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Index

101

EditorialCurrent Concepts in Arthroplasty 2010: Rajesh Malhotra : 104

Symposium on Joint ReplacementHow to Interpret Postoperative X-rays of Total Hip Replacement :Surabhi Garg, Bhavuk Garg, Rajesh Malhotra : 106

Total Hip Arthroplasty in Femoral Neck Fracture :Arun Kannan, Rajesh Malhotra : 110

Polymicrobial Infection Following Total Knee Replacement– An Uncommon Entity : Shuvendu Prosad Roy,

Owais Quereshi, ON Nagi, Sumit Kumar Jain : 114

Extra Articular Deformity Correction in TKA :Pratyush Gupta, Vijay Kumar, Rajesh Malhotra : 118

VOL XII No 3 : July-September 2010

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VOL XII No 3 : July-September 2010102

Pediatric FracturesTitanium Elastic Nails for Pediatric Femur Fractures:Clinical and Radiological Study :Nishikant Kumar, Laljee Chaudhary : 124

Congenital DeformityCongenital Talipes Equinovarus (CTEV) :Surendra U Kamath : 130

Neural TumourMobile Schwannomma of the Cauda Equina :Amit Agrawal, SR Joharapurkar, Anand Kakani, A Chaudhary : 134

Pioneers in OrthopaedicsPioneers in Orthopaedics : Bhavuk Garg, Rajesh Malhotra : 139

Ortho QuizOrtho Quiz-24 : Bhavuk Garg, Rajesh Malhotra : 140

Answer and Discussion to Ortho Quiz 23 :Bhavuk Garg, Rajesh Malhotra : 141

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VOL XII No 3 : July-September 2010104

Dr. Rajesh MalhotraProfessor

Deptt. of OrthopaedicsAll India Institute of

Medical SciencesNew Delhi

editorial �

Current Concepts in

Arthroplasty 2010

Current concepts in arthroplasty 2010 was organised by the Department of Orthopedics and theOrthopedic Research Society of AIIMS at the All India Institute of Medical Sciences, New Delhion Aug 21-22, 2010. The theme of this annual ritual this year was “Mastering ArthroplastyTechniques”. Faculty for the conference included several eminent national and international

orthopedic surgeon teachers. Over 250 delegates attended and actively participated in the conference.

The importance of technique in the performance of arthroplasty remains supreme and is the single mostimportant determinant of the outcome after the appropriate patient selection. Restoration of functionand longevity of the implant are intimately dependant on the technique of arthroplasty. This is especiallyimportant the present day when the persons undergoing arthroplasty are younger and younger. Theydemand more from their replaced joints, put it to test through loading to the extent undertaken only inthe laboratories in the past, and, are sure to outlive their joints. For them the arthroplasty is not just toalleviate suffering but also to enable them to participate in sports, often competitive. A technically perfectarthroplasty is the surgeon’s best bet to guarantee that the patient’s expectations are met.

The conference was inaugurated by the Chief Guest Dr V M Katoch, Director General, Indian Councilof Medical Research and Secretary, Department of Health Research. Prof RC Deka, Director AIIMS, ProfRani Kumar, Dean AIIMS, Prof PP Kotwal, Head, Department of Orthopedics and President, OrthopedicResearch Society and the author, Organizing Secretary of the conference were the other dignitariespresent on the dais during the ceremony. Dr Katoch stressed the need for ensuring the sound bone healthamong the Indians and the need to establish task forces to that effect. While he lauded the efforts tobring the latest technology to India, he urged the clinicians to work towards the development ofindigenous technology which will serve the needs of the common man better at affordable cost.

The plenary session had a lecture by Prof PP Kotwal who presented his experience with the arthroplastyof ankle and the small joints. These arthroplasties are increasingly indicated and performed at theadvance centres and the results are getting better and more predictable. Author then delivered a talkon “How to do a successful THR” essentially enunciating all the technical details and principles to befollowed to perform technically sound total hip arthroplasty. Dr Wolfram Kluge from UK then deliveredhis talk on the prosthesis selection for THR. The choices available for the components and bearingsfor the THR are numerous now and the age, sex, activity level and functional demands are all importantfor the selection. The consensus now is to use 36 mm head wherever possible for best performance, wearresistance and stability. Bone conserving arthroplasty should be preferred in young patients. Highlycross-linked polyethylene has improved wear resistance but one must remember that all highly cross-linked polyethylenes are not alike and may at times be brittle. Ceramic on ceramic remains a good optionfor young patients, especially females who may not be good candidates for metal on metal articulation,

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105VOL XII No 3 : July-September 2010

particularly before they have completed their family. Cemented hips are still a good choice in patients with verywide femoral canals and poor quality bone.

This was followed by three live hip replacement surgeries. First, author performed a bone conservingBirmingham mid head resection hip replacement on a 30 year old male with ankylosing spondylitis. This wasfollowed by a bone conserving proxima stem with pinnacle cup and a ceramic on ceramic 36mm size bearinghip replacement performed on a 35 year old male with avascular necrosis by Dr Wolfram Kluge demonstratingthe principles of prosthesis selection propagated in the lectures. Author then performed the Versys and Trilogyhip replacement with highly cross linked polyethylene and 36 mm femoral head with impaction grafting of theacetabulum in a 45 year old lady with rheumatoid Arthritis and protrusio acetabuli.

The next session began with a talk by Dr Kluge on the dysplastic hip followed by a talk by the author on THRin osteoporosis. The following session saw some interesting case discussions moderated by Dr Vijay Kumar.Panelists included Prof P K Dave, Dr SKS Marya, Dr Wolfram Kluge, Prof VK Gautam and Prof A K Mehtaniin addition to the author.

The afternoon session heralded the beginning of the knee session. Dr Alfred Tria from the United Statescaptivated the audience with his talks on choice of prosthesis for TKR in young patients (including the Oxinium)and the biomechanics and rationale of the bicruciate substituting knee. Prof Kotwal delivered talk on preventionof infection in TKA. A question and answer session followed and the day one was wrapped up after that.

Dr Gautam Chakraborty, the first Indian to be the Secretary of British Association for the Surgery of the Knee(BASK) and consultant from the NHS Trust of Huddersfield and Calderdale, UK, delivered the first talk on daytwo on preoperative planning and choosing the right patient for TKR. Dr Tria then delivered a fantastic talkon soft tissue balance and rotational alignment in TKR with the demonstration of excellent algorithms in theform of cross board. Dr Gautam then outlined his criteria for the prosthesis selection for the TKR. Dr Triadelivered a talk on the use of Constrained knee in primary TKR. Dr Kluge then delivered his talk on NavigatedTKR. Dr Tria then gave a talk on the latest development in the field of TKR i.e. patient specific cutting blocks.The technology involves performing MRI on the patient according to a standard protocol. The data gleanedfrom the MRI is then used to fashion nylon cutting blocks permitting the preparation of the bones withpredetermined alignment, axis and bone cuts. The technique is quick, precise and does not involve use of anyother jig. Moreover, it does not need violation of the medullary canal thus adding safety to the procedure. DrTria then performed a live demonstration surgery using the VISIONAIRE, a technique for patient specificcutting blocks patented by the Smith & Nephew. This incidentally was the first time that this technique wasperformed in India. The patient had been prepared in advance, the MRI study was undertaken and the datasent to USA for preparation of blocks about 3 weeks before the planned date for surgery.

After the scintillating surgery performed with patient specific cutting blocks, Dr Tria demonstrated the surgeryusing Bicruciate substituting (Journey®) and then delivered a talk on unicondylar knee replacement. Dr Gautamthen delved on the techniques of avoiding and managing arthrofibrosis in TKR. Dr Tria then presented hisexperience on avoiding and managing patellar problems. Dr Gautam then presented his protocol for managingthe peri-prosthetic fractures following TKR. The final talk of the conference was delivered by Dr Tria on themanagement of the bone defects in TKA.

The final session on Case Discussion (TKR) saw some interesting and lively discussions emanating from thepanelists including Drs Gautam Chakraborty, Alfred Tria, Wolfram Kluge, Jitendra Maheshwari and the author.The conference ended on a jubilant note with the delegates showering compliments on the faculty and rejoicingin their newfound knowledge.

The current concepts in arthroplasty conference has enjoyed constant support and encouragement from theparticipants for a very long time and efforts are afoot to make it even better. The meeting next year, CurrentConcepts in Arthroplasty 2011, will be held jointly with British Association for the Surgery of Knee (BASK)as the first Indo British Joint Meeting for Knee Surgery on 19th -20th August, 2011 followed by the hip sessionsin continuity on the afternoon of 20th and the forenoon of 21st August, 2011.I hope to see you all there!

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VOL XII No 3 : July-September 2010106

Total hip replacement is one of the most success-ful and satisfying orthopaedic procedures, per-formed today. As the science regarding total hipreplacement has evolved in terms of biomechan-ics, tribology and designs, it has also becomenecessary to detect early changes, which can leadto future complications or failures, if untreated.Although a lot of newer modalities have come upfor evaluation of postoperative total hip imagingincluding MRI, this article focuses on plain X-rays, which are the most common as well as feasi-ble for follow-up evaluation.

MATERIALS USED IN THR

Most of the current total hip designs use eithertitanium alloys or cobalt-chromium alloys as hard-ware. Both are radio-opaque, however, titanium is

less dense than cobalt-chromium. PMMA is fre-quently used in cemented THR and is again radio-paque, due to presence of barium powder. Crosslinked polyethylene is the most commonly usedarticular surface and is radiolucent. Ceramics(Zirconia and Alumina) have also become stand-ard materials and are radiopaque, however lessthan the metals.

FIXATION

Fixation of components to bone may occur throughdirect mechanical fixation, passive interference fit,bone cement, and porous ingrowth. Methods ofdirect mechanical fixation such as screws are gen-erally obvious on radiographs. Passive interfer-ence fit or press fit components are held in positionby the shape of the components and the space intowhich they are tightly fitted. Bone cement may beused as an adhesive. Porous ingrowth fixation isbased on the principle that remodeling bone canattach itself directly to the component, holding itin place.

How to Interpret PostoperativeX-rays of Total HipReplacement

SURABHI GARG

Dept. of RadiodiagnosisSafdarjung Hospital

BHAVUK GARG

Sr. Research Associate

RAJESH MALHOTRA

Professor

Deptt. of Orthopaedics

AIIMS, New Delhi

Keywords: Total hip replacement, X-rayinterpretation

ABSTRACT

Total hip replacement is one of the most successful and satisfying orthopaedicprocedures, performed today. As the science regarding total hip replacement hasevolved in terms of biomechanics, tribology and designs, it has also becomenecessary to detect early changes, which can lead to future complications or failures,if untreated. Although a lot of newer modalities have come up for evaluation ofpostoperative total hip imaging including MRI, this article focuses on plain X-rays,which are the most common as well as feasible for follow-up evaluation.

“Fixation of

components to bone

may occur through

direct mechanical

fixation, passive

interference fit, bone

cement, and porous

ingrowth”

SYMPOSIUM ON

JOINT REPLACEMENT

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107VOL XII No 3 : July-September 2010

ALIGNMENT

Acetabular and femoral component positioningshould mimic normal anatomy. The distance fromcenter of the femoral head to teardrop (or otheridentifiable landmark) should be equal bilaterally.This is called the horizontal center of rotation. (Fig.1) Excessive lateral positioning of the acetabularcomponent increases the risk for dislocation andmay cause limping. The trans-Ischial line is usedas a reference to measure the lateral inclination ofthe acetabular cup (30-50°) (Fig. 1). This line is alsoused to measure any leg length discrepancy. Leglength discrepancy up to 1 cm is well tolerated. Ahigh positionened cup is better tolerated than alateral positioned cup. The anteversion of theacetabular cup should be 5-25°. Exact measure-ment of this angle on a cross-table or true lateralradiograph is not possible. Measurement with CTis more accurate.

The preferred position of the femoral componentis with the stem centered in the femoral canal. Thecenter of rotation of the femoral head should be atthe level of the tip of the greater trochanter. Varusposition of the femoral stem predisposes to loos-ening and fracture.

NORMAL CEMENTED TOTAL HIP

ARTHROPLASTY

Normal X-ray findings are quite different in ce-mented arthroplasty than cementless because ofmore reactive changes. Lucency at the metal-cement interface along the proximal lateral aspectof the femoral stem may be seen on the initialpostoperative radiograph as a reflection of subop-timal metal-cement contact at the time of surgery.

A stable lucent zone is good, but if the lucencyenlarges or develops at the metal-cement interfaceduring follow up, then it is a sign of loosening (Fig.1). Ideally there is only a 3-4mm layer of cementaround the prosthesis.

At the bone-cement interface a thin fibrous layermay form as a response to local necrosis of os-seous tissue due to the heat of the cement-polym-erization. It becomes stable by 2 years. On radio-graphs this layer is seen as a lucent zone thatshould be <2mm, delimited from adjacent bone bya thin sclerotic demarcation line that runs parallelto it.

Several zones (Fig. 2) have been described aroundthe femoral as well as acetabular aspect to com-ment on lucencies.

NORMAL CEMENTLESS TOTAL HIP

ARTHROPLASTY

Following changes are commonly seen in a normalcementless total hip arthroplasty (Fig. 3):� Thin lucent lines� Proximal stress shielding� calcar resorption� Pedestal formation� Cortical thickening

In stable non-cemented hip arthroplasties, lucentzones at the metal-bone interface do occur, as itusually is a combination of bone ingrowth andfibrous tissue ingrowth that provides the fixationin most cases. This fibrous tissue presents as alucent zone at the interface. Again it should bestable and well within a range of 1 -2 mm. If they

Fig. 1: Horizontal center of rotation and acetabular

inclination in relation to trans-Ischial line (B)Fig. 2: “Gruen” zones and “DeLee and Charnely” zones

“The preferred position

of the femoral

component is with the

stem centered in the

femoral canal. The

center of rotation of

the femoral head

should be at the level

of the tip of the

greater trochanter”

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VOL XII No 3 : July-September 2010108

stay stable for 2 years than fixation by a strongfibrous tissue has taken place.

Stress shielding or bone resorption is seen in areasthat are relatively unstressed. The forces are trans-mitted through the relative stiff femoral stem andare seen as osteoporosis in the proximal femur withthinning of the cortex and bone resorption of thefemoral neck. This is seen medially as calcarresorption, as the calcar has lost it’s function. It isalso called calcar round off.

ABNORMAL FINDINGS

Complications related to hip replacements are mostlyrelated to fractures, dislocations, component loos-ening, component failure, and infection. Howeverabnormal findings can be discussed as follows:

Wide lucent zone at cement-bone interface

A wide (>2 mm) lucent line along the cement-boneinterface is due to the formation of a granuloma-

tous membrane and is not a normal finding (Fig. 4).Usually, this membrane is the result of componentloosening.

Well-defined areas of bony destruction

Well defined lucent areas around prosthesis usu-ally indicate bone resorption in response toparticulate debris. They are most often seen nearthe tip of the prosthesis or near its medial borderand do not conform to the shape of the prosthesis,thus distinguishing them from the more diffuselywide cement-bone lucent zones.

Asymmetric position of the femoral head

within the acetabular component

Change in the position of the femoral head withinthe acetabulum (Fig. 5) should be carefully lookedfor on follow-up radiographs. This finding may bedue to dislocation of the femoral head or to acetabu-lar disruption, liner displacement, deformity, orwear.

Fig. 3: Normal radiological findings in a cementless total hip arthroplasty

Fig. 4: Loosening suggested by wide lucency

at cement bone interface

“Stress shielding or

bone resorption is

seen in areas that are

relatively unstressed.

The forces are

transmitted through

the relative stiff

femoral stem and are

seen as osteoporosis

in the proximal femur

with thinning of the

cortex and bone

resorption of the

femoral neck”

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109VOL XII No 3 : July-September 2010

Cement fracture

Cement fracture is an indicator of prosthetic loos-ening. It is often accompanied by other evidence ofcomponent subsidence. Despite the presence of acement fracture, the patient may be asymptomatic.

