ORTHOWALKATHON- a Life Time Journey through Orthopaedics


Journal of Clinical Orthopaedics | Vol 1 | Issue 1 |  July – Dec 2016 | page:62 | Dr. K. V. Chaubal

Dr. Aseem Parekh, Prof and HOD of Orthopaedics and President of Bombay Orthopaedic Society, had the privilege of spending an inspiring half day with the living legend and doyen of Orthopaedics in India, our very own Dr. K. V. Chaubal.

ORTHOWALKATHON- a Life Time  Journey through Orthopaedics

The third of four siblings, Dr. Chaubal was born into a family where education and discipline came naturally to the family. Father was a teacher in a government school. An emphasis on the importance of an all round development, also saw his forays into sports.
From Elphinstone College, Dr. Chaubal entered the portals of medicine through the Seth G. S. Medical College. His interest in Orthopaedics led him to Nair Hospital from where following a registrar post, he qualified for his M.S. (General Surgery). With a nature, passionate to enhance his knowledge and skills, Dr. Chaubal headed to England to complete his FRCS.
Dr. Chaubal’s hard work, diligence and sincerity, that he humbly calls “luck”, saw him take steady and progressive steps upwards from a casualty officer at Lambeth Hospital to a surgical SHO and a registrar. His skills, knowledge and grit as a person and as a surgeon, were due, he felt in large extent to his teachers, Mr. Harold Bolton, Sir Lloyd Griffiths and Sir John Charnley at the Manchester Royal Infirmary. Sir Lloyd although reluctant to see his “good boy” move away to Liverpool, was gracious to give him a high recommendation to broaden his vistas.
In 1960 armed with FRCS and Mch (Orth), Dr. Chaubal returned to Mumbai. Always modest about his achievement, Dr. Chaubal attributes his entry into Orthopaedics in India as an Asst. Orthopaedic surgeon at the St. George Hospital, as a “windfall”. A JJ fellowship with three other surgeons took him across length and breadth of India and was truly an eye opener and initiation into Orthopaedics in India. He recalls being “back to earth from the stratosphere”, more determined than ever to face the problem inherent in the practice of Orthopaedics in India.
Calling himself as a “generalist” in the widest possible sense, Dr.Chaubal was trained in all areas of Orthopaedics and could undertake any challenge in Orthopaedics with his vast knowledge and experience. All this stood him in good stead as he sat out to establish the dept of Orthopaedics at the B.Y.Nair hospital. So many of us that have passed through the portals of this institute know the depth of gratitude we owe to this luminary. Dr. Parekh was particularly struck by the humility of Dr. Chaubal. Unlike many, he gives continued gratitude to his teachers right from his school to graduate and post graduate education. He remembers them vividly, for their knowledge and excellence in imparting it. He has gained much and grown to his present stature from their generous, sympathetic and academic natures. There was never any slacking and discipline and punctuality was sacrosanct. Sincerity, discipline, punctuality and absolute integrity continue to be the mantra of his life.
It was at the felicitation function of Dr. R. J. Katrak (on his being awarded an Honorary fellowship of the British Orthopaedic Association), that the idea of starting the Bombay Orthopaedic Society was mooted. This small band of pioneers focussed their concepts and thoughts into making Orthopaedics as a special career. So if today, our vibrant association is 51 years old, it is to this small band that we owe a debt of gratitude.
Dr. Chaubal is a man of few words, but one of great depth. It is perhaps, in some of these gems of his that we can get a great insight into him and enrich our lives.
1. I can be progressive only if I listen to other people.
2. You don’t compete with somebody, compete with yourself.
3. Ethics is easier to practise than to define.
4. Is evidence based medicine based on evidence that is cooked up?
5. Experience counts a great deal and surgery is destined to the practice of medicine.
6. You always meet people along the way, you have to learn from them deep down.
7. And finally family upbringing, education and environment determine the person you become.

How to Cite this article: Chaubal KV. ORTHOWALKATHON- a Life Time  Journey through Orthopaedics.  Journal of Clinical Orthopaedics July – Dec 2016; 1(1):62.

Dr. K. V. Chaubal.

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Growth Modulation for Angular Deformities around the Knee: Literature Review

Vol 1 | Issue 1 |  July – Dec 2016 | Page 52-55 | Avi Shah, Mandar Agashe

Authors: Avi Shah [1], Mandar Agashe [1].

[1] Department of Orthopaedics, BJ Wadia hospital for children, Mumbai, India.

Address of Correspondence
Dr Mandar Agashe,
Department of Orthopaedics,
BJ Wadia hospital for children,
Mumbai, India.
E-mail: mandarortho@gmail.com.

Growth modulation for angular deformities in the limbs in paediatric age group has been known for many decades [1]. Phemister had described his method of epiphyseodesis in the early 20th century [2] and Blount popularized his method of epiphyseal stapling which became the treatment of choice for hemi-epiphyseal growth modulation for many years [3]. However, both these methods caused permanent epiphyseodesis and were also associated with significant complications related to the implants and instrumentation [4-7].  This scenario changed drastically with the introduction of the revolutionary “8-plate” or “tension-band plate” by Dr. Peter Stevens in 2007 [8.] This “8-plate” was a low- profile, easy to use and relatively inexpensive implant and had the biggest advantage of causing minimal disturbance of physeal and periosteal blood supply- thus making it an ideal choice for temporary hemi-epiphyseodesis for correction of angular deformities at any age before skeletal maturity. The early results of this method were uniformly encouraging and it gained widespread acceptance over the next few years.  However, as with any new method, more and more usage meant more and more nuances were understood of the method and clinicians all over the world started sharing their experiences, difficulties, modifications and technical tips about these tension band plates [9-12]. This has led to a preponderance of literature about this topic over the last few years. It is our endeavor in this article to put forth a brief summary of the recent literature related to 8 plates as regards Biomechanics, results, Failure, comparison of various implants and use in pathological physes.

A number of articles have been written about the various biomechanical aspects of hemiepiphyseodesis. Since the basic scientific explanation by Hueter in 1862 about the phenomenon of mechanical manipulation of bone growth [13] as well as Volkmanns description of assymetrical growth of the physis [14], these two articles have formed the basis of the concept of epiphyseal stapling and hemi-epiphyseodesis for deformity correction.
Over the last decade and a half, various authors have described many animal models about stimulation and manipulation of physeal growth. One of the best studies which described the pros and cons of hemiepiphyseal stapling versus other methods of growth modulation was described by Aykut in 2005 [15]. In his study, he compared sub-periosteal placement of staples to extra-periosteal placement in an animal model and found extra-periosteal placement to be better in terms of reliable correction as well as physeal growth after removal. This led to the start of the research for a more reliable and reversible method of epiphyseodesis which can be applied extra-periosteally (as against staples which require sub-periosteal placement).
Peter Stevens first put forth his series of patients with angular deformities of the knee treated with 8-plate epiphyseodesis in 2007 [8]. As a follow-up to that article, he also published a very important basic science/animal model article in 2008 [16]. He had then stated that at least as per animal studies, 8 plates and staple systems have equivalent rate of correction but with the 8 plates being the method with theoretically lesser complications. This was a time when the 8 plates were just being introduced and there was still a question whether the correction was as good as the epiphyseal staples.  Another article by Sanpera et al [17] also put forth an interesting proposition. In this article published in 2012, the authors put forth the importance of the single tether which was more effective in the angular correction of deformities rather than the implant itself. This article showed that the 8 plate applied singly is equally effective with a single staple, but is more effective than the double staples which are more commonly applied. Hence the authors have commented that 8 plate works as a single tether on which the correction takes place. Thus they have said that it is better to put a single staple rather than put a double one.
One of the latest article about basic biomechanics about growth modulation was the one written by Schoenleber et al in 2014 [18]. This article studied the very important topic of screw size, number and configuration in a bone model. They concluded that screw size and number had no effect on the rate of angular correction but described the configuration of screws to be the most important. The authors have stated that parallel screws are the best as regards the rate of angular correction as compared to divergent screws. This is very important clinically and has advised the clinician about perfectly parallel placement of the screws for better correction.

Results/ Comparison
The minimally invasive techniques of epiphyseodesis viz Blounts stapling, screw epiphyseodesis and 8 plate epiphyseodesis have made this procedure much more simple, predictable and technically less challenging than the epiphsyeo-metaphyseal fusion as proposed by Phemister [2].  Haas described reversible retardation of the physeal growth with his wire loop technique, mostly in animal experiments but also in a small number of patients [19]. Based on his work, Blount and Clarke described their early results of physeal stapling in 1949 [3] and this method revolutionized the treatment of angular deformities especially around the knees in paediatric patients. The technique evolved over the years and two extra-periosteal Vitallium staples became the standard of care for a number of years.  During the course of many years, many authors then started showing their own results of Blounts stapling which were not as good as those shown by Blounts own unit [6-7]. Though experimentally, Blounts staples were shown to retard but not stop physeal growth, a number of patients developed permanent epiphyseodesis. Also, since the plates needed to be hammered in, the extra-periosteal placement of the plates used to become sub-periosteal and hence physeal bars were commonly seen. The other important complications of the Blounts staples were the three “B’s” i.e Backing out, Breakage and Bending. This led to a number of difficulties in the long term outcome of staples leading people to look for better alternatives. The other main problem with Staple epiphyseodesis used to be its timing1. A number of complicated methods of predicting the time for epiphyseodesis have been developed namely the Green-Andersens charts, Multiplier methods etc [20]. There used to be significant problems with using these methods. The accuracy of most of these methods is similar, with significant inter-and intra observer variability. Hence clinicians started looking for a more reversible method of epiphyseodesis which does not cause any permanent damage to the physis.  Peter Stevens published his series of patients with angular deformities in the knee treated with his new “8-plate” system [8]. The 8-plates were small, low-profile, two-hole plates with a small central hole for the guiding hole for the physis. Two screws are placed- one on each side of the physis and the plate is necessarily placed in the extra-periosteal fashion. The screws have got good anchorage in the cancellous meta- and epi-physeal bone and the screws can diverge at the screw-plate interface as the physeal growth occurs at the other end of the physis. Due to this, the incidence of back-out, bending and breaking of the screws is much less as compared to the staples. Due to the extra-periosteal nature of the implant, there is very little chance of a physeal bar formation and hence very little chance of permanent epiphyseodesis. Also, as a single extra-periosteal plate is sufficient for all but one indication (correction of flexion deformity of the knee), the application of the 8-plate is simple and can be done without much difficulty even in the most distorted anatomy. This multi-faceted feature of the 8-plate was a great improvement over the staples and this has led to a rapid expansion of indications for epiphyseodesis and a renewed interest in this field. A number of authors then described the good early results of this simple to use technique. Ballal et al described their results of hemiepiphyseodesis for genu valgum and showed good to excellent correction in most of the patients [21]. Many researchers have also endeavoured to find out the average rate of correction with femoral and tibial 8-plates. On an average, the rate of correction for a femoral 8plate is about 0.7-0.9 degrees per month, 0.5-0.6 degrees per month for the tibia and about 1.4-1.6 degrees per month for both femur and tibia [3,21,22]. However this rate depends on the age of the child, menarchal status in the female as well as rate of overall growth of the child.  There has been a growing consensus that the 8-plate has superseded the staple. However there have been only a few prospective studies which have directly compared 8-plates with the staples. Two of the earliest articles comparing to methods of epiphyseodesis were by Weimann et al [23] (which was a comparative analysis in patients) and Goyeneche et al [24] (which was an animal experiment). Both studies concluded that 8-plates were almost equivalent in the magnitude and degree of correction though 8-plates had better adherence to the bone as compared to staples and this was very useful in preventing back-outs which were very common with staples.  Another very high quality article by Gotleibsen et al has described the results of a randomized control trial comparing the 8 plates with staples [25]. This article showed equivalent results of 10 patients treated with staples as compared to 10 patients treated with 8 plates in terms of rate of correction, complications as well as pain scores with the difference being statistically insignificant. This was a very important article which proved that even though the primary results of 8 plates are good and the 8-plate as a system is very easy to use, modular and low-profile, actual improvement over the old system has not been documented and hence stapling still remains the gold standard as far as growth modulation is concerned. The search is still on for a study which emphatically proves the superiority of the 8-plates over the staples.

