ortho front

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Orthofront

March 2009

B O MB AY O R T H O PA E DI C S O CI E T Y


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3/48

The trem endous effort of the editorial team needs to be lauded as the first issue of the

O rt h of r on t w a s ap p re c ia t ed b y t h e me m be r s. T h e ev i de n ce t o t h is w a s t he

c o n gr a t u l at o r y s m s 's , l e t t er s a n d e m a i ls t h a t f o l l o we d w i t h t h e i n a u gu r a l i s s u e. M a n y

felt that the m agazine was just light reading that one could assim ililate the take hom e

m e ss a g es e a s i l y, w a s s o p l e as a n t t o r ea d t h a t t h ey c o u l d f i ni s h i t a t o n e g o , a s i t w a s

v e r y i n t er e s t in g a n d f i na l l y t h e y c o u l d g et t h e d e li b e ra t i o ns o f t h e c li n i c al m e e ti n g a t

t h e ir o w n c l i n i cs w i t ho u t a tt e n di n g t he m e et i n g . S o j u st a b i g t h a n k yo u o n b e h al f o f t h e

editorial board for the appreciation, it was the worth the effort.

The second issue brings another conglom eration of clinical m eetings with difficult and

interesting cases, relevant articles from all speciality branches and above all som e

follow- ups of im portant cases presented in the earlier clinical m eetings and published

i n t h e f i r st i s s u e. Yo u r p o s i ti v e f e ed b a ck h a s g i v e n i m p et u s t o o u r e d i t or i a l t e am t o p u t

their best foot forward again. We were a little disappointed at the lack of response to

o u r O rt h oq u iz . S u re l y, t h e r e sp o ns e wa s no t d if f ic u lt o r w er e y ou j u st t o o l a zy t o

respond. Do respond to this time, there' s a prize waiting to be won.

We are in the continuous process of learning and im provising. Efforts are being m ade

t o o u ti l i z e t h e co m m en t a r y o f e x p er t s i n t h e f i e l d w h i l e p u t ti n g u p a n d wo r k i n g t h ec l i n i ca l c as e . I f y o u h a v e a n y i d e a th a t y ou w o u l d l i k e to s h a re w i th u s , w e w ou l d b e t o o

pleased to study the sam e and try to im plem ent them .

As the outgoing President of our esteem ed society and also the editor of the

Orthofront I had the opportunity to witness the strong bonding and cooperation of m y

executive com mittee m em bers to execute a num ber of innovative agenda and items in

the calendar of events 2008- 09.

I a m o v e rj o y e d t ha t m y d r e a m t o s e r ve y o u a s t h e Pr e s i de n t o f o u r e s t ee m ed s o c i et y

h a s b e en f u l f i ll e d a n d I a m h a pp y t o h a v e l ef t m y f o o t pr i n t i n t h e s a nd s o f t i m e. Ye s I c a n

p r o u d ly s a y t h a t t o g et h e r w e a c h i e ve d m u c h .

Dr. N. Antao

Editor's Noteeditorialboard

Editor-in-chief

Dr. Nicholas Antao

Asst. Editor

D r. A l a ri c A r o oj i s

Board Members

Dr. Vikas Agashe

D r. M a n i sh A g a r wa l

D r. M i h ir B a p at

D r. H a r is h B h e n de

D r. M o h a n D e s ai

Dr. Sangeet Gawhale

Dr. Arvind Goregaonkar

Dr. Anil Karkhanis

Dr. Pranjal Kodkani

Dr. Rujuta Mehta

D r. S u b ra n s h u M o h a n ty

D r. A b h a y N e n e

Dr. Dinshaw Pardiwalla

Dr. Aseem Parekh

Dr. Hemant Patankar

Dr. Ram Prabhoo

D r. A j ay P u ri

Dr. Arvind Thakur

D r. S u d hi r W a rr i e r

3

contentsEdit or's Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

B iop sy of Muscul oske let al Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Manage me nt of I nf ect ed Tot al Joint Re placement . . . . . . . . . . . . . . . . . . 6

C o nt r ov e rs y : O p en f r ac t ur e -t o c l o se t h e w o un d p r im a ri l y o r n o t? . . . . . 1 0

An art icle review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2

R e c e n t ad v a n ce s i n c a r t i la g e r e c on s t ru c t i v e su r g e r y i n I n d i aGuide lines - Pat hologi cal Fract ure s in Childre n . . . . . . . . . . . . . . . . . . . 17

Mode rn Tre nds In Sp inal Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . 20

T he te n commandment s of hand frac tures . . . . . . . . . . . . . . . . . . . . . . . 24

Se lect ed Case Present at ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

( B O S C l i n i c al M e e t in g N ai r H o s pi t a l )

Se lect ed Case Present at ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

( B O S C l i n i c al M e e t in g S i on H o s p it a l )

Ortho Qui z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Fol low-up of some cases p re se nt ed earl ier . . . . . . . . . . . . . . . . . . . . . . 35

T he BOS - All I ndia Best Resi dent Award . . . . . . . . . . . . . . . . . . . . . . . . 36

F or um O n E th i ca l An d Le ga l Co nc e rn s In O rt ho pa ed ic P ra ct ic e . . . . . . 3 7

Gue st Lect ure: Dr. Freddie Fu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38


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4

B io ps y o f M us cu lo sk el et al Tu mo rsDr. Ajay Puri, Dr. Manish Agarwal

Ortho f ro n t M a rc h 2 0 0 9

A biopsy is perhaps the most vital step in the diagnostic When a needle biopsy is non-diagnostic, it can easily

w or ku p o f b on e a nd s of t t is su e t um or s. I t i s i mp or ta nt b e r ep ea te d, o r a n o pe n b io ps y c an b e p er fo rm ed

t h at a c l in i ci a n k n ow s h o w t o o b ta i n a d eq u at e m a te r ia l w i th o ut ma j or m o rb i di t y t o t h e p a ti en t . H ea l in g o f ai n t he l e a st t r a um at ic w ay w it h ou t j e op ar di si ng w ou nd i s n ot e nd an ge re d a nd t hu s , t re at me nt w it h

s u b se qu e nt l o ca l c o nt r ol o f t h e t u mo r. A p o or l y p l ac e d r a d i a t i o n a n d c h e m o t h e r a p y c a n b e s t a r t e d

b io ps y i nc is io n, a p oo rl y p er fo rm ed b io ps y, o r t he i mm ed ia te ly i f n ec es sa ry. T he re i s l es s d is ru pt io n o f

c o mp l ic a ti o ns o f a b i op s y m a ke i t d i ff i cu l t t o s a lv a ge a n s o ft t i ss u e a n d f a s c ia l p l a n es . T h er e i s l e ss r i sk o f

e xt re mi ty a nd , i n s om e i ns ta nc es , m ay a ff ec t t he i nc re as ed s tr es s r is er s a nd p at ho lo gi ca l f ra ct ur es .

survival of the patient.I n a r e as w h i ch a r e di f f i c ul t t o ac c e s s su c h a s t h e sp i n e

I d ea l ly, t h e b i op s y m u st b e p er f or m ed b y o r u n de r t h e o r p e lv i s t h e n e ed l e b i op s y c a n b e g u id e d u s in g C T

s u pe rv i si o n o f t h e s u rg e on w h o w il l b e c a rr y in g o u t t h e i m ag i ng o r a n i m ag e i nt e ns i fi e r t o e ns u re a c cu r at e

f in al t re at me nt . B io ps y s h ou ld b e r eg ar de d a s t he f in al t ar ge ti ng . R eg ar dl es s o f t he t yp e o f b io ps y, i ts

d i a g no s t ic p r o ce d u re , n o t a s a s h o r tc u t t o d i a g no s i s . I t p l a c em e n t i s c r i t ic a l . F o r a p p ro p r ia t e p l a c em e n t o f t h es h ou l d b e p e rf o rm e d a f te r a l l t h e i ma g in g s t ud i es h a ve b i op s y, t h e s u r g eo n n e ed s t o k n ow t h e p r o b ab l e

b e en p er f or m ed . T h e o pt i mu m in t eg r at i on o f c l in i ca l d i ag n os i s a n d t h e e x te n t o f t h e t u mo r a n d s h ou l d h a ve

a nd r ad io gr ap hi c i nf or ma ti on p ri or t o b io ps y h as e st ab li sh ed a n o pe ra ti ve p la n p ri or t o b io ps y. H e

i m po r ta n t i m p li c at i on s f o r t h e d i a gn o si s o f b o ne s h ou l d n o t b e c o nc e rn e d o n ly w i th o b ta i ni n g a t i ss u e

t um or s, a nd i s n e ce ss ar y f or a cc ur at e p at ho lo gi c d ia gn os is b ut s h ou ld a ls o t hi nk a bo ut t he d ef in it iv e

i nt er pr et at io n. T hi s is w he re t he m ul ti di sc ip li na ry o pe ra ti ve p ro ce du re . Tr an sv er se i nc is io ns i n t he

c o op e ra t io n b e tw e en r a di o lo g is t , c l in i ci a n a n d t h e e x tr e mi t ie s a r e a l mo s t a l wa y s c o nt r ai n di c at ed b e ca u se

pathologist becomes vital. the site of t h e incision c annot be exc ised en b loc w ith

t he l on g it ud in al ly d ir ec te d se gm en ts o f b on e orT ho ug h t he ma te ri al ob ta in ed by a n o pe n b io ps y i s

m us cu lo a po ne ur ot ic c om pa rt me nt s. T he re fo re , a

g e n e ra l l y a d e qu a t e i n q u a n ti t y a n d le s s c ha l l en g i n g to l o n g it u d i na l b i o ps y i n c i si o n m u s t a l wa y s b e u s e d i n t h et h e sk i ll s o f t h e pa t ho l og i st , i t i s a m or e t ra u ma t ic

e x t re m i ty. T h e m a j or n e u r ov a s c u la r s t r u ct u r e s s h o u l dp ro ce du re . I t in vo lv es g re at er t is su e tr au ma , m or e

b e a v oi d e d b e c a u se i f t h e y a r e c on t a m in a t ed d u ri n gb l oo d lo s s an d hi g he r r i sk o f c o mp l ic a ti o ns s u ch a s

t h e bi o ps y t h ey m a y h a ve t o b e sa c ri f ic e d du r in g t h ehematoma, infection and p athologic f racture. If a

d e f in i t i ve p r o c e d ur e t h a t f o l l o ws . T h e b i o p sy t r a c t a l s otourniquet is used there is always a fear that the oozing

s h o u l d n o t t r a v e r s e a n o r m a l a n a t o m i c a lfrom tumor vessels after the tourniquet is released may

m us c ul os ke le ta l c om pa rt me nt i n o rd er t o r ea ch ac o nt a mi n at e l a rg e a r ea s o f t h e l im b . A n o p en b i op s y

compartment that is involved by tumor, so that it will notrequires general anaesthesia. It is less forgiving and a

be necessary to remove both compartments at the timec o rr e ct t ec h n iq u e i s of u t mo s t i m po r ta n ce i f l i mb

o f t he d ef in it iv e pr oc ed ur e. T he c om mo n s it es a res a lv a ge is c on s id e re d . T h e s k in r e mo v ed at f in a l

mentioned in Table 1.procedure is more and can compromise closure durings a lv a ge s u rg e ry. P er c ut a ne o us b i op s y o f b o ne o f fe r s I n a d ul t s t h e n e ed l e b i op s y i s p e rf o rm ed u n de r l oc a l

s ev er al a dv an ta ge s c om pa re d wi th o pe n p ro ce du re s. a na es th es ia . Fo r c hi ld re n a s h or t g en er al a na es th es ia

A needle biopsy can be performed as an out-patient may be required. After adequate preparation of the skin

procedure u nder local a naes thes ia w ith very low the shortest path to the lesion is used, avoiding

m o rb i di t y. I t d o es h o we v er r e qu i re a s k il l ed a n d i m po r ta n t n e ur a l a n d v a sc u la r s t ru c tu r es a n d n o t

e x p e r i e n c e d p a t h ol o g i s t t o r e a c h a n a c c u r a t e t r av e rs i ng a n at o mi c al c o mp a rt m en t s. I n c a se o f s o ft

d ia gn os is . N ee dl e b io ps ie s c an r ea ch d ee p a re as o f t is su e t um or s t he s pe ci me n i s o bt ai ne d f ro m t he m as s

t he s ke le to n t ha t a re o th er wi se a cc es si bl e o nl y b y o pe n u si ng t he Tr u- c ut n ee dl e- bi op sy s ys te m. I n c as e o f

o p e ra t i on a n d m u l t ip l e s p e c im e n s c a n b e ob t a i ne d b o n e t u m or s t h e s p e c im e n i s e a s i ly o b t a in e d f r o m t h e

withou t increasing morbidity. soft tis sue component. T he s ample from the soft tissue