Component migration

Component migration is diagnostic for loosening.It is seen as tilting or cranial migration of theacetabular cup or as subsidence (>10mm) andvarus tilting of the femoral stem.

Periprosthetic fractures or dislocations

Periprosthetic fractures and dislocations are obvi-ous on x-rays. Fractures may be seenpostoperatively in patients with poor bone stockand long stem revision prostheses or when theanatomy is abnormal as in hip dysplasia or priorsurgery. They are also more common in non-cemented femoral stems, as these have to fit ex-actly and can cause a fracture during insertion.The incidence of fractures ranges from 0.1 to 1.0percent for cemented components and 3 to 18percent for uncemented components. Mostintraoperative fractures occur on the femoral side.Dislocation can be in posterior, anterior or lateraldirection.

Heterotopic ossification

Heterotopic Ossification occurs when primitivemesenchymal cells in the surrounding soft tissuesare transformed into osteoblastic cells that formmature lamellar bone. It typically occurs aroundthe femoral neck and adjacent to the greater tro-chanter and occurs in 15-50% of patients. Manypatients with radiographically low-grade hetero-topic ossification are asymptomatic. If it becomessymptomatic, hip stiffness is the most commoncomplaint and pain is rarely a problem.

Infection

There are no specific radiological criteria for diag-nosing infection and may mimic loosening or smallparticle disease. With more aggressive organisms,progression can be rapid, with bone destructionand sinus tract formation, resulting in boneresorption and lucencies.

SUMMARY

Radiographs obtained after total hip replacementshow characteristic changes that indicate a normalresponse or the development of complications.Knowledge of the importance of the various radio-graphic findings facilitates accurate diagnosis andthe ordering of appropriate further investigations.Comparison of serial radiographs is also importantto pick up early changes.

BIBLIOGRAPHY1. DeLee JC, Charnley J. Radiological demarcation

of cemented sockets in total hip replacement. Clin

Orthop 1976;121:20-32.

2. Cruen TA, McNeice CM, Amstutz HC. Modes of

failure of cemented stem-type femoral compo-

nents: a radiographic analysis of loosening. Clin

Orthop 1979;141:17-27.

3. Johnston RC, Fitzgerald RH, Harris WH, et al.

Clinical and radiographic evaluation of total hip

replacement. J Bone Joint Surg 1990; 72:161-

168.

4. Coetz DD, Smith EJ, Harris WH. The prevalence

of femoral osteolysis associated with components

inserted with or without cement in total hip

replacements. J Bone Joint Surg 1994; 76:1121-

1129.

5. Weissman BN. Radiographic evaluation of total

joint replacement. In: Kelley WN, Harris ED Jr.

Ruddy S. Sledge CB, eds. Textbook of rheuma-

tology. 4th ed. Philadelphia, Pa: Saunders, 1994.

6. Levitsky KA, Hozack WJ, Balderston RA, et al.

Evaluation of the painful prosthetic joint. J

Arthroplasty 1991;6:237-244.

7. Lieberman JR. Huo MH, Schneider R, et al.

Evaluation of painful hip arthroplasties. Bone

Joint Surg 1993;75:475-478.

8. Aliabadi P, Tumeh 55, Weissman BN, et al.

Cemented total hip prosthesis: radiographic and

scintigraphic evaluation. Radiology 1989;173:203-

206.

9. Oyen WJ, van Horn JR. Claessens RAMJ. Diag-

nosing prosthetic joint infection. Nucl Med

1991;32:2195-96.

10. Engh CA, Massin P. Suthers KE. Roentgenographic

assessment of the biologic fixation of porous-

surfaced femoral components. Clin Orthop

1990;257:107-128.

11. Weissman BN. Imaging of joint replacement. In:

Resnick D, ed. Diagnosis of bone and joint

disorders. 3rd ed. Philadelphia, Pa: Saunders,

1995;559-606.

12. Kattapuram SV, Lodwick CS, Chandler H. Porous-

coated anatomic total hip protheses: radiographic

analysis and clinical correlation. Radiology

1990;174:861-864.

Fig. 5: Asymmetric

position of femoral head

suggestive of wear

“Periprosthetic

fractures and

dislocations are

obvious on x-rays.

Fractures may be seen

postoperatively in

patients with poor

bone stock and long

stem revision

prostheses or when

the anatomy is

abnormal as in hip

dysplasia or prior

surgery”

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VOL XII No 3 : July-September 2010110

INTRODUCTION

The debate regarding the ideal treatment for femo-ral neck fracture has been raging for decades now.Most surgeons seem to prefer internal fixation inpatients less than 60 years of age and arthroplastyin patients more than 80 years of age.1 The 60 to 80year age group is a grey area.1 Advanced physi-ological age (not chronological age), poor bonequality, low functional demand, and medical co-morbidities guide towards a decision in favour ofprosthetic replacement. The issues with regard tointernal fixation in the elderly are myriad. Oste-oporotic bone provides poor hold for fixationdevices. The compliance needed with non-weightbearing instructions further complicates the is-sue. The high risk of nonunion, upto 30% in largemeta-analyses,2 and the need for multiple surger-ies in patients with less than optimal medicalconditions are deterrents to the consideration forosteosynthesis in this age group. Even whereunion is achieved, the problem is not entirelysolved. Zlowodski et al3 have documented short-ening of more than 5 mm in as many as 66% andvarus collapse in upto 39 % in united femoral neck

fractures in the elderly. They further stated thatboth these factors were predictive of the need forassistive walking device. Meta-analyses4,5 andprospective randomised trials6 have demonstrateda ten-fold lower complication rate and better func-tion with arthroplasty as compared to internalfixation in the elderly population. In view of theabove facts, prosthetic arthroplasty has beenincreasing in popularity as the preferred treatmentfor femoral neck fracture in the elderly. However,the ideal arthroplasty option for elderly adultswith femoral neck fracture lacks consensus. Thisarticle will attempt to address the role of total hiparthroplasty in displaced femoral neck fractures inthe elderly population.

ARTHROPLASTY OPTIONS FOR FEMORAL NECK

FRACTURE

Arthroplasty options for femoral neck fracturesinclude hemiarthroplasty, which can be non-modu-lar like the Austin-Moore and Thompson or modu-lar with unipolar or bipolar components, and totalhip arthroplasty. Hemiarthroplasty has been usedin preference to THR in these cases in view of theintact acetabulum, with THR relegated to caseswith prior acetabular disease such as osteoarthritis,rheumatoid arthritis, pathological fractures withacetabular involvement by the neoplastic process

Total Hip Arthroplasty inFemoral Neck Fracture

ABSTRACT

The fracture of the femoral neck remains an unresolved issue. While the superiority ofprosthetic replacement over internal fixation in displaced femoral neck fractures in theelderly has been established by prospective randomised trials and meta-analyses,the ideal arthroplasty option for this indication remains to be established. The traditionalpreference for hemiarthroplasty has been challenged by recent evidence in favour oftotal hip arthroplasty. This article addresses the role of total hip arthroplasty in thisindication on the basis of current level of evidence.

ARUN KANNAN

Senior Resident

RAJESH MALHOTRA

Professor

Deptt. of Orthopaedics,

All India Institute of

Medical Sciences,

New Delhi

Keywords: Femoral neck fracture,

“Most surgeons seem

to prefer internal

fixation in patients

less than 60 years of

age and arthroplasty in

patients more than 80

years of age. The 60 to

80 year age group is a

grey area”

SYMPOSIUM ON

JOINT REPLACEMENT

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111VOL XII No 3 : July-September 2010

etc. An international survey showed that 42%prefer bipolar arthroplasty, 32% prefer unipolararthroplasty and only 17% prefer THR.1 Emergingevidence from comparative trials and meta-analy-ses, however, has placed a question mark over thesuperiority of hemiarthroplasty over THR in thisindication.

COMPARISON OF HEMIARTHROPLASTY AND

THR

One of the arguments in favour of hemiarthroplastyis that it is a simpler procedure with a shorteroperative time as compared to THR. This wasexpected to benefit the elderly population with acompromised physiological reserve and medicalco-morbidities. Comparative trials7-9 and meta-analysis10 have been able to establish thathemiarthroplasty does, in fact, have lower opera-tive times. However, the shorter operative timewith hemiarthroplasty does not have any effect onmortality rates after surgery.7-10 In addition, meta-analysis by Parker et al has demonstrated nodifference in terms of hospital stay, infection rates

and requirement for blood transfusion betweenthe two groups.10

Subjecting the elderly population to multiple sur-geries invokes a high risk. The ideal treatment forthis group should be a single procedure thatwould last their life time. In the meta-analysis byParker et al10 the major reoperation rate for THRwas 3.2% as compared to 7.8% forhemiarthroplasty, although the minor reoperationrate was greater with THR. Hopley et al11 in theirmeta-analysis demonstrated lower reoperation ratewith THR with a pooled relative risk of 0.57. Boththe studies have further stated that the inclusionof studies which compared uncementedhemiarthoplasty with THR had a bearing on theresult and the observed benefit in reoperationrates with THR mitigated in studies that used onlycemented stems for hemiarthroplasty.

Several studies have compared the functionaloutcome between hemiarthroplasty and THR forfemoral neck fracture. Keating et al employed theEuroQol and Health related quality of life index,7

Baker et al utilised the Oxford hip score8 whileRavikumar et al12 Blomfeldt et al9 andMouzopoulos et al13 used the Harris hip score forcomparing the functional outcome. All the studiesas well as the meta-analysis by Parker et al10

showed THR to have a superior functional out-come as compared to hemiarthroplasty.

Studies specifically evaluating residual pain afterarthroplasty for femoral neck fracture have noteda lower incidence of residual pain and superiorpain score with THR.9,14 Keating et al comparedcemented hemiarthroplasty with THR and foundno difference in residual pain at one year but abetter outcome with THR at 2 years follow-up.7

Meta-analysis has revealed lower residual pain atone year with THR as compared to uncementedhemiarthroplasty.10

Higher dislocation rates after THR for femoralneck fracture has deterred many surgeons fromthis surgery. Meta-analysis of randomised trialsby Parker et al10 has noted a higher pooled dislo-cation rate with THR (7.9%) as compared tohemiarthroplasty (4.3%). The systematic reviewand meta-analysis of randomised, quasi-randomised and comparative studies by Hopley etal11 however, noted no difference in dislocationrates. But the authors noted a tendency towardshigher dislocation rates after total hip arthroplasty

Fig. 1: Internal fixation in femoral neck fracture (a,b);

went into non-union (c) and was treated with valgus osteotomy (d) The

patient ultimately required total hip arthroplasty (e) after implant failure.

The treatment thus involved three surgeries and inability to work for the

entire duration of treatment

“Subjecting the elderly

population to multiple

surgeries invokes a

high risk. The ideal

treatment for this

group should be a

single procedure

that would last

their life time”

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VOL XII No 3 : July-September 2010112

among randomised and quasi-randomised trialsand this trend was most pronounced in studieswith balanced patient baseline profiles and follow-up intervals of two or more years. The use ofposterior approach has been found to have higherdislocation rates and this has prompted a call forthe use of anterior approach in this indication.15

The use of large diameter heads has been the othermeasure adopted to reduce dislocation rates.Barnett et al recorded no dislocations in a cohortof 46 hips treated with 36 mm diameter heads.16

CONSIDERATIONS WITH THR IN FEMORAL

NECK FRACTURE

A surgeon performing THR for femoral neck frac-tures needs to pay attention to several factors.The timing of surgery in these cases is crucial.Surgical delay of greater than 48 hours in elderlypatients with hip fractures has been shown tosignificantly increase mortality rates.17 It is there-fore vital to avoid delay in medically fit patients.This converts the THR, which is usually a planned,elective procedure to one with a time constraint.Most femoral neck fractures in the elderly areassociated with osteoporosis and the surgeonneeds to take this into consideration and needs toevaluate the patient as a whole with attention tothe status of the spine, ipsilateral and contralateral

limb. One needs to be careful and gentle in han-dling the limb during THR to avoid a disaster in theform of intra-operative fractures. Cemented stemsallow better fixation in porotic bone and earlyweight bearing but result in reduced periprostheticbone mineral density (BMD). Use of high viscos-ity cement and a slightly delayed application ofcement in the osteoporotic bone is advisable.Uncemented stems improve stress transfer andmay preserve BMD but are plagued by issues withfixation. Osteoporosis demands long-term treat-ment with bisphosphonates or anabolic agent,namely, teriparatide along with supplementationof calcium and vitamin D.

CONCLUSION

Prosthetic replacement has become establishedas the standard of care in elderly patients withdisplaced femoral neck fractures. While surgeonshave traditionally preferred hemiarthroplasty toTHR, the current level of evidence does not showsuperiority of one over the other. THR scores overhemiarthroplasty in terms of major reoperationrates, functional outcome and residual pain whilehemiarthroplasty is better in terms of dislocationrates. The HEALTH Study (Hip fracture Evalua-tion with Alternatives of Hip Arthroplasty), a largeprospective randomised multi-center trial compar-ing THR with modular hemiarthroplasty isunderway and is expected to throw more light onthe issue and provide an answer to this debate.

SUMMARY

� Prosthetic replacement has become estab-lished as the standard of care for elderly withfracture neck femur

� Traditionally hemiarthroplasty preferred inpatients without evidence of arthritis

� Emerging evidence in favour of primary THRin view of better function and lower reoperationrate

� Large size head and anterolateral approachmay reduce dislocation rates with THR

� Take osteoporosis into consideration whileperforming THR

� Prevent another fracture- continue treatmentof osteoporosis post-operatively

REFERENCES

1. Bhandari M, Devereaux PJ, Tornetta P 3rd,Swiontkowski MF, Berry DJ, Haidukewych G, et al.Operative management of displaced femoral neckfractures in elderly patients. An internationalsurvey. J Bone Joint Surg Am 2005;87(9):2122-30.

2. Lu-Yao GL, Keller RB, Littenberg B, Wennberg

Fig. 2: Hemiarthroplasty for a 68 year old male for femoral neck fracture

(a,b) failed at 1 year (c) and required THR with bone grafting of the

acetabulum (d).

a b

c d

“Most femoral neck

fractures in the elderly

are associated with

osteoporosis and the

surgeon needs to take

this into consideration

and needs to evaluate

the patient as a whole

with attention to the

status of the spine,

ipsilateral and

contralateral limb”

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113VOL XII No 3 : July-September 2010

JE. Outcomes after displaced fractures of thefemoral neck. A meta-analysis of one hundredand six published reports. J Bone Joint Surg Am1994;76(1):15-25.

3. Zlowodzki M, et al. The effect of shortening andvarus collapse of the femoral neck on functionafter fixation of intracapsular fracture of the hip:a multi-centre cohort study. J Bone Joint Surg Br2008;90(11):1487-94.

4. Zlowodzki M, Brink O, Switzer J, Wingerter S,Woodall J Jr, Petrisor BA, et al. The effect ofshortening and varus collapse of the femoral neckon function after fixation of intracapsular fractureof the hip: a multi-centre cohort study. J BoneJoint Surg Br 2008;90(11):1487-94.

5. Rogmark C, Johnell O. Primary arthroplasty isbetter than internal fixation of displaced femoralneck fractures: a meta-analysis of 14 randomizedstudies with 2,289 patients. Acta Orthop2006;77(3):359-67.

6. Blomfeldt R, Törnkvist H, Ponzer S, Söderqvist A,Tidermark J. Comparison of internal fixation withtotal hip replacement for displaced femoral neckfractures. Randomized, controlled trial performedat four years. J Bone Joint Surg Am2005;87(8):1680-8.

7. Keating JF, Grant A, Masson M, Scott NW, ForbesJF. Randomized comparison of reduction andfixation, bipolar hemiarthroplasty, and total hiparthroplasty. Treatment of displaced intracapsularhip fractures in healthy older patients. J BoneJoint Surg Am 2006;88:249-60.