Failures and special situations:
After the great initial enthusiasm about the 8 plates, there was a rampant use of this method in a large number of indications which included not just idiopathic (or nutritional) angular deformities but also conditions with pathological and sick physis. The results of these series were not that encouraging and the initial euphoria was slightly dampened by these results.
Blounts disease is one condition in which 8-plates were used quite frequently. However Schroerlucke et al were one of the first to describe their series of patients of Blounts disease treated with 8 plates [9]. In this series, there was a failure/complication rate of as much as 44% which was unacceptably high. Another article from the Baltimore group also put forth similar results especially in obese patients with Blounts disease [11]. They also said that it is the metaphyseal screw which almost always breaks and the breakage is at the level of the screw bone junction and not the screw plate junction. Thus they have suggested that especially in obese kids, it is best to use solid noncannulated screws to prevent such complications and failures. Another article by Masquijo et al in 2016 [10], discussed the causes of failure in a heterogenous group of patients of which the commonest was hypophosphatemic rickets. A few others have described their results in pathological physes with mixed results. Dr. Peter Stevens from Utah has one of the highest number of patients with pathological physes treated with 8 plates and he has shown good results in a select group of patients [26]. Some other authors like Mckenzie et al from DuPont institute [27] and Grill et al [28] have also shown their results in skeletal dysplasia, Hypophosphatemic rickets, etc. The most prominent advantage which has been cited by these authors is the fact that 8-plates can be safely used in very young children without any risk of permanent physeal damage which is a very important factor in skeletal dysplasia where the rate of growth is very poor.

Growth modulation for angular deformities around the knee is a very important tool in the armamentarium of the orthopaedic surgeon. With the advent of the 8-plates, this procedure has become safe, easy to reproduce and with very few complications.
Extra-periosteal placement of a single tether (8-plate) is the most important factor in producing the best results. The screws have to be placed parallel for the best correction rather than convergent or divergent. The average rate of correction is about 0.7-0.8 degree per month for femur, 0.5-0.6 degrees per month for the tibia and 1.4-1.6 degrees per month for both simultaneously.  8-plates can definitely be attempted in pathological physes like Blount disease, hypophosphatemic rickets, Skeletal dysplasia etc, though the rate of correction is much less predictable and failure rate is relatively high.


1. Eastwood DM, Sanghrajka AP. Guided growth: Recent advances in a deep-rooted concept. J Bone Surg (Br), 2011;93-B:12-18
2. Phemister DB. Operative assessment of longitudinal growth of bones in the treatment of deformities. J Bone Joint Surg 1933;15:1-15
3. Blount WP, Clarke Gr. Control of Bone growth by epiphyseal stapling: a preliminary report. J Bone Joint Surg (Am) 1949;61-A: 320-9
4. Brockway A, Craig WA, Cockrell BR Jr. End result of sixty-two stapling operations. J Bone Joint Surg (Am) 1954;36-A:1063-7
5. Park SS, Gordon Je, Luhmann SJ, Dobbs MB, SChoenecker PL. Outcome of hemiepiphyseal stapling for late-onset tibia vara. J Bone Joint Surg (Am) 2005;87-A:2259-66
6. Fraser RK, Dickens DRV, Cole WG. Medial physeal stapling for primary and secondary genu valgum in late childhood and adolescence. J Bone Joint Surg (br) 1995;77-B:733-5
7. Gorman TM, Vanderwerff R, Pond M, MacWilliams B, Santora SD. Mechanical axis following staple epiphyseodesis for limb length inequality. J Bone Joint Surg (Am) 2009; 91-A: 2430-9
8. Stevens PM. Guided growth for angular correction: a preliminary series using a tension band plate. J Pediatr Orthop. 2007 Apr-May;27(3):253-9.
9. Schroerlucke S1, Bertrand S, Clapp J, Bundy J, Gregg FO. Failure of Orthofix eight-Plate for the treatment of Blount disease. J Pediatr Orthop. 2009 Jan-Feb;29(1):57-60
10. Masquijo JJ, Firth GB, Sepúlveda D Failure of tension band plating: a case series. J Pediatr Orthop B. 2016 Jul 8.
11. Burghardt RD, Specht SC, Herzenberg JE. Mechanical failures of eight-plate guided growth system for temporary hemiepiphysiodesis. J Pediatr Orthop. 2010 Sep;30(6):
12. Gaumetoe E, Mallet C, Souchet P, Mazda K, Ilharreborde B. Poor efficiency of Eight-plates in treatment of limb length discrepancy. J Pediatr orthop 2016;36-7: 715-9
13. Hueter C. Anatomische Studien an den Extremitatengelenken Neugebonener und Erwachsener. Virchow Arch 1862;25:572-99 (In German)
14. Volkmann R. Die Krankherten der Bewegungsorgane, In Pitha, Bilroth, eds. Handbuch der Allgemeinen und Speciellen Chirurgie, Bd 2. Abt A, s-694. Stuttgart: Ferdinand Enke, 1869.
15. Aykut US, Yazceki M, Kandemir U, et al. The effect of temperory epiphyseal stapling on growth plate: A radiological and immunohistochemical study in rabbits. J Pediatr Orthop 2005: 25-3: 336-341
16. Mast N, Brown NAT, Brown C, Stevens P. Validation of Genu Valgum model in a Rabbit hind limb. J Pediatr Orthop 2008;28:375-380
17. Sanpera I, Raluy-Collado D, Frontera-Juan G, et al. Guided growth:The importance of a single tether: An experimental study. J Pediatr Orthop 2012;32:815-820
18. Schoenleber SJ, Lobst CA, Baitner A, Standard SC. The Biomechanics of guided growth: does screw size, plate size or screw configuration matter? J Pediatr Orthop 2014;23:122-125
19. Haas SL. Retardation of bone growth by a wire loop. J Bone Joint Surg 1945;27:25-36.
20. Andersen M, Green WT, Messner MB. Growth and predictions of growth in the lower extremities. J Bone Joint Surg (Am) 1963;45-A:1-14
21. Ballal MS, Bruce CE, Nayagam S. Correcting genu varum and genu valgum in children by guided growth. Temporary hemiepiphyseodesis using tension band plate. J Bone Joint surg (Br) 2010:92:273-8.
22. Guzman H, Yaszay B, Scott VP, Bastrom T, Mubarak SJ. Early experience with medial femoral tension band plating in idiopathic genu valgum. J Child Orthop 2011;5:11-17.
23. Wiemann JM, Tryon C, Szalay EA. Physeal stapling versus 8 –plate hemiepiphyseodesis for guided correction of angular deformity around knee. J Pediatr Orthop 2009; 29:481-5.
24. Goyeneche RA, Primomo CE, Lambert N, Miscione H. Correction of bone angular deformities: experimental analysis of staples versus 8-plate. J Pediatr Orthop.2009 Oct-Nov;29(7):736-40.
25. Gottliebsen M, Rahbek O, Hvid I, et al. Hemiepiphyseodesis: Similar treatment times for tension-band plating and for stapling. Acta Orthop 2013; 84:202-206
26. Stevens PM, Klatt JB. Guided growth for pathological physes. Radiographic improvement during realignment. J Pediatr Orthop 2008;28:632-9.
27. Kaissi AA, Farr S, Ganger R, Klaushofer K, Grill F. Windswept lower limb deformities in patients with hypophosphatemic rickets. Swiss med Wkly 2013;143:w13904.

How to Cite this article: Shah A, Agashe M. Growth Modulation for Angular Deformities around the Knee: Literature Review. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):52-55.

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Spine – Relevant articles in 2016

Vol 1 | Issue 1 |  July – Dec 2016 | Page 48-52 | Arvind G Kulkarni

Authors: Arvind G Kulkarni [1].

[1] Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Mumbai, India.

Address of Correspondence
Dr Arvind G Kulkarni,
Mumbai Spine Scoliosis & Disc Replacement Centre,
Bombay Hospital &Medical Research Centre,
Mumbai, India.
E-mail: drarvindspines@gmail.com.

Mumbai is considered the Mecca for Spine Surgery. Many legends and centers have contributed immensely to the development of spine as a distinct specialty in Mumbai. Fittingly, this initial issue of the Bombay Orthopaedic Society edited by the illustrious Dr Nicholas Antao has delegated sumptuous space to literature on spine and spinal disorders. A journey through the past year’s high impact factor- journals like The Spine Journal, Spine, JNS-Spine, European Spine Journal, Journal of Spinal Disorders and Techniques and the Global Spine journal reveals that the perspectives may change with time but the basics still remain the same. There has been an increasing talk among researchers about adjacent segment degeneration, clinically significant adjacent segment disease, issue of post-operative dysphagia after anterior cervical surgeries, importance of natural history in spinal disorders, about the ever increasing scope of minimally invasive surgeries from the basic decompression to deformity corrections and the accuracy of pedicle screw insertion. This synopsis ends up with summarizing some significant contributions by Indian authors to the literature this year.

Adjacent segment Degeneration and Clinically significant adjacent segment Disease
Since fusion procedures have become so frequent the entities called ‘adjacent segment degeneration (ASD)’ and ‘adjacent segment disease (ASDis)’ are becoming issues of concern. Motion preservation surgeries, especially ‘artificial disc replacement’ was proposed as an alternative to fusion that had the potential to minimize the incidence of ASD. Does it really do so in the long run is a million dollar question? Although there is no Level I evidence, in a meta analysis involving 1474 patients, Pan A and colleagues’ [1] have evaluated the efficacy of motion preservation procedures to prevent ASD or ASDis compared to fusion procedures in lumbar spine. They indicated that the prevalence of ASD and ASDis and reoperation rate on the adjacent level were lower in motion preservation procedures group than in the fusion group. More over shorter stay in hospital was found in motion preservation group and no difference in terms of operation time, blood loss, and VAS and ODI improvement between the two groups. Another interesting paper on ASD throws light on the risk factors associated with the same. Heo Y et al [2] in their 10 years follow-up study of 401 patients where fusion surgeries were performed for spondylolysthesis at L4-5 or L4-5-S1 focused on risk factors that affected clinically symptomatic ASD (CASD). They evaluated six significant factors affecting CASD development. Among these risk factors, facet degeneration, isthmic-type spondylolisthesis, and the type of fusion show higher hazard ratios and seem to be clinically more relevant than the other three factors (age, overall lordosis, and segmental lordosis).

Minimally invasive decompression in lumbar degenerative spondylolisthesis
The debate on the type of surgical procedure for degenerative spondylolisthesis goes on forever. Since conventional procedures for decompression involving surgical invasion of facet joints and surrounding soft tissue could increase instability and exacerbate clinical symptoms, decompression combined with fusion is generally recommended. Gen Mori et al [3] evaluated the outcomes in cases of lumbar degenerative spondylolisthesis at a follow-up of 5 years after treatment with minimally invasive decompression with examination of pre- and postoperative slippage, intervertebral disc changes, and clinical results. The hypothesis that this study relied on is the natural history of LDS and the preservation of anatomical structures in MED. The authors concluded that if minimally invasive decompression can be performed to treat LDS, it is believed that preoperative percentage slip and intervertebral disc degeneration do not have to be included in the appropriateness criteria for fusion.