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5Ortho f r on t M a rc h 2 0 0 9

mass is as representative as from the intraosseous operative hematoma is prevented. If a tourniquet is

c om po ne nt . W he re th e l es io n i s e nt ir el y i nt ra os se ou s, u s ed i t m u st b e a p pl ie d w it ho ut e x sa ng ui na ti on a nd

b o n e h a s t o b e p e n et r a te d . F o r o b t ai n i n g c o r e s f r o m m u s t b e r e l ea s e d p r i or t o c l o s u re s o t h a t h e m os t a s is

b o ne t h e J a ms h id i n e ed l e i s u s ed . A v oi d b i op s yi n g c a n b e a c hi ev e d. T h e b i op s y s i te m u st b e c l os e d

h e a v il y c a l c if i e d o r o s s i fi e d a n d n e c ro t i c a r e as . c a r e fu l l y t o p r e ve n t n e c r os i s . S u c t io n d r a in s s h o u l d n o t

b e u s e d i f m a l ig n a n t d i se a s e i s l i ke l y, a s t h e d r a in a g eI n a n o p en b i op s y t h e c o rr e ct t e ch n iq u e i s e v en m o re t u b e t r ac t c a n b e a s i t e f o r t u m o r s p r ea d a n d w i ll h a v e t oc r it i ca l in o r de r t o re d uc e th e c om p li c at i on r a te s . T h e

b e ex ci se d e n b lo c w it h t he b io ps y s it e. I f a dr ai n m us ti n c i si o n s h o u ld b e a s sm a l l a s co m p at i b l e w i t h t h e

be used, the tract should be adjacent to and in line witho b ta i ni n g of a n a d eq u at e ti s su e s pe c im e n. N o f la p s

t h e b i o p sy i n ci s io n . I f t h e f a c i li t y f o r f r oz e n s e ct i on e x is t sm u s t b e r a is e d s o t h a t ti s s u e c o nt a m in a t i on i s a t a

then it is preferable to ask the pathologist to comment ifm i ni m um . F ro m t h e in c is i on , o n e mu s t d ir e ct l y m o ve

the material obtained during biopsy is representative.d own to t he ar ea of in ter es t. T he peri ph er y o f a ny

This can reduce the incidence of repeat biopsies due tom a l ig n a n t t u mo r i s i t s m o s t v i ab l e , r e p re s e n ta t i v e a nd

inadequate material. All the material collected at biopsyd i a g no s t i c p o r ti o n , w h e re a s t h e c en t r a l po r t io n i s o f t en

should be processed at one place. It is a bad idea ton e cr o ti c . I f a m a li g na n t bo n e tu m or h a s a s of t t is s ue

divide the material and send it to different pathologye x t e n s i o n , a b i o p s y f r o m t h e s o f t t i s s u e i s

laboratories. Due to the heterogeneous nature of manyrepresentative and it is not always necessary to biopsysarcomas this can lead to different reports and more

t h e b o ne . V i o la t i n g th e c o r te x o f a b o n e t ha t c o n ta i n sc on fu si on . Fo r a ny d is cr ep an cy, i t i s b et te r t o s ee k

m a li g na n t t u mo r m a y l ea d t o p a th o lo g ic a l f r ac t ur e . As u b s e qu e n t o p i ni o n s o n t h e s a m e m a t er i a l b y s e n d in g

b i o p s y f r o m t h e s o f t t i s s u e c o m p o n e n t i s a sslides and blocks for review.

r e p re s e n ta t i ve a n d e a s i er t o o b t a in . I f t h e b o n e m u st b e

o p e ne d a s ma l l c ir c u l ar h o l e sh o u l d b e m a de w i th a A b i o ps y t h e re f o r e n o t o n l y p l a y s a v i t al r o l e i n d i a g no s i s

t r ep h in e , s o t h at o n ly m i ni m um s t re s s- r is e rs a r e b u t c a n a l so h a ve a b e ar i ng o n d e fi n it i ve m a na g em en t

c r e a te d . I f a h o l e h a s b e e n c r e a te d i n t h e b o n e, i t s h o u l d a n d u l t i ma t e s u r v iv a l o f t h e p a t ie n t . T h o u gh t e c h ni c a ll y

b e p lu g g e d w i t h G e l f oa m o r m e t h yl m e th a c r yl a t e t o s i m pl e i t r e q ui r e s c o n s id e r ab l e t h o u gh t a n d p l a nn i n g

p r e ve n t b l e ed i n g i n t o t h e s o f t t i s s ue s . M e t ic u l o u s p r i or t o i t s e x e cu t i on i n o r d er t o b e o f m a x i mu m b e n e fi t

h em os ta si s i s n ec es sa ry s o t ha t s ub st an ti al p os t- t o t he s u rg eo n a nd t he p at ie nt .

Clavic le Through a n incision t hat is parallel to th e long axis of the clavicle

Scapula A n obliqu e incision which passes from superior lateral over the acromian to distal

m e d ia l n e ar t h e l ev e l o f t h e i nf e r i or c o r n er o f t h e s c ap u l a .

Proximal Humerus Through anterior deltoid

Dis tal Humerus Posteriorly

Pelvis A long a line pass ing from the pubic t ubercle to the anterior s uperior i liac s pine over t he

i l i ac c r e s t a n d t o t h e p o s te r i or s u p e ri o r i l i ac s p i n e d e p en d i n g u p o n t h e l o c a ti o n o f t h e

l es io n. A no th er i nc is io n l in e f ro m A SI S t o g re at er t ro ch an te r. N ev er t hr ou gh t he

buttock.

H ip & p ro xi ma l fe mu r T hr ou gh t he l at er al a pp ro ac h. D o no t cr os s I M s e pt um .

Dis tal femur Anterior, medial or lateral and proximal to the suprapatellar pouch. Never through the

rectus femoris. Do not enter the joint

Pr ox im al ti bia A nt er om edi al o r a nt ero la tera l as pec t. D o n ot en te r t he joi nt. Nev er mi dl in e t hr o t he

p a t el l a r t e n do n .

T AB L E 1


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6 Ortho f ro n t M a rc h 2 0 0 9

M an ag em en t o f I nf ec t edTotal Joint Replacement

Dr. Shubhransu S. Mohanty, Dr. Mandar Agashe

Ta b le 1 .P r o st h e ti c t o t al j o in t r ep l a c em e n t h a s b ec a m e a

Classification of infected total joint r eplacements.p o w er f u l to o l i n t h e m an a g e me n t o f s e v er e d i sa b l in g

a r t h ri t i s, w i t h a s u c c es s r a te a p pr o a c hi n g 9 9% . A l m o stCategory Definition

1 million total joint replacements take place world wide

P o si t i ve in t r a o p e ra t i ve c ul t u r e Tw o o r m o r e i n t ra -e v er y y e ar a n d w i th t h e i n cr e as i ng l o ng e vi t y o f s e ni o r

operative positive forc i ti z en s co u pl e d w i th t h e d em a nd s o f y o un g , a c ti v e

the same organismarthroplasty recipients, it is estimated that this number

m a y b e e v en m o re y e a r a f te r y e ar. H o we v er, d e sp it e i t sE a r ly p o s t- o p er a t iv e i n f e ct i o n A p p ar e n t w i t hi n o n e

s u c ce s s, j o in t re p la c em e nt s ur g er y i s no t w it h ou tm on th o f s ur ge ry

c o m p l i c a t i o n s , i n c l u d i n g a s e p t i c l o o s e n i n g ,

Late chronic infec tion Presenting after oned is lo ca ti on , p er ip ro st he ti c f ra ct ur e, a nd t h e m os tm on th o f s ur ge ry w it hd r e ad e d o n e o f a l l , i n f e ct i o n .

insidious onset ofThe rate of infection following total joint replacement is

symptomsf or tu na te ly q ui te lo w, a bo ut 1% i n h ip a nd s ho ul de r

Acute hematogenous infection Acute onset of clinicalreplacements and about 2% in knee replacements. The

s y mp t om s i n al o w r a t e o f i n f e ct i o n c a n b e a tt r i b ut e d to t h e ro u t i ne u s e

p r e vi o u s ly w e llo f p e r i- o p er a t iv e a n t i b i ot i c s , t h e u s e o f c l e a n- a i r f i l t er i n g

functioning joint.s y s t e ms a n d s c r u p u lo u s m a i nt e n a nc e o f o p e ra t i n g

r o o m a s ep s i s b y O R p e r s on n e l .Pr evention of infection after total joint r eplacement :

D e e p p r o st h e ti c i n f e ct i o n i m p ai r s f u n c t io n a n d g e n e ra l

P r e - o p e r a t i v e e v a l u a t i o n a n d c a r e a n d g e n e r a lhealth, and its management is difficult and expensive. m e a s ur e s l i k e c e s sa t i on o f s m o k in g a n d m a i n t en a n c eSome infections are clearly blood borne but the source

o f h y gi e ne , s p ec i al at t en t io n s h ou l d b e p a id to th eo f m os t o f t he ot he rs ca n b e t ra ce d t o o pe ra ti ve

m e d i c a l c o - m o r b i d i t i e s . D i a b e t e s s h o u l d b ec o nt a mi n at i on b y e i th e r r o om a i r o r s k in f l or a e i th e r t h e

a d eq u at e ly u n de r c o nt r ol . I n p a ti en t s w it h r h eu m at o ids u rg i ca l t ea m s o r t h e pa t ie n ts . C o st -e f fe c ti v e pe r i-

arthritis, it is worthwhile to withhold methotrexate in theoperative strategies are therefore critical in reducing

p e r i- o p er a t iv e pe r i od a s i t ma y c a u s e i m m u no -the incidence of post-surgical infection.

s u p p re s s i on . A s a g en e r a l r u l e , a n y s o r t o f s k i n i n f e ct i o n

Classification : s h o u ld b e t r e a t ed p r i o r t o s u r g e ry. D e n t al a n d u r i n a ry

infections have to be treated.T h e C o ve n tr y c l as s if i ca t io n o f p os t op e ra t iv e wo u nd

Per i-oper ative management : strategies to reduce theinfection is still widely used. Stage 1 infections occurred

n u m b er o f c o n t am i n a nt pa r t ic l e s i n t h e o p e ra t i v e f i e ldw i t hi n 3 m o n th s o f s u r g er y, s t a g e 2 in f e c ti o n s o cc u r r ed

a r e a n i m po r ta n t c o mp o ne n t o f p ro p hy l ac t ic e f fo r ts .b e t we e n 3 m o nt h s to 2 y e a r s o f s u r g er y w h i le s t ag e 3

There is some controversy regarding the use of routinew e r e l a t e i n f e ct i o n s w h i ch o c c u r re d af t e r 2 y ea r s of

p r e- o pe r at i ve s k in d i si n fe c ti o n o v er a p er i od o f 1 2 -2 4surgery. Schmalzried et al classified these infections

hours with some experts saying that prior to immediatea c c o r d i n g t o t h e m o d e o f i n f e c t i o n - s u r g i c a l ,

p r e -s u r g ic a l s k i n p r e pa r a ti o n , e v e n r o u t in e h y g i en e i sh a e m at o g e no u s o r r e c u rr e n t. H o w ev e r i t i s v er y d i f f ic u l t

s u ff i ci e nt . A d he s iv e d r ap e s a r e u s ua l ly w i de l y u s edt o a c cu r at e ly d e te rm i ne th e e x ac t m o de of d e ep

t h o u g h t h e i r e x a c t b e n e fi t is y e t t o b e d o c u me n t ed .i nf ec ti on i n e ac h c as e. A n ew c la ss if ic at io n b y E st ra da

Good operative room discipline is essential in reducinget al (Table-1) reflects the increasing incidence of

p o s t- o p er a t iv e i n f e c ti o n r a t es . R e d uc t i o n i n t h e n u m b errevision surgery and current management concepts.