8. Baker RP, Squires B, Gargan MF, Bannister GC.Total hip arthroplasty and hemiarthroplasty inmobile, independent patients with a displacedintracapsular fracture of the femoral neck: arandomized, controlled trial. J Bone Joint Surg Am2006;88:2583.

9. Blomfeldt R, Törnkvist H, Eriksson K, SöderqvistA, Ponzer S, Tidermark J. A randomised control-led trial comparing bipolar hemiarthroplasty withtotal hip replacement for displaced intracapsular

fractures of the femoral neck in elderly patients.J Bone Joint Surg Br 2007;89(2):160-5.

10. Parker MJ, Gurusamy KS, Azegami S. Arthroplast-ies (with and without bone cement) for proximalfemoral fractures in adults. Cochrane DatabaseSyst Rev 2010;6:CD001706

11. Hopley C, Stengel D, Ekkernkamp A, Wich M.Primary total hip arthroplasty versushemiarthroplasty for displaced intracapsular hipfractures in older patients: systematic review. BMJ2010;340:c2332. doi: 10.1136/bmj.c2332.

12. Ravikumar KJ, Marsh G, Jairaj P. Internal fixationvs hemiarthroplasty vs total hip replacement fordisplaced subcapital fractures of the femur - 13year results of a prospective randomized study[abstract]. J Bone Joint Surg Br 1998;80(Suppl1):50-1.

13. Mouzopoulos G, Stamatakos M, Arabatzi H,Vasiliadis G, Batanis G, Tsembeli A, et al.Thefour-year function results after a displacedsubcapital fracture treated with three differentsurgical options. International Orthopaedics2008;32(3):367–73.

14. Skinner P, Riley D, Ellery J, Beaumont A, CoumineR, Shafighian B. Displaced subcapital fractures ofthe femur: a prospective randomized comparisonof internal fixation, hemiarthroplasty and total hipreplacement. Injury 1989;20(5):291-3.

15. Enocson A, Hedbeck CJ, Tidermark J, PetterssonH, Ponzer S, Lapidus LJ. Dislocation of total hipreplacement in patients with fractures of thefemoral neck. Acta Orthop 2009;80(2):184-9.

16. Barnett AJ, Burston BJ, Atwal N, Gillespie G,Omari AM, Squires B. Large diameter femoralhead uncemented total hip replacement to treatfractured neck of femur. Injury 2009;40(7):752-5.

17. Shiga T, Wajima Z, Ohe Y. Is operative delayassociated with increased mortality of hip fracturepatients? Systematic review, meta-analysis, andmeta-regression. Can J Anaesth 2008;55(3):146-54.

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VOL XII No 3 : July-September 2010114

Polymicrobial Infection FollowingTotal Knee Replacement –An Uncommon Entity

SHUVENDU PROSAD ROY

Arthroplasty Fellow

OWAIS QUERESHI

Arthroplasty Fellow

ON NAGI

Chairman

SUMIT KUMAR JAIN

Junior Consultant

Deptt. of Joint Replacement

and Reconstruction Unit

Sir Ganga Ram Hospital,

New Delhi

Keywords: Total knee replacement,Infection, Polymicrobial, 2 stage revision

INTRODUCTION

Infection following a total knee replacement con-tinues to be a difficult problem. Despite a reduc-tion in the rates of infection in adult reconstructiveprocedures the total number of cases of infectedarthroplasties are increasing due to larger numberof procedures being carried out1 and also prob-ably due to procedures being carried out in smallcentres where the infrastructure is inadequate.Over the years a large amount of information hasbeen gathered about the diagnosis and manage-ment of post operative infection, but still thisentity is considered to be a devastating complica-tion. Although staphylococcus is the most com-mon organism isolated from the culture of infectedtotal knee arthroplasty (TKA), infection with gramnegative organisms are not uncommon and occa-sionally even a polymicrobial infection may beencountered which pose a diagnostic and thera-peutic challenge.2 We are presenting a case ofinfected total knee arthroplasty with a polymicro-bial infection.

CASE REPORT

The patient, a 56 year old female with rheumatoidarthritis on disease modifying anti rheumatoiddrugs (DMARD), had undergone bilateral TKA ata different centre with an uneventful post opera-tive recovery. Three months after the index sur-gery she developed swelling in her right kneealong with low grade fever following a prodromeof mild pain and difficulty in walking for a fewweeks. Patient didn’t have any recognisable epi-sode of bacteraemia. She was diagnosed as acuteseptic arthritis of the prosthetic joint at the indexcentre and the aspirate of the right knee joint wassent for gram staining and culture and sensitivityfollowed by administration of broad spectrumantibiotics. The right knee joint was debrided andthe polyethylene insert was replaced. The culturesensitivity report of the aspirate revealed Staphy-lococcus aureus and the antibiotics were contin-ued according to the antibiogram with discontinu-ation of the DMARDS. In spite of appropriateantibiotic therapy she continued with swelling inthe knee, low grade fever, and alteration of localskin colour. Nine months after the debridementshe came to our centre with the previously men-

“Infected

arthroplasties are

increasing due to

larger number of

procedures being

carried out and also

probably due to

procedures being

carried out in small

centres where the

infrastructure is

inadequate”

ABSTRACT

Infection following a total knee replacement continues to be a difficult problem.Despite a reduction in the rates of infection in adult reconstructive. Over the years alarge amount of information has been gathered about the diagnosis and managementof post operative infection, but still this entity is considered to be a devastatingcomplication. Although staphylococcus is the most common organism isolated fromthe culture of infected total knee arthroplasty (TKA), infection with gram negativeorganisms are not uncommon and occasionally even a polymicrobial infection maybe encountered which pose a diagnostic and therapeutic challenge. .

SYMPOSIUM ON

JOINT REPLACEMENT

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115VOL XII No 3 : July-September 2010

tioned presentation. After evaluation of thehaemogram (Table 1) and the radiograph (Fig. 1);the diagnosis of infective loosening was con-cluded and a two stage revision surgery wasplanned.

During the first stage surgery all components andthe bone cement were removed preserving theunderlying cancellous bone. Debridement of thepseudo membrane of the bone-cement inter-phaseand synovectomy was done. Samples from all thedifferent tissues were sent for culture and sensi-tivity separately. Bone cement spacer was made ofantibiotic, erythromycin 0.5 gm as glucoheptonateand colistin sulphomethate sodium 3000,000 I.U.,with additional three gram of vancomycin powdermixed with one full dose of bone cement to achievebroad spectrum antibiotic coverage. The organ-isms grown in the culture with their antibioticsensitivity are mentioned in Table 2. Intravenousamikacin and clindamycin were continued for sixweeks after surgery. Post-operative recovery ofthe patient was satisfactory and there was noobvious sign of infection clinically at follow upafter sixth and twelfth week.

Second stage surgery (prosthesis re-implanta-tion) was done after twelve weeks of first stagesurgery. Haemogram and markers of inflammationbefore this procedure are mentioned in Table 1.

Same protocol of tissue debridement, antibioticcement regime and post operative antibiotic re-gime of first stage surgery were followed. Therewas no growth from the tissue culture. At one yearfollow-up the patient was walking pain free withreversal of local skin changes (Fig. 2).

DISCUSSION

Early and accurate diagnosis of infection at thesite of a total knee arthroplasty is imperative for asuccessful management of this difficult problem.Pain may be the earliest and sometimes the onlypresentation of the infection and demands anassessment for the presence of infection.3 Aspira-tion of the suspected knee is an important earlyinvestigation that should be performed and dis-continuation of antibiotics for a period prior toaspiration may be required to get a positive cul-ture.4 Other investigations that can be used areerythrocyte sedimentation rate and C-reactiveprotein level, bisphosphonate scans and indium–labelled leukocyte scan. These are especially use-ful in doubtful and follow-up cases. Once infec-tion has been established, identification of theinfecting organism and their antibiotic sensitivityis the cornerstone of management of infection inthe presence of an implant. Staphylococcus aureusis the most frequently isolated organism5 andpolymicrobial infections are relatively rare.2,6 Thenature of the infecting organism has some bearingon the prognosis. Prognosis of patients with pol-ymicrobial infections is poorer as compared to thatof infections by Staphylococcus epidermides.Prognosis is also poor with infection by highvirulence organisms like enterococcus.2 Estab-lishment of clinical classification of infection is animportant step in the management of infectionwith prosthesis. According to this classification(Table 3) 4 our patient falls under the category of

Table 1: Haematological markers of inflammation

At Presentation At 12 weeksone year after after 2nd Debridementindex surgery (2ND stage of revision)

ESR 101 mm (1st hour) 24 mm (1st hour)

C-Reactive Protein 35mg% 17mg%

Total Leucocyte Count 14.4 thousand/µl 10.6 thousand/µl

Fig. 1: X-Ray both knees with prosthesis in situ A/P view; a) immediate postoperative after index surgery showing good

peri-prosthetic bone stock, b) one year after index surgery showing peri-prosthetic lytic areas both in femur and tibia in

the right knee (white arrows)

“Pain may be the

earliest and

sometimes the only

presentation of the

infection and demands

an assessment for the

presence of infection.

Aspiration of the

suspected knee is an

important early

investigation”

a b

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VOL XII No 3 : July-September 2010116

to most of the common antibiotics but later on theinfection turned out to be polymicrobial, and theorganisms were multidrug resistant. Even the sta-phylococcus showed resistance to some of theantibiotics to which it was sensitive initially. Thesefinding highlights certain factors, such as theimportance of taking tissue sample for culturepreferably during an antibiotic free period cannotbe ignored as culture of aspirate usually yields asubstantial number of both false positive and falsenegative results.6 Secondly the facilities for carry-ing out the debridement should be proper as onemay end up introducing another hospital acquiredresistant organism in the already infected joint ascould be a possibility in this case. Though inci-dence of polymicrobial infection is mentioned insome publications but none have mentioned anyprotocol about how one can plan the antibiotictherapy to deal with multiple organisms withoutcompromising the patient’s compliance. We usederythromycin and colistin as integrated commer-cial formulation and vancomycin was added toachieve a local multidrug coverage. Though thereis no established clinical evidence of efficacy oferythromycin and colistin but efficacy of vanco-mycin is clinically established.7 In patients with

Fig. 2: Right knee after one year showing

normal skin colour with broad surgical scar

“Prognosis of patients

with polymicrobial

infections is poorer as

compared to that of

infections by

Staphylococcus

epidermides.

Prognosis is also poor

with infection by high

virulence organisms

like enterococcus”

Table 2: Culture repoart and antibiogram

Organism Antibiogram Growth from †Sensitive Resistant

Growth from initial aspirateStaphylococcus aureus Amoxyclave Penicillin, Ampicillin Synovial fluid

Cefazoline ErythromycinGentamicinCo-trimoxazoleTetracyclineCeftriaxoneCefotaxime

Growth from tissues of second debridementEnterococcus fecium Tigecycline Ampicillin, gentamycin Specimen III, IV

Vancomycin

Escherichia coli Amikacin Ampicillin, cefepime, Specimen I, III, IVColistin cefoperazone+salbactum,Imipenem ciprofloxacin, gentamycinTigecycline

Staphylococcus aureus Clindamycin Penicillin, erythromycin, Specimen I, III, IV, Voxacillin Amoxyclave, Cefazoline,vancomycin Gentamicin,

Co-trimoxazol,Tetracycline

Klebsiella pneumoniae Amikacin Ampicillin, Specimen III, IVcolistin cefoperazone+salbactum,gentamycin ciprofloxacinimipenem

† Specimen I - Joint fluid, Specimen II – Synovium, Specimen III - Tibial pseudomembrane, Specimen IV - Femoralpseudomembrane, Specimen V - Implant swab (biofilm)

late chronic infection and the exchange of insertonly was not sufficient, as per the available litera-ture. The initial culture of the patient had revealedonly Staphylococcus aureus which was sensitive

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117VOL XII No 3 : July-September 2010

Table 3: Classification of TKA infection with clinical presentation and management protocol4

Type of infection Clinical presentation Management protocolI. Positive Intra Operative Culture May present as aseptic loosening Conservatively with 6-8weeks of

any time after surgery, positive intravenous or oral antibiotics as perculture of specimen obtained during culture reportrevision for aseptic loosening.

II. Early Post Operative Infection < 4 WeeksA. Superficial A. Superficial infection at surgical A. Antibiotics (may require debridement)B. Deep site, fever with acute signs of B. Debridement, insert change and

inflammation, joint not involved. antibiotic cement beads in jointB. All above features with joint and i.v. antibiotics.

involvement.

III. Acute Hematogenous >4 weeks, Deep infection due to Debridement, retention of prosthesishematogenous seeding, acute onset if not loose, but replacement ofseptic focus present local signs polyethylene insert, antibiotic cementof inflammation, fever, no sinus. beads in joint and i.v. antibiotics;

If implant loose two stage exchangearthroplasty.

IV. Late Chronic > 4 Weeks, Indolent onset, usually Two stage exchange arthroplastyno fever, local skin changes present,sinus may be present.

multiple failed debridements there is always achance of polymicrobial or multidrug resistantinfections. In such situations it is prudent toensure a broad spectrum of local drug delivery asby the time the diagnosis is established the patienthas already undergone surgery and nothing canbe done to increase the spectrum of the antibioticin the bone cement. Furthermore alteration of themechanical properties of the cement by addition ofantibiotics is not a concern in a cement spacer. Ifwe consider the sensitivity of various organismsin this case (Table 2) it is clear that addition ofmultiple antibiotics in the bone cement providedan added cover along with post operative periodintravenous amikacin and clindamycin which werecontinued for six weeks. We believe that this wasthe real achievement in dealing with this difficultclinical situation. The duration of antibiotic therapyin the post operative period in the first and secondstage of a revision arthroplasty is also importantand most authors accept it to be six to eight weeks.4

Decision for second stage of revision is takenusually two weeks after the C-reactive proteinlevel comes to normal.4 The post op recovery ofour patient was satisfactory and there were noclinical signs of infection at follow up after six andtwelve weeks. Although C- reactive protein levelwas not normal but second stage surgery (pros-thetic re-implantation) was carried out becausethe patient was a known case of rheumatoid arthri-tis and there was disease activity at that time,

which explains the raised C- reactive protein levelbut it was less than the time of debridement.

In conclusion we can say that in an infected TKAthe debridement should be as meticulous as pos-sible and attempts should be made to providebroad spectrum coverage of antibiotics in thecement spacer for optimum results.

REFERENCES1. Sculco TP. The economic impact of infected total

joint arthroplasty. In Instructional Course Lec-tures, American Academy of Orthopaedic Sur-geons. Vol. 42, pp 349-351. Rosemont, Illinoi,American Academy of Orthopaedic Surgeons,1993.

2. Hirakawa K, Stulberg BN, Wilde AH, Bauer TW,Secic M. Results of 2-stage reimplantation forinfected total knee arthroplasty. J Arthroplasty1998;13:22-8.

3. Ayers DC, Dennis DA, Johanson NA, Pelligrini VDJr. Common complications of total knee artroplasty.J Bone Joint Surg Am 1977;79:278-311.

4. Tsukyama DT, Goldberg VM, Kyle R. Diagnosisand management of infection after total kneearthroplasty. J Bone Joint Surg Am 2003;85:75-80.

5. Windsor RE, Bono JV. Infected total kneereplacements. J Am Acad Orthop Surg 1994;2:44.

6. Valle CJD, Bogner E, Desai P, Lonner JH, AdlerE, Zuckerman JD, Cesare PE. Analysis of frozensections of intraoperative specimens obtained atthe time of reoperation after hip or knee resectionarthroplasty for the treatment of infection. J BoneJoint Surg Am 2003;85:75-80.

7. Taggart T, Kerry RM, Norman P, Stockley I. Theuse of vancomycin impregnated cement beads inmanagement of infection of prosthetic joints. JBone Joint Surg Br 2002;84:70-2.