Understanding Pedicle Screw misplacement
Due to better primary stability and repositioning options, pedicle screws are increasingly used during posterior stabilization of the cervical spine. However, the serious risks generally associated with the insertion of screws in the cervical spine remain. Bredow J et al [4] conducted a study to examine the accuracy of pedicle screw insertion with the use of 3D fluoroscopy navigation systems. Data of 64 patients were collected during and after screw implantation (axial and sub axial) in the cervical spine. 207 screws were implanted from C1 to C7 and analyzed for placement accuracy according to post operative CT scans and following the modified Gertzbein and Robbins classification. It was concluded that axial and sub axial screws can be inserted with a high grade of accuracy using 3D fluoroscopy-based navigation systems. Nevertheless, while this useful innovation helps to minimize the risks of misplacement, the surgery is still a challenge, as arising complications remain severe. The accuracy rate of pedicle screw (PS) placement varies from 85% to 95% in the literature. This demonstrates technical ability but does not represent the impact of screw misplacement on individual patients. A retrospective study conducted by Sarwahi V et al [5] quantifies the rate of screw misplacement on a per-patient basis to highlight its effect on potential morbidity. Of the 2724 screws placed in 127 patients, a total of 2396 screws were accurately placed (87.96%). A total of 247 screws (9.07%) were benign misplaced, 52 (1.91%) were intermediate misplaced, and 29 (1.06%) were considered in screw at risk (SAR) group. Per-patient analysis showed 23 (18.11%) of patients had all screws accurately placed (AP), thirty-five (27.56%) had IMP and 18 (14.17%) had SAR. Per-patient analysis reveals more concerning numbers toward screw misplacement. With increasing pedicle screw usage, the number of patients with misplaced screws will likely increase proportionally. Better strategies need to be devised for evaluation of screw placement, including establishment of a national database of deformity surgery, use of intra-operative image guidance, and reevaluation of postoperative low-dose CT imaging.

Oswestry Disability Index [ODI]
ODI has long been used to study the outcomes of patients suffering from lumbar degenerative disorders. A significant reduction in ODI scores is an index of patient’s satisfaction and reduction of disability, although there has not been quantification for the same as to what value indicates as being significant. Van Hooff ML et al [6] suggested an ODI score ≤22 indicates the achievement of an acceptable symptom state and can hence be used as a criterion of treatment success alongside the commonly used change score measures. At the individual level, the threshold could be used to indicate whether or not a patient with a lumbar spine disorder is a “responder” after elective surgery.

Knee-up test
Post- operative neurological deficit is one of the complications of spine surgery that is most dreadful for the surgeon as well as the patient. Efforts have been put since years to reduce this complication. One of the simplest ways to detect if such an event has occurred before extubation of the patient is a Knee- Up test. Yugue et al [7] conducted a prospective study of 521 patients where the patient’s knee is passively lifted up and the patient is able to maintain this position in both legs, the result is negative, whereas when the patient is unable to maintain the knee in an upright position for one or both legs, the result is positive. The sensitivity, specificity, positive predictive value, and negative predictive value were 88.9, 99.8, 94.1, and 99.6, respectively.

Parkinson’s disease (PD) and cervical myelopathy
Parkinson’s disease (PD) is a common movement disorder in elderly patients and co-existence with cervical myelopathy complicates the situation. There have been questions about the efficacy of surgery in such patients and thus providing them with a better quality of life. Xiao R et al (The Spine Aug 2016) conducted first study to characterize QOL outcomes following cervical decompression and found significant reduction in pain-related disability was observed following decompression. However, PD predicted diminished improvement in overall QOL measured by the EQ-5D.

Novel approach for lumbar interbody fusion
Lumbar interbody fusion is being long used as the method of choice in lumbar degenerative disorders and is most commonly done through posterior approaches (PLIF and TLIF). The direct anterior approach requires mobilization of the great vessels to access the intervertebral disc spaces cranial to L5/S1. Molloy et al [9] came up with a novel extensile anterolateral retroperitoneal approach for lumbar interbody fusion from L1 to S1 which is safe, muscle-splitting, psoas-preserving, one-incision approach and thus revolutionize interbody fusion technique.

Glass ceramics spacers
Constant efforts are being made to improve the fusion rates in patients suffering from lumbar degenerative disorders. The most recent advent is the CaO-SiO2-P2O5-B2O3 glass ceramics spacer. Lee JH et al [10] found that ceramics spacer showed a similar fusion rates and clinical outcomes compared with titanium cage however, the bone fusion area directly attached to the end plate was significantly higher in the bioactive glass ceramics group than in the titanium group.

Anterior Cervical surgeries and the role of steroids
Dysphagia is a common post-operative symptom for patients undergoing anterior cervical spine procedures. Siasios I et al [11] studied the current literature regarding the effect of steroid administration in dysphagia after anterior cervical spine procedures through a literature search. Steroid administration protocol involved dexamethasone in few, Methylprednisolone in others. In four studies, steroids were applied intra-venous, while in one study, locally in the retropharyngeal space. Short-term dysphagia and prevertebral soft tissue swelling (PSTS) were diminished by steroid administration, according to the results of two studies. In one study, prevertebral soft tissue edema was not affected by the steroid usage. Furthermore, short-term osseous fusion rate was impaired by the steroid administration, according to the findings of one study. After a review of 44 patients undergoing multilevel (2-, 3-, 4-level) ACDF, 22 of which received RP steroid, Koreckij TD et al [12] noted a trend toward decreased PSTS on initial postoperative radiographs, but was no longer evident at 6 weeks. NDI, although improved from pre-operative scores, failed to demonstrate significant differences between groups. Locally delivered methyl prednisone did not result in increased rates of short-term postoperative complications

Top 100 cited article in cervical spine surgery
Cervical spine surgery is a rapidly evolving and challenging subspecialty that owes its advancements to many individuals and their pioneering works that have shaped the way we practice modern cervical spine surgery today. A study conducted by Branko Skovrlj et al [13] identifies the authors and 100 topics that made the greatest impact in the field of cervical spine surgery over the course of the last century and the beginning of this century. The top article was cited 826 times; the 100th article, 133 times; and the mean number of citations for the top 100 articles were 203.6. The oldest article was by Rogers published in 1957. The newest article was published in 2009 by Murrey et al. Eighty-three percent of the top 100 cited articles were published after 1980, with the 1990s producing the largest number of highly cited articles (35%). The top 100 articles were published in 18 journals, with the top three journals publishing 72% of the articles. The top journal was Spine with 39 articles followed by the Journal of Bone and Joint Surgery American Volume with 20 articles and the Journal of Neurosurgery with 13 articles. The three most popular categories were cervical spinal fusion with 17 articles, surgical complications with 9 articles, and biomechanics of the cervical spine with 9 articles. Eighty-six first authors contributed to the top 100 articles. Only three authors were credited with three or more publications and only one author, Abumi, had four publications in the top 100. The top articles originated from nine different countries, with the United States (65%) being the most prolific. There were 61 institutions responsible for the top-cited articles with Hokkaido University in Sapporo, Japan contributing the most articles with five publications in the top 100.

Prediction of posterior ligamentous complex injury in thoracolumbar fractures using non-MRI imaging techniques.
Rajasekaran S and colleagues [14] formulated a radiological index based on plain radiographs and computer tomography (CT) to reliably detect posterior ligamentous complex (PLC) injury without need for MRI. They assessed thoracolumbar fractures with doubtful PLC with MRI, CT and radiographs. PLC injury was assessed with the following radiological parameters: superior-inferior end plate angle (SIEA), vertebral body height (BH), local kyphosis (LK), inter-spinous distance (ISD) and inter-pedicular distance (IPD) and correlated with MRI findings of PLC injury. They proposed that on plain radiographs the presence of LK greater than 20° and ISD difference greater than 2 mm can predict PLC injury. These guidelines may be utilized in the emergency room especially when the associated cost, availability and time delay in performing MRI are a concern.

Irreducible AAD
SK Srivastava et al [14] demonstrated an excellent technique for a difficult problem. The study reinforces the safety and efficacy anterior release for reduction of IAAD. They concluded that anterior release followed by instrumented posterior fusion is a safe and effective modality of treatment for IAAD associated with basilar invagination. This opens up a new avenue for this difficult problem.

Clinical efficacy of tapered rods in posterior cervicothoracic instrumentation
The cervicothoracic spine is a junctional area with complex biomechanics. Kulkarni AG et al [15] analyzed the efficacy of tapered rod system in clinical scenarios in the short term. In their study no biomechanical failure occurred in any of the 14 patients and intraoperative complications were noted in none. This is the first study on the efficacy of tapered rods and demonstrates that tapered rods are an excellent and a viable option to connect screws to stabilize cervicothoracic junction in the short term.


1. Pan A, Hai Y, Yang J, Zhou L, Chen X, Guo H. Adjacent segment degeneration after lumbar spinal fusion compared with motion-preservation procedures: a meta-analysis. Eur Spine J. 2016 May;25(5):1522-32.
2. Heo Y, Park JH, Seong HY, Lee YS, Jeon SR, Rhim SC, Roh SW. Symptomatic adjacent segment degeneration at the L3-4 level after fusion surgery at the L4-5 level: evaluation of the risk factors and 10-year incidence. Eur Spine J. 2015 Nov;24(11):2474-80.
3. Mori G, Mikami Y, Arai Y, Ikeda T, Nagae M, Tonomura H, Takatori R, Sawada K, Fujiwara H, Kubo T. Outcomes in cases of lumbar degenerative spondylolisthesis more than 5 years after treatment with minimally invasive decompression: examination of pre- and postoperative slippage, intervertebral disc changes, and clinical results. J Neurosurg Spine. 2016 Mar;24(3):367-74.
4. Bredow J, Oppermann J, Kraus B, Schiller P, Schiffer G, Sobottke R, Eysel P, Koy T. The accuracy of 3D fluoroscopy-navigated screw insertion in the upper and subaxial cervical spine. Eur Spine J. 2015 Dec;24(12):2967-76.
5. Sarwahi V, Wendolowski SF, Gecelter RC, Amaral T, Lo Y, Wollowick AL, Thornhill B. Are We Underestimating the Significance of Pedicle Screw Misplacement? Spine (Phila Pa 1976). 2016 May;41(9):E548-55.
6. van Hooff ML, Mannion AF, Staub LP, Ostelo RW, Fairbank JC. Determination of the Oswestry Disability Index score equivalent to a “satisfactory symptom state” in patients undergoing surgery for degenerative disorders of the lumbar spine-a Spine Tango registry-based study. Spine J. 2016 Oct;16(10):1221-1230.
7. Yugué I, Okada S, Masuda M, Ueta T, Maeda T, Shiba K. “Knee-up test” for easy detection of postoperative motor deficits following spinal surgery. Spine J. 2016 Aug 9. pii: S1529-9430(16)30866-X.
8. Xiao R, Miller JA, Lubelski D, Alberts JL, Mroz TE, Benzel EC, Krishnaney AA, Machado AG. Quality of life outcomes following cervical decompression for coexisting Parkinson’s disease and cervical spondylotic myelopathy. Spine J. 2016 Nov;16(11):1358-1366.
9. Molloy S, Butler JS, Benton A, Malhotra K, Selvadurai S, Agu O. A new extensile anterolateral retroperitoneal approach for lumbar interbody fusion from L1 to S1: a prospective series with clinical outcomes. Spine J. 2016 Jun;16(6):786-91.
10. Lee JH, Kong CB, Yang JJ, Shim HJ, Koo KH, Kim J, Lee CK, Chang BS. Comparison of fusion rate and clinical results between CaO-SiO(2)-P(2)O(5)-B(2)O(3) bioactive glass ceramics spacer with titanium cages in posterior lumbar interbody fusion. Spine J. 2016 Nov;16(11):1367-1376.
11. Siasios ID, Dimopoulos VG, Fountas KN. Local steroids and dysphagia in anterior cervical discectomy and fusion-does the employment of rhBMP-2 make their use a necessity? J Spine Surg. 2016 Sep;2(3):234-236.
12. Koreckij TD, Davidson AA, Baker KC, Park DK. Retropharyngeal Steroids and Dysphagia Following Multilevel Anterior Cervical Surgery. Spine (Phila Pa 1976). 2016 May;41(9):E530-4
13. Skovrlj B, Steinberger J, Guzman JZ, Overley SC, Qureshi SA, Caridi JM, Cho SK. The 100 Most Influential Articles in Cervical Spine Surgery. Global Spine J. 2016 Feb;6(1):69-79.
14. Rajasekaran S, Maheswaran A, Aiyer SN, Kanna R, Dumpa SR, Shetty AP. Prediction of posterior ligamentous complex injury in thoracolumbar fractures using non-MRI imaging techniques. Int Orthop. 2016 Jun;40(6):1075-81.
15. Srivastava SK, Aggarwal RA, Nemade PS, Bhosale SK. Single-stage anterior release and posterior instrumented fusion for irreducible atlantoaxial dislocation with basilar invagination. Spine J. 2016 Jan 1;16(1):1-9.
15. Kulkarni AG, Dhruv AN, Bassi AJ. Posterior Cervicothoracic Instrumentation: Testing the clinical efficacy of Tapered Rods (Dual-Diameter Rods). J Spinal Disord Tech. 2015 Dec;28(10):382-8.