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o f O R p e r so n n e l h a s p r o ve n e f f e ct i v en e s s i n r e d uc i n g s e d i me n t a ti o n r a t e ( E S R ) a n d C - r e a ct i v e p r o te i n ( C R P)

t he n um be r o f c ol on y- f or mi ng u ni ts i n c ir cu la ti ng a ir. a re ke y i nd ic at or s i n t he pa ti en t w ho ha s n o o th er

Also use of systems combining high filtration efficiency, reasons for their elevation such as rheumatic diseases

f re qu en t a ir c ha ng e a nd un i- di re ct io na l a ir f lo w a nd by o r o th er i nf la mm at or y c on di ti on s. A n E SR > 3 0 m m p er

u se o f i mp er me ab le c lo th in g o r s ui t v en ti la ti on g re at ly h ou r h as be en s ho wn t o h av e a se ns it iv it y o f 8 2% , a

h el ps i n r ed uc in g s h ed di ng b y o pe ra ti ng r oo m s pe ci fi ci ty o f 8 5% , a p os it iv e p re di ct iv e v al ue o f 5 8%

pers onnel. and a negative predictive value of 95%. The CRP is a

b e tt e r i n di c at o r o f i n fe c ti o n a s i t i s m or e s en s it i ve a n dAntibiotic pr ophylaxis: T he ef fi ca cy o f an tib iot icr e t u rn s t o n o r m al w i t h in t h e f i r st t h r e e w ee k s a f t er

p r o ph y l a xi s f o r t h e p r e ve n t io n o f p o s t s u r g i ca l w o u n do p er a ti o n, c o mp a re d to t he E SR , w h ic h c a n t a ke u p t o

i n fe c ti o ns h a s b e en p ro v ed b y s e ve r al r a n do m iz e do n e y e a r t o b e c o me n o r m al . A C R P v a l u e > 1 0 mg / l h a s

c o nt r ol t r ia l s. T h e us u al p r ot o co l f ol l ow e d in m a nyb ee n a ss oc ia te d w it h a 9 6% s en si ti vi ty, a 9 2%

centres is to give a broad spectrum antibiotic like a 1stspecificity, a 74% positive predictive value and a 99%

o r 2 n d g en e ra t io n c e ph a lo s po r in j u st p r i or t o s u rg e ry,n e ga t iv e p re d ic t iv e v al u e. I f b o th t h e ES R a n d CR P a r e

a n d f u r th e r t w o i n je c t io n s a f t er 1 2 a n d 2 4 h ou r s l a t er.e l ev a te d, t h e p ro b ab i li t y o f i n fe c ti o n h a s b e en n o te d t o

Also antibiotic prophylaxis is needed to preventb e 8 3 %, a n d w h en b o th a r e n e ga t iv e i n fe c ti o n m a y b e

h a e m at o g en o u s i nf e c t io n a s i n c a s e s of d e n ta l s e ps i s ,reliably excluded.

urinary tract infections etc.

RADIOLOGICAL INVESTIGATIONSD I A GN O S IS A N D M A N AG E M EN T O F I N F E C T I ONI N TOTAL JOINT REPLACEMENT Plain r adiogr aphs: T ho ug h p la in r ad io gr ap hs a re

f r e q ue n t ly n o r m al i n a c u t e i n f e ct i o ns , c h r o ni c i n f e ct i o nE a r l y p o s t -o p e r at i v e i n f ec t i o n:

c a n c a u s e r ad i o gr a p h ic c h a n g es , i n c l ud i n g p er i o s ti t i s ,

E ar ly p os t- su rg ic al i nf ec ti on i s us ua ll y o ve rt a nd osteopenia, endosteal reaction, and rapid progressive

p u ru l en t . D i ag n os i s i s m a de b y h i st o ry a n d c l in i ca l l o o s en i n g o r o s t e ol y s i s. O s t eo l y s is a n d l o o s en i n g m a y

e x a m i n a t i o n i t s e l f . T h e p a t i e n t h a s s i g n i f i c a n t b e n on -s pe ci fi c b u t t he po ss ib il it y o f i nf ec ti on m us t

c o n s t it u t i on a l s y m p to m s a n d f e v e r, w i t h l o c a l s i gn s o f always be considered when these processes are rapid,

a c u t e i n f l am m a ti o n . U l t ra s o u n d h e l ps i n l o c a ti n g t h e p a r t i c u l ar l y w h e n t h e r e a r e n o i n d i c a t o rs o f a

l o c a ti o n o f i n f e ct e d h a em a t om a o r l o c al i z e d ab s c e s s i f mechanical cause.

any and helps in guiding ultrasound guided aspiration.M a g n et i c r e a s on a n c e i m a gi n g : MRI scans have gotT h e r o l e o f a s p i ra t i on o f j o i nt f l u i d r e m a in s c o n t r o ve r s ia ll im it ed r ol e t o p la y i n t he d em on st ra ti on o f p er i-

w i t h m a n y s u r g eo n s u s i n g j o in t a s p i ra t i on t o g u i d e t he i rp r o st h e t ic i n f ec t i o ns d u e t o t h e a r t if a c t s d u e t o t he

d i a g no s i s a n d ma n a g em e n t t ho u g h i t s u s e h a s n otp r o st h e s es t h em s e l ve s . H o w ev e r n e w er t e c h n iq u e s i n

b e en p r ov e n b y c o nt r ol t r ia l s. T h e C - re a ct i ve p ro t ei nM R I t ec h no l og y a r e o n t h e h or i zo n w h ic h c a n e li m in a te

levels have got a high predictive value in the diagnosist h es e a r ti f ac t s a n d h e lp i n d i ag n os i s o f t h es e p er i -

t h an er y th ro c yt e s e di me nt at io n r at e. S of t t is s ueprosthetic infections.

d e b r i d e m e n t w i t h r e t e n t i o n o f p r o s t h e s i s w i t h

R a d i o n u c l i d e b o n e s c a n : A technetiu m-Tc99mi mp re gn at io n o f l oc al a nt i- bi ot ic c em en t b ea ds i s

( 9 9 M Tc ) is o t o pe b on e s c a n i s o f t e n p e r fo r m ed in t h ec u r r en t l y t h e m ai n s t ay o f t r e a tm e n t

a s se s sm en t o f a fa i le d T HA . A l th o ug h i t h a s a hi g hC h r o ni c d e e p s e a te d i n f ec t i o n:

s e n s it i v it y, t h e l o w s p e ci f i c it y f o r i n f ec t i o n l i m it s i t s u s e .I t i s o f t en d i f f ic u l t t o d i a g no s e c h r o ni c i n f e ct i o n i n t o t a l I n d i um - 1 11 - l a be l l ed w h i t e c el l s c a n s h a ve a m u c h

j o in t a n d t o d i st i ng u is h f r om a s ep t ic l o os e ni n g. Pa i n i s h i gh e r s e ns i ti v it y i n i n fe c ti o n, w h ic h h a s b e en f o un d t o

t h e c o m mo n e s t p r e se n t in g f e a t ur e , w i t h d e v el o p in g b e 77 %, w it h s pe ci fi ci ty o f 8 6% , a p os it iv e pr ed ic ti ve

r e s tr i c t io n o f m o t io n i n p r e vi o u s ly w e l l- f u n c ti o n i ng j o i nt . v a l u e o f 5 4 % , a n d a n eg a t i ve p re d i ct i v e v a l u e o f 9 5 % .

T he re ar e v er y r ar el y a ny l oc al si gn s o f i nf la mm at io n H ow ev er, t hi s t es t i s e xp en si ve an d t im e c on su mi ng .

a n d a hi g h d e g re e o f c l i n ic a l s u s p ic i o n i s n e c e ss a r y t o O t h er i s o t op e s h av e b ee n i n v es t i g a te d b u t n o n e ha s

diagnose this entity. d e m on s t r at e d c l in i c a ll y u s e f u l se n s i ti v i ty o r s p e ci f i c it y.

T h e us e o f r a di o ac t iv e i mm u no g lo b ul i n G h a s a ls oSer ological investigations:

b e e n d e s c ri b e d b u t h as n o t be c o me c o mm o n , a s i t s

Assessment of the white blood cell count is of limited s en si ti vi ty a nd s pe ci fi ci ty w er e s im il ar t o t ho se of

b e ne f it a s it i s fr e qu e nt l y n o rm a l. T h e e r yt h ro c yt e standard laboratory investigations.


8/48


Positron Emission Tomography: Positron emiss ion s pecificity was very high in the range of 95 to 97 %.

t o m o g r a p h y u s i n g f l u o r i n e - 1 9 - f l u o r o - 2 - d e o x y - D - O w i ng t o t h e w i d e v a r i at i o n i n t h e r e po r t ed s e n s i t iv i t y,

g l u c o se h a s b e e n u s e d t o de t e ct s i te s of i n c r ea s e d intra-operative Gram staining should be interpreted

m e t ab o l i c a c t i vi t y, s u g g es t i v e o f i n f e ct i o n . T h e r e p or t e d w i t h c a u t io n .

s en sit iv ity of t hi s me th od wa s 91. 7%, wit h 9 6. 6%I n tr a -o p er a ti v e t i ss u e c u lt u re : The highest standard

specificity. However, areas that showed a non-specifici n t h e di a gn o si s o f a n i n fe c te d TH A h as a l wa y s b ee n

i nc re as e in u pt ak e w er e s ee n u p t o a n a ve ra ge of 7 1i n t r a- o p er a t iv e t i s s u e c u l tu r e . U s i n g a m i n i m um o f t w o

m on th s a ft er o pe ra ti on , e ve n i n u ni nf ec te d T HA . T he p o s i ti v e s a m pl e s , t h e s e n s it i v i ty i s 9 4 % ,a n d w i t h 9 7 %authors concluded that the area of increased uptake

specificity. However, intra-operative tissue culture is notm a y b e mo r e i m po r ta n t t h an t h e i n te n si t y. A l th o ug h

a l w ay s p o si t i ve , e v e n i n p a t ie n t s wh o a re p os i t i ve b y a l lt h e s e r e s u lt s a r e e n c ou r a g in g , f u r t h er s t u d y i s r e q u i r ed .

the other criteria mentioned and who symptomatically

M i c r o b i o l o g i c a l a n a l y s i s : T h e o r g a n i s m s m o s t i m p ro v e w i t h m a n a ge m e nt o f t h e ir p r es u m e d i n f ec t i o n.

commonly isolated in infected Total joint replacements the exact reason for this is still to be found out.

are Staphylococcus aureus and StaphylococcusI n t r a- o p er a t iv e f r o z en s e c t io n : V ar i o us d ef i n i ti o n s o f a

e p id e rm i di s , f o ll o we d b y G r am - ne g at i ve b a ct e ri a .p o si t iv e f r oz e n s e ct i on h a ve b e en i n ve s ti g at e d i n t h e

Coagulase-negative staphylococci are increasing inl i t e r a t u r e . S t u d i e s t h a t c o n s i d e r e d f i v e

p r e va l e nc e i n m o d er n t i m es . A l s o i t i s i m p or t a n t t o d op o l ym o r ph o n u c le a r l e u c oc y t e s pe r h i g h - po w e r f i e l d t o

t h e a n t ib i o t ic s e n s it i v it i e s o f t h e s e o rg a n i s ms i s o l a t ed b e i nd ic at iv e o f i nf ec ti on h av e d em on st ra te d aa s th ey h av e n ee n s ho wn t o va ry f ro m ti me to t im e.s e ns i ti v it y b e tw ee n 4 3% a n d 1 0 0% , w i th a s p ec i fi c it y

Vancomycin resistance, for instance, in particular withr a n g in g f r o m 9 4 % t o 1 0 0 A fr o z e n s e c t io n c a n a l s o b e

e n te r oc o cc i , h a s b e en r e po r te d to b e o n t h e r i se i nu se d t o as s es s er ad ic at io n o f i nf ec ti on d ur in g re -

e n t e r o c o c c a l p e r i - p r o s t h e t i c i n f e c t i o n s . T h i simplantation in a two-stage revision.