“In patients with

multiple failed

debridements there is

always a chance of

polymicrobial or

multidrug resistant

infections”

“In conclusion we can

say that in an infected

TKA the debridement

should be as

meticulous as possible

and attempts should

be made to provide

broad spectrum

coverage of antibiotics

in the cement spacer

for optimum results”

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VOL XII No 3 : July-September 2010118

INTRODUCTIONThe most common deformity in osteoarthritic kneeis varus which is secondary to intra-articular boneloss in majority of the cases. Sometimes there maybe associated extra-articular deformity in the fe-mur or tibia. An intra-articular bone loss may co-exist with the extra-articular deformity. The extra-articular deformity is either in the metaphysealregion around knee or in diaphysis of femur ortibia. An extra-articular deformity is a great chal-lenge in performing a successful TKA in order toachieve mechanical alignment, balanced soft tis-sue, and joint line at anatomical position.1,2

Long-term survival of the TKA is dependent onproper restoration of the mechanical axis, balanc-ing of periarticular soft tissue and accurate orien-tation of the individual prosthetic components.Mechanical axes of the femur, tibia and the limb areto be restored in TKA either by an extra-articularprocedure or intra-articular bone resection.3

AXES IN TKAThe most important axis in TKA is mechanical axis.All the procedures are intended to restore themechanical axis of the limb which extends fromcentre of head of femur to the centre of the ankle.This axis must pass through the centre of knee.The mechanical axis of femur (Fig.1) extends from

centre of head to the centre of knee. Normally themechanical axis is 3° varus to the midline axis ofbody. The anatomical axis of femur, which extendsfrom tip of trochanter to centre of knee, is 9° varusto midline axis of body and 6° varus to the mechani-cal axis of limb. When the femur is deformed,because of any cause, its mechanical axis deviatesfrom the mechanical axis of the limb.

The mechanical axis and anatomical axis are samein normal tibia, which extends from centre of kneeto the centre of ankle. This is 3° varus to the midlineaxis of body.

CAUSES OF EXTRA-ARTICULAR DEFORMITY� Fracture malunion – most common� Rickets� Paget’s disease� Fibrous dysplasia� Osteomalacia� Congenital deformity� Prior osteotomy

Investigations� Standing scanogram� Three dimensional tomographic reconstruc-

tion (for complex two or three planar deform-ity)

Pre-operative planningThe pre-operative planning begins with assess-ment of the standing scanogram to determine the

Extra Articular DeformityCorrection in TKA

PRATYUSH GUPTA

Research Associate

VIJAY KUMAR

Assistant Professor

RAJESH MALHOTRA

Professor

Deptt. of Orthopaedics,

All India Institute of

Medical Sciences,

New Delhi

ABSTRACT

The most common deformity in osteoarthritic knee is varus which is secondary to intra-articular bone loss in majority of the cases. Sometimes there may be associated extra-articular deformity in the femur or tibia. An intra-articular bone loss may co-exist with theextra-articular deformity. The extra-articular deformity is either in the metaphysealregion around knee or in diaphysis of femur or tibia.

Keywrods: Extra articular deformity,osteoarthritic knee, TKA

“An extra-articular

deformity is a great

challenge in

performing a

successful TKA in

order to achieve

mechanical alignment,

balanced soft tissue,

and joint line at

anatomical position”

SYMPOSIUM ON

JOINT REPLACEMENT

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119VOL XII No 3 : July-September 2010

mechanical and anatomical axes of femur and tibia.Three dimensional tomographic reconstructionsshould be done to assess complex bi- or tri-planardeformities. A line is drawn perpendicular to themechanical axes at knee for anticipated distalfemoral cuts. If the line passes through the attach-ment of medial or lateral collateral ligament, intra-articular correction of deformity should not bedone. Angles between anatomical and mechanical

axes are measured in view of using intra-medullarycutting jigs.

A line is drawn from the medullary canal of thedistal part of the tibia to knee joint (Fig. 2). If thisline passes within the tibial condyle, a TKA withintra-articular bone resection should be planned.The proposed tibial cut is drawn perpendicular tothis line. If the distal tibial axis does not passthrough the tibial plateau or if the deformity is morethan 30° in the coronal plane, a corrective oste-otomy should be done. A custom-made prosthesismay be required if the anatomy of the tibia issubstantially altered.

Radiographic measurements should be correlatedwith the clinical examination, as the procedurerequires thorough understanding of both the bonyand soft tissue deformities. Flexion deformityshould be determined on lateral roentgenogram.

Technique of correctionDeformity correction in TKA can be done by anextra-articular osteotomy or an intra-articular boneresection. An extra-articular corrective osteotomyis performed either as a first procedure followed byTKA after 6-12 months or simultaneously withTKA as a single stage operation. A meticulous pre-operative planning is required to completely as-sess the deformity associated and the correctionrequired. Several issues must be considered whenchoosing between intra- and extra-articular cor-rection: the magnitude of the deformity, the dis-tance from knee, whether the deformity is in thefemur or tibia and the direction of the deformity(flexion, extension, varus, valgus or/and rotation).Though uniplanar deformity in the coronal planeis the most common extra-articular deformity, itcould be biplanar when deformity also exists insaggital plane or triplanar when there is an asso-ciated element of rotation.4

Extra-articular correctionIndication

� If the deformity is close to the joint� If the deformity in femur is more than 20° in the

coronal plane� If the plane of distal femoral cut is likely to

compromise integrity of medial or lateral col-lateral ligament

� Severe femoral bowing with minimalosteophytes and severe lateral laxity in varusknees

� If the distal tibial axis does not pass throughthe tibial plateau

� If the deformity in tibia is more than 30° in thecoronal plane

Fig. 1: Showing mechanical and anatomical

axes of femur and tibia, and their relations

with midline axis of body and articular

surface of knee

Anatomical axis

Mechanialaxis

Midlinebodyaxis

Distal femoral cutperpendicular tomechanical axis

Tibal cutperpendciular tomechanical axis

Fig. 2: Showing line drawn in the line in the medullary canal of distal part

of tibia and how it is passing through the tibial plateau. As shown in D, the

line is outside the tibial plateau

A B C D

“A line is drawn from

the medullary canal of

the distal part of the

tibia to knee joint. If

this line passes within

the tibial condyle, a

TKA with intra-

articular bone

resection should be

planned”

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VOL XII No 3 : July-September 2010120

� Complex ligamentous imbalance on templatedintra-articular bone resection

Contraindication� All the mild deformities which can be managed

by intra-articular bone resection, osteotomyshould not be performed.

� If cognitive function is not good and thepatients has difficulty in following or remem-bering the instructions

ResultsLonner JH in their series of 11 patients reported amean improvement of 77 points compare to pre-operative knee society score. Their post operativeaverage knee society functional score was 81points. Post-operative limb alignment, based onscanogtram, was restored within 2° of normal ineach patient.3

Complications� Prolonged osteotomy healing / non-union� Arthrofibrosis� Prolonged duration of surgery (Krackow’s

(152 mn) for a major valgus series)� Increased blood loss� Limb length discrepancy� Extensive soft tissue dissection� Prolonged non/protected weight bearing� Prolonged rehabilitation� Difficulty in fixation of osteotomy� Second procedure for hardware removal

Intra-articular correctionIntra-articular bone resection was the preferredtechnique of Insall to correct the extra-articulardeformity. Medial and lateral collateral ligaments,which are the static stabilizers of knee, are at-tached 25mm from the joint line on the femur. So,an extra-articular osteotomy should be done, if theintegrity of the collateral ligaments is being com-promised by distal femoral cut. Intra articular cor-rection is the preferred method for correction ofdeformity and restoration of alignment. Howeveran extra-articular correction should be done whereintra-articular correction is contraindicated.5

ResultsWang JW and Wang CJ reported their results ofTKA in 15 patients with extra-articular deformitycorrected by intra-articular bone resection. Theyreported an improvement of knee society scorefrom 22.3 points pre-operatively to 91.7 points atthe time of last follow-up, and the average kneesociety function score improved from 28.0 pointspreoperatively to 87.3 points at the time of lastfollow-up. The average mechanical axis of the

Fig. 4: Showing restoration of limb alignment by TKA

Fig. 3: Showing lines drawn perpendicular to mechanical axes of femur

and tibia to know the anticipated bone cuts during operation

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121VOL XII No 3 : July-September 2010

knee improved from 22.7° of varus preoperativelyto 0.3° of varus at the time of last follow-up.1

Complication� Technique may alter the position of joint line� Femoral component may not always rest flush

on the cut bone surface� Oblique gaps left between the prosthesis and

the bone, on concavity of the deformity mayneed to be filled with cement, structural bonegraft or wedges

� Complex soft tissue imbalance� Wolff et al reported some cases of instability

due to asymmetric bone resection6

Surgical TechniqueThe basic principle for intra-articular correction ofthe deformity remains the same as in any routinecase of TKA. However, in order to accommodatethe extra-articular deformity conservative boneresection and an extensive soft tissue release maybe necessary. An extra-medullary guide systemshould be used to cut the femoral condyle when

the deformity is in the middle third or when an intra-medullary rod has failed to pass through theangular deformity. Otherwise intra-medullary guidesystem should be used. The point of entry in themedullary canal of femur is guided by the type ofdeformity. The point of entry is in the Lateralfemoral condyle in varus deformity while its in themedial condyle in case of valgus deformity.1,3

If intra-medullary guide system is used to cut thetibia, the point of entry for the intra-medullaryguide rod should be in lateral condyle in varusdeformity and in medial condyle in valgus deform-ity of tibia. The extra-medullary guide systemsshould be used if the intra-medullary rod fails topass through the site of angular deformity. Mini-mal amount of bone should be removed fromlateral condyle (not more than 10mm). If defectproduced by the tibial cut is more than 5 mm,cortico-cancellous graft should be used. Once thebone cuts are made soft tissue balancing emergesas a most important and difficult part of the proce-dure.1,3

As varus is the most common deformity beingencountered, this requires more of lateral condyleresection than medial condyle. A valgus deformitycorrected intra-articularly produces medial insta-bility and a varus deformity similarly correctedproduces lateral instability. Medial and lateralinstability are not equally important. Lateral insta-bility is less important because the lateral side ofthe joint is dynamically stabilized by the muscleson the lateral side, including the biceps femoris,the iliotibial tract, the lateral head of the gastroc-nemius, the popliteus, and even the quadriceps.The muscular stabilizers on the medial side are notnearly as effective as on the lateral side. Therefore,valgus deformity will be difficult to correct andstabilize than varus deformity. Instability must beaddressed, either by soft tissue balancing or theuse of a constrained prosthesis.3

Such oblique cuts of articular surfaces, which areperpendicular to mechanical axes, result in relativelengthening of lateral structures in varus knees, asit produces a trapezoidal extension and/or flexiongap. The structures addressed in graded stepwiserelease includes osteophytes to be removed fromposteromedial tibial flare, subperiosteal elevationof deep MCL, posteromedial capsule, semimem-branosus, reduction osteotomy of posteromedialaspect of upper tibia, superficial MCL and pesanserinus. In cases of severe femoral bowing withminimal osteophytes a medial epicondylar oste-otomy may be required (Fig.5).7

Fig. 5: Shows osteotomy of medial condyle

done to balance excessively tight medial

soft tissue

A

C

B

“In order to

accommodate the

extra-articular

deformity conservative

bone resection and an

extensive soft tissue

release may be

necessary”

“An extra-medullary

guide system should

be used to cut the

femoral condyle when

the deformity is in the

middle third or when

an intra-medullary rod

has failed to pass

through the angular

deformity”

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VOL XII No 3 : July-September 2010122

Mullaji et al preferred to perform a tibial osteotomyif an asymmetric gap is obtained despite full medialrelease except detachment of superficial MCL andrelease of pes insertion (Fig.6). They revised theproximal tibial cut parallel to the distal femoral cutand obtained a rectangular flexion and extensiongap. They made a separate cut parallel to theproximal tibial cut in the metaphysis of tibia and thewedge osteotomy is performed by this cut andanother cut made perpendicular to the mechanicalaxis of tibia. A wedge, with base on convex side,would be removed from metaphysis which shouldbe equal to the wedge removed from proximal tibiato obtain a rectangular gap. They preferred to fix

the osteotomy site with the stemmed tibial compo-nent. If the wedge osteotomy was difficult toclose, they removed 1cm of fibula to facilitate theclosure.8

Use of computer assisted tensioning device inbalancing complex soft tissue issues may givemore accurate results. Recent reports of compu-ter-assisted TKA in patients with extra-articulardeformity indicated good results with appropriatebone cuts and soft tissue release. A correctiveosteotomy can also be accurately performed whenrequired using computer navigation although thesurgeon needs to be well versed with the use ofcomputer navigation in routine cases before usingit for extra-articular deformities, which may betechnically challenging.9

The new custom made jigs (Fig.7a,b) for femur andtibia give accurate cuts according to preoperativeplanning. These may have advantage of decreas-ing the time of surgery along with accurate align-ment.

DISCUSSION

It is technically difficult to correct a severe extra-articular deformity by means of intra-articular re-section of bone combined with soft-tissue balanc-ing. Some authors have recommended correctiveosteotomy before total knee arthroplasty if thedeformity is ≥15° in the proximal part of the tibia orthe distal part of the femur. However this carriesthe risk of all the disadvantages and complicationsof osteotomy. Our decision for an intra-articularcorrection rests on the perpendicular on the me-chanical axes at the centre of knee. If the lineperpendicular to mechanical axis did not passthrough the insertion of the collateral ligaments,

Fig. 6: A, Trapezoidal extension gap after release of deep MCL,

posteromedial capsule, and removal of posteromedial tibial flare, leaving

superficial MCL and pes anserinus. B, Tibial cut parallel to the distal

femoral cut removing medial base wedge, metaphyseal lateral base

wedge of same degree, 1 cm segment removal from fibula. C, Osteotomy

closed, rectangular extension obtained

A B C

Fig. 7a,b: Shows custom made tibia and femur cutting jigs made-up of polyethylene

A B

“In cases of severe

femoral bowing with

minimal osteophytes a

medial epicondylar

osteotomy may

be required”

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123VOL XII No 3 : July-September 2010

an intra-articular bone resection is indicated tocorrect the extra-articular deformity at the time ofindex operation.10,11

Mann et al reported the result of the preferredtechnique of Insall after it had been used to treata series of deformities. They concluded while thetechnique appeared to be effective at two years, itmay alter joint-line position and the femoral com-ponent may not always flush with the cut bonesurfaces; rather, oblique gaps left between theprosthesis and the bone, on the concavity of thedeformity, may need to be filled withpolymethacrylate, structural bone graft or wedges.5

The theoretical concern in such cases are thatstructural support may be insufficient and obliqueshear forces may make the bone-cement interfacesvulnerable to early demarcation and perhaps leadto long-term failure.12

Another concern pointed out by Wolff et al is that,in the presence of notable femoral deformity, res-toration of the normal mechanical axis with intra-articular resection may normalize orientation ofthe knee but hip adduction or abduction is stillnecessary to keep the knee and ankle parallel to theground in the stance phase of the gait.6

Simultaneous corrective osteotomy, to correctsevere mechanical malalignment prior to TKA, isadvisable to ensure maintenance of structuralsupport of the prosthesis and to avoid complexligamentous imbalance.3 The corrective osteotomyfor the extra-articular deformity depends not onlyon the extent of deformity but also on the locationof osteotomy in relation to the deformity. Thelarger the deformity and the closer it is to the kneejoint, greater its impact on the knee joint.5 Perform-ing corrective extra-articular ostrotomy and kneearthroplasty during the same operative session istechnically difficult but effective. An extensivesoft tissue dissection is required, osteotomy oftibial tuberosity may be necessary for adequateexposure. Corrective osteotomy is performed be-fore the TKA. Intra-medullary fixation of oste-otomy is a preferred technique for diaphysealcorrection, and pre-contoured blade-plate for themetaphyseal osteotomy. Extra-medullary guttingguides should be used with intra-/extra medullaryimplants. The amount of wedge resection duringosteotomy is highly subjected to human errorsand the results of osteotomy may be different indifferent hands. Once the osteotomy has beendone the relation of anatomical axis to the me-chanical axis changes to what was measured dur-ing pre-operative planning. So, a new pre-opera-tive and per-operative planning is warranted for

intra-articular bone resection to compensate anyunder or over correction at the osteotomy site.3

A one stage procedure in the form of intra-articularbone resection is cost effective, requiring lesshospitalisation and a shorter length of stay. Addi-tionally, the procedure is reproducible and mayeven provide for better outcomes. Extra-articularosteotomy option can lead to malunion or nonun-ion, instability, decreased range of motion andother complication of osteotomy. As correctionosteotomy options also increase incision area,prolonged rehabilitation and increase the chanceof infection, our preferred method is the 1-stagedTKA intra-articular corrective bone resection tech-nique.4,9

CONCLUSION

Intra-articular bone resection should be the firstchoice for correction of extra-articular deformity inTKA. When the intra-articular cuts are so obliquethat it can compromise balancing and stability ofthe knee joint, an extra-articular correction of de-formity before TKA must be considered. Intra-articular corrective bone resection is easier, costeffective, reproducible and it allows early weightbearing and rehabilitation.