How to Cite this article: Kulkarni AG. Spine – Relevant articles in 2016. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):48-52.

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Orthopaedic Oncology – Relevant articles in 2016

Vol 1 | Issue 1 |  July – Dec 2016 | Page 45-48 | Ajay Puri

Authors: Ajay Puri [1].

[1] Surgical Oncology, Tata Memorial Hospital, Mumbai, India.

Address of Correspondence
Dr Ajay Puri,
Chief Orthopaedic Oncology,
Prof. & Head – Surgical Oncology,
Tata Memorial Hospital, Mumbai,
E-mail: docpuri@gmail.com.

This article encapsulates in brief the important publications pertaining to orthopaedic oncology that were published within the last year.

Giant cell tumor:
An article by Benevenia et al looked at the outcomes in giant cell tumors (GCTs) following standard intralesional resection-curettage and adjuvant treatment using bone graft, with or without supplemental polymethylmethacrylate (PMMA). [1] Complications evaluated included recurrence, fracture, and joint degeneration. Of the 43 patients included in the study 21 patients were reconstructed using femoral head allograft with or without PMMA and 22 patients were reconstructed using PMMA alone. At a mean follow up of 59 months (range, 12–234 months) non oncologic complications (articular fractures and osteoarthritis) occurred less frequently in patients treated with bone graft than those treated without (10% [two of 21] versus 55% [12 of 22]). With the numbers available, there was no difference in tumor recurrence between patients treated with bone graft versus without (29% [six of 21] versus 32% [seven of 22]). They concluded that compared with PMMA alone, the use of periarticular bone graft constructs reduces postoperative complications apparently without increasing the likelihood of tumor recurrence. Gaston and colleagues have written an excellent overview on the current status of denosumab the new “wonder drug” for giant cell tumors. [2] Denosumab a monoclonal antibody to RANK ligand is recommended as the first option in inoperable or metastatic GCT. Denosumab has also been used pre-operatively to downstage tumors with large soft tissue extension to allow for less morbid surgery. However the role of Denosumab for conventional limb GCT of bone is yet to be defined. Questions such as whether local recurrence rates will be decreased with the adjuvant use of Denosumab along with surgery and the long term use and toxicity of this agent still remain unanswered. They advise that complicated cases of GCT requiring Denosumab treatment should be referred and followed up at expert centres. So that further collaborative studies involving clinical trials and rigorous data collection may help to identify the optimum use of this drug.

Chondroid lesions:
A study by Wilson et al looked at the prevalence and cost of unnecessary advanced imaging studies (AIS) in the evaluation of long bone cartilaginous lesions. [3] A total of 105 enchondromas and 19 chondrosarcomas arising in long bones were reviewed. Advanced imaging was defined as MRI, CT, bone scan, skeletal survey, or CT biopsy. Of patients diagnosed with an enchondroma, 85 % presented with AIS. The average enchondroma patient presented with one unnecessary AIS. The average unnecessary cost per enchondroma patient was $1,346.18. Orthopaedic surgeons and radiologists need to be more pragmatic while recommending radiologic imaging in these patients as unnecessary AIS are frequently performed and are a significant source of expense.  Central chondrosarcoma of bone can be divided into low-grade (Grade 1) and high-grade (Grade 2, Grade 3, and dedifferentiated) chondrosarcomas. [4] Although en bloc resection has been the most widely used treatment, in selected patients with low-grade chondrosarcomas of long bones, curettage is safe and effective. This approach requires an accurate preoperative estimation of grade to avoid under- or overtreatment. Roitman et al evaluated the concordance of preoperative image-guided needle biopsy and postoperative findings in differentiating low-grade from high-grade central chondrosarcomas of long bones and its comparison with the concordance in central pelvic chondrosarcomas. Of the 126 central chondrosarcomas, 41 were located in the pelvis and the remaining 85 cases were located in long bones. The study considered 39 (95%) and 40 (47%) of them, respectively in which histological information was complete regarding preoperative and postoperative tumor grading. Concordance between the preoperative biopsy and the final pathological analysis in terms of histological grade was much higher in long-bone chondrosarcoma than in pelvic chondrosarcoma (83% [33 of 40] versus 36% [14 of 39]). The authors thus concluded that image-guided needle biopsy, when performed by a specialist radiologist and evaluated by an experienced bone pathologist, is a useful tool in determining the histological grade of long-bone chondrosarcomas allowing identification of true low-grade tumors. The same appears not to be true for pelvic lesions, in which histological grade established by needle biopsy should be interpreted with caution.

Chui et al set out to identify additional histologic variables of prognostic significance in high-grade osteosarcoma. [5] Slides of pretreatment biopsy and primary post neoadjuvant chemotherapy resections from 165 patients with high-grade osteosarcoma were reviewed. Univariate analyses confirmed the prognostic significance of metastatic status on presentation, primary tumor size, anatomic site, and histologic subtype. Additionally, the identification of lymphovascular invasion 10% or more residual viable tumor, and 10 or more mitoses per 10 high-powered fields assessed in post treatment resections were associated with poor survival, retaining significance in multivariate analyses. A prognostic index incorporating primary tumor size and site, and significant histologic features assessed on resection (ie,lymphovascular invasion status, mitotic rate, and extent of viable tumor) was developed. This scoring system segregated patients into 3 risk categories with significant differences in overall survival and retained significance in an independent validation set of 42 cases. Laitenen and colleagues evaluated the prognostic and therapeutic factors influencing the oncological outcome of parosteal osteosarcoma. [6] Eighty patients with a primary parosteal osteosarcoma had an overall survival of 91.8% at five years and 87.8% at ten years. Local recurrence occurred in 14 (17.5%) patients and was associated with intralesional surgery and a large volume of tumor. 80% of the local recurrences were dedifferentiated high-grade tumors. Medullary involvement by the lesion or the use of chemotherapy had no impact on survival while Local recurrence was a poor prognostic factor for survival. The authors concluded that the role of chemotherapy in the treatment of parosteal osteosarcoma is not as obvious as it is in the treatment of conventional osteosarcoma and the mainstay of treatment is wide local excision.

Ewing’s sarcoma:
A paper by Albergo and others questioned the traditional “cut off” (< / > 90 %) between poor and good responders in patient’s of Ewing’s sarcoma who had chemotherapy. [7] Patients were grouped according to the percentage of necrosis after chemotherapy: Group I: 0% to 50%, Group II: 51% to 99% and Group III: 100%. There were significant differences in survival between the groups of necrosis: 0% to 50% (OS: 49% and EFS: 45% at five years, respectively) compared with 51% to 99% (OS: 72% and EFS: 59% at five years, respectively) and 100% (OS: 94% and EFS: 81% at five years. The authors concluded that only patients with 100% necrosis after chemotherapy should be classified as having a good response to chemotherapy because they have significantly better rates of survival compared with those with any viable tumor in the surgical specimen. This may have implications on the addition of adjuvant therapy in the post op period, both on the need to add local radiotherapy and intensify subsequent chemotherapy in the “poor” responders.

Soft Tissue Sarcomas:
Bonvalot et al evaluated the relationship between local control and overall survival (OS) in extremity soft tissue sarcomas (ESTS). [8] 531 consecutive patients with a median follow-up period of 7 years were reviewed. The 5-year actuarial local recurrence (LR) rate and OS were 8 % and 80 %. Predictors of worse OS were grade 3, leiomyosarcoma, male gender, and age, whereas tumor size, margin status, and LR were not. In the multivariate analysis, specific subtypes (epithelioid sarcoma and myxofibrosarcoma) and margin size < 1 mm correlated with LR, whereas grade and the tissue constituting the surgical margins did not. The authors thus concluded that specific subtypes and surgical margin size < 1 mm correlated with a higher LR while neither the margin status nor LR affect OS. Thus specific subtypes (epithelioid sarcoma and myxofibrosarcoma), which demonstrated higher LR could require larger margins to offset their bad impact.  Smith and colleagues from the Royal Marsden Hospital evaluated 556 patients that underwent resection of primary extremity soft-tissue sarcoma. [9] They concluded that the local recurrence-free survival (LRFS) did not differ significantly between histological subtypes. Distant metastasis-free survival (DMFS) and disease-specific survival (DSS) were found to differ significantly between subtypes with the worst outcomes in patients with undifferentiated pleomorphic sarcoma. However, on multivariable analysis, histological subtype was not found to be independently prognostic for LRFS, DMFS or DSS. Metastatic disease developed in 149 patients, with the lungs being the most common site of first metastasis. The site of first metastasis differed between subtypes, with extrapulmonary metastases predominant in myxoid liposarcoma. This series suggests that the patterns of metastatic disease in extremity sarcoma are not uniform and histological subtype should be considered alongside other patient and tumor factors, such as tumor grade, size and patient age, in order to facilitate tailored follow-up regimens.

Metastatic bone disease:
Kim et all investigated whether closed intramedullary (IM) nailing with percutaneous cement augmentation was better than conventional closed nailing at relieving pain and suppressing tumors in patients with metastases of the femur and humerus. [10] A total of 43 underwent closed IM nailing with cement augmentation for long bone metastases. A further 27 patients, who underwent conventional closed IM nailing, served as controls. The mean pain scores of patients who underwent closed nailing with cement augmentation were significantly lower than those of the control patients post-operatively and the progression of the metastasis was suppressed in more patients who underwent closed nailing with augmentation compared to those in the control group. Thus percutaneous cement augmentation of closed IM nailing can improve the relief of pain and limit the progression of the tumor in patients with metastases to the long bones.

An article from Japan compared the infection rates after reconstructing frozen autograft with non-coated implants and iodine-coated implants (group I). [11] Sixty-two patients were included in group N and there were 38 patients in group I. Among other complications deep infection occurred in 10 (16.1%) patients in group N and only in one (2.6%) in group I. The authors thus concluded that using iodine-coated implants for patients with malignant bone tumor minimized risk of infection. The importance of this article lies in the fact that this novel coating may have important implications extendible to joint replacements and implants used in trauma as well.  Surgical resection of desmoid tumors has traditionally been the mainstay of therapy, but this is a potentially morbid approach with high rates of recurrence. These tumors remain a management dilemma and the current trend has been towards conservative treatment rather than intervention. A retrospective analysis by Park et al identified 47 patients with a diagnosis of desmoid tumor from all anatomic sites. [12] 20 patients were managed with surveillance, 24 patients with surgery, and three patients with other approaches. Clinical and tumor characteristics between treatment groups were not significantly different. With a median follow-up of 36 months, there was one complete regression, five partial regressions, and 13 stable diseases among the surveillance group. Only one patient under observation progressed, crossing over to surgical resection. Among 24 patients managed with surgery, 13 patients developed local recurrence. There was a statistically superior progression-free survival in the surveillance group. This data further supports the currently held belief that an initial conservative approach to desmoid tumors that may spare patients the morbidity and risk of recurrence that accompanies potentially extensive operations.