emphasises the importance of identifying the pathogen

before initiating antibiotic treatment. TREATMENT

W h en t h er e is a hi g h i n de x 1) Antibiotic suppr ession:P r e - op e r a ti v e a s p i ra t i on :

o f s u s p ic i o n o f p e r i- p r os t h e ti c i n f e ct i o n, t h e jo i n t s h o u l dAntibiotic suppression as the sole modality of treatment

b e a s p i r a t e d a n d t h e c u l t u r e a n d s e n s i t i v i t i e sshould be reserved for those patients who are unable to

d e t er m i n ed . A p o s i t iv e t e s t i s d e f in e d a s a g r o w t h i n t w ou n d e rg o a o n e - s ta g e o r t w o s t ag e r e v is i o n s u r g er y d u es ep ar ate s pe cim en s. G ro wth i n o ne s pec ime n i sto severe medical co-morbidities. There have been

g e ne r al l y n o t c on s id er e d a c au s e f or c o nc e rn u n le s sseveral studies investigating the rate of recurrence of

the clinical and serological features are worrisome, ini nf ec ti on w it h a nt ib io ti c s up pr es si on t he ra py, b ut t he

which case the aspiration is repeated.p a ti e nt p op u la t io n s, t h e st a gi n g of t h e in f ec t io n a n d

Molecular biological investigation: Po ly me ra se ch ai n m et ho ds o f t re at me nt h av e va ri ed , m ak in g co mp ar is on

r e ac t io n ( P CR ) a n d e n zy m e- l in k ed i m mu n os o rb e nt o f r e su l ts d i ff i cu l t. G e ne ra l ly a b r oa d s p ec t ru m

a ss ay h av e bo th b ee n e va lu at ed i n t he di ag n os is o f a nt ib io ti c t he ra py i nc lu di ng hi gh er : a nt ib io ti cs l ik e

i nf ec te d To ta l j oi nt re pl ac em en ts . T he PC R i s h ig hl y L in ez ol id ar e u se d, t ho ug h i t i s s ai d t ha t a dd it io n o f

s e ns i ti v e. I t i s , h o we v er, v e ry l e ss s p ec i fi c d u e t o i t s r i fa m pi c in i n t h e t r ea t me n t r e gi m en i s v e ry u s ef u l f o r t h e

i n a b il i t y t o d i s t in g u i s h b e t we e n a c t i ve a n d e r a di c a t ed s a m e.

i n f e ct i o ns . I m m u no f l u or e s c en c e m i c r o s c op y a n d P C R2) Oper ative debr idement:

h a v e i s ol a t ed c o l o ni s a t io n w i t h a n o r g a ni s m i n b e t we e n

O p e ra t i v e d e b ri d e me n t a nd r et e n t io n o f t h e in f e c te d6 3 % an d 7 3% o f e x t ra c t ed p r os t h e s es , c o m pa r e d t o

prosthesis should be reserved for acute infections . Thes t an d ar d t ec h ni q ue s , w h ic h d et e ct e d co l on i sa t io n i n

r e po r te d r a te f o r e r ad i ca t io n h a s b e en b e tw ee n 2 6 %o n l y 4 % t o 2 2% .

a n d 7 1 % f o l l ow i n g o p e n d e b r id e m en t S t a ti s t ic a lINTRA-OPERATIVE CONFIRMATION

a n a l ys i s o f t h e i n di c a t io n s f o r o p e ra t i v e d e b ri d e me n t

I n tr a -o p er a ti v e g r am s t ai n : Intra-operative gram showed improved quality adjusted life expectancy and

s t a i ni n g i s a v e r y g o o d m et h o d o f d i a g no s i s o f i n f e ct i o n c os t- ef fe ct iv en es s w h en r ev is io n a rt hr op la st y w as

i n t ot al j oi nt r ep la ce me nt t ho ug h i n a r ec en t s tu dy a p e r f o r m e d i n y o u n g , h e a l t h y p a t i e n t s , w h e r e a s

s e ns i ti v it y o f o n ly 4 3 t o 55 % w a s no t n ot e d th o ug h i t s d e b ri d e me n t w a s m or e b e n ef i c i al i n p a t ie n t s w it h


9/48


reduced life expectancy. This statistical model has not Despite its widespread acceptance, two-stage revision

been confirmed clinically. h as several controversial aspec ts, i ncluding the timing

of the procedure, the use of antibiotic-loaded cement at3) Resection ar thr oplasty:

t h e s ec o nd s t ag e a nd t h e u se o f u n ce m en t ed

R e s e ct i o n a r t h ro p l as t y s h o u l d b e re s e rv e d f o r p a t ie n t s c o mp on e nt s . T h e i d ea l d u ra t io n o f a n ti b io t ic t h er a py

w h o s e m ed i c a l c on d i ti o n m a k es a m o r e e x t en s i v e b et we en s ta ge s ha s no t be en e st ab li sh ed , b ut a

p r o c ed u r e u n s a f e. O v e ra l l , t h e p o o r f u n c t io n a l r e s u lt s m i n i mu m o f s i x w e ek s i s t h e s t a n da r d . A s r e g a rd s t h e

c om pa re d t o r ev is io n T HA m ak e r es ec ti on o nl y a t im in g o f t he s ec on d s ta ge , r ec en t s tu di es h av esalvage procedure for the patient unable to tolerate a a d vo c at e d r ev i si o n b e tw e en s i x w ee k s a n d t h re e

full revision. m on th s af te r t he f ir st s ta ge . M an ag em en t of t he

d ef ic ie nc y i n b on e s to ck at t he ti me of r ev is io n i s a4 ) S i n g le s t a g e r e v i si o n :

p r ob l em . A l th o ug h a l lo g ra f t h as b e e n r e co m me n de d

Single-stage exchange revision using antibiotic-loaded f o r a n a s ep t ic r e vi s io n , t h er e i s a th e or e ti c al co n ce rn

cement was first popularised in Europe. This technique t h a t i t s u s e f o l lo w i ng i n f e c t i on m a y i n c r ea s e t h e r a t e o f

h a s b e e n r e c o m m e n d e d i n i m m u n o c o m p e t e n t r e c u rr e n c e. H o w ev e r t h i s h a s n o t b e e n s u b s t an t i a te d

p a t ie n t s w i t h a n a c u t e o r e s t a bl i s h ed ch r o n ic i n f ec t i o n, f u l l y i n c l i n ic a l s t u di e s .

s e n s it i v e t o f ir s t -l i n e a nt i b io t i c s. F o r t h i s t ec h n i qu e t o6) Antibiotic-loaded spacer s:

b e s u c c e s s fu l , t h o r ou g h d e b ri d e me n t m u s t b e c a r r ie d

out and a course of parenteral antibiotics administered The articulated spacer provides proper soft-tissue andp o s t- o p er a t i ve l y f o r a m i n i mu m o f s i x w e ek s . B e f o re t h i s l i m b l e n g t h b e t w e e n s t a g e s . T h i s h a s s e v e r a l

m a j or o p e ra t i on , a m i c r ob i o l og i c a l d i a gn o s i s h a s t o a d v a nt a g e s, i n c l ud i n g i m p ro v e d f u n c t io n , p r e se r v a ti o n

be made and a complete plan regarding antibiotics to of bone stock, prevention of soft-tissue contracture and

b e g i v e n h a s t o b e w o r ke d o u t b e f o re h a n d. A f u l l r a n g e a s a s o u r c e o f l o c a l d e l iv e r y o f a n t i bi o t ic s . H o we v e r,

of implants have to be there, as well as the mechanical the custom prosthesis was noted to provide higher hip

and soft tissue problems likely to be encountered have scores, a reduced hospital stay and enhanced function

t o b e k e pt i n m i n d . C u s t om - m a de p r o s th e s e s m ay a l s o b et we en s ta ge s. A t r ev is io n t he re w as a r ed uc ed

b e r e q u ir e d w h e n t h e re is ex c e s si v e d e s tr u c t io n o f s u r g ic a l t i me , r e d uc e d b l oo d l o ss a n d t r an s f u s io n

b on e. I n g en er al , e ve ry e ff or t h as to be ma de to r e qu i re m en t s a n d a l o we r r a te o f p o st - op e ra t iv e

conserve as much bone as pos sible. dislocation.

H o w ev e r, a n u m b e r o f s t u d ie s c o m pa r i ng s i n g l e- s t a g e SUMMARY

versus two-stage exchange all favoured the two-stageI n fe c ti o n i n t o ta l j o in t r e pl a ce m en t c o nt i nu e s t o b e

p r oc e du r e. E l so n h a d a 1 2. 4 % r a te of f a il u re wi t h t h es o ur c e of c o ns t an t f r us t ra t io n t o j oi n t re pl a ce m en t

s i n g le - s t ag e m e t h od , c o m pa r e d t o 3 . 5% w i t h t h e t w o -s ur ge on s w or ld wi de . A h ig h i nd ex o f s us pi ci on i s

s t a g e p ro c e du r e . V er y s i m i la r r e s u lt s w e r e re p o rt e d b yn e ce s sa r y f o r t h e d ia g no s is o f p os t -o p er a ti v e w ou n d

G a rv i n e t al i n a l ar g e s t ud y, w i th a r ec u rr e nc e ra t e o fi n fe c ti on . A l on g wi t h c l in i ca l e x am in a ti o n a n d h is t or y,

10.1% and 5.6% of cases, respectively.serological investigations like ESR and CRP along with

5) Two-stage r evision sur ger y : joint aspirations help in diagnosis. Radiological

i n v es t i g at i o n s l i k e p l a in r a d io g r a ph s , M R I s ca n s a ndThis has become the standard procedure throughout

v a r io u s B o n e s c a n s c er t a i nl y a i d i n t h e d ia g n o si s b u tN o r th A m e ri c a a s we l l a s t he r es t of t h e w o r ld . . I n t h i sa r e n o t d i ag n os t ic i n t h em s el v es . O n ce d ia g no s ed ,

m e th o d, a f te r t h e r em o va l o f t h e i nf e ct e d p ro s th e si s ,p o s t s u rg i c a l wo u n d i n f ec t i o n h a s t o b e d e a lt w i t h

t h e p a ti e n t i s k ep t o n a c o r s e o f p a r en t e ra l a n t ib i o t ic sa g g r es s i v el y w i t h l o n g t e r m a n t i -b i o ti c s , d e b ri d e me n t ,

f o r a p e ri o d o f 3 t o 6 w e ek s a n d t h e pa t i en t s ' E S R , C R Po n e s t a g e o r t w o s t a g e r e v is i o n s u r g er i e s b e i n g t h e

and joint aspirates are monitored for normalization.Invarious options available. All in all, the last word is yet to

m os t i ns ta nc es a t em po ra ry s pa ce r o f a nt ib io ti c-be said about this dreaded entity and we still await a

loaded cement is inserted at the first stage andd ef i ni t iv e pl a n o f m a na g em e nt w hi c h c a n b e us e d f o r

r em o ve d at t he s ec o nd o pe r at i on . H ig h d os e s ofall.

a n t ib i o t ic i n t h e c e m en t ha v e b e e n s h o w n n o t t o c a u s e

s y s t em i c t o x ic i t y. U s u a l a n t i bi o t ic s t o b e m ix e d w i t h

cement are Vancomycin, Gentamicin or Tobramycin.