REFERENCES

1. Wang JW, Wang CJ. Total knee arthroplasty for arthritis of

the knee with extra-articular deformity. JBJS

2002;84A(10):1769-74.

2. Hungerford DS. Extra-articular deformity is always correct-

able intra-articularly: to the contrary. Orthopaedics 2009;32(9).

3. Lonner JH, Siliski JM, Lotke PA. Simultaneous femoral

osteotomy and total knee arthroplasty for treatment of

osteoarthritis associated with severe extra-articular deform-

ity. JBJS 2000;82A(3):342-8.

4. Koenig JH, Maheshwari AV, Ranawat AS, Ranawat CS.

Extra-articular deformity is always correctable intra-articularly:

in the affirmative. Orthopaedics 2009;32(9).

5. Mann JW, Insall JN, Scuderi GR. Total knee arthroplasty in

patients with associated extra-articular angular deformity.

Orthop Trans 1997;21:59.

6. Wolff AM, Hungerford DS, Pepe CL. The effect of extra-

articular varus and valgus deformity on total knee arthro-

plasty. Clin orthop 1991; 271: 35-51

7. Clayton ML, Thompson TR, Mack RP. Correction of align-

ment deformities during total knee arthroplasties: staged soft-

tissue releases. Clin Orthop 1986;202:117-24.

8. Mullaji AB, Padmanabhan V, Jindal G. Total knee arthro-

plasty for profound varus deformity: technique and radiologi-

cal results in 173 knees with varus of more than 20 degrees.

J arthroplasty 2005;20:550-61.

9. Battros J, Klika AK, Lee HH. The use of navigation in total

knee arthroplasty for patients with extra-articular deformity.

J Arthroplasty 2008;23:74-8.

10. Cameron HU, Welsh RP. Potential complications of total

knee replacement following tibial osteotomy. Orthop Rev

1988;17:39-43.

11. Roffi RP, Merritt PO. Total knee replacement after fractures

about knee. Orthop Rev 1989;19:614-20.

12. Chen F, Krackow KA. Management of tibial defect in total

knee arthroplasty. A biomechanical study. Clin orthop

1994;305:249-57.

“Simultaneous

corrective osteotomy,

to correct severe

mechanical

malalignment prior to

TKA, is advisable to

ensure maintenance of

structural support of

the prosthesis and to

avoid complex

ligamentous

imbalance”

“A one stage

procedure in the form

of intra-articular bone

resection is cost

effective, requiring

less hospitalisation

and a shorter length of

stay. Additionally, the

procedure is

reproducible and may

even provide for better

outcomes”

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VOL XII No 3 : July-September 2010124

INTRODUCTION

Femoral shaft fracture is an incapacitating injuryin children (Flynn et al, 2002 and Heybelly et al,2004). The treatment has traditionally been agerelated, influenced by the type of injury, associ-ated injuries and the location and type of fracture.The aim of fracture treatment is not only anatomi-cal realignment, but also restoration of muscle andjoint function as close as possible to the normal.Psychological recovery is accelerated by earlymobilisation which encourages healing of frac-

ture, maintenance of normal circulation, preserva-tion of tone of the muscles and restoration of themovements of the joints.

Because of rapid healing and spontaneous correc-tion of angulations most of femoral shaft fracturesin children younger than six years of age can betreated conservatively (Buckley, 1997). Above sixyears of age all such fractures when treated non-operatively could have loss of reduction, malun-ion, intolerance and complication associated withplaster. Near the end of skeletal maturity accuratereduction is necessary as angular deformity is nolonger correctable by growth. In skeletally matureadolescents, use of an antegrade solid lockedintramedullary nail has become the standard oftreatment.

Titanium Elastic Nails forPediatric Femur Fractures:Clinical and Radiological Study

NISHIKANT KUMAR

LALJEE CHAUDHARY

Deptt. of Orthopaedics

Darbhanga MedicalCollege and Hospital,Bihar

PAEDIATRIC FRACTURES

ABSTRACT

Background: Management of femoral diaphyseal fractures in the age group 6-16years is controversial. There has been a resurgence worldwide for operative fixation.Material and methods: Twenty children (15 boys, 5 girls), aged 6-16 years with femoraldiaphyseal fractures were stabilized with Titanium Elastic Nail (TEN). Patients underwentsurgery within ten days of their injury. The results were evaluated using Flynn’s scoringcriteria.Results: All 20 patients were available for evaluation after a mean of 24 months (15-32 months) of follow-up. Radiological union in all cases was achieved in a mean timeof 8 weeks. Full weight bearing was possible in a mean time of 10 weeks (8-12 weeks).The results were excellent in 14 patients (70%) and successful in 6 patients (30%).Conclusion: Intramedullary fixation by TEN is an effective treatment of fracture in femurin properly selected patients of the 6 - 16 years age group.

Keywords: Femoral diaphyseal fractures,children and adolescents, operative treatment,Intramedullary fixation, TEN, ESIN

“Because of rapid

healing and

spontaneous

correction of

angulations most of

femoral shaft

fractures in children

younger than six years

of age can be treated

conservatively”

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125VOL XII No 3 : July-September 2010

In patients between 6 – 16 years of age there hasbeen a tendency towards operative approach.Titanium elastic nailing (TENs) which is variouslyknown as elastic stable intramedullary nailing(ESIN) has become the choice of stabilisation inpaediatric long bone fractures, particularly thefemoral shaft fracture. The present study is aimedat the evaluation of intramedullay fixation withtitanium elastic nails in children with femoral frac-tures. Until recently skeletal traction and applica-tion of a cast was the preferred method of treat-ment of diaphyseal femoral fractures in childrenand young adolescent.

The ideal device for the treatment of most femoralfractures in children would be a simple load-shar-ing internal splint that allows mobilization andmaintenance of alignment and extremity lengthuntil bridging callus forms. The device would

exploit the child’s dense metaphyseal bone, rapidhealing and ability to remodel without riskingdamage to the epiphysis or the blood supply to thecapital femoral epiphysis.

The perceived advantage of this technique (TENS)includes early union due to repeated micromotionat fracture site, respect for the epiphysis, earlymobilization, early weight bearing, scar accept-ance, easy implant removal and high patient sat-isfaction rate. Most importantly implant does notendanger either the epiphysis or the blood supplyto femoral head. Besides titanium has excellentbiocompatibility. Titanium elasticity limits theamount of permanent deformation that the nailundergoes during insertion. More importantlyelasticity promotes callus formation by limitingstress shielding.

The biomechanical principle of titanium elasticnail is based on the symmetrical bracing action oftwo elastic nails inserted into the metaphysis,each of which bears against the inner bone at threepoints. This produces following four propertiesnamely, flexural stability, axial stability, transla-tional stability and, rotational stability.

However, it must be borne in mind that a largerseries should be observed for a longer durationbefore accepting this method. There should be astandardization of the nail as different implantmanufacturers are coming with their own modifi-cations. The initial results of fixation of femoralshaft fractures with titanium elastic nails havebeen encouraging.

MATERIAL AND METHODS

Twenty children (15 boys and 5 girls) in the agegroup of 6-16 years (average 10.8 years) withfemoral shaft fracture were stabilized with Tita-nium Elastic Nail (TEN) between April 2007 toOctober 2009. The predominant mode of injurywas due to fall from height (50%). Right-sidedinvolvement was seen in 13 cases (65%) and leftside in 7 cases (35%). Mid-diaphyseal fracture offemur was found in 70% of cases and subtro-chanteric fracture in 30% cases. About 50% pa-tients underwent surgery within 10 days of theirinjury. The surgery was carried out in the Depart-ment of Orthopaedics, Darbhanga Medical Col-lege and Hospital, Laheriasarai, Darbhanga, Bihar,India.

Nails are available in diameter range from 2.5 mmFig. 1: Instruments used

“Titanium elastic

nailing (TENs) which is

variously known as

elastic stable

intramedullary nailing

(ESIN) has become the

choice of stabilisation

in paediatric long bone

fractures, particularly

the femoral shaft

fracture”

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VOL XII No 3 : July-September 2010126

to 4.5 mm The nails are colour coded for identifi-cation. The nails are straight except for a bent tip.Special instruments including radiolucent reduc-tion tool, nail holder, nail bender, insertion device,nail extractor, vice grip and a nail impactor (Fig. 1)are used for insertion.

All the patients treated with TENS had skin/skel-etal traction for approximately 1 week. As is thepolicy of our institution, the traction pin (4.76 mmthreaded Steinmann Pin) was inserted in the oper-ating room under local anaesthesia. The pin wasinserted in the region of tibial tuberosity anterola-teral to posteromedial plane. Some patients wereput on skin traction. Compound fractures wereprimarily thoroughly debrided and upper tibialskeletal traction applied. The injured limb was puton a Bohler’s – Brawn splint and adequate weightapplied. This is essential to minimize pain, musclespasm and shortening. Appropriate tetanusprophylaxis, along with the antibiotics and anal-gesics were administered. Patients with compoundwound were given parenteral broad spectrumantibiotics. As soon as the patient became fitfor anaesthesia and surgery he/she was posted forfixation of femoral shaft fractures with titaniumelastic nail. Good preoperative X-ray (Fig. 2) of theinjured femur were used to estimate the nail diam-eter and to develop an approach to plan theincision.

General/spinal (above 14 years) anaesthesia wasgiven with full aseptic and antiseptic precautionson an image intensifier compatible operation table.

OPERATIVE TECHNIQUE

The patient is placed supine on radiolucent frac-ture table and upper tibial skeletal traction pinremoved. The legs, especially the contralateralleg, is abducted to allow the surgeon to stand onthe medial as well as on the lateral side of the leg.This facilitates insertion of the nail from medialside. The limb is prepared and draped to giveaccess to the entire femur and knee joint and topermit manual manipulation of the thigh. Theimage intensifier is placed so that one can get APand lateral view of the femoral shaft. The monitoris placed in such a way that surgeon can have easyvision when inserting the nail and reducing thefracture.

The selection of the insertion point for the nails ismedial and lateral at the top of the flare of the medialand lateral condyles so that after insertion theywill tend to bind against the flare of the condyles.If the nails are inserted too low, they will tend tobackout, which is a troublesome complication. Inaddition, the insertion should be posterior to midline of the shaft so that if the nails backout, theywill be less likely to enter the synovial pouch.

A 5mm incision is made on the lateral side of the legextending about two finger breadth above thesuperior pole of the patella. (The superior pole ofthe patella lies slightly above the level of thephysis). A guide wire for 6.5 mm cannulated screwis passed at 45 degrees angulation at the level ofthe superior pole of the patella. Over this a drill holeis made with the cannulated drill bit. Using acurved bone awl, the hole is extended cephalad toelongate the hole and avoid cracking of the cortexwhen the rod is inserted. An alternative method isto pass the guide wire horizontally through thelateral entry point, let it come medially through thebone, soft tissue and skin and then to insert thecanulated drill bit from the medial cortex in aretrograde manner to make the medial entry point.The medial entry hole is similarly elongated usinga curved bone awl in cephalad direction. Thediameter of nail should be 2/5 of the internaldiameter of the medullary canal. (Nail diameter =0.4 x Canal diameter).

Ideally, the lateral nail should extend to the level ofthe greater trochanter and the medial nail into the

Fig. 2 : Preoperative x-ray of femur (AP and Lat view)

“The perceived

advantage of this

technique (TENS)

includes early union

due to repeated

micromotion at

fracture site, respect

for the epiphysis,

early mobilization,

early weight bearing,

scar acceptance, easy

implant removal and

high patient

satisfaction rate”

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127VOL XII No 3 : July-September 2010

femoral neck. Assuming a midshaft diaphysealfracture, if both nails reach above the level of thelesser trochanter, the fixation will be adequate. Thelevel of fracture when the nails are inserted ismarked on the nails by placing the nail on the thighso that the tip reaches the level of top of lessertrochanter. The nails should be present at thislevel to make a gentle “C”. The amount ofprebending should be equal for both the nails.

Both the nails are inserted through the entry holesone after the another and are driven upto thefracture site. It is important that sufficient reduc-tion of the fragment is achieved so that about halfof the medullary canal is filled. The reduction ishelped by the use of F-tool which is a radiolucentdevice. The arms of the F-tool are readjusteddepending on the fracture configuration and bulkof thigh viewing with the image intensifier demon-strates which nail would be the easiest to driveacross the fracture site. This nail is advancedabout 2 cm and then rotated. Motion of the proxi-mal fragment demonstrates the nail is in proximalfragment. At this point, it is advanced further byrotating this nail, further reduction of the fracturecan be accomplished and then the second nail isadvanced.

The traction is released and both nails are ad-vanced to their full length. The entire femur is seenwith the image intensifier to ensure that the frac-ture is reduced and not distracted and that thenails are properly positioned. Rotational and an-gular mal-reductions are checked and if presentthe same is corrected by partially withdrawing thenails, correcting the deformity and reinserting thenails. When the nail is at its final position, it wasmarked with a pen or clamp about 10 to 20 mm fromthe insertion hole. The nail is slightly retracted toallow easy access to this cut off point. The nailsare cut at the marked level and advanced so thatthey lie against the supracondylar flare of thefemur in order to avoid symptoms at the insertionsite. The nail position is confirmed with imageintensifier throughout the femoral shaft in antero-posterior and lateral position.

A knee immobilizer or controlled motion brace witha lockable knee should be used for additionalsupport. The knee immobilizer or controlled mo-tion brace should be used at the times except whenbathing. The patient is started on range of motionof the knee and three point touch down exercisethe day after surgery. When early callus formation

is observed, weight bearing can be increased andexternal support can be discontinued when radio-graphic healing is complete. It is important that thepatient bear weight because this provides themotion at the fracture site that leads to early callusformation. In all cases post-operative x-rays antero-posterior and lateral views are taken.

In the post-operative period parenteral antibioticswere continued for 5 days and then oral antibioticswere given till stitch removal. Stitches were re-moved on the 12th post-operative day. After re-moval of stitch by 13th to 14th day post-operativepatients were discharged.

Patients underwent regular follow up in the outpatients department for clinical and radiologicalevaluation in the immediate post-operative period(Fig. 3), at 4 weeks, 8 weeks (Fig. 4), 12 weeks (Fig.5), 24 weeks, 35 weeks or till the publication of thisseries, whichever was earlier.

RESULTS

The median duration of the surgery was 80 min (60-120 min). All 20 patients were available for evalu-ation after a mean of 24 months (15-32 months) offollow-up. All patients were encouraged to do hipand knee non- weight bearing exercises from firstpost-operative day. Weight bearing was allowedaccording to the fracture geography and fixation.

Fig. 3: Immediate postoperative x-ray of

femur (AP and Lat view)

“The entire femur is

seen with the image

intensifier to ensure

that the fracture is

reduced and not

distracted and that the

nails are properly

positioned. Rotational

and angular

mal-reductions are

checked and if present

the same is corrected

by partially

withdrawing the nails,

correcting the

deformity and

reinserting the nails”

“It is important that

the patient bear weight

because this provides

the motion at the

fracture site that leads

to early callus

formation”

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VOL XII No 3 : July-September 2010128

At the end of 1st post operative week all patientswere made ambulatory on crutches allowing weightbearing according to the quality of fixation. By 8th

week all the patients were bearing weight with only2 patients with touchdown weight bearing. Out of20 cases, 2 cases complained of irritation of skin atthe entry site, associated with the prominence ofthe ends of the nails.