1. Benevenia J, Rivero SM, Moore J, Ippolito JA, Siegerman DA, Beebe KS, Patterson FR. Supplemental Bone Grafting in Giant Cell Tumor of the Extremity Reduces Nononcologic Complications. Clin Orthop Relat Res. 2016 Mar 1. [Epub ahead of print]
2. Gaston CL, Grimer RJ, Parry M, Stacchiotti S, Dei Tos AP, Gelderblom H, Ferrari S, Baldi GG, Jones RL, Chawla S, Casali P, LeCesne A, Blay JY, Dijkstra SP, Thomas DM, Rutkowski P . Current status and unanswered questions on the use of Denosumab in giant cell tumor of bone. Clin Sarcoma Res. 2016 Sep 14;6(1):15.
3. Wilson RJ, Zumsteg JW, Hartley KA, Long JH, Mesko NW, Halpern JL, Schwartz HS, Holt GE. Overutilization and Cost of Advanced Imaging for Long-Bone Cartilaginous Lesions. Ann Surg Oncol. 2015 Oct;22(11):3466-73.
4. Roitman PD, Farfalli GL, Ayerza MA, Múscolo DL, Milano FE, Aponte-Tinao LA. Is Needle Biopsy Clinically Useful in Preoperative Grading of Central Chondrosarcoma of the Pelvis and Long Bones? Clin Orthop Relat Res. 2016 Feb 16. [Epub ahead of print]
5. Chui MH, Kandel RA, Wong M, Griffin AM, Bell RS, Blackstein ME, Wunder JS, Dickson BC. Histopathologic Features of Prognostic Significance in High-Grade Osteosarcoma. Arch Pathol Lab Med. 2016 Aug 23. [Epub ahead of print]
6. Laitinen M, Parry M, Albergo JI, Jeys L, Abudu A, Carter S, Sumathi V, Grimer R. The prognostic and therapeutic factors which influence the oncological outcome of parosteal osteosarcoma. Bone Joint J. 2015 Dec;97-B(12):1698-703.
7. Albergo JI, Gaston CL, Laitinen M, Darbyshire A, Jeys LM, Sumathi V, Parry M, Peake D, Carter SR, Tillman R, Abudu AT, Grimer RJ. Ewing’s sarcoma: only patients with 100% of necrosis after chemotherapy should be classified as having a good response. Bone Joint J. 2016 Aug;98-B(8):1138-44.
8. Bonvalot S, Levy A, Terrier P, Tzanis D, Bellefqih S, Le Cesne A, Le Péchoux C. Primary Extremity Soft Tissue Sarcomas: Does Local Control Impact Survival? Ann Surg Oncol. 2016 Aug 4. [Epub ahead of print] [Epub ahead of print]
9. Smith HG, Memos N, Thomas JM, Smith MJ, Strauss DC, Hayes AJ. Patterns of disease relapse in primary extremity soft-tissue sarcoma. Br J Surg. 2016 Oct;103(11):1487-96
10. Kim YI, Kang HG, Kim JH, Kim SK, Lin PP, Kim HS . Closed intramedullary nailing with percutaneous cement augmentation for long bone metastases. Bone Joint J. 2016 May;98-B(5):703-9.
11. Shirai T, Tsuchiya H, Terauchi R, Tsuchida S, Mizoshiri N, Igarashi K, Miwa S, Takeuchi A, Kimura H, Hayashi K, Yamamoto N, Kubo T. The outcomes of reconstruction using frozen autograft combined with iodine-coated implants for malignant bone tumors: compared with non-coated implants. Jpn J Clin Oncol. 2016 Aug;46(8):735-40.
12. Park JS, Nakache YP, Katz J, Boutin RD, Steffner RJ, Monjazeb AM, Canter RJ. Conservative management of desmoid tumors is safe and effective. J Surg Res. 2016 Sep;205(1):115-20.

How to Cite this article: Puri A. Orthopaedic Oncology- Relevant articles in 2016. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):45-48.

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Foot and Ankle in 2016 – The Big Questions!

Vol 1 | Issue 1 |  July – Dec 2016 | Page 42-44 | Abhishek Kini

Authors: Abhishek Kini [1].

[1] Foot and ankle reconstructive surgeon, Sportsmed Mumbai., India.

Address of Correspondence
Dr.Abhishek Kini,
Foot and ankle reconstructive surgeon,
Sportsmed Mumbai. , India
E-mail: kiniabhishek@gmail.com.

Some of the major questions in surgery have never been answered. While the push for evidence-based medicine is clearly a strong and well reasoned one for some interventions, perhaps the answer is self-evident – in the same way that parachutes will never be subjected to a randomized controlled trial, neither will chest drains for tension pneumothoraces. Somewhere beneath these self-evident truisms, however, lie accepted interventions (such as TKA and ACL reconstruction) that don’t always stand up to evaluation in a randomized control trial setting. In an era where nanotechnology is touching our lives and the Tata nano is hitting our roads, the “nano” or minimally invasive surgery (MIS) is coming in vogue.

Does MIS have a role in ankle fixation?
Minimally invasive surgery (MIS) has a number of potential clinical, cosmetic (and even financial) advantages – on paper at least! The majority of readers will remember the fashion for mini-hip, followed
by ‘mini-knee’, so given the lack of advantage these passing surgical fads have shown (and some have even been discredited due to higher complication rates), it is with some trepidation that we should approach this paper from Taipei, a retrospective comparative series of mini versus open reduction and internal fixation
for unstable ankle fractures [1]. The authors make a reasonable comment that in the face of higher infection rates and compromised soft tissues, there is perhaps an argument for minimally invasive surgery. The surgical teams undertook a retrospective study of 71 patients, all with 44-B type fractures. Whilst there is no argument that MIS is more complicated than the open approach, there is still very much debate about the relative benefits of each approach. MIS is not as easy to perform as open surgery – there is a learning curve, and special equipment is needed. The authors report essentially no differences in any of the outcome measures other than lower wound complication rates in the MIS group. This paper certainly supports the concept of MIS surgery in ankle fractures to reduce complication rates, however, in the face of other, better studies (such as the randomised controlled trials from Edinburgh reporting the fibular nail), a prospective randomised controlled trial would really be needed here to prove any kind of superiority. One of the most common procedures done in adult foot and ankle reconstruction in our setting is a subtalar fusion, the gold standard procedure for varying reasons from primary inflammatory arthritis to secondary post traumatic arthrosis. The pendulum has significantly shifted towards MIS by arthroscopic assisted subtalar fusion, especially in minimally deformed hindfoot, but the debate persists on.

One screw a screw too few..?
Achieving a stable fixation during arthrodesis is the key to reducing complications including metal-work fatigue and nonunion. The compression screw has long been the most reliable fixation in arthrodesis, although there are a variety of screw configurations around, all of which have their
potential advantages
in either surgical
access, achieving
compression or
stability. Researchers from Western Michigan University undertook a
biomechanical study
using a surrogate
bone model of the
subtalar joint [2]. They
tested three potential constructs – a single posterior screw, two minimally divergent posterior screws, and a highly divergent screw construct. The stability of the constructs was tested using a servo-hydrolic testing apparatus. As perhaps could be predicted, the two divergent screws offered significantly higher torsional stability over either of the other constructs. While this in itself is not surprising, it is important to add a slight note of caution: divergent screws by their nature do not increase the compression with the addition of the second screw and, as such, care should be taken in placement of the initial screw specifically to ensure that as much compression as possible is achieved prior to placement of the second screw, to ensure effective fusion. The Achilles tendon has brought the downfall of mighty warriors in battlefield as well as it brings agony and downfall of mighty surgeons (warriors) in their operation theatres (battlefield). This Trojan war on Achilles tendon is fought on.

Cast versus early weight bearing following Achilles tendon repair ..
The treatment of the Achilles tendon continues to vex many trauma and foot and ankle surgeons. Not only is the decision to operate fraught with difficulty, but the choice of rehabilitation regime is far from clear. To make matters worse, although there are some short-term studies, there are no longer-term randomized controlled trials on which to base these decisions. Researchers in Finland report the ten-year outcomes of their randomized controlled trial comparing cast immobilization with a restricted motion brace allowing neutral plantar flexion and early weight bearing [3]. At a mean of 11 years following treatment, there were no differences in their primary outcome measure of the Leppilahti score at final follow-up (92.2 vs 93.6) and no differences in secondary outcomes including plantar flexion peak torques, or angular velocity measurements. Interestingly, there were differences in peak torque
and isokinetic strength which were maintained between one and 11 years compared with the contralateral side, however, it is arguable whether or not these differences are clinically significant, given the impressively normal functional scores. The same research team reports their study of 60 patients, all presenting with an acute Achilles tendon rupture managed over a three-year period [4]. At 14 years of follow-up, 55 patients were available for review. All patients were managed with a similar splinting protocol as their rehabilitation, with the only difference being that 28 patients received a simple end-to-end suture repair while 27 patients received a fascial flap-augmented repair. The research team reported myriad outcomes including the Leppilahti Achilles tendon score, isokinetic plantar flexion strength (peak torque and the work-displacement deficit at 10° intervals over the ankle range of motion), tendon elongation, and the RAND 36-item health survey. The bottom line is that the end-to-end repair group performed better at final follow-up. There were no differences in re-rupture rates and the augmented group had poorer calf muscle deficit that persisted right through to final follow-up. Hence giving us clear indications for not augmenting our Achilles tendon repairs.  Another major controversy in foot is management is the naïve looking but grossly disabling Lisfranc’s injury. The question is whether to Primarily fuse or ORIF the second tarsometatarsal joint in the context of severe trauma?  The Lisfranc joint has been the cause of some head scratching over the past few years. Ever since the publication of a randomized controlled trial suggesting fusion was superior to fixation, this has become an ongoing debate. The anxiety for the operating surgeon, especially in treating younger, higher demand patients, is whether a primary fusion or ORIF. By definition, fusion limits the functional capability of the foot in the future, due to either loss of
the joint or the inherent shortening that always occurs. Hence there is general hesitance to fuse joints in the younger population and a tendency to try and preserve motion by joint reconstruction in the index surgery. A paper from Hospital for Special Surgery, New York, has some significant value in this perspective [5]. It does present the return to function data for a mixed group of purely ligamentous and mixed osseoligamentous injuries after primary fusion at index surgery. The study has a retrospective design and utilized patient reported activity level questionnaires, and concludes participation in sports as equivalent to pre-injury in 64% and reduced in 25% of patients. This was a mixed group of partial fusions, including single column or all three. The activities referred to included impact sports, and relied on patient declaration to record the premorbid activity levels. It is reasonable to advise patients contemplating a primary fusion that on average just over half of patients make a full return to sporting activity following this kind of surgery. There was a higher risk of metalwork removal in the ORIF group, although this is not surprising as many surgeons routinely remove metal- work inserted for ORIF but do not for a fusion. Clearly there is still some way to go to narrow the evidence gap in Lisfranc injuries, and we are still waiting for the ‘definitive study’ to inform practice. However, for the time being these functional data do reassure all involved in their care that these patients may be successfully treated with a fusion, and that the long-term results are not as bad as one might think. It appears that in spite of a single study favoring fusion, there is little in the way of evidence to support the suggestion that fusion outdoes ORIF and that for the moment at least, the two methods appear to be equivocal and ‘dealers choice’. Questions, are a linguistic expressions used to make a request for information. As we look forward to the dawn of 2017, the horizon will come up with newer questions which will paint / reflect on our sea of knowledge a better picture for better understanding and betterment of services of foot and ankle reconstruction.