10/48


Th e c on tro vers y c on ti nu es o n wh eth er in t he ope n t he t ime o f in ju ri es . H owev er i n th e c iv il ia n in ju ri es i t' s

f r a c t ur e s t he w o u nd b e c lo s e d pr i m ar i l y. Tr a d it i o na l n o w c l e ar t h a t t h e i n f e ct i n g o r g a ni s m s a r e m a i nl y f r o m

w i s d om s u g g e st s t h a t t h e s e w o u nd s a r e b e t t er l e f t t h e h o s p it a l n o s o co m i al p a t t er n r a t h er t h a n f r o m t h e

o p en . I n m a ny c a se s , t h er e i s i n te r na l d eg l ov i ng a n d c o nt a mi n at i on . P at z ak i s e t a l f o un d t h at o n ly 1 8% o f

m u sc l e d a ma g e i s o ft e n u n re c og n is e d a t th e ti m e o f i n fe c ti o ns we r e c a us e d b y t h e s a me o r ga n is m i n it i al l y

i n i t ia l d e b ri d e me n t . T h e b o r de r l in e i s c h a em i c m u s c le i s o l at e d i n t h e p e r io p e ra t i ve c u l t u re s . M o r e o f t e n, t h e

c a n g e t n e cr o se d a t a l a te r d a te a n d i f t h e s k in i s c l os e d, i n fe c ti n g o r ga n is m s w er e p s eu d om o na s a n d g r am

i t m ay p ot en ti al ly c re at e a s it ua ti on w it h d ec re as ed n e g a t i v e o r g a n i s m s w h i c h r e f l e c t e d h o s p i t a l

r e do x p o te n ti a ls a n d f a ll in g p H, e n co u ra g in g a n ae r ob i c n o so c om i al pa t te rn . I n t h e l i gh t of t h is , i t i s pr u de n t t h at

o r g a ni s m s l i k e c l o s tr i d ia a n d o t h e rs t o g r o w. F u lm i n a nt t h e s e w o u n ds a r e c l o s ed e a r ly a n d n o t l e f t o p e n f o r a

a n d s p r e ad i n g n e c r ot i s in g m y o f as c i t is m a y e n s u e. T h e l o n g p e r i od i n t h e h o s p i ta l e n v i r o n me n t . Th e e a r l y

c o nc e pt o f 2 n d l o ok d e br i de m en t e a rl y o n a t 2 4 -4 8 c l os u re i n t h es e w o un d s c a n b e i n t h e f o rm o f e a rl yh o u r s e m e rg e d t o o b v i at e t h i s . H o w ev e r w i t h t h e a d v e nt p r i ma r y s k i n c l o s ur e , s k i n g r a f ti n g , d a y 1 f l a p.

o f b r o a de r s p e ct r u m a n t ib i o t ic s , r i g o ro u s d e b ri d e me n t ,T h e r e w e r e t h r e e p r e v i o u s s u c h s t u d i e s w i t h

a v a i la b i l it y o f p u l s e l a v a ge , p o s s ib i l it y o f p r o vi d i ng e ar l yr e t ro s p ec t i v e c o h o rt c om p a ri n g ea r l y c l o s ur e as

s o f t t is s u e c ov e r a r o s e. T h e re w e re a r ti c l e s on f i x an do p p os e d t o t h e d el a y ed c l o s u r e. T h e s e ar e b y R u s s el l

f l ap s u g ge s ti n g d ay 1 f l a p c o ve r f o r t h es e i n ju r ie s w i th( 1 99 0 ), D eL o ng ( 1 99 9 ), a n d b y H o hm a nn ( 2 00 6 ). T he y

better outcome. Proponents of delayed closurehad some conflicting results. (figure 1 & 2)

f o l l ow e d t h e ol d e r s c h o ol o f t r e at i n g w ar i n j ur i e s w he r e1t h e i n f e c t i n g o r g a n i s m s w e r e m a i n l y f r o m t h e S . R aj as ek ar an p ub li sh es hi s e xp er ie nc e w it h t he

c o nt a mi n at i on f r om s oi l , c l ay, d u st w hi c h o c cu r re d at t ec hn iq ue of p er fo rm in g p ri ma ry s ki n c lo su re wi th

C on tr ov er sy : O pe n f ra ct ur e- t o c lo se t hew ou nd p ri ma ri ly o r n ot ? A n a rt ic le r ev ie w

D r. M oh a n M D e s a i

F i g u re 1 : I n f e ct i o n r a t e a f t er p r i m ar y v e r su s d e l ay e d w o u n d c l o s ur e i n o p e n f r a c tu r e s . F r o m: O r t h o pa e d i c t r a u ma di r e ct i o n s M a r ch 2 0 0 7

F i g u re 2 : De l a y ed u n i o n o r n o n u n io n f o l l o wi n g p ri m a r y v e r su s d e la y e d w o u n d cl o s u r e f o r o p e n f r a c tu r e s .

F r o m: O r t h op a e d ic t r a u ma d i r e ct i o n s Ma r c h 2 0 0 7.


11/48


g r ad e I II c o m po u nd f r a ct u re s i n J B JS ( Br ) F eb r ua r y O n e p a ti e nt r e qu i re d r e pe a t d eb r id e me n t a n d o n ly 3

2 00 9. Th is i s p ro ba bl y t he f ir st o f i ts k in d p ap er p at ie nt s r eq ui re d a f la p c ov er. I t w as i nt er es ti ng t o n ot e

publishing the mid-term results of this technique at 5 that of the 173 patients 161 patients had bony healing

y ea rs . T he y p er fo rm ed t he p ri ma ry s ki n c lo su re i n w it ho ut r eq ui ri ng s ec on da ry i nt er ve nt io n. 3 9 i .e . a ll t he

g r a d e I I I A a n d B i n j u ri e s i f c e r t ai n i n c l us i o n c r i te r i a w e r e u p p er l i m b f r a c tu r e s u n i t ed w i t ho u t r e q ui r i ng a n y

m e t . H e e x c l ud e d a l l f r a c tu r e s w i t h v a s c u la r i n j u ri e s s e c o nd a r y p r o c ed u r e . O v e ra l l i n f e ct i o n r a t e w a s 9 . 2 %

r e q u ir i n g r e p ai r ( G r a de I I I C G u s t il o ) . O n l y t h o s e c a s e s . O u t o f w h i c h 6 . 4 % w e r e s u p er f i c ia l i n f e ct i o ns a n d o n l y

w e r e i n c l ud e d w h e re t h e d e b ri d e me n t c o u l d b e d o n e 2 . 9 % we r e d e e p i n f e ct i o ns . 9 2 . 5% o f t h e fr a c t ur e sw i th i n f i rs t 1 2 h o ur s o f i n ju r ie s a n d a f te r d e br i de m en t e v en t ua l ly u n it e d. D e la y ed u n io n w a s o b se r ve d i n

t h e r e w a s n o s k i n l o s s a l l ow i n g p r i ma r y c l o s ur e w i t ho u t s e v e n p a t ie n t s ( 4 % ) a n d n o n u n io n i n s i x ( 3 . 5 %) . P r i ma r y

tension. He excluded the patients with drug dependent wound healing was observed irrespective of the size of

d ia be te s, p er ip he ra l v as cu la r d is ea se , p at ie nt s w it h t he wo un d o r t he si te . T he pr es en ce of b le ed in g f ro m

c o mp a rt m en t s y nd r om e s o r t h os e w i th p o ly t ra u ma w i th t h e wo u nd m a rg i ns w h ic h c o ul d b e a pp o se d w it h ou t

i n j u ry s e v er i t y s c o r es m o r e t h a n 2 5 . H e s t a b il i s e d a l l t e n s io n w a s f o u n d t o b e m o r e i m p or t a n t t h a n t h e s i z e ,

t he se f ra ct ur es e it he r w it h p ri ma ry i nt er na l f ix at io n o r n at ur e, s it e o f t he w ou nd o r t he m et ho d o f i nt er na l

w i th e x te rn a l f i xa t io n . I t w a s n e ce s sa r y t h at t h e w o un d f i xa t io n . I n s h or t , i n c a re f ul l y s e le c te d p a ti en t s e v en i n

s h ou l d n o t b e c o nt a mi n at ed w i t h s e wa g e o r o r ga n ic g r ad e I I I A a n d B c o mp ou n d f r ac t ur e s i t 's s a fe r t o c l os e

matter. He described wound healing classification and the skin primarily.

d e f in e d t h e o u t co m e i n t o e xc e l le n t , g o o d a n d p oo r R a ja s ek a ra n e m ph a si z ed th a t o u t o f a l l t h e o p eng r ou p s. T h e w o un d h e al in g ha d 4 g ro u ps ; g r ou p A -

f r ac t ur es t h ey t r ea t ed o nl y 3 3 % o f t h e pa t ie n ts w er ep ri ma ry w ou nd he al in g; g ro up B -m ar gi na l w ou nd

s u it a bl e f o r t h e pr i ma r y s k in c l os u re a n d w ar n ed t h a tn e c r os i s n o t r e q ui r i n g su r g i ca l i n te r v en t i o n; g r o u p C -

closure of all wounds without adequate debridementw o u n d n ec r o s is r e q u i ri n g s u r g ic a l i n t er v e n ti o n l i k e

a n d i n t h e p r e se n c e o f t e n s io n w o u l d b e d is a s t ro u s .s e c o n d a r y s u t u r i n g ; g r o u p D - w o u n d n e c r o s i s

REFERENCES:requiring surgical intervention like flap cover.

1. S . R a ja s ek a ra n e t a l - I m m e di a t e p r i m ar y s k in c l os u r e i nO u t o f 1 7 3 p at i e nt s t h a t we r e i nc l u d ed i n t h e s t ud y 1 4 3t y p e- I I I A a nd B o pe n f r a c tu r e s r e s u lt s a f t e r a m in i m umpatients had skin healing primarily. 26 patients healedo f f i ve y e ar s - J B o ne J oi n t S u rg e ry 2 0 09 ; 9 1B

w i t ho u t n e e d in g a n a d d it i o na l s u r g i c a l i n t er v e nt i o n .

W it h B es t c o mp l im e nt s f r om :

I PC A L AB OR AT OR IE S


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Articular cartilage injuries have remained a challenge tot h e o r th o pa e di s t f o r c e nt u ri e s. I n t h e p a st d e ca d e,

h o w e ve r, s i g n i f ic a n t a d v a nc e s ha v e o c c u r re d i n

c a r t il a g e s u r g er y, a n d t h e r e a r e n u me r o us s u r g i c a l

options available based on pertinent criteria (Fig. 1).

T h e go a l of c a rt i la g e re c on s tr u ct i ve s u rg e ry i s t he

r e st o ra t io n o f t h e b i om e ch a ni c al a n d p h ys i ol o gi c

f un ct io ns o f a rt ic ul ar c ar ti la ge b y t he c om pl et e

r e c o n s t r u c t i o n o f i t s m i c r o a r c h i t e c t u r e . T h e s e

techniques include osteochondral autograft transfer,

a u t o l o g o u s c h o n d r o c y t e i m p l a n t a t i o n , a n do s t e oc h o n dr a l a l l og r a f t t r a n sp l a n ta t i o n. E a c h o f t h e s e

i s n o w a v a i la b l e i n I n d i a.

Osteochondral Autograft Transfer (OATS) /

Mosaicplasty

O A TS i n v o lv e s t h e t r a n s f er o f o s t e oc h o n dr a l p l u g s f r o m

r e la t iv e ly n o n- w ei g ht b ea r in g r e g io n s o f t h e k n ee t o

r e s t or e d a m a ge d a r t ic u l a r c a r t il a g e . T h e p e r ip h e ra l

p ar ts o f b ot h f em or al c on dy le s at t he l ev el of t he

p a t el l o f em o r al j o i nt s e r ve a s d o no r s i t es . T h e g r af t i s

s e c u re d in a p re s s - f it m a nn e r, a n d n o f ur t h e r f i x a ti o n i sr e q ui r e d ( F i g . 2 ) . A l t h ou g h t h e re ar e r e p or t s o f t r e at i n g

l a r g e l es i o n s w it h t h i s t e c hn i q u e, t h e i d e al l e s i o n i s u p t o

4 cm2 / 2 cm diameter. Additionally, lesions deeper than

1 0 m m a re n o t a m en a b l e to O A TS a l o n e, s i n c e pl u g s

m a y n o t b e l o ng en o ug h f o r a d eq u at e f i xa t io n . O AT S

c an b e pe rf or me d th ro ug h a s ma ll a rt hr ot om y o r

a r th r os c op i ca l ly, h o we v er, s o me l es i on s a re m or e

a me na bl e to a n o pe n p ro ce du re , a s th e si te m ay b e

i na cc es si bl e b ec au se o f a p os te ri or l oc at io n o rbecause of an inability to flex the knee sufficiently.

I n a p r o sp e c ti v e ou t c o me s s t u dy, J a k ob f o l lo w e d 5 2

p a t ie n t s w h o u n d e r we n t m o s a i cp l a s ty f o r a n a v e r ag e o f[1]

3 7 mo n th s . L e si o ns s i z ed u p t o 1 6 c m2 w e re i n c lu d ed .

T he st ud y f ou nd th at 92 % of p at ie nt s re po rt ed

i n c r ea s e d k n e e f u n c t io n a t l at e s t fo l l ow - u p. B i o ps i e s

w e r e p e r f or m e d in f o u r p a t ie n t s 4 to 4 1 m o nt h s a f te r

s u rg e ry. H i st o lo g ic e x am i na t io n s re v ea l ed t h at t h e

transplanted cartilage retained its hyaline character.