Out of 20 cases, 10 mm (1 cm) shortening wasobserved in 4 cases. These were among the earliercases of the series and with comminuted fractures.Out of 20 patients, 3 patients showed 10 degree orless angulation in the lateral plane and one patienthad an eight degree angulation in the antero-posterior plane. No broken nail was observed inany of the 20 cases. Out of 20 cases, 2 implantswere removed. The Nails were removed by open-ing the entry site used at the time of initial surgery.These patients had to undergo knee physiotherapyagain and regained movements at the knee. Norefracture was observed in the series of 2 casesthat underwent nail removal.

DISCUSSION

The urbanisation and industrialisation of societyhas increased the incidence of trauma and roadtraffic accidents.. As a result the incidence offemoral shaft fractures in children are on the rise.Paediatric femoral fractures are treated by a varietyof methods including traction, immediate spica-cast, traction followed by spica cast, internal fixa-tion with plate and screws, external fixation andintramedullary fixation.

In this present series titanium elastic nail was usedas a mode of fixation in different types of femoralfractures in children between ages 6 to 16 years. 20cases were treated and evaluated radiologically,clinically and functionally for the efficacy of tita-nium elastic nailing.

In this study an observation was made betweenthe time-interval between injury, admission andoperation. The advantages of early stabilisationand mobilization of patients, have been proved inliterature.

In the present study the majority (70%) of casesunderwent closed nailing. In 6 cases (30%) nailingwas done by open technique. All cases requiringopen technique were old cases.

In the present study in most of the case (75%) theoperative time was between 60 – 90 min. In 5 cases(25%) the operative time was 90 – 120 min. In mostcases (60%) 2.5 mm nail was used. In 30% of cases3 mm nail and in 10% 3.5 mm nail was used. TENavailable in standard length of 440 mm were used.The diameter of nail (range 2.5 mm to 4.5 mm) to beused was determined on the basis of the size ofmedullary canal of the femur of the particularpatients. To determine the size of the titanium nailsto be used, femoral diaphyseal internal diameterwas measured on both anteroposterior and lateralroentgenograms and was divided by 2 and 0.5 mmwas subtracted from that calculation for eventualnail diameter as determined by Kasser and Beaty(2001).

In our series 10 mm (1 cm) shortening was ob-served in 4 cases. 3 patients showed 10o angula-tion in lateral plate and one patient had 8o angula-tion in AP plane. The result were evaluatedaccording to scoring criteria of titanium elastic nailby Flynn et al (2001).

In our series results were excellent in all the cases.Heinrich et al (1994) reported that 22% of theirpatients had an extension over 5 mm, and 11% hada shortening under 5 mm. In a study comparingseveral methods including elastic nail the maxi-mum shortening was observed in the early castinggroup which was followed by external fixator groupwhere as lengthening was observed only in exter-nal fixator group. In our study only 4 cases had 1cm shortening which was not evident clinically.Herndon et al (1989) reported that malunion devel-oped in seven of 24 patients who were treated with

Fig. 4: 8th Week postoperative x-

ray of femur (AP and Lat view)

Fig. 5: 12th week postoperative x-

ray of femur (AP and Lat view)

“The diameter of nail

(range 2.5 mm to 4.5

mm) to be used was

determined on the

basis of the size of

medullary canal of the

femur of the particular

patients”

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129VOL XII No 3 : July-September 2010

traction while no malunion was observed in 21children who were treated using TEN.

In an antegrade and retrograde TEN study byGalpin et al (1994) it was reported that 35 out of 37patients had excellent improvement in terms ofangular deformity. We had angulation less than 10degree towards varus/valgus or antero/posterioronly in 4 patients (20%). In our series unionprogressed satisfactorily in all 20 cases. At the endof 8 weeks, 14 cases showed fair to good callusformation with 6 cases showing little callus forma-tion. No bone grafting was required in any cases.There was no significant malunion in the series.

Flynn et al found TEN advantageous over hip-spica in treatment of femoral shaft fractures inchildren. Buechsenschuetz et al (2002) docu-mented that the titanium nail is superior in terms ofunion, scar acceptance and overall patient satis-faction compared to traction and casting. Ligier etal (1988) treated 123 femoral shaft fracture withelastic stable intramedullary nail and all fracturesunited. Similarly Narayanan et al (2004) stabilizedwith TEN. In our series of 20 cases, in 2 casesimplants were removed after complete union.

In the present series, by the time stitches wereremoved all 20 cases could do straight leg raising.At the end of study period 15 patients (75%) coulddo full range of motion at knee joint.

All patients were encouraged to do hip and kneenon-weight bearing exercises from first post-op-erative day. At the end of 1st postoperative week allpatients were made ambulatory on crutches, al-lowing weight bearing according to the quality offixation.

Flynn et al used a knee fixating device to controlthe pain, to support quadriceps and to prevent theend of nail causing any soft tissue irritation in theknee until the callus tissue appears (4 – 6 weeks).The patients were able to walk at day 9 on theaverage with the help of equipment and at week 8.5on average without the equipment.

In our series patients were made ambulatory oncrutches after 1st postoperative week. Partial weightbearing was allowed at 6 weeks (Range 4 – 8 weeks)and full weight bearing was allowed at 10 weeks(Range 8 – 12 weeks).

The results of this present series in comparable tothose of other series on management of femoralshaft fracture in children. It has definite advan-tages over the other conventional implants infixing femoral shaft fracture, in children.

CONCLUSION

Intramedullary fixation by TEN is a method ofchoice due to lower complication rate, good out-come, easy and easier postoperative maintenancein the femoral shaft fractures of patients agedbetween 6 and 16 years.

REFERENCES

1. Flynn JM, Skaggs D, Sponseller PD, Ganley TJ,

Kay RM, Leitch KK. The operative management

of Pediatric fractures of the lower extremity. J

Bone Joint Surgery Am 2002;84:2288-300.

2. Heybelly M, Muratli HH, Celeb L, Gulcek S,

Bicimoglu A. The results of intramedullary fixation

with titanium elastic nails in children with femoral

fracture. Acta Orthop Traumatol Turc 2004;38:

178-87.

3. Buckley SL. Current trends in the treatment of

Femoral shaft fractures in children and adoles-

cents. Clin Orthop 1997;338:60-73.

4. Kasser JR, Beaty JH. Femoral shaft fractures. In

Beaty JH, Kasser, JR, editors. Reckwood and

Wilkins ‘Fracture in children”, 5rh ed. Philadelphia:

Lippincott Williams and Wilkins 2001:p.941-80.

5. Flynn JM, Hresko T, Reynolds RA, Blasier RD,

Davidson R, Kasser J. Titanium elastic nails for

pediatric femur fractures: a multicenter study of

early results with analysis of complications. J

Pediatr Orthop 2001;21:4-8.

6. Galpin RD, Willis RB, Sabano N. Intramedullary

nailing of pediatric femoral fractures. J Pediatr

Orthop 1994;14:184-9.

7. Buechsenschuetz KE, Mehlman CT, Shaw KJ,

Crawford AH, Immerman FB. Femoral shaft frac-

tures in children: traction and casting versus

casting versus elastic stable intramedullary nail-

ing. J Trauma 2002;53:914-21.

8. Ligier JN, Metaizeau JP, Prevot J, Lascombes P.

Elastic stable intramedullary nailing of femoral

shaft fractures in children. J Bone Joint Surg [Br]

1988;70:74-7.

“Intramedullary

fixation by TEN is a

method of choice due

to lower complication

rate, good outcome,

easy and easier

postoperative

maintenance in the

femoral shaft

fractures of patients

aged between 6 and

16 years”

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VOL XII No 3 : July-September 2010130

Congenital TalipesEquinovarus (CTEV)

CONGENITAL DEFORMITY

SURENDRA U KAMATH

Associate Professor

Deptt. of OrthopaedicSurgery

Kasturba Medical College

Mangalore, Karnataka

ABSTRACT

Congenital talipes equinovarus or congenital club foot is an important and mostcommon congenital anomaly of the lower limb. The condition involves the entire leg,at least from the knee downwards. The thinness of the calf is caused by musclewasting, which is intrinsic part of the condition and not simply a result of treatment orprolonged periods of splintage that were used in the past. Idiopathic congenital clubfoot may be associated with other congenital anomalies like metatarsus varus, jointlaxity, developmental dysplasia of hip and other deformities in the limbs such as ringconstrictions, syndactyly and missing or extra digits. Most agree that the initialtreatment should be non-operative and should begin in first week of life. This involveselongation of contracted soft tissue by passive manipulation taking advantage offavourable viscoelastic properties of connective tissue. Because club foot is avariable condition, there is a wide variety of operations available from simple tendoachilles lengthening and posterior capsulotomies to complete peritalar release.There is debate about which operation is more satisfactory, and the most sensibleapproach seems to be to tailor the details and the extent of surgery to the severity ofdeformity.

Keywords: Club foot, Congenital talipesequinovarus, Conservative treatment, Softtissue release

INTRODUCTION

Congenital talipes equinovarus or congenital clubfoot is an important and most common congenitalanomaly of the lower limb. In severe untreatedcases, the appearance resembles that of a club.Also it should be noted that the condition in-volves the entire leg, at least from the knee down-wards. The thinness of the calf is caused bymuscle wasting, which is intrinsic part of thecondition and not simply a result of treatment orprolonged periods of splintage that were used inthe past. Congenital club foot is a complex deform-ity that may be difficult to correct. The deformityhas four components equinus, varus, adductus

and cavus .It has a tendency to recur until the ageof six or seven years. The recurrence in an adoles-cent is usually associated with incomplete correc-tion rather than being secondary to growth alone.

EPIDEMIOLOGY

Congenital club foot occurs in about 1-3/1000 livebirths. It is reported to be most common inPolynesians and Maoris, in whom the incidence isup to 6/1000. The reported incidence is 3.5/1000 inblack South Africans, but only 1/2000 live births inthe Japanese and Chinese. The ratio of male tofemale is 3 to 1 and 40 % of cases are bilateral.Congenital club foot appears to be of geneticorigin if one child in a family has the deformity thechance of second having it is 1: 36. In 32.5 % ofidentical twins both had club foot, whereas in only2.9% if fraternal twins both had club feet.1

“Congenital club foot

is a complex deformity

that may be difficult to

correct. The deformity

has four components

equinus, varus,

adductus and cavus .It

has a tendency to

recur until the age of

six or seven years”

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131VOL XII No 3 : July-September 2010

Idiopathic congenital club foot may be associatedwith other congenital anomalies like metatarsusvarus, joint laxity, developmental dysplasia of hipand other deformities in the limbs such as ringconstrictions, syndactyly and missing or extradigits.

AETIOLOGY

The aetiology of congenital club foot remainsunknown.The three common suggestions are� Intrauterine moulding� Neuromuscular imbalance� Delayed intrauterine development

Intrauterine moulding

In 1934 Browne suggested that intrauterine mould-ing was the major cause of club foot and evolveda method of treatment involving boots and a barconnecting the feet. It does not explain the calfwasting and other features of the deformity; how-ever it could increase the severity of deformity, inpatients with multiple pregnancies andoligohydraminios.

Neuromuscular imbalance

This has been strongly advocated, particularlyfollowing the identification of a high property oftype 1 muscle fibres in the calf of the affected side.An increased amount of fibrosis in the muscleswith reduction in their excursion, together withincreased fibrosis in the ligament and the jointcapsule, has also been noted on the affected side.The permanent muscle wasting and recurrent con-tracture that occurs in club foot strongly suggestthat a neuro muscular disorder is involved.2

Delayed onset of intra uterine development

As the foot develops, it passes from an equinovarusposition to the common calcaneovalgus positionat birth. It has been suggested that a delay in thisprocess, arresting development at the equinovarus

stage, could be a cause of club foot. This delaymay be caused by a failure of the normal changesin the vascular anatomy of the embryo.3

PATHOLOGICAL ANATOMY

The most severe deformities in a club foot occurin the hind foot of the foot. The talus and cal-caneus are generally deformed and in severeequinus, the calcaneus is in varus angulation andmedially rotated and the navicular is severelydisplaced medially. These components of the de-formity are inextricably inter related. The liga-ments of the posterior aspect of the ankle and ofthe medial and plantar aspect of the foot areshortened and thickened. The muscles and ten-dons of the gastrocnemius, tibialis posterior andtoe flexors are shortened.

DIAGNOSIS AND INVESTIGATIONS

It is important not to confuse congenital club footwith postural equinovarus deformity caused byintra uterine moulding which recovers spontane-ously or with simple stretching in a few days. Intrue unilateral club foot, the foot is always smalleron the affected side and the calf is wasted.

Secondary courses of club foot should be lookedfor and these include neuromuscular disorders (e.g.spinal dysraphism, spinal muscular atrophy) andsoft tissue and bony disorders (e.g.: arthrogryposis,constriction rings, tibial dysplasia). Club foot iscommonly associated with generalized syndromeslike diastrophic dwarfism and chromosome anoma-lies like trisomy 21, trisomy 18.4

Intrauterine diagnosis can sometimes be madeusing ultra sonography. The foot deformity can beseen, but it is important to be cautious about theprognosis at this early stage. It is impossible todetermine whether the condition is primary orsecondary, which has a major affect on ultimateoutcome.

“Idiopathic congenital

club foot may be

associated with other

congenital anomalies

like metatarsus varus,

joint laxity,

developmental

dysplasia of hip and

other deformities in

the limbs such as ring

constrictions,

syndactyly and

missing or extra

digits”

“In true unilateral club

foot, the foot is

always smaller on the

affected side and the

calf is wasted”

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VOL XII No 3 : July-September 2010132

There remains no generally accepted, simplemethod of assessing club foot. Harrold and Walkermethod is a simple and easy method that involvesa dynamic rather than a purely static assessmentof deformity. In this method the degree of correc-tion of equinus and varus deformities in responseto firm pressure by the examiner is recorded5

� Type I : Mild- if both equinus and varus can becorrected to neutral.

� Type II: Moderate- if equinus and varus canboth be corrected to with in 20 degrees

� Type II: Severe – if there is more than 20degrees of incorrectible equinus or varus de-formity or both.

MANAGEMENTWhen presented with a new born infant with a trueclub foot deformity (not a simple postural deform-ity), it is essential to examine the child carefully andtry to decide whether the club foot is simplyidiopathic or is associated with some other anomaly.While counselling the parents about an idiopathicclub foot, it must be emphasized that, though it ispossible to correct the deformity, the affected footwill never be the same as normal foot. In particularthe calf remain wasted and the club foot will remainshorter than normal foot. Also movements of theaffected foot are likely to be restricted.

The goal of treatment is to reduce or eliminate thedeformities so that the patient has a functionalpain free planti grade foot with good mobility andwithout callosities and does not need to wearmodified shoes.

CONSERVATIVE TREATMENT

The principle of repeatedly manipulating the footand then holding it in the corrected position byStrapping, splintage or plaster remains the corner-stone of conservative treatment. Most agree thatthe initial treatment should be non-operative andshould begin in first week of life. This involveselongation of contracted soft tissue by passive

manipulation taking advantage of favourableviscoelastic properties of connective tissue. HiramKite popularised the method of manipulation andcasting which involved sequential gentle correc-tion of abduction, inversion and dorsiflexion fol-lowed by weekly casts applied after manipulationfor 6 to 8 weeks.

Ponseti described a method of corrective manipu-lation and serial application of casts followed bytendo achilles tenotomy and transfer of tibialisanterior tendon if indicated found to be successfulin alteast 85% of the patient.6-8

SURGICAL TREATMENT8-10

� Timing of surgery: There has been muchdebate about the timing of surgery for clubfoot. Some surgeons advocate very early sur-gery (first few weeks of life). Others suggestssurgery at 3 months and third group suggestssurgery at about 9-12 months. In recent longterm follow up studies, no statistical benefithas been shown for operating early ratherthan at 9-12 months, when children with nor-mal motor development attempt to stand.

