should be routinely identified and protected. -Trochanteric osteotomy may be required for exposure -When dislocation is difficult, removal of portion of the posterior acetabular wall maybe required. -In severe cases, the head is incarcerated into the acetabulum, such cases require osteotomy of the neck at the desired level and removal of the head is facilitated by a corkscrew or rarely as piecemeal. -The medial wall of the acetabulum is thin or may be partly membranous, and it should not be perforated. -Medial reaming should be avoided -Only peripheral reaming should be done to make the acetabular dome to converge -A protrusio cup is available which avoids medial bone grafting -If the pelvis is osteoporotic it is better to fix an antiprotrusio cage rather than attempting to press-fit the acetabular component and causing a fracture.

Ref: 1. McCollum DE, Nunley JA, Harrelson JM: Bone-grafting in total hip replacement for acetabular protrusion. J Bone Joint Surg Am 1980;62:1065-1073. 2. Ranawat CS, Zahn MG: Role of bone grafting in correction of protrusion acetabuli by total hip arthroplasty. J Arthroplasty 1986;1:131-137. 3. Van de Velde S, Fillman R, Yandow S. Protrusio acetabuli in Marfan syndrome: indication for surgery in skeletally immature Marfan patients. J Pediatr Orthop. 2005; 25:603-6. 4. Van De Velde S, Fillman R, Yandow S: The aetiology of protrusio acetabuli: literature review from 1824 to 2006. Acta Orthop Belg 2002; 72:524. 6. Dunlop CC, Jones CW, Maffulli N: Protrusio acetabuli. Bull Hosp Jt Dis 2005; 62:105