Recent advances inc ar ti la ge r e co ns tr uc ti ve s u rg er y i n I nd ia

D r. D i n s h a w P a rd i w a l a

F i g u re 1 : D e c i s io n m a k i ng i n t h e s ur g i c al t r e at m e n t of c h o n d ra l

d e f e c t s in t h e k n e e T h e K D A H a l g o ri t h m .

F i g . 2 : O s t e o c ho n d r a l a ut o g r af t m o s a i c pl a s t y i n v o lv e s t h e p r e s s -

f i t t r a ns f e r o f o s t e o ch o n d r al p l u g s f ro m r e l at i v e l y n o n -wei ghtbea r i ng r egi ons of the knee to r estor e da ma ged a r ti cul a r

ca r ti l a ge l esi ons upto 4 cm2 / 2 cm di a meter.


13/48


I n a s t u d y c o m p ar i n g O AT S t o m i c ro f r a ct u r e , G u d a s i s a l s o l i m it e d t o t h e t r e at m e nt o f c a r t il a g e d e f ec t s l e s s

p e r f or m e d a r a n d o m iz e d c o n t r ol l e d t r ia l w i t h 5 7 t h a n 4 c m 2 , d u e t o t h e l i m it e d a m o u nt o f a u t o lo g o u s[2]

a th le te s . 2 8 O AT S a nd 29 mi cr of ra ct ur es we re tissue available. Although there is a seamless osseous

p e rf o rm ed , w i th a n a v er a ge f ol l ow - up o f 3 7 mo n th s . A l l i n t e gr a t io n o f t h e pl u g s , a p e rs i s t en t g a p r e m ai n s a t t h e[3]

l e si o ns w er e 1 c m 2 to 4 c m2 . R e su l ts a t 3 ye a rs l e ve l o f t h e c a rt i la g e . T h es e g a ps a p pe a r t o b e f i ll e d

d e m on s t r at e d t h a t 9 6 % o f t h e O A TS g r o u p h a d g o o d t o w i t h f i b r ou s t i s s ue . T h i s r a i se s c o n c er n , s i n c e m u l t ip l e

e x c e l l en t r e s u l t s , a s c o m p a r ed t o 5 7 % o f t h e p e r si s t e nt g a p s m i g h t a f f e ct j o i nt c o n g ru i t y a n d c r e at e

m ic ro fr ac tu re g r ou p. W he n u s in g r et ur n t o s po rt a s a n a st ar ti ng po in t f or c ar ti la ge de ge ne ra ti on .o u t c om e , c o m pa r i s on d e m on s t r at e d t h a t 9 3 % o f O A TS

S y n th e t ic M o s ai c p l as t y I m p l an t spatients were able to return to sport at 6 months, while

R e ce n tl y, t h e u se o f s y nt h et i c i mp l an t s f or t h e re p ai r o fonly 52% of microfracture patients were able to return to

f oc al de fe ct s ( Fi g. 3 ) h as be en a dv oc at ed . T he ses p o r t a t t h a t t i m e. A d d it i o n al l y, b i o ps i e s o f t h e r e p ai r

s y n t h e t i c s c a f f o l d s , f r e q u e n t l y c o n s i s t i n g o fc ar ti la ge w er e pe rf or me d at o ne y ea r i n 2 5 of t he

p o ly l ac t id es - c o- g ly c ol i de s , c a n b e u s ed e i th e r a l on ep a t i e n t s . M i c r o f r a c t u r e p a t i e n t s a l l h a d a

f or a foc al def ec t or as a del iv er y v eh ic le fo rfibrocartilaginous repair, while all OATS repairs retained

c h on d ro c yt e s o r g r ow th f a ct o rs . T h ey a r e de s ig n ed t otheir hyaline cartilage at one year.

b e m ul ti ph as ic i n n at ur e c on st ru c te d o f a po ro usO AT S h a s t h e a d va n ta g e o f b e in g a s i ng l e- s ta g e

cartilage phase and a porous bone phase and their

p r o ce d u r e. A d d it i o n al l y, t h e d e f ec t i s r e pa i r ed wi t h d eg ra da ti on c an b e ta il or ed ( ap pr ox im at el y 6 t o 9h y a l in e c a r t il a g e , a s c o m p ar e d t o f i br o c a rt i l ag e i nm on th s) . T hi s m ul ti ph as ic d es ig n a ll ow s o ne t o

m i c r of r a c tu r e . T h e re i s n o r i s k o f d i s ea s e t r a n s mi s s i ona d dr es s b o t h t h e r e ge n er a ti o n o f a r ti c ul a r c a rt i la g e, a s

a s s e en w it h a l lo g ra f ts , a n d i t i s a re l at i ve ly l ow - co s tw el l a s t he su b ch on dr al bo ne . N ie de ra u er a nd

p r o ce d u r e w i t h n o re q u ir e m en t o f o r d er i n g g r a f ts o rcolleagues showed that focal osteochondral defects

i m pl a nt s . H o we v er, t h is p r o ce d ur e d o es c a r ry r i sk o ftreated with various implant constructs can be repaired

d o n or s i t e m o r b i di t y ( p a t el l o f em o r al p a i n a n d c r e p i t us ) , [4]wi th a h ya li ne- li ke c ar tila ge . U nli ke O ATS , th is

w i t h t h e p o te n t i al o f d e g en e r at i v e c h an g e s f r om g r a f tt e c h ni q u e is n o t l im i t ed b y d e f ec t s i z e si n c e a ny

h ar ve st in g. O AT S c an b e a te ch ni ca ll y d em an di ngn u m b er o f s y n t h et i c p e g s m a y b e i m p la n t ed . M o r eo v e r,

p r oc e du r e, a s th e su r ge o n n e ed s to r ec r ea t e t h es i n c e th e r e is n o g r a ft h a r v es t , t h e r e i s n o d on o r s i t e

n o r ma l c o n t ou r o f t h e k n e e i n t h r ee d i m en s i o ns . O AT S

F i g . 3 : S y n t h e ti c o s t e o c ho n d r al i m p l an t s

(Tr ufi t) ha ve the abi l i ty to r econstr uct

l a r ge s i z e d d e f ec t s s i n ce a n y n u m b e r o f

s y n t h et i c p e g s ma y b e i mp l a n t ed .

M or eover, si nce ther e i s no gr a ft ha r vest,

t h e r e i s no d o no r s i t e m o r b id i t y o r f u r t h er

d e g e n er a t i on o f t h e d o n o r c o m p ar t m e n t

a s i s o f c o n c e rn d u r i ng m o s a i c pl a s t y.


14/48


m or bi di ty o r f ur th er d eg en er at io n o f t he d on or a s i s o f c ho nd ro cy te s i so la te d. T he c e ll s a re c u lt ur ed f o r 4

c o n c er n d u r in g m o s a ic p l a st y. w e e ks , w h i c h i n c r ea s e s t h e n u m b er o f c e l ls b y a f a c t or

of 100. Since the implanted cartilage cells need a stableAutologous Chondr ocyte Implantation (ACI)

e nv ir on me nt i n w hi ch t o h ea l, p re di sp os in g f a ct or s

ACI was first reported by Brittberg and associates, in such as meniscal pathology, ligamentous instability,1 99 4, a s an a lt er na ti ve f or t he t re at me nt o f a rt ic u la r a n d ma l a li g n m en t s h ou l d be a d dr e s s ed p r io r t o[5]

c a r t il a g e i n j u ri e s . T h e i n v es t i g at o r s s t a t ed t h a t t h i s implantation.

procedure produces a hyaline-like cartilage repair. It isThe second stage of the procedure takes place 4 to 6

a t wo - st a ge pr o ce d ur e , w i th t h e f i rs t st e p b e in g th ew e e ks a f t e r t h e b i op s y. E x p os u r e i s d ep e n de n t u p on

a r th r os c op i c h a rv e st i ng of c h on d ro c yt e s f r om t h ed e fe c t l o ca t io n w i th c o mm o n u t il i za t io n o f a m e di a l o r

p a t ie n t ' s k ne e . T h e c h o nd r o c yt e s a r e th e n c u l t ur e d i nl a t er a l p a r a pa t e ll a r m i n i -a r t h ro t o my. T h e f i r s t s t e p i n t h e

vitro and reimplanted back into the knee during asecond stage is defect preparation. All unstable and

s u b s e qu e n t op e n o p er a t i on . N o r el a t io n s h ip h a s b ee ndamaged cartilage is debrided back to a healthy, stable

f o u n d be t w ee n d e f ec t s i ze a n d c li n i c al o u t co m e .r i m. V er t ic a l w a ll s ar e fo r me d wi t h a s ha r p b l ad e to

Therefore, it seems that ACI is more amenable to largerc r e a te a w e l l- s h o u ld e r ed l e s i o n . C a r e i s t a k e n t o a v o i d

defects than the previously described procedures. p e n et r a ti o n i n t o t he s u b c h on d r a l b o n e , a s t h i s wo u l d

T he f ir st s ta ge in A CI in vo lv es a n a rt hr os co pi c stimulate a fibrous response similar to microfracture or

e v al u at i on o f t h e fo c al c h on d ra l le s io n . T h e su r ge on a b ra s io n a r th r op la s ty. E a rl i er g e ne r at i on s o f A C I u s e d

s ho ul d as se ss t he s iz e, c on ta in me nt , d ep th , a nd e i t h er a p e r io s t ea l f l a p s u t u r ed t o t h e c ar t i la g e r i m to

potential bone loss of the lesion. Lesions 3 mm to 6 mm c o ve r t h e c ar t il a ge d e f ec t a n d c on t ai n t h e i nj e ct e d

d e ep e r t h an t h e s u bc h on d ra l bo n e r eq u ir e d b o ne c u lt u re d c ho n dr oc y te s , o r a c o ll a ge n s c af f ol d t ha t i s

g r a f ti n g pr i o r t o AC I wi t h t h e e a r li e r g e n er a t i on s of A C I , s e e de d w i th t h e p a ti e n t' s h a r v es t e d c h on d r oc y t e s

h o we v er w it h C h on d ro n ( 4 th g e ne r at i on A C I) t h i s i s n o t (MACI - matrix induced chondrocyte implantation) as a

a l i mi t at i on . T h e op po s in g s u rf a ce o f t h e ca r ti l ag e m e a n s o f c h o n d r o c y t e d e l i v e r y . R e p o r t s o f

d e f ec t s h o u l d b e a s s e s se d f o r d e g en e r at i o n . G r a de I I I c o m pl i c a ti o n s , i n c l ud i n g g r a f t h y p e r t r op h y u s i n g t h e s e

l e s io n s o f t h e o p po s i n g s ur f a c e ar e c o n s id e r ed a t e ch n iq u es , l e d t o th e u se o f b i oa b so r ba b le f ib r inr e la t iv e c on t ra i nd ic a ti o n t o A CI . T h e n e xt s t ep i s t he c on st ru ct s a s a n a lt er na ti ve . T he 4t h g en er at io n

h a r v es t i n g o f t h e c h o n d ro c y t es . T h i s i s p e r f or m e d w it h C h on d ro n a v ai l ab l e in I n di a u ti l is e s a c ho n dr o cy t e

a c o r e bi o p s y p u n c h . T h e p re f e rr e d lo c a t io n s i n cl u d e f i b r in c o n s t ru c t t h a t i s i n j ec t e d d i re c t l y i n t o t h e d e fe c t ,

t he l at er al ed ge o f t he i nt er co nd yl ar n ot ch o r t he a n d w h i c h s o l id i f i es w it h i n 7 m in u t e s o f d e l iv e r y ( F i g . 4 ) .

superomedial trochlea. The subchondral bone should T h e s e n ew c h o n dr o c y te d e l iv e r y p r o ce d u r es h a v e t h e

b e s l i g h tl y p e n et r a te d d u r i ng t h i s p r o c e du r e t o a l l o w a potential benefits of decreased operating time, smaller

f i b r oc a r t il a g e r e pa i r o f t h e d o n o r s i t e . inc isions, even distribution of chondrocytes, and

d e c re a s e d p a i n . T h e r e p ai r c o n s tr u c t i s th e n c h e c ke dT h e c a r t il a g e s p e ci m e ns a r e s e n t t o t h e l a b o r a to r y i n a

f o r s t ab i li t y b y m o vi n g t h e k n ee f ro m fu l l e xt e ns i on t os te ri le t u be w it h c ul tu re m ed iu m. T he h a rv es te d

f le xi on f or 1 0 cy cl es . T he p os to pe ra ti ve p ro to co lc a r t i l a g e i s e n z y m a t i c a l l y d i g e s t e d a n d t h e

F i g . 4 : A u t o l og o u s c h o n d ro c y t e i m p l an t a t i on ( C h o n dr o n ) f o r a l a r g e l a t e r al f e m o r a l c o n dy l e o s t e o c h on d r a l d e f e ct . F o l lo w i n g f i r st s t a g e

a r t h ro s c o p ic c a r t il a g e b io p s y a n d i n v i t r o c ho n d r oc y t e c u l t ur e , t h e c h o nd r o c y t e f i b r in m i x t ur e i s i n je c t e d i n t o th e d e f e c t .