� Choice of procedure: Because club foot is avariable condition, there is a wide variety ofoperations available from simple tendo achilleslengthening and posterior capsulotomies tocomplete peritalar release. There is debateabout which operation is more satisfactory,

“The goal of treatment

is to reduce or

eliminate the

deformities so that the

patient has a

functional pain free

planti grade foot with

good mobility and

without callosities and

does not need to wear

modified shoes”

“Ponseti described a

method of corrective

manipulation and

serial application of

casts followed by

tendo achilles

tenotomy and transfer

of tibialis anterior

tendon if indicated

found to be successful

in alteast 85% of

the patient”

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133VOL XII No 3 : July-September 2010

and the most sensible approach seems to beto tailor the details and the extent of surgeryto the severity of deformity.4

� Later problems: Common problems are per-sistent forefoot adduction and supination,recurrent equinus (with or without varus),sagitally breached or bean shaped foot andthe cavovarus foot.� Recurrent supination and adduction of

the forefoot is probably the most commonresidual deformity following primary sur-gery. Probably results from failure to fullycorrect the medial side of foot and from apersistent weakness of the evertor mus-cles. The heel is well corrected but thepatient continues to walk with forefoot inadduction and supination particularly inthe swing phase of gait. A lateral transferof the tibial anterior tendon may help inpatient with evertor weakness and a mo-bile foot.� Recurrent equinus with or without

varus much be carefully assessed toascertain whether the deformity is prin-cipally in forefoot, the hind foot orboth. This can be done by taking a truelateral radiograph of whole foot bycarefully positioning. Alternativelyfoot may be examined under anaesthe-sia and screening it in operating thea-tre before surgery.

� If the deformity is principally in theforefoot it is essential to undertake theprocedure that will correct the forefooton the hind foot.

� If the deformity is in the hind foot,repeat posterior release.

� If the deformity is in both the hind footand forefoot a major repeat of softtissue release must be performed par-ticularly in younger patients. In olderpatients various options includeIlizarov technique, triple arthrodesisand supramalleolar osteotomy.

� Sagitally breached or bean shaped foot inwhich the medial column of foot is the onetoo short and the lateral column too long.

This deformity can be corrected by length-ening the medial column by a medial re-lease and a taking tuck out of lateral col-umn by excision of calcaneocuboid joint.It is important that any equinus is cor-rected before this type of surgery and alsothat forefoot is supinated and not pro-nated.

� Cavovarus foot is said to be associatedwith failure to release the plantar fascia atthe initial operation. It is commonly seenafter postero medial release in which na-vicular appears to be tethered by the scartissue; cavus and varus deformity increasewith time. It is essential to use the blocktest to determine whether the hind foot ismobile; if the hind foot is mobile pronationof first and second metatarsals can becorrected by medial release and if neces-sary basal metatarsal osteotomy. If thehind foot is stiff, a Dwyer calcaneal oste-otomy to correct os calcis into valgusmust be undertaken

� Over correction is a problem after some ofthe more radical procedures. It is morecommon after second and third revisionprocedure.

REFERENCES1. Wynn-Davis R. Family studies and cause of

congenital club foot. J Bone J Surg 1964;46 B:445

2. Handelsman JE, Badalmante ME. Neuromuscular

studies in club foot. J Pediatr Orthop 1986;6:23.

3. Bohm M. The embryologic origin of club foot J

Bone J Surg 1929;11:229.

4. Fixsen JA Club foot. Surgery 1997;217-21.

5. Harrold AJ, Walker CJ. Treatment and Prognosis

in congenital club foot. J Bone J Surg 1982;65

B:8-11.

6. Ponseti IV. Congenital club foot : Fundamentals

of treatment 1996: Oxford University Press,

Newyork.

7. Ponseti IV. Treatment of Congenital Club Foot. J

Bone J Surg 1992;74A:448-453

8. Cooper BM, Dietz FR. Treatment of Idiopathic

Club Foot. J Bone J Surg 1995;77A:1477-89.

9. Bensahel H, Czukonyi Z, Degripper Y. Surgery in

residual club foot – one stage medioposterior

release ‘a la carte’. J Pediatr Orthop 1987;7:145.

10. Cummings RJ, Lovell WW. Current concepts

review – operative treatment of congenital idi-

opathic club foot. J Bone J Surg 1988;70A:1108-

1112.

“Common problems

are persistent forefoot

adduction and

supination, recurrent

equinus (with or

without varus),

sagitally breached or

bean shaped foot and

the cavovarus foot”

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VOL XII No 3 : July-September 2010134

INTRODUCTION

Intradural schwannoma in the cauda equina re-gion is an uncommon but an important cause oflower back pain and/or sciatic syndrome tumorthat account for only 6% of spinal tumors.1-5

Rarely because of the unique anatomical charac-teristics schwannoma in the cauda equina regioncan migrate at multiple levels and pose difficultdiagnostic and management challenge. 6-11

CASE REPORT

A 35 year gentleman presented with the history ofprogressive low back pain of two year durationincreased by coughing/sneezing and worsenedover last six months significantly limiting his dayto day activities. The pain was radiating to boththe lower limbs over the posteremedial aspects ofboth the thighs. There were no focal motor orsensory deficits. There was no history of bowel/bladder disturbances. Neurologic examinationincluding motor/sensory functions, deep andsuperficial tendon reflexes were normal. X-raylumbar spine antereo-posterior and lateral view

was normal. Based on the clinical findings andcharacteristic history of pain a potential spaceoccupying lesion in the cauda equina region wassuspected. An urgent magnetic resonance imaging(MRI) of the lumbar spine was performed and itshowed a lesion about 4.0 ×1.5 ×1.5 cm in size, atthe level of the third and forth lumbar vertebrae,isointense on T1-weighted images becoming mark-edly hyperintense on T2-weighted images (Fig-ure-1A-C) suggestive of intradural cauda equinatumor. The patient underwent a complete L3-4laminectomy; however to our surprise we couldnot find the tumor at that level (the level wasconfirmed with the C-arm) and a L5 laminectomywas also performed. Once the lower limited of duralopening was extended a well-defined, freely mo-bile, yellowish, soft, elastic, encapsulated, andmultilobular intradural tumor attached to the nerveroot popped out (Figure-1D). The tumor was iden-tified and excised from its proximal and distal nerveroot attachments. Postoperatively, the patient’scondition was unremarkable and histopathologyconfirmed a diagnosis of cellular schwannoma.

DISCUSSION

Certain cauda equina tumors particularly thoseattached to the roots in the lumbar spinal canal

AMIT AGRAWAL

Professor and Head

Deptt. of Neurosurgery

SR JOHARAPURKAR

Director

ANAND KAKANI

Associate Professor

Deptt. of Neurosurgery

A CHAUDHARY

Associate Professor

Deptt of Anaesthesiology

Datta Meghe Institute ofMedical Sciences,Sawangi (Meghe),Wardha (India)

Mobile Schwannomma of theCauda Equina

NEURAL TUMOUR

ABSTRACT

Intradural schwannoma in the cauda equina region is an uncommon but an importantcause of lower back pain and/or sciatic syndrome tumour that account for only 6% ofspinal tumours. Rarely because of the unique anatomical characteristics schwannomain the cauda equina region can migrate at multiple levels and pose difficult diagnosticand management challenge. Bearing in mind the possibility of mobility of the tumour,it has been recommended to carry out a second magnetic resonance imaging scanafter changes in posture; also, pre-operative or intra-operative radiological imagingstudies would be useful correct localization of the lesion and will help to preventexcessive multilevel laminectomy and to minimise surgical morbidities.

Keywords: Cauda equina, Spinalschwannoma, Cauda equina, Mobile caudaequina tumour

“Certain cauda equina

tumors particularly

those attached to the

roots in the lumbar

spinal canal may

migrate several

levels”

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135VOL XII No 3 : July-September 2010

may migrate several levels. 7 The possible mecha-nisms of tumor mobility include elongation of thenerve root by tension resulting from the tumorweight, 7 the redundant nerve root, 8,12 the dilata-tion of the subarachnoid space induced by theextramedullary tumour. 13 straining, sneezing,coughing or muscular relaxation after anaesthe-sia, 14-16 the positive pressure ventilation, the po-sition of the patient, 6,17-19 and/or the thrust of theinjected radiopaque material during myelography.10,11 Further, when the patient is put in proneposition for the surgery and the lumbar spine andhips are in extension, when the nerve roots be-come considerably slack. 20 All these factors eitheralone or in combination may cause shifting ofcauda equina tumours in the spinal canal. What-ever the cause of the displacement and mobility,and the most important aspect is the identificationand accurate localisation of the cauda equinetumors as these can migrate in any direction due

to these multiple factors. 7,17,18 Bearing in mind thepossibility of mobility of the tumor, it has beenrecommended to carry out a second magneticresonance imaging scan after changes in posture,6 also perioperative or intraoperative radiologicalimaging studies would be useful correct localiza-tion of the lesion and will help to prevent excessivemultilevel laminectomy and to minimise surgicalmorbidities. 7,8,17,18

REFERENCES1. Osborn RE, DeWitt JD. Giant cauda equina

schwannoma: CT appearance. Am J Neuroradiol

1985;6(5):835-6.2. Woodruff JM, Kourea HP, Louis DN, Sheithauer

BW. Schwannoma. In: Kleihues P, Cavanee WK(eds). World Health Organization Classification ofTumours, Pathology and Genetics: Tumours ofNervous System. Lyon: IARC Press, 2000:164-6.

3. Bursztyn EM, Prada A. Intradural cauda equinaschwannoma. Surg Neurol 1986;26(6):567-70.

4. Kagaya H, Abe E, Sato K. Giant cauda equinaschwannoma: a case report. Spine 2000;25:268-72.

5. McCormick PC, Post KD, Stein BM. Intraduralextramedullary tumors in adults. Neurosurg Clin NAm 1990;1:591-608.

6. Isu T, Iwasaki Y, Akino M, Nagashima M, Abe H.Mobile schwannoma of the cauda equina diag-nosed by magnetic resonance imaging. Neurosur-gery 1989;25(6):968-71.

7. Marin-Sanabria EA, Sih IM, Tan KK, Tan JSH.Mobile cauda equina schwannomas. SingaporeMed J 2007;48(2):e53.

8. Hollin SA, Drapkin AJ, Wancier J, Huang YP.Mobile schwannoma of the cauda equina. Casereport. J Neurosurg 1978;48:135-7.

9. Friedman JA, Atkinson JL, Lane JI. Migration of anintraspinal schwannoma documented byintraoperative ultrasound: case report. Surg Neurol2000;54:455-7.

10. Caracalos A. Elusive cauda equina tumor. JNeurosurg 1987;67:952.

11. Tavy DL, Kuiters RR, Koster PA, Hekster RE.Elusive tumor of the cauda equina. Case report. JNeurosurg 1987;66:131-3.

12. Pau A, Orunesu G, Sehrbundt Viale E, Turtas S,Zirattu G. Mobile neurinoma of the cauda equina.Case report. Acta Neurochir (Wien) 1982;60:115-7.

13. Iizuka H, Iida T, Akai T. Mobile neurinoma of thecervicothoracic junction. Surg Neurol 1998;50:492-3.

14. Husag L, Schubiger O, Probst C. [Neurinoma ofthe cauda equine] Schweiz Arch Neurol NeurochirPsychiatr 1980;127:205-11.

15. Murai H, Arai M, Satoh K, et al. [Mobile spinalneurenteric cyst] A case report. Seikei Geka1991;42:1746-9.

16. Satoh T, Kageyama T, Kamata I, Date I. [Mobileneurinoma of the cauda equina; a case report] NoShinkei Geka 1991;19:891-6.

17. Friedman JA, Wetjen NM, Atkinson JL. Utility ofintraoperative ultrasound for tumors of the caudaequina. Spine 2003;28:288-90.

18. Namura S, Hanakita J, Suwa H, et al. Thoracicmobile neurinoma. Case report. J Neurosurg1993;79:277-9.

19. Tomimatsu T, Yamamura I, Kawaguchi N, et al. [Amobile tumor of the cervical spinal cord. A casereport] Kantoh Seisaisi 1974; 5:213-8. Japanese.

20. Ehni G, Moiel RH, Bragg TG. The “redundant” or“knotted” nerve root: a clue to spondylotic caudaequina radiculopathy. Case report. J Neurosurg1970;32:252-4.

Fig. 1: Pre-operative magnetic resonance images showing intradural

cauda equina lesion, isointense on T1W image (A), becoming

hyperintense on T2W images (B,C), intra-operative photograph revealing

freely mobile tumour attached to the nerve root

“Bearing in mind the

possibility of mobility

of the tumor, it has

been recommended to

carry out a second

magnetic resonance

imaging scan after

changes in posture”

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VOL XII No 3 : July-September 2010136

Posterior ankle impingement syndrome (PAIS) isa clinical disorder characterised by posterior anklepain that occurs in forced plantar flexion. In thepast, other terms were used as synonyms for PAIS:Posterior block of the ankle, posterior trianglepain, talar compression syndrome, os trigonumsyndrome, os trigonum impingement, posteriortibio-talar impingement syndrome and nutcracker-type syndrome. However, PAIS is generally con-sidered to be the clinical disorder characterised byposterior ankle pain in forced plantar flexion.

Pain in the posterior ankle may result from manycauses and therefore may present a diagnosticchallenge. In contrast to patients with anteriorankle pain that occurs in regions with structuresthat are accessible to palpation, hind foot struc-tures are deeply situated and anatomically arecontiguous to one another, making direct palpa-tion difficult.

AETIOLOGY (FIG. 1)

Posterior ankle impingement can be caused byoveruse or trauma. It is important to differentiate

between these two, because posterior impinge-ment from overuse has a better prognosis. Aposterior ankle impingement syndrome due tooveruse is mainly found in ballet dancers andrunners. Running with forced plantar flexion suchas downhill running, can impose repetitive stresseson the posterior aspect of the ankle joint. Thesestresses can put extreme pressure on the anatomicstructures normally present between the calcaneusand the posterior part of the distal tibia. Throughexercise, the joint mobility and range of motiongradually increase, progressively reducing thedistance between the calcaneus and the posteriorportion of the distal tibia. Overall, if abnormalstructures, such as a (slightly displaced) os trig-onum (Fig. 2), hypertrophic posterior talar proc-ess, a thickened posterior joint capsule, post-traumatic scar tissue, post-traumatic calcificationsof the posterior joint capsule, a loose body in theposterior part of the ankle joint, or an osteophyteat the posterior distal tibia, are present, they maybe compressed during hyperplantar flexion. Thepresence of a prominent posterior talar process oros trigonum in itself is not sufficient to produce thesyndrome.

The posterior talar prominence becomes com-pressed between the tibia and the calcaneus dur-ing forced plantar flexion. In the presence of an os

Posterior Ankle ImpingementSyndrome

ANKLE DISORDERS

ABSTRACT

Posterior ankle impingement syndrome (PAIS) is a clinical disorder characterized byposterior ankle pain that occurs in forced plantar flexion. Pain in the posterior ankle mayresult from many causes and therefore may present a diagnostic challenge. In contrastto patients with anterior ankle pain that occurs in regions with structures that areaccessible to palpation, hind foot structures are deeply situated and anatomically arecontiguous to one another, making direct palpation difficult.

BHAVUK GARG

Sr. Research Associate

PP KOTWAL

Professor and Head

Deptt. of Orthopaedics

AIIMS, New Delhi

Keyword: Posterior Ankle impingementsyndrome

“PAIS is generally

considered to be the

clinical disorder

characterised by

posterior ankle pain in

forced plantar flexion”

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137VOL XII No 3 : July-September 2010

trigonum, this can lead to micromotion of the ostrigonum, and pain. A fracture can occur if theposterior talar process is prominent. Compressionof the posterior joint capsule can lead to calcifica-

tion. Combined supination and plantar flexion(leading to a lateral ankle ligament lesion) in somepatients also leads to compression ofposteromedially located joint structures. In thesepatients, the post-traumatic calcifications oftenare located posteromedially (Fig. 3).