1. Chiang CC, Tzeng YH, Lin CC, Huang CK, Chang MC. Minimally Invasive Versus Open Distal Fibular Plating for AO/OTA 44-B Ankle Fractures. Foot Ankle Int. 2016 Jun;37(6):611-9.
2. Jastifer JR, Alrafeek S, Howard P, Gustafson PA, Coughlin MJ. Biomechanical Evaluation of Strength and Stiffness of Subtalar Joint Arthrodesis Screw Constructs. Foot Ankle Int. 2016 Apr;37(4):419-26.
3. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Kangas J, Siira P, Leppilahti J. Early functional treatment versus cast immobilization in tension after Achilles rupture repair: results of a prospective randomized trial with 10 or more years of follow-up. Am J Sports Med. 2015 Sep;43(9):2302-9.
4. Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med. 2016 Sep;44(9):2406-14.
5. MacMahon A, Kim P, Levine DS, Burket J, Roberts MM et al. Return to Sports & Physical activities after Primary Partial Arthrodesis for Lisfranc Injuries in Young Patients. Foot Ankle Int. 2016 Apr;37(4):355-62.

How to Cite this article: Kini  A. Foot and Ankle in 2016 – The Big Questions!. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):42-44.

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Shoulder Surgery – Relevant articles in 2016

Vol 1 | Issue 1 |  July – Dec 2016 | Page 41-42 | Dipit Sahu

Authors: Dipit Sahu [1].

[1] Sir H.N. Reliance hospital, Saifee Hospital, Dr R N Cooper Hospital and HBT Medical College, Mumbai, India.

Address of Correspondence
Dr Dipit Sahu, ,Consultant Shoulder Surgeon, Sir H.N. Reliance hospital, Saifee Hospital, Dr R N Cooper Hospital and HBT Medical College, Mumbai, India
E-mail: orthotripod@gmail.com

1. Conservative treatment of atraumatic cuff tears
An important question about atraumatic rotator cuff tears is that which ones will need surgical repair and which of them could be successfully managed by physiotherapy. The MOON group [1] in their prospective study of 433 patients found that 20% of patients failed conservative therapy and the most important indicative factors were low expectations from physiotherapy, high activity level and non -smoking status. The factors, which were non-predictive of failure of physical therapy, were the size of the tear, VAS pain score status. The ones who eventually decided to opt for surgical treatment did so in the first 12 weeks of the therapy. Moreover it does reaffirm the belief that majority of the atraumatic cuff tears can be managed conservatively. However it is hard to put it in clinical practice perspective. The main result of the paper is that low patient expectation is the most important determinant of failure of conservative therapy in the management of atraumatic cuff tears.

2. Intra articular lesions in first time dislocators and recurrent dislocators
The researchers from Korea [2] tried to answer very pertinent questions regarding the differences in the observed intra articular lesion between first time dislocators and recurrent dislocators. They compared two groups of patients who underwent arthroscopic bankart repair, one who had only one dislocation episode and other group who had recurrent dislocation episodes. They found that there was a higher incidence of anterior glenoid erosion and ALPSA lesions in the group with recurrent dislocators. This also resulted in a higher failure rate with a higher incidence of recurrent subluxation and apprehension in the group with patients with recurrent dislocation as compared to the first time dislocation group.

3. Intramedullary nails in proximal humerus fractures have a higher complication rate
Intramedullary nails have recently gained popularity in the management of 2 and 3 part proximal humerus fracture because of the improved biomechanics and minimal exposure required to treat these fractures. However locked plates have been the gold standards in the management of such fractures. Can the intramedullary nails have better outcomes than locked plating? This prospective randomized study hypothesized that the outcomes will be no different in the two groups. And indeed they did find that final constant scores were not different at the end of one year [3]. However an important finding was that there was a higher complication rate (28 adverse events versus 10 in plating group) in the intra medullary nail group, with a higher incidence of re-operation and a higher incidence of rotator cuff tears.

4. North American experience with Arthroscopic Latarjet
Arthroscopic latarjet was first introduced in France by Laurent Lafosse and since then has become increasingly popular in North America and rest of the world. However the steep learning curve limits its use in the hands of highly experienced arthroscopy surgeons. Athwal et al [4] analyzed their results in a series of 83 patients who underwent Arthroscopic latarjet by 5 senior experienced arthroscopy surgeons. They found that there was a 25% incidence of complication rate. However the most significant of all was a graft fracture and inability to fix the graft with 2 screws in 6 patients. Nerve related complications were observed in 1 patient. Their complications rate is not much different from those in open latarjet, but the complications are unique to arthroscopic procedure like inability to fix the graft with two screws in 6 patients since an open procedure could have avoided this problem.

5. Association of rotator cuff tears with progression of shoulder arthritis
The association between rotator cuff tears and progression of arthritis in the shoulder has always been of great interest. However the exact relationship has not been deeply studied. The study from Washington University St Louis, attempts to investigate the relation between the presence of asymptomatic cuff tears and progression of osteoarthritis and cuff tear arthropathy [5]. In their study of 138 patients with median follow up of 8 years, they found minimal progression of arthropathy and arthritis as compared to the control group but no significant effect of the size of the tear, the enlargement of the tear size or the symptomatic status of the patient on the progression of arthropathy. However they evaluated their patients using ultrasound to assess the size and retraction of the tear, and the follow-up was also minimal (median 8 years)

6. Atraumatic shoulder instability has unsatisfactory outcome after labral repair
Posterior shoulder instability is rare but poses a challenge for the treating physician. A standard approach to treat posterior instability has not been yet defined. This retrospective study in 41 shoulders compared the clinical outcomes after arthroscopic capsulolabral repair in traumatic and atraumatic posterior shoulder instability and its relation with the glenoid retroversion [6]. They found less favorable clinical outcomes after repair following atraumatic instability as compared to traumatic one. They also found that atraumatic shoulder instability was associated with a higher glenoid retroversion angle as measured by the vault method. This suggests that the treatment of atraumatic posterior shoulder instability is challenging and needs to be investigated further.



1. Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL, Harrell F, Holloway BG, Jones GL, Ma CB, Marx RG, McCarty EC, Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW; MOON Shoulder Group.. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2016 Aug;25(8):1303-11.
2. Shin SJ, Ko YW, Lee J. Intra-articular lesions and their relation to arthroscopic stabilization failure in young patients with first-time and recurrent shoulder dislocations. J Shoulder Elbow Surg. 2016 Nov;25(11):1756-1763.
3. Gracitelli ME, Malavolta EA, Assunção JH, Kojima KE, dos Reis PR, Silva JS, Ferreira Neto AA, Hernandez AJ. Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. J Shoulder Elbow Surg. 2016 May;25(5):695-703.
4. Athwal GS, Meislin R, Getz C, Weinstein D, Favorito P. Short-term Complications of the Arthroscopic Latarjet Procedure: A North American Experience. Arthroscopy. 2016 Oct;32(10):1965-1970.
5. Chalmers PN, Salazar DH, Steger-May K, Chamberlain AM, Stobbs-Cucchi G, Yamaguchi K, Keener JD. Radiographic progression of arthritic changes in shoulders with degenerative rotator cuff tears. J Shoulder Elbow Surg. 2016 Nov;25(11):1749-1755.
6. Katthagen JC, Tahal DS, Montgomery SR, Horan MP, Millett PJ. Association of Traumatic and Atraumatic Posterior Shoulder Instability With Glenoid Retroversion and Outcomes After Arthroscopic Capsulolabral Repair. Arthroscopy. 2016 Oct 4.

How to Cite this article: Sahu D. Shoulder Surgery – Relevant articles in 2016. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):41-42.

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Intramedullary osteosclerosis of the Tibial Midshaft in a 38-year-old female: A case report with review of literature

Vol 1 | Issue 1 |  July – Dec 2016 | Page 58-61 | Sanesh V Tuteja, Sunil H Shetty, Ravindra G Khedekar, Rajendraprasad R Butala.

Authors: Sanesh V Tuteja [1], Sunil H Shetty [1], Ravindra G Khedekar [1], Rajendraprasad R Butala [1].

[1] Department of Orthopaedics, Dr. D.Y Patil Hospital and Research Centre, Navi Mumbai

Address of Correspondence
Dr. Tuteja Sanesh Vijay
Department of Orthopaedics, DY Patil Univeristy School of Medicine and DY Patil Hospital. Sector -5, Nerul, Navi Mumbai – 400 706.
E-mail: stuteja@hotmail.com


Intramedullary osteosclerosis of the tibia is a lesser-known entity with only a few cases reported in literature. We present a case of bilateral diaphyseal intramedullary osteosclerosis in a 38- year old female presenting with vague pain affecting both the legs, aggravated by walking, worse at night. Radiological workup revealed thickening of the cortex at the midshaft region with no periosteal reaction or abnormal soft tissue shadow. Histopathological findings were suggestive of osteosclerosis with normal trabeculae and features of osteonecrosis. The patient was treated with excisional biopsy of the lesion resulting in curing of her symptoms. Intramedullary osteosclerosis is an important differential diagnosis in cases of intramedullary sclerosis of long bone.
Keywords: Intramedullary Osteosclerosis, tibia, excisional biopsy.


Intramedullary osteosclerosis of the tibia is a lesser-known entity with only a few cases reported in literature. [1, 2] Although the clinical, radiological and histopathological features are well recognized, the treatment of such patients remains unclear.
We present an uncommon case of osteosclerosis of bilateral tibia presenting as vague pain in both the legs, confirmed by ruling out other causes clinically, radiologically and on biopsy. The patient was treated surgically by excision of the sclerotic bone segment, which relieved the patient off her symptoms.

Case History

A 38-year-old female presented to our hospital with complains of pain over the left leg of 8 months duration. The pain aggravated on exertion and at night and was not relieved by analgesic use. The patient gave no history of trauma, running or other athletic activities, fever, weight loss, back and groin pain or any other co-morbid conditions.  Local examination revealed tenderness over the shin bilaterally with no palpable swelling or skin changes. Hip and spine examination were within normal limits. Peripheral pulsations were well felt and there was no neural deficit. Laboratory findings were as follows: Hemoglobin-10.7 g/dl, TLC – 8.2 x 103 / μl (N 64%, L 28.9%, M 6.4%, E 0.5%, B 0.2%), C-reactive protein – 1.36 mg/L, Erythrocyte sedimentation rate – 33 mm/hr, Serum blood Glucose – 102 gm/dl, Serum Calcium, Serum. PO4, Serum Alkaline Phosphate, Serum. Vitamin D3 and Serum Parathyroid were all within normal limits.  Radiographs (Fig. 1) showed cortical thickening at the mid-diaphyseal region of both the legs, left more than right with no periosteal reaction. There was no visible fracture, osteolysis or soft tissue shadow. CT scan (Fig. 2) and MRI (Fig. 3) imaging on a 1.5 T machine revealed cortical thickening and near complete obliteration of marrow cavity at the mid-diaphyseal level of the tibia. An open biopsy was performed on the left leg and approximately 1.5 x1.5 cms bone block removed from medial surface of the tibia and sent for biopsy; which was suggestive of osteonecrosis. The patient had 90% relief of symptoms following biopsy and was started on analgesics. On 8 months follow-up, the patient continued to have about 90% pain relief in the left leg, however had now developed symptoms on the opposite side. An excisional biopsy was planned on the right tibia. Intra-operatively, the site showed sclerosis of the cortex with complete obliteration of the medullary canal. A cortical window was made and excision of the sclerotic segment was performed. The continuity of the medullary canal was restored by drilling proximally and distally (Fig.1&4) Histopathological findings revealed normal trabecular pattern with features of osteonecrosis. The patient had no operative complications and the wounds healed well. Complete relief of symptoms was noted in the right leg within 48 hours of surgery. The patient continued to have mild pain in the left leg, however it did not restrict her activities.