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i n v ol v e s e a r ly R O M , w i t h t h e u s e o f C P M . T h e p a t ie n t i s f o l l ow - u p w a s 1 9 m o n t hs , a n d a v e r ag e l e s io n s i z e w a s

k e p t n o n w ei g h t be a r in g f o r 6 w e ek s . W e ig h t b ea r i n g i s 5 c m 2 . A t o n e y e a r, 8 8 % o f p a t ie n t s i n t h e A C I g r o u p

t h e n p r o g re s s e d o v e r t h e n e x t 6 we e k s. P a ti e n ts a re s h o w ed g o o d t o e x c el l e nt f u n c t io n a l s c o r es , c o m p ar e d

t y p i ca l l y p e r mi t t ed t o r e t ur n t o l i g h t s p o r t a t 6 m o n th s t o 6 9 % i n t h e O A TS g r o u p. A d d it i o na l l y, s e c o nd l o o k

postoperatively. arthrosc opy in 60 patients revealed th at 82% of lesions

t re at ed by A CI ha d g oo d o r e xc el le nt re pa ir s, a sI n a S w ed i sh s t ud y, P et er s on e v al u at e d t he l o ng - te r m

c o mp a re d t o on l y 3 4 % in t h e OA TS g r ou p . B i op s ie s o f[6]d ur ab il it y o f 1 st g e ne ra ti on A CI . 6 1 p at ie nt s w it h f oc al

1 9 pa t i en t s i n t h e A C I g r o u p w e r e t a k en a t on e ye a r.cartilage defects of the knee underwent ACI and had anS e v en o f t h e s e r e pa i r s d e m on s t r at e d h y a l in e c a r t i l ag e

a v er a ge f ol l ow - up o f s e ve n y e ar s . A t 2 ye a rs , 5 0 (8 2 %)o f n o rm a l ap p ea r an c e, s e ve n d e mo n st r at e d a m ix o f

patients had good to excellent clinical results.h y a l in e a n d f i b r o c ar t i la g e , a n d f i v e d e m on s t r at e d a

Additionally, 85% of patients with isolated femoralm a i n ly f i b r oc a r t il a g e r e pa i r. O f i n t er e s t , o n e p a t ie n t w a s

condyle lesions had good to excellent results. However,b i o p s i e d a t b o t h o n e y e a r a n d t w o y e a r s

t h e s e ou t c o me s w e re n o t a s g oo d i n p a t el l a r l e s io n s ,p o s t op e r at i v el y. A t 1 y e a r, t h e r e pa i r s h o w ed a m i x t u r e

w h e re o n ly 1 1 o u t o f 1 7 p at i e nt s ( 6 5% ) h a d g o o d t oo f h y a l in e an d f ib r o c ar t i la g e ; w h e re a s af t e r 2 y ea r s , t h e

excellent results at 2 years. The outcomes seemed tor e p ai r w a s m a i n ly h y a l in e c a r t il a g e. T h i s s u p p or t s t h e

i m p ro v e o v e r t i m e, w i t h 5 1 p a t ie n t s r e p or t i ng g o od o rc l ai m o f P et e rs o n t h at t h es e r e pa i rs ca n m a tu r e t o

excellent clinical results at latest follow-up (range 5 toh y a l in e - l ik e c ar t i la g e a s m u ch a s 2 y e a r s a f t e r

1 1 y e ar s . ) Te n f a i l ur e s d id o c c u r; h o w ev e r, n o f a il u r es i mp la nt at io n. N o b io ps ie s o f t he O AT S g ro up w er eo c c u r re d a f t er 2 ye a r s . T h e i n v es t i g at o r s c o n c lu d e d

t h a t if A C I i s s uc c e s s fu l , a l o n g- l a s ti n g , d u r a bl e r ep a i r i s performed. The investigators concluded that ACI was

a c h i ev e d . B i o p sy s p e c im e n s w e r e t a k en f r o m 1 2 of t h e s up er io r t o O AT S; h ow ev er, t hi s s tu dy w as o f l ar ge r

p a ti en t s a t a m e an o f 5 4 m o nt h s p o st o pe r at i ve ly. 8 lesions, approaching the recommended upper limit for

p a t i e n t s h a d r e p a i r s w i t h h y a l i n e - l i k e c a r t i l a g e OATS.

characteristics, while 4 were fibrous in nature.Osteochondral Allograft Transplantation

I n a m ul t i c en t e r p r o sp e c ti v e s t u d y i n t h e U n i t ed St a t e s,A special situation arises when a large sectoral defect[7]

B r o wn e s t u di e d 87 p a t ie n t s wh o u n d er w e nt A C I .e x i st s w i t h s i g n if i c a nt b o n e l o ss . T h e o n ly v i a b le o p t i on

P a ti e n t s w e r e f o l lo w e d f o r 5 y e a rs . T h e p at i e nt s i n t h i si n t h i s s i t u a t i o n i s o s t e o c h o n d r a l a l l o g r a f t

c o ho r t h a d r el a ti v el y l a rg e de f ec t s, m e as u ri n g a nt r a n sp l a nt a t i on . T h e u s e o f o s t e oc h o n dr a l a l l og r a f ts

a v er a ge o f 5 c m 2. A d di t io n al l y, 7 0 % of t h es e p at i en t s

a l lo ws f o r t h e t ra n sf e r o f h y al in e c a rt i la g e t o r ep a ir t h ea l re a dy h a d on e f ai l ed c a rt i la g e re p ai r p r oc e du r e, d e f ec t , w h i le n o t be i n g li m i te d b y i t s s iz e . M o r eo v e r i t i smaking this a challenging patient population. Sixty-two

t h e o n ly t e c h ni q u e t ha t c a n r e c o ns t r u ct l a r g e s ec t o r alpatients had improved functional outcomes at five

o s te o ch o nd ra l d e f ec t s t h re e- d im e ns i on a ll y ( F ig . 5 ) .y e a r s. S i x pa t i en t s r em a i n ed u n c h an g e d an d 1 9

T h e re i s no d o no r s i t e m o r bi d i ty i n v o lv e d in t h e u se o fp a t ie n t s r ep o r te d w o rs e n e d co n d i ti o n s . T h e s t ud y

a l lo g ra f ts . A d di t io n al ly, a l lo g ra f ts m a y b e t a ke n f r omconcluded that ACI proved to be an effective treatment

y o un g er, h e al t hi e r d on o rs i n w h om th e qu a li t y o f b o nef o r l a r g e a r ti c u l ar d e f ec t s t h a t f a i l ed p r e v i o us a t t e m pt s

a n d c a r t il a g e i s s up e r io r t o th a t of t h e h o s t . H o w ev e r,at restoration.

t h e u s e o f o s t eo c h o n dr a l a l lo g r a ft s i s n o t w it h o u t

d r a wb a c k s. T h e u s e of f r e s h f r o z en a l l og r a f ts i mp a r t s aC om pa ri ng AC I t o O AT S, B en tl ey c on du ct ed a

r i s k o f d i s e a s e t r a n s m i s s i o n a n d p o s s i b l y a np r o sp e c ti v e , r a n do m i z ed t r i a l i n 1 0 0 p a ti e n ts [ 8 ] . M e a n

F i g . 5 : O s t e o c ho n d r al a l l og r a f t t r an s p l an t a t i on f o r a n e x t e n si v e s e c t or a l o s te o c h o nd r a l d e fe c t o f t h e f e m o ra l t r o c hl e a i n a y o u n g ma l e .


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4. Niederauer GG, Slivka MA , Leatherbur y NC, et al.i mm u no ge ni c r es p on s e. O s te oc h on d ra l a ll og ra f tsE va lu at io n o f m ul ti ph as e i mp la nt s f or r ep ai r o f f oc als h o w a t im e - de p e nd e n t l o s s o f v i a b le c ho n d r oc y t e s

[9] o s t e o c h o n d r a l d e f e c t s i n g o a t s . B i o m a t e r i a l s .w h en r e fr i ge r at ed . T h er ef o re , a l lo g ra f ts a r e o f l i mi t ed2000;21:2561-74.

availability and should be transplanted within a narrow

w i nd o w o f t i me . B u gb e e a nd a s s o ci a te s r e po r te d t h e 5 . B r it t be r g M , L i nd ah l A , N i ls s on A , e t a l . Tr e at me n t o f d ee pc a r t i l a g e d e f e c t s i n t h e k n e e w i t h a u t o l o g o u sr e su l ts o f a l lo g ra f t t r an s pl a nt a ti o n i n 9 7 kn e es , w i th a n

[10] c h o n d r o c y t e t r a n s p l a n t a t i o n . N E n g l J M e d .a ve ra ge f ol lo w- up o f 5 0 mo nt hs . O f 6 1 kn ee s th at h ad

1994;331:889-95.allografting to one surface, the authors reported goodt o ex c e ll e n t r e s u lt s i n 7 9 % o f p a t ie n t s . O f 3 0 kn e e s t h a t 6 . Pe te rs on L , B ri tt be rg M , K iv ir an ta I , A ke rl un d EL , e t al .

Au tologous ch ond rocyte transplantation. Biomech anicsunderwent allografting to two opposing surfaces, onlyand long-term d u rability. Am J Sports Med. 2002;30:2-12.5 3 % h ad g o o d t o e xc e l le n t re s u l ts . A s t u dy b y G h a z av i

a n d co w o rk e r s s h o we d an 8 6 % s u c c es s r at e of 1 2 7 7. Browne JE , Anderson AF, Arcier o R, et al. Clinicalk n ee s t r ea t ed wi t h o s te o ch o nd r al al l og r af t s. T h ey o u tc o m e of a u t ol o g ou s c h on d r oc y t e im p l a nt a t io n a t 5

y e a r s i n U S s u b j e c t s . C l i n O r t h o p R e l a t R e s .d e m on s t r at e d t h a t g ra f t s u r v iv o r s hi p w a s 9 5 % a t 5[11] 2005;(436):237-45.y e ar s , 7 1 % a t 1 0 y e ar s , a n d 6 6 % a t 2 0 y e ar s .

8 . B en tl ey G , B ia nt L C, C ar ri ng to n R W, e t al . A p ro sp ec ti ve ,REFERENCESr a nd om i se d c om p ar i so n o f a ut o lo g ou s c ho n dr o cy t e

1 . J a ko b R P, F ra n z T, G a ut i er E , M ai n il -V ar l et P. A ut o lo g ou s i mp la nt at io n v er su s m os ai cp la st y f or o st eo ch on dr al

o s t eo c ho n d r al g r a f ti n g i n t h e k n e e: I n d i ca t i on , r e s ul t s , d efects in th e knee. J Bone Joint Surg Br. 2003;85:223-30.a n d r e f l ec t i on s . C l i n O r t h op R e l a t R e s . 2 0 0 2; ( 4 0 1) 1 7 0- 8 4 .