The patient usually reports chronic or recurrentposterior ankle pain caused or exacerbated byforced plantar flexion or push-off activities, suchas dancing, kicking, downhill running, sliding, andwalking in shoes with high heels, among others. Insome patients, forced dorsiflexion is also painful.In this dorsiflexed position, traction is applied tothe posterior joint capsule and posterior talofibularligament, both attaching to the posterior talarprocess.

On examination, there is pain on palpation of theposterior aspect of the talus. Prone position isrecommended for evaluating ankle and subtalarrange of motion as well as for a complete Achillestendon examination. The examiner can apply arotational movement on the point of maximal plantarflexion, thereby ‘‘grinding’’ the posterior talar proc-ess/os trigonum between tibia and calcaneus. Anegative test rules out a posterior impingementsyndrome.

IMAGING

Conventional radiographs (Figure 4) can demon-strate an acute or chronic fracture of the trigonalprocess, the presence of an os trigonum, andimpingement on dynamic view. This projectionalso is used to measure ankle range of motion.Computed tomography (CT), although able toclarify the bony margins, fails to differentiatebetween an old fracture and an os trigonum. Bonescintigraphy, however, is a helpful diagnostic tool.MRI is especially useful in posterior impingementsyndrome. Bone contusions representmicrotrabecular fractures, oedema, and haemor-rhage in the bone marrow without cortex disrup-tion. They are not visible on radiographs or CTimages. Other findings associated with PAIS andwell demonstrated on MRI include fragmentation,pseudarthrosis, and FHL tenosynovitis, as well astibio-talar and subtalar synovitis.

MANAGEMENT

Posterior impingement, whether acute or chronic,often improves with rest alone. Initial treatment ofthe trigonal process disease includes rest, ice,anti-inflammatory medication, avoidance of forced

Table 1: Aetiology of posterior ankle impingement

Etiological Classification of PAISPatiology ExampleTrigonal process Fracture (acute or chronic)

Synchondrosis injuryTrue compression

FHL dysfunction TenosynovitisTibiotalar pathology Posterior capsuloligamentous injury

OsteochondrtisFracture

Subtalar Pathology OsteochondritisArthritis

Other Calcified inflammatory tissueProminent calcaneus posterior process

Combined FHL tenosynovitis and synchondrosis injury

Fig. 2: Os-trigonum

Fig. 4: Os trigonumFig. 3: Multiple bony calcifications

Clinical Features

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VOL XII No 3 : July-September 2010138

plantar flexion, and, occasionally, casting for 4 to6 weeks. Corticosteroid injection can effectivelyprovide temporary pain relief.

When nonsurgical treatment and rehabilitationexercise fail, for either acute or chronic injury,surgical excision of the fractured trigonal processor os trigonum is indicated. The type of surgerywill vary depending on the location and cause ofankle impingement. The approach to the posteriorankle for excision of the injured structures is eithermedial or lateral. When a prominent calcaneusposterior process is present, it should be partiallyresected. In patients with a concomitant FHLtenosynovitis, tendon sheath release is indicated.Surgery is required when severe stenosis of the

Fig. 5: Edema of the steida process suggestive of injury

fibro-osseous tunnel is present, accompanied bypain, triggering, and tendon contracture or tendontears.

For management of posterior ankle impingementthe two-portal posterior endoscopic ankle ap-proach with the patient in a prone position hasshown to offer excellent access to the posteriorcompartment of the ankle joint, the posteriorsubtalar joint, the flexor hallucis longus tendon,and os- trigonum. Management of posterior ankleimpingement, by means of a two-portal endo-scopic hind-foot approach, compares favourablyto open surgery. Hind-foot endoscopy causesless morbidity and facilitates a quick recovery.

REFERENCES

1. Jaivin JS, Ferkel RD. Arthroscopy of the foot andankle. Clin Sports Med 1994;13:761-83.

2. Hamilton WG, Geppert MJ, Thompson FM. Pain inthe posterior aspect of the ankle in dancers:Differential diagnosis and operative treatment. JBone Joint Surg Am 1996;78:1491-500.

3. Howse AJ. Posterior block of the ankle joint indancers. Foot Ankle 1982;3:81-3.

4. Marotta JJ, Micheli LJ. Os trigonum impingementin dancers. Am J Sports Med 1992;20:533-6.

5. Jones DC. Tendon disorders of the foot andankle. J Am Acad Orthop Surg 1993;1:87-94.

6. Paulos LE, Johnson CL, Noyes FR. Posteriorcompartment fractures of the ankle. Am J SportsMed 1983;11:439-43.

7. Karasick D, Schweitzer ME. The os trigonumsyndrome: Imaging features. Am J Roentgenol1996;166:125-9.

8. Mitchell MJ, Bielecki D, Bergman AG, Kursunoglu-Brahme S, Sartoris DJ, Resnick D. Localization ofspecific joint causing hindfoot pain: Value ofinjecting local anesthesia into individual jointsduring arthrography. Am J Roentgenol1995;164:1473-6.

9. Bureau NJ, Cardinal E, Hobden R, Aubin B.Posterior ankle impingement syndrome: MR imagingfindings in seven patients. Radiology2000;215:497-503.

10. Wakeley CJ, Johnson DP, Watt I. The value of MRimaging in the diagnosis of the os trigonumsyndrome. Skeletal Radiol 1996;25:133-6.

11. Hedrick MR, McBryde AM: Posterior ankle im-pingement. Foot Ankle 1994;15:2-8.

12. Van Dijk CN, Scholten PE, Krips R. A 2-portalendoscopic approach for diagnosis and treatmentof posterior ankle pathology. Arthroscopy2000;16:871-6.

“When nonsurgical

treatment and

rehabilitation exercise

fail, for either acute or

chronic injury, surgical

excision of the

fractured trigonal

process or os trigonum

is indicated”

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139VOL XII No 3 : July-September 2010

Pioneers in OrthopaedicsPIONEERS IN ORTHOPAEDICS

BHAVUK GARG

Sr. Research Associate

RAJESH MALHOTRA

Professor

Deptt. of Orthopaedics

AIIMS, New Delhi

Otto Wilhelm Madelung was a German surgeonwho was a native of Gotha, a city on the northernedge of the Thuringian Forest. From 1865, hestudied medicine at the universities of Bonn, Ber-lin, and Tübingen, obtaining his doctorate atTübingen in 1869. He later worked in a militaryhospital during the Franco-Prussian War. From1871 to 1873, Madelung was an assistant to CarlDavid Wilhelm Busch at the surgical clinic inBonn, where he established surgical practice in1872. He was habilitated at the Bonn surgical clinicin 1873, and in 1873-1874, he worked in the patho-logical institute under Georg Eduard Rindfleisch.In 1874, he visited Great Britain and the UnitedStates, and afterwards returned to Bonn, where hebecame an assistant professor of surgery in 1881.Later he became a professor of surgery at Rostock(1882) and Strasbourg (1894).

Madelung had a successful career in Strasbourgwhere he established an efficient department. Atthe end of World War I when the city was cededto France, French colleagues replaced Madelungand other German faculty members, Madelungbeing the last of the German lecturers to leave, twoyears later. After a short period of house arrestMadelung retired to Göttingen, where he died in1926.

Otto Madelung is remembered for his work withan orthopedic disorder known as Madelung’s

deformity, which is aprogressive curva-ture of the radiusbone in the forearm.This condition wasearlier mentioned byGuillaume Dupuytrenin 1834, AugusteNélaton in 1847, andJ o s e p h - F r a n ç o i sMalgaigne in 1855,however Madelungwas the first physi-cian to provide a com-prehensive, clinicaldescription.

Madelung also described a benign form of lipoma-tosis characterized by symmetrical deposits ofadipose tissue in the area of the neck, shouldergirdle, arms, and upper trunk of the body. Today,this disorder goes by several names including“Madelung’s syndrome”, benign symmetriclipomatosis and multiple symmetric lipomatosis. Ifthe condition is confined to the neck, it is some-times referred to by the eponym “Madelung’sneck”.

Madelung specialized in abdominal surgery, andis also known for his pioneer work with intestinalanastomosis and laparotomy.

Otto Wilhelm Madelung(1846-1926)

“Otto Madelung is

remembered for his

work with an

orthopedic disorder

known as Madelung’s

deformity”

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VOL XII No 3 : July-September 2010140

ORTHO QUIZ-24

ORTHO QUIZ

Question: Discuss the most probable diagnosis.

BHAVUK GARG

Sr. Research Associate

RAJESH MALHOTRA

Professor

Deptt. of Orthopaedics

AIIMS, New Delhi

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CASE HISTORY

A 4 years old boy presented to us with unilateral mild right elbow flexion contracture. On examination,right forearm was shorter than left. Right sided supination was restricted and elbow was fixed in 30degrees of pronation. There was no syndromic association. His x-rays are shown as below (Fig.1).

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141VOL XII No 3 : July-September 2010

Answer and Discussion toOrtho Quiz 23

ORTHO QUIZ

BHAVUK GARG

Sr. Research Associate

RAJESH MALHOTRA

Professor

Deptt. of Orthopaedics

AIIMS, New Delhi

Answer to Ortho Quiz 2010 No. 23

Sacral Agenesis

Sacral Agenesis

DISCUSSION

Caudal regression syndrome or sacral agenesis(or hypoplasia of the sacrum) is a little-known andrare congenital disorder in which there is abnormalfoetal development of the lower spine—the cau-dal partition of the spine. It occurs at a rate ofapproximately one per 25,000 live births.

AETIOLOGY

Sacral agenesis is often associated with maternaldiabetes mellitus. Renshaw postulated that thecondition is teratogenically induced or is a spon-taneous genetic mutation that predisposes to orcauses failure of embryonic induction of the cau-dal notochord sheath and ventral spinal cord. Thedorsal ganglia and the dorsal (sensory) portion ofthe spinal cord continue to develop. The vertebraeand motor nerves are not subsequently induced,and the sacral agenesis results. Sensation remainsintact because the dorsal ganglia and the dorsalportion of the spinal cord have been derived fromthe neural crest tissue. This disturbance in thenormal sequence of development explains theobservation that the lowest vertebral body withpedicles corresponds closely to the motor level,whereas the sensory level is distal to the motorlevel.

Dr. N. K. Kapahtia, Aurangabad

CLASSIFICATION

Renshaw (1978) classified sacral agenesis in fourtypes:� Type I: Total or partial unilateral sacral agen-

esis� Type II: Partial sacral agenesis with a partial

but bilaterally symmetrical defect and a stablearticulation between the ilia and a normal orhypoplastic first sacral vertebra (most com-mon).

� Type III: Variable lumbar and total sacral agen-esis with the ilia articulating with the sides ofthe lowest vertebra present

� Type IV: Variable lumbar and a total sacralagenesis, the caudal end-plate of the lowestvertebra resting above either fused ilia or aniliac amphiarthrosis

CLINICAL FEATURES

The clinical appearance of a child with sacralagenesis ranges from one of severe deformities ofthe pelvis and lower extremities to no deformity orweakness whatsoever. Those with partial sacralagenesis may have no symptoms. Those withcomplete sacral agenesis may be severely de-formed, with multiple musculoskeletal abnormali-ties, including foot deformities, knee flexion con-tractures, hip flexion contractures, dislocated hips,spinal-pelvic instability, and scoliosis. The pos-

“Sacral agenesis is

often associated with

maternal diabetes

mellitus”

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VOL XII No 3 : July-September 2010142

ture of the lower extremities has been comparedwith a “sitting Buddha”. Anomalies of the viscera,especially in the genitourinary system and therectal area, are common. Inspection of the backreveals a bone prominence representing the lastvertebral segment, often with gross motion be-tween this vertebral prominence and the pelvis.Flexion and extension may occur at the junction ofthe spine and pelvis rather than at the hips.

Neurological examination usually reveals intactmotor power down to the level of the lowestvertebral body that has pedicles. Sensation, how-ever, is present down to more caudal levels. Evenpatients with the most severe involvement mayhave sensation to the knees and spottyhypoesthesia distally. Bladder and bowel controloften is impaired.

MANAGEMENT

Extensive investigation of the whole spine; thegenitourinary, cardiovascular, and gastrointestinaltracts should be done in the initial approach ofpatients with lumbosacral agenesis.

Three major trends of management have beendescribed:� Ablation of the lower extremities (subtro-

chanteric level or knee disarticulation) plusprosthetic fitting

� Spinal pelvic fusion: “increase abdominal

capacity, and protect viscera from unphysi-ologic compression”

� Correction of the inferior limb deformities andorthotic fitting; based on the fact that mostpatients have preserved protective sensationand proprioception of the lower extremities.“Spinal-pelvic motion is helpful to maintainthe sitting position in patients with fixed flexioncontracture of the hips”.

Proper care of patients with sacral agenesis is bestprovided by a treatment team, including an ortho-paedic surgeon, urologist, neurosurgeon, paedia-trician, physical therapist, and orthotist-prosthet-ist.

REFERENCES

1. Andrish J, Kalamchi A, MacEwen GD. SacralAgenesis: A Clinical Evaluation of the Manage-ment, heredity and associated anomalies. ClinOrthop 1979;139:52-57.

2. Banta JV, Nichols O. Sacral Agenesis. J BoneJoint Surg 1969;51:693-703.

3. Dumont CE, Damsin JP, Forlin E, Carlioz H.Lumbosacral Agenesis. Spine 1993;18:1229-35.

4. Renshaw TS. Sacral Agenesis. The PediatricSpine-Principles and Practice 1994;1:2214. RavenPress, New York

5. Phillips WA. Sacral Agenesis. Spine-Principlesand Practice 1994;1:2214. Raven Press, NewYork.

7. Phillips WA, Cooperman DR, Linquist RC, SullivanRC, Millar EA. Orthopaedic Management ofLumbosacral Agenesis. Long Term Follow Up. JBone Joint Surg 1982;64A:1282-94.

“Ture of the lower

extremities has been

compared with a

sitting Buddha”

“Neurological

examination usually

reveals intact motor

power down to the

level of the lowest

vertebral body that

has pedicles”

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I want to subscribe to international class journals of the CMPMedica India Pvt Ltd

ABOUT MYSELF

Name Dr. _____________________________________________________________________________

Qualifications ____________________________________ Speciality _______________________________

Sex Male Female Date of Birth

Postal address _____________________________________________________________________________

________________________________________________________ Pin

Phone (Off.)____________________Res.____________________Mobile______________

Fax___________________ E. Mail_____________________________________________

Occupation _____________________________________________________________________________

I am interested in subscription of your following journals

4. JPOG ________________

5. Cardiology Today _______

6. Orthopaedics Today _____

7. Clinical Assist __________

Please find enclosed my subscription vide DD No. _________________________________ drawn on

____________________________ for Rs. ___________________________.

Signature

SUBSCRIPTION TARIFFS (inclusive of postage charges)

PUBLICATION PERIODICITY 1 YR 2 YRS 3 YRS 5 YRS OVERSEAS

(1 YR)

CIMS Quartely Rs. 660 — — — —

IDR Triple i Bimonthly Rs. 840 Rs. 1510 Rs. 2140 Rs. 3150 Rs. 5040

Medical Progress Monthly Rs. 2040 Rs. 3670 Rs. 5200 Rs. 7650 —

JPOG Monthly Rs. 2040 Rs. 3670 Rs. 5200 Rs. 7650 —

Cardiology Today Bimonthly Rs. 720 Rs. 1300 Rs. 1840 Rs.2700 Rs. 10800

Orthopaedics Today Quarterly Rs. 480 Rs. 870 Rs. 1225 Rs. 1800 Rs. 7200

Clinical Assist Annual Rs. 399

Note : All remittances only by DD payable at Bangalore in the name of “CMPMedica India Pvt Ltd”

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