Frontal and (B) lateral radiographs of the left and (C) frontal and lateral radiographs of the right tibia demonstrating bilateral cortical thickening and endosteal sclerosis. No periosteal reaction is seen


Intramedullary sclerosis is an idiopathic uncommon condition associated with new bone formation commonly affecting the shaft of the tibia in middle aged women It presents with vague pain in the legs, which increases on exertion and is not relieved on analgesic use. The pain worsens with disease progression. Examination findings usually reveal soft tissue edema and bony tenderness on deep palpation. [1,2,3]


Radiographs reveal selective endosteal diaphyseal hyperostosis, which varies in length and severity from minimal to complete obliteration of the medullary cavity, and may be associated with expansion of the bone. The sclerotic changes are strictly located in the diaphysis of long bones and when the disease is bilateral there is a tendency for asymmetry. Neither a periosteal reaction nor soft-tissue abnormalities are noticed. High resolution computed tomography confirms the medullary sclerosis and in addition is able to show any cortical irregularities.[1, 3] MRI typically shows the sclerotic areas with low signal intensity. No or minimal increase in signal intensity is noted in fat suppressed T2 and contrast enhanced T1 images, however mild enhancement may be present in the medullary cavity and adjacent soft tissues respectively, probably as a reaction process.[4, 5] The differential diagnosis of the condition includes Sclerosing disorders of the bones viz. Tumors (osteoid osteoma, metastasis), infections (chronic osteomyelitis), healing stress fractures, metabolic and endocrinal causes like hypervitaminosis A, Renal Osteodystrophy, pseudohypoparathyroidism. [3, 4] Other causes include Sclerosing bone dysplasias like Osteopetrosis, Pyknodysostosis, enostosis, osteopoikilosis, osteopathia striata, melorheostosis, metaphyseal dysplasia, hyperostosis corticalis generalisata, Worth Disease (Autosomal Dominant osteosclerosis), Camurati- Engelmann disease, Ribbing Disease, Sclerosteosis, metaphyseal dysplasia.


The lack of periosteal reaction, soft tissue involvement and bilateral affections are features of intramedullary osteosclerosis which are characteristically different from a malignant tumours like an osteogenic sarcoma, lymphoma or osteoblastic metastasis.  Osteoid osteoma may be ruled out by the lack of a classical history and of a radiolucent nidus. Chronic recurrent multifocal sclerosing osteomyelitis is more common between adolescent and children and commonly affect the metaphyseal region.  The lack of a fracture line and presence of intramedullary sclerosis rule out a stress fracture [5]. Generalised osteosclerosis are features of Renal osteodystrophy and pseudohypoparathyroidism which can be ruled out with the help of laboratory findings. Hypervitaminosis A shows classical features of a periosteal new bone formation with sparing of the medullary canal. Sclerosing dysplasias can be differentiated from Intramedullary osteosclerosis on radiological findings. Paget’s diease may mimic Intramedullary Osteosclerosis radiologically, however can be differentiated from it on the basis of normal Alkaline Phosphatase levels. Ribbings disease and Camurati – Engelmann disease are almost identical to intramedullary osteosclerosis on radiology and require clinical, laboratory and histological analysis for differentiation. [1, 6, 7] The differentiating features of Camurati – Engelmann disease include Autosomal Dominance disease presenting in the first decade, manifests as a bilateral disorder causing pain, progressive leg weakness, elongated extremities, and gait disturbances. [8] In contrast, Ribbing’s Disease is an autosomal recessive disorder seen after puberty with no sex predominance, and may be either unilateral or bilateral. Intramedullary Osteosclerosis is non-heriditary and commonly affects women. [9] Radiological features of Camurati – Engelmann disease include bilateral fusiform thickening of the cortex of long tubular bones. In addition, intramembranous bones like skull may be involved resulting in anaemia. On the other hand, Ribbings disease shows similar features however, involves only the long bones [10]. Intramedullary osteosclerosis also presents with similar radiological findings, and is essentially a diagnosis of exclusion [2]. Histological findings of Camurati – Engelmann disease include osteoblastic and osteclastic activity indicating both bone formation and resorption, whereas Ribbings disease and Intramedullary osteosclerosis demonstrate only osteoblastic activity [4]. The non- hereditary nature along with female predominance helps differentiate Intramedullary Osteosclerosis from the two conditions.  We treated our patient by making a cortical window on the medial cortex of the tibia and restoring the medullary canal by drilling holes through the endosteal surface of the sclerotic segment with the presumption that decompression resulted in pain relief and that obliteration of the medullary canal caused recurrence of the pain as reported previously. When the patient returned to our clinic after a month, her pain had subsided. The 8 – month follow-up radiograph of the left leg showed a persistent cortical thickening in the tibia and an obliterated medullary canal. However, her symptoms had improved remarkably. Many authors [8, 10, 11- 16] have advocated intramedullary decompression by reaming, curettage, or by making a window at the lesion for pain relief based on the belief that bone marrow edema causes pain. Medullary decompression appears to improve symptomatology and can be used to treat patients not responding to the medical line of management. However, it does not correct the primary cause of disease.



Intramedullary sclerosis is an idiopathic uncommon condition affecting the shaft of the tibia and is an important differential diagnosis for painful diaphyseal sclerotic conditions. Medullary Decompression may offer relief to patients in whom pain does not resolve with conservative treatment.


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How to Cite this article: Tuteja SV, Shetty SH, Khedekar RG, Butala RR. Intramedullary osteosclerosis of the Tibial Midshaft in a 38-year-old female: A case report with review of literature. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):58-61.

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How to Tame the Flood of Literature? A Round-up of Knee Surgery Research in 2016

Vol 1 | Issue 1 |  July – Dec 2016 | Page 37-40 |  Miten Sheth

Authors:  Miten Sheth [1].

[1] The Knee Clinic, First floor, Panchsheel Building, Paanch Rasta, Mulund West, Mumbai , India

Address of Correspondence
Dr Miten Sheth,
The Knee Clinic, First floor, Panchsheel Building, Paanch Rasta, Mulund West, Mumbai , India
E-mail: imiten@gmail.com

There have been several interesting publications pertaining to the knee this year. Promising new technologies were described, contemporary implants and approaches were evaluated and conflicting evidence was deciphered through well-designed reviews and meta-analysis. We aim to summarize innovations, trends and consensuses in knee surgery with this article. There has been increased interest in the use of tranexamic acid (TXA) during total knee arthroplasty (TKA). The Michigan group [1] reported their experience of 23000 odd TKAs concluding that TXA use was associated with decreased blood loss and transfusion risk, without increased risk of complications. Researchers from Louisville [2] found topical TXA to be a safe and efficacious alternative to intravenous TXA. Xing et al [3] reported a meta-analysis of ten studies, including one study conducted this year at Bombay hospital [4], noting that the combination of intravenous and topical TXA reduced post-operative blood loss without increasing the risk of thromboembolism. There have been some high-profile papers concerning unicompartmental arthroplasty (UKA) recently. The Oxford UKA remains a slightly controversial intervention in the knee world. The Netherlands group [5] supported the use of Phase III mobile-bearing Oxford Knee in medial compartment osteoarthritis with 90.6% survival at fifteen years. The Texas group [6] showed 88% survivorship at ten years and excellent function. The Oxford group [7] themselves reported the largest ever single series of around 1000 UKAs with a ten-year cumulative survival rate of 93.2%. Notably, they mentioned that good results of UKAs can be achieved even by trainee surgeons, if performed at a high-volume centre. The anterior cruciate ligament (ACL) has always been an enigma and we seem to discover new things every year. Japanese surgeons from Kobe [8] evaluated factors affecting quadriceps strength recovery after ACL reconstruction with a hamstring tendon autograft. Pre-operative quadriceps strength, age, sex, and knee pain are independently associated with post-operative quadriceps strength recovery. Fink et al [9] prospectively studied acute and delayed ACL surgery patients for two years and found no impact of surgical timing on the objective and subjective outcomes. Cadaver research at Pittsburgh [10,11] concluded that the ACL isthmus is located almost half of the distance between the insertion sites. The cross-sectional area of the ACL at the isthmus is largest with the knee unloaded and at 90° of flexion, and the area decreases with extension and applied loads. ACL reconstruction with graft fixation and tension for anteromedial bundle – 45°/ 30N and posterolateral -15°/ 10N, most closely matched intact knee kinematics. Clinical research at Pittsburgh [12] revealed that increased slope of the lateral tibial plateau might be an important anatomical variable predicting high-grade rotatory laxity in patients with ACL injury. While there are raised expectations from newer approaches to ACL reconstruction like the “All-inside technique”, there is very little in the way of objective evidence to support it over the traditional methods. Surgeons from Vienna [13] and Hampshire [14] followed around 100 patients to a minimum of two years post-surgery. While both these studies reported improved functional outcomes and stability with a re-rupture rate of 12.7% and 6.5% respectively, French surgeons from Reims [15] found that a year after surgery, around 50% of patients had residual anterior tibial translation > 3 mm. Meniscal ramp and root lesions are a subject of increasing interest. Ramp lesions constitute a common but often missed entity in ACL deficient knees. Laprade et al [16] summarized the anatomy, biomechanics, diagnostic strategies, recommended treatment options, and post-operative protocol. A controlled laboratory study by Amis et al [17] proved that anterior and external rotational laxities were significantly increased after sectioning of the posteromedial menisco-capsular junction in an ACL deficient knee. These were not restored after ACL reconstruction alone but were restored by ACL reconstruction combined with posterior menisco-capsular repair. Sonnery-Cottet et al [18] classified these lesions and reported improved outcomes of ramp repair at a minimum two-year follow-up with a 6.8% failure rate. Our understanding of the meniscal root has evolved in the last five years. A critical analysis review of the evaluation, treatment and outcomes of meniscal root tears was done this year by the team from New York [19]. Mayo Clinic, Rochester [20] provided the natural history benchmark for clinical outcomes in patients undergoing non-operative treatment. Untreated root tears are associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at five year follow-up. Surgeons from Korea [21,22,23] reported favorable mid-term outcomes after pull-out fixation especially in patients with decreased meniscus extrusion at post-operative one year follow-up. Grade ≥ III chondral lesions, varus alignment, and older age were found to predict a poor prognosis after root fixation. A meta-analysis of case series showed that root repair resulted in significant improvements in the post-operative subjective scores. However, meniscus extrusion was not reduced and progression of arthrosis was not prevented completely. World literature is full of reports on osteoarthritis of the knee. However, there is little data to support decision making. A 3-year, double-blind, randomised, placebo-controlled trial of 500 odd patients studied the effect of vitamin D supplementation on knee osteoarthritis (VIDEO study) [24]. The authors concluded that vitamin D supplementation has no role in the management of knee OA. A Cochrane review by the team from Sao Paolo [25] could not draw definite conclusions to help us decide between micro fracture, drilling, mosaicplasty, and allograft transplantation for cartilage defects. Of note though, treatment failure, with recurrence of symptoms, occurred with both microfracture and mozaicplasty. Multi center trials threw light on some interesting facts this year. The Research in OsteoChondritis of the Knee (ROCK) study group [26] developed a classification system for arthroscopic evaluation of osteochondritis dissecans (OCD) of the knee that demonstrated excellent intra- and inter-observer reliability. The Multicenter Orthopaedic Outcomes Network (MOON) group [27,28] reported 32% incidence of high-grade pre-operative knee laxity in a cohort of around 2300 patients who underwent primary isolated ACL reconstruction. The presence of this laxity was associated with significantly increased odds of revision surgery but had no association with outcome scores at two years. Chronic ACL tears, generalized ligamentous laxity, and meniscus tears are associated with high-grade Lachman, pivot shift, and anterior drawer tests. Female patients and age younger than 20 years are associated with increased odds of a high-grade pivot-shift test. The Delaware-Oslo ACL cohort study [29] advised return to sports 9 months or later after ACL reconstruction, and more symmetrical quadriceps strength prior to return, to reduce the re-injury rate. The Multicenter ACL Revision (MARS) study [30] identified prior lateral meniscectomy and grade 3 to 4 changes of the trochlea as factors associated with worse outcomes after revision ACL reconstruction. Articles debating the existence of anterolateral ligament, efficacy of hyaluronic acid or platelet rich plasma, and nature of cartilage healing filled up world literature this year. Navigation, robotics and patient-specific instrumentation in total knee arthroplasty were discussed with caution, concern and confidence. In spite of the plethora of new information, a lot of questions remain unanswered yet. Original research, multi-centric collaboration and systematic analysis of published evidence are the key to better understanding of the knee.


1. Hallstrom B, Singal B, Cowen ME, Roberts KC, Hughes RE. The Michigan Experience with Safety and Effectiveness of Tranexamic Acid Use in Hip and Knee Arthroplasty. J Bone Joint Surg Am. 2016 Oct 5;98(19):1646-1655.
2. Spanyer J, Patel J, Emberton E, Smith LS, Malkani AL. Topical Tranexamic Acid in Total Knee Arthroplasty Patients with Increased Thromboembolic Risk. J Knee Surg. 2016 Oct 5. [Epub ahead of print]
3. Yuan ZF, Yin H, Ma WP, Xing DL. The combined effect of administration of intravenous and topical tranexamic acid on blood loss and transfusion rate in total knee arthroplasty: Combined tranexamic acid for TKA. Bone Joint Res. 2016 Aug;5(8):353-61.
4. Jain NP, Nisthane PP, Shah NA. Combined Administration of Systemic and Topical Tranexamic Acid for Total Knee Arthroplasty: Can It Be a Better Regimen and Yet Safe? A Randomized Controlled Trial. J Arthroplasty. 2016 Feb;31(2):542-7.
5. Lisowski LA, Meijer LI, Bekerom MP, Pilot P, Lisowski AE. Ten- to 15-year results of the Oxford Phase III mobile unicompartmental knee arthroplasty: a prospective study from a non-designer group. Bone Joint J. 2016 Oct;98-B(10 Supple B):41-47.
6. Emerson RH, Alnachoukati O, Barrington J, Ennin K. The results of Oxford unicompartmental knee arthroplasty in the United States: a mean ten-year survival analysis. Bone Joint J. 2016 Oct;98-B(10 Supple B):34-40.
7. Bottomley N, Jones LD, Rout R, Alvand A, Rombach I, Evans T, Jackson WF, Beard DJ, Price AJ. A survival analysis of 1084 knees of the Oxford unicompartmental knee arthroplasty: a comparison between consultant and trainee surgeons. Bone Joint J. 2016 Oct;98-B(10 Supple B):22-27.
8. Ueda Y, Matsushita T, Araki D, Kida A, Takiguchi K, Shibata Y, Ono K, Ono R, Matsumoto T, Takayama K, Sakai Y, Kurosaka M, Kuroda R. Factors affecting quadriceps strength recovery after anterior cruciate ligament reconstruction with hamstring autografts in athletes. Knee Surg Sports Traumatol Arthrosc. 2016 Aug 23. [Epub ahead of print]
9. Herbst E, Hoser C, Gföller P, Hepperger C, Abermann E, Neumayer K, Musahl V, Fink C. Impact of surgical timing on the outcome of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016 Aug 22. [Epub ahead of print]
10. Fujimaki Y, Thorhauer E, Sasaki Y, Smolinski P, Tashman S, Fu FH. Quantitative In Situ Analysis of the Anterior Cruciate Ligament: Length, Midsubstance Cross-sectional Area, and Insertion Site Areas. Am J Sports Med. 2016 Jan;44(1):118-25.
11. Sasaki Y, Chang SS, Fujii M, Araki D, Zhu J, Marshall B, Linde-Rosen M, Smolinski P, Fu FH. Effect of fixation angle and graft tension in double-bundle anterior cruciate ligament reconstruction on knee biomechanics. Knee Surg Sports Traumatol Arthrosc. 2016 Sep;24(9) 2892-8.
12. Rahnemai-Azar AA, Abebe ES, Johnson P, Labrum J, Fu FH, Irrgang JJ, Samuelsson K, Musahl V. Increased lateral tibial slope predicts high-grade rotatory knee laxity pre-operatively in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016 May 6. [Epub ahead of print]
13. Schurz M, Tiefenboeck TM, Winnisch M, Syre S, Plachel F, Steiner G, Hajdu S, Hofbauer M. Clinical and Functional Outcome of All-Inside Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years’ Follow-up. Arthroscopy. 2016 Feb;32(2):332-7.
14. Yasen SK, Borton ZM, Eyre-Brook AI, Palmer HC, Cotterill ST, Risebury MJ, Wilson AJ. Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction. Knee. 2016 Sep 27.[Epub ahead of print]
15. Bressy G, Brun V, Ferrier A, Dujardin D, Oubaya N, Morel N, Fontanin N, Ohl X. Lack of stability at more than 12 months of follow-up after anterior cruciate ligament reconstruction using all-inside quadruple-stranded semitendinosus graft with adjustable cortical button fixation in both femoral and tibial sides. Orthop Traumatol Surg Res. 2016 Oct 4.[Epub ahead of print]
16. Chahla J, Dean CS, Moatshe G, Mitchell JJ, Cram TR, Yacuzzi C, LaPrade RF. Meniscal Ramp Lesions: Anatomy, Incidence, Diagnosis, and Treatment. Orthop J Sports Med. 2016 Jul 26;4(7).
17. Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, Amis AA. Posteromedial Meniscocapsular Lesions Increase Tibiofemoral Joint Laxity With Anterior Cruciate Ligament Deficiency, and Their Repair Reduces Laxity. Am J Sports Med. 2016 Feb;44(2):400-8.
18. Thaunat M, Jan N, Fayard JM, Kajetanek C, Murphy CG, Pupim B, Gardon R, Sonnery-Cottet B. Repair of Meniscal Ramp Lesions Through a Posteromedial Portal During Anterior Cruciate Ligament Reconstruction: Outcome Study With a Minimum 2-Year Follow-up. Arthroscopy. 2016 May 13.[Epub ahead of print]
19. Krych AJ, Reardon PJ, Johnson NR, Mohan R, Peter L, Levy BA, Stuart MJ. Non-operative management of medial meniscus posterior horn root tears is associated with worsening arthritis and poor clinical outcome at 5-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2016 Oct 19.[Epub ahead of print]
20. Strauss EJ, Day MS, Ryan M, Jazrawi L. Evaluation, Treatment, and Outcomes of Meniscal Root Tears: A Critical Analysis Review. JBJS Rev. 2016 Aug 9;4(8).
21. Chung KS, Ha JK, Ra HJ, Nam GW, Kim JG. Pullout Fixation of Posterior Medial Meniscus Root Tears: Correlation Between Meniscus Extrusion and Midterm Clinical Results. Am J Sports Med. 2016 Aug 24.[Epub ahead of print]
22. Chung KS, Ha JK, Ra HJ, Kim JG. Prognostic Factors in the Midterm Results of Pullout Fixation for Posterior Root Tears of the Medial Meniscus. Arthroscopy. 2016 Jul;32(7) 1319-27.
23. Chung KS, Ha JK, Ra HJ, Kim JG. A meta-analysis of clinical and radiographic outcomes of posterior horn medial meniscus root repairs. Knee Surg Sports Traumatol Arthrosc. 2016 May;24(5):1455-68.
24. Arden NK, Cro S, Sheard S, Doré CJ, Bara A, Tebbs SA, Hunter DJ, James S, Cooper C, O’Neill TW, Macgregor A, Birrell F, Keen R. The effect of vitamin D supplementation on knee osteoarthritis, the VIDEO study: a randomised controlled trial. Osteoarthritis Cartilage. 2016 Nov;24(11):1858-1866.
25. Gracitelli GC, Moraes VY, Franciozi CE, Luzo MV, Belloti JC. Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults. Cochrane Database Syst Rev. 2016 Sep 3;9:CD010675.
26. Carey JL, Wall EJ, Grimm NL, Ganley TJ, Edmonds EW, Anderson AF, Polousky J, Murnaghan ML, Nissen CW, Weiss J, Lyon RM, Chambers HG; Research in OsteoChondritis of the Knee (ROCK) Group. Novel Arthroscopic Classification of Osteochondritis Dissecans of the Knee: A Multicenter Reliability Study. Am J Sports Med. 2016 Jul;44(7):1694-8.
27. Magnussen RA, Reinke EK, Huston LJ; MOON Group, Hewett TE, Spindler KP. Effect of High-Grade Preoperative Knee Laxity on Anterior Cruciate Ligament Reconstruction Outcomes. Am J Sports Med. 2016 Aug 1.
28. Magnussen RA, Reinke EK, Huston LJ; MOON Group, Hewett TE, Spindler KP. Factors Associated With High-Grade Lachman, Pivot Shift, and Anterior Drawer at the Time of Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2016 Jun;32(6):1080-5.
29. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul;50(13):804-8.
30. MARS Group.. Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016 Jul;44(7) 1671-9.

How to Cite this article: Sheth M. How to Tame the Flood of Literature? A Round-up of Knee Surgery Research in 2016. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):37-40.

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Orthopaedic Trauma – Relevant articles in 2016

Vol 1 | Issue 1 |  July – Dec 2016 | Page 36-37 | Rohan Gala, Sanjay Dhar

Authors: Rohan Gala [1], Sanjay Dhar1 [1].

[1] Department of Orthopaedic Surgery, Dr D.Y.Patil Medical college, New Bombay, Maharashtra, India

Address of Correspondence
Dr Sanjay Dhar,
Department of Orthopaedic Surgery, Dr D.Y.Patil Medical college, New Bombay, Maharashtra, India
E-mail: drsanjaydhar@gmail.com

Over the years, there has been a constant attempt of orthopaedic surgeons worldwide to come up with newer techniques & improve the standard techniques of fracture fixation, reduce the risk of postoperative infection & to help patients achieve a good functional outcome to lead a better life.

“Die-punch” fractures of the distal end of radius have always been difficult to classify due their complex nature. Scheck et al defined it as a dorsal fracture fragment of the lunate fossa at the distal end of radius in 1962. As per the current concepts Zhang et al devised a new classification system in which they classified die punch fractures into 5 types which showed good inter-observer reliability and intra observer reproducibility, thus aiding the clinician to assess these injuries with relative ease [1].
Speaking of classifications, a recently devised classification system for proximal tibial fractures described by LUO et al [2], also known as the three column classification was applied and anatomical locking plates to treat complex three column fractures were invented. These plates proved to be far superior to the standard locking plates.
This year seemed to have more emphasis on tibial plateau fractures as Reza Firoozabaadi et al [3] identified a subset of bicondylar plateau fractures with a hyperextension varus deformity known as HEVBTP and they found a higher incidence of associated injuries like compartment syndrome and neurovascular injuries in this type. They laid down the radiographic hallmarks of this pattern, which were, loss of posterior slope of tibial articular surface, tension failure of posterior cortex, compression of the anterior cortex and varus deformity on the coronal plan
Open tibial fractures in adults have existing protocols outlining treatment strategies in detail. However, Ramsabbu et al [4] in their study on open tibial fracture management in paediatric age group concluded that more