9. Malinin T, Temple HT, Buck BE . Transplantation of2 . G ud a s R , K a le si n sk a s R J, K i mt y s V, e t a l . A pr o sp e ct i ve o s t eo c ho n d r al a l l o g r af t s a f t er c o l d st o r a ge . J B o n e J oi n t

r an do mi ze d c li ni ca l s tu dy o f m os ai c o st eo ch on dr al Su rg Am. 2006;88:762-70.a u t ol o g ou s t r a n s p la n t a ti o n v e r s us m i c r o f r ac t u re f o r t h e

1 0. B ug be e WD, C on ve ry F R. O st eo ch on dr al a ll og ra ftt r e a tm e n t of o s t eo c ho n d ra l d e f ec t s i n t h e k n ee j o i n t i ntransplantation. Clin Sports Med . 1999;18:67-75.you ng ath letes. Arth roscopy. 2005;21:1066-75.

11. Ghazavi MT, Pritzker KP, Davis AM, et al. Fresh3. Hor as U, Pelinkovic D, Her r G, et al. Autologouso s t e o c h o n d r a l a l l o g r a f t s f o r p o s t - t r a u m a t i cch ond rocyte implantation and osteoch ond ral cylind ero s t eo c ho n d ra l d e f e ct s o f t h e k n e e. J B o n e J o in t S u r g B r.t ra ns pl an ta ti on i n c ar ti la ge r ep ai r o f t he k ne e j oi nt . A1997:79:1008-1013.p r os p ec t iv e, c o mp a ra t iv e t ri a l. J B o ne J o in t S ur g A m .

2003;85:185-92.


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G u i de l i nes - Pa th ol o gi cal F r a ctu r e s i n C h i ldr e n

Dr. Rujuta Mehta

Diagnosis

Tr iv ia l tr au ma o r n o h/ o tr au ma

C om mo n s it es f e mu r, h u me ru s, t ib ia

P r e -e x i st i n g l e s io n - e . g c y s t e r o di n g a t l e a st 1

cortex or weight bearing area of bone eg calcar

Tr ea t c au s e an d e ff e ct k e ep in g g r ow t h i n m i nd .

F i g 1 : F r a ct u r e i n p r e - e xi s t i ng f i b r o us

d y s p l as i a , t h r o c o r e b i o p sy s c a r

Investigations

S k el e ta l s u rv e y, a r th r og r am s

R ol e o f s ca nn og ra m, a li gn me nt v i ew s

U SG , C T w it h/ wi th ou t 3 D, M RI

H o r mo n a l a s s a y s / m a r ke r s / ot h e r s e r ol o g i ca l t e s t s

F i g 2 : M R I o f t h e s a me l e s io n a s f i g 1 s h o w in g l a rg e r

a r e a o f i n v o lv e m e n t t h a n o n X- r a y.

Management

R o le o f B o ne g ra f ts f i ll e rs l ik e G b o ne

A dj uv an t t he ra py

R ol e o f c on se rv at iv e m an ag em en t/ i nt ra -l es io na l

injections etc.

C h oi c e o f i m pl a nt -I M s u pp o rt v / s p l at es

F i g 3 : I . M S t a b il i s a ti o n o f f i b r ou s d y s p l as i a l e s i on s

Complications

R es u rg e ry / re f ra c tu r e r a te s

C o mp l ic a ti on s o f a d ju v an t t h er a py

N on -u ni on s e tc .

M ig ra ti on o f i m pl an ts

I n f e c t io n a n d i m p l a n t m i g r at i o n c o m p li c a t i ng r e f r ac t u r e i n

osteogenesi s i nper fecta

CONGENITAL PSEUDOARTHROSIS TIBIA

C as e 1 - S wa pn al i

3 yrs old at presentation- given a protective brace, child

n o n c o m pl i a nt , t r i pp e d o ve r a b e d - sh e e t a nd f r a c tu r e d

t hr o t he c y st ic a re a. G en E xa m- c af a u l ai t s po ts o n

b ac k a nd ab do me n, n o o th er s ti gm at a. O pe ra te d


18/48


p r i m a r i l y t e c h n i q u e o f c o m p l e t e e x c i s i o n o f

p s e u da r t hr o t ic s e g m en t a n d s u r r o un d i ng d i s e a s ed

s o f t y t i s s ue , c o n t ra l a te r a l t i b ia l in t e rp o s it i o n g r a f t w i t h

I M n a i l in g e n ga g i n g c a l c an e u m a l s o- a n t eg r a d e, w i t hc a n c e ll o u s g r af t i n g w it h p r o te c t i on i n p a l s te r 6 m t h s .

Result: C om pl et e u ni on . Fu rt he r p la n p ro te ct io n i n

brace till skeletal maturity and retaining the IM support

e x c h an g e n a i l in g w i t h a w a t c h o n a n k le v a l g u s a n d l i mb

l e n g th d i s c re p a nc y

C as e 2 - M an al i

P r es e nt e d a t 11 m th s , I M n a il i ng w it h o n la y m a te rn a l

Tibial grafting with fixation done, devise retained 1.5 yrs

n o u n i o n . I l i za r o v d o ne a t 3 . 5 y r s o f a g e , w i th r e - ex c i s io n

o f d i se a se t i ss u e , wi t h I m n a il i ng w i th c a nc e ll o us B G

i l i ac c r e s t , w it h r e b o n e g r a ft i n g

D i s t ra c t io n a n d c om p r es s i o n f o r 3 m t h s, c o n s ol i d at i o n

3 m t hs . I m n ai l r et a i n ed 1 y r. R e s u lt i n g u n i o n. F u rt h e r

p la n p ro te ct io n i n b ra ce t il l s ke le ta l m at ur it y a nd

retaining the IM support exchange nailing with a watch

on ankle valgus and limb length discrepancy.

C as e 3 - I sh aa n

O n f o ll o w u p s i nc e 6 m t hs o f a g e 5 y r s o f a g e t i ll d a te

n o t y e t f r a c tu r e d, r e f u s es b r a c e- b o t h a n g u l at i o n a n d

deformity improving, fibula more involved, Tibia intact.

F ur th er p la n I nt er ve nt io n w it h E xc is io n a nd I M n ai li ng

i n c l ud i n g f i b u la f i xa t i on w i t h B G a n d f u r t he r p r o te c t io n

when the fracture occurs.


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C as e 4 - S ol eh a

P r im a ry : l i ve v a sc u la r f i bu l a d o ne a t 1 . 5 y r s o f a g e,

f ix ed w it h I M n ai li ng , u ni te d bu t re fr ac tu re d wi th in 8

mths. Treated with simple Bone grafting and repeat I M

n a il in g w i th p ro t ec t io n i n p la s te r f o r 6 mt h s a n d b r ac e

t h en o n .

Messages

D if fi cu lt c on di ti on t o t re at , l at er s ur ge ry m ar gi na ll y

b e t te r r e s u lt s a s d i s ea s e i t se l f r e m ai n s l e ss a c t i v eas age advances and burn's out.

C o mp l et e e x ci s io n w it h I M n a il i ng a n d r et a in i ng th e

I M s u p p or t t il l s k el e t al m a tu r i ty a n d B on e g ra f t i ng

works well in average hands

I l iz a ro v an d li f e v a sc u la r f i bu l a e x ce ll e nt p ri m ar y

u n io n r a te s b ut h i gh r e fr a ct u re r a te s , p r ob l em s o f

LLD and ankle valgus to be watched for particularly

if fibula is not addressed. Both procedures

t e c h n ic a l l y d e m an d i n g a nd l o n g l ea r n i ng c u r v e ,

b e t t er a s a r e s er v e p ro c e du r e f o r f a i l ed c a s e s a t a

l a t er a g e .

REFERENCES :

1 . E PO S s t ud y J PO B vo l 9 . N o 2 . 2 00 0.

2 . B o er o S , Ca t ag n i M e t a l .J P O 1 9 97 , 17 : 67 5- 8 4

3 . P ho R WH e t a l . J BJ S B r. 19 85 ;6 7: 64 -6 9

4 . D ro r P al ey, M au ri zi o C at ag ni C OR R 1 98 2 ,n o 2 80 . p g 8 1-

9 3

5 . P a th o lo g y a n d n a tu r al H i st o ry o f C P T H a ro l d B o yd . C O RR1 6 6: 5 - 13 , 1 9 82


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Introduction: b o dy c a us i ng c e n t ra l b o dy c o ll a ps e / v e rt e br a p l an a .

P os t er i or e le m en t af f ec t io n a n d s k ip l es i on s a re t heS pi na l Tu be rc ul os is i s o n t he ri se n ot on ly i n t heo t h e r c o m m on e r v a r ie t i es s e en i n p r a c ti c e .

s u b co n ti n en t , b u t a l so in t h e w es t er n w o rl d . A s mo r e

and more cases present to orthopedic clinics all over ' D i s c s p a r in g ' l e s io n s a r e b e i n g s e e n c o m m on l y t o d ay,

t h e w o r l d, a c a d em i c a n d c l i n i ca l i n t e r es t i n t u b e rc u l o s is m a k i n g r a d i o l o g i c a l d i a g n o s i s m o r e a n d m o r e

a m o n gs t s u r g e on s i s r i s i n g . T h i s a r ti c l e r e vi e w s o u r intriguing.

u n de r st a nd i ng o f s p in a l tu b er c ul os i s, a n d ta k es u sT h e c l i n ic a l r e l ev a n c e o f t h e s e n ew f o r m s o f S p i na l T B i s

t h ro u gh s o me o f t h e cu r re n t th i nk i ng o n t h e s u b je c t.that radiological diagnosis can no longer be as 'certain'

N ew er c on ce pt s, s om e di ff er en t f ro m tr ad it io na la s i n t h e p as t , a n d a ll l e s io n s h a ve t o b e vi e w ed w i th

b e l ie f s , a l s o c o m e f or t h i n t h e e n s u in g d i s c u s si o n .s u s pi c i on , k e ep i n g t h e mi n d op e n fo r m u lt i p le

Epidemiological trends: differentials including spinal tumors.

S p i na l T B (a n d m os t f o rm s o f e x t ra p u l mo n a r y T B ) i s Ty p e s o f s pi n a l a f f ec t i o n i n T B

b e l ie v e d to b e r ea c t i va t i on o f d o r ma n t d is e a s e ( f r o m1 . T h e C la s si c l e si o n i s S p on d yl o di s ci t is

c h i l d h o o d e x p o s u r e ) r a t h e r t h a n f r e s h a i r b o r n e

i n f e ct i o n s. A t r a n s i e nt s t a t e o f l o w er e d i m m u ni t y i s o f t e n 2 . C en tr al B o dy l es io ns

r e sp o ns i bl e f o r d i se a se r ea c ti v at i on . D u e t o t h is3 . P ar a di s ca l d is e as e w i th d is c s p ar i ng

reason, Multi Drug Resistant (MDR) TB is thought to be

l e ss c o mm o n i n e x tr a p ul m on a ry T B t ha n i n p u lm o na r y 4 . P os t er i or e le m en t T B

T B, ( wh ic h i s o ft en a de no vo , a ir bo rn e i nf ec ti on a nd5 . S k ip l e si o ns m u lt i pl e n o n- c on t ig u ou s v e rt e br a l

h e n c e m or e l i k el y t o b e f r o m n e we r, r e s i st a n t s t ra i n s )involvement

H a vi n g s a id th a t, M D R T B i n t h e s p in e i s n o t a t a l l

u n c o mm o n , a n d h as m a n a ge d t o ma k e s u rg e o n s 6 . I v or y v e rt e br a sc l er o ti c r ea c ti o nu n c e rt a i n o f t h e i r d i a gn o s i s a n d m a n a ge m e nt , c a u s i ng

7 . I n tr a s p in a l t ub e rc u lo m asg r e a t c o n ce r n t o w ar d s t h i s u n f a v or a b l e m o de r n t r e n d.

T h e p er c en t ag e o f M D R T B s p in e i n c h il d re n i s m u ch Presentation of Spinal TB

h i gh e r t h an a d ul t s, a n d t h at i n u r ba n c e nt e rs h a s b e enS p i ne T B o f t e n p r e se n t s w it h t h e i n n oc u o u s s y mp t o m

r epo rt ed to be hig her th an in ru ral se tt in gs . T heo f b ac k pa in , w hi ch m ay n ot b e a cu te or s ev er e. T he

r e po r te d r at e s o f M D R T B s p in e i n o u r c o un t ry v a ry f r omc l as s ic a l c on s ti t ut i on a l s ym p to m s of f e ve r, l o ss o f

5 t o 2 0% . X D R T B ( ex t re m el y d r ug r e si s ta n t TB i s t h ea

ortho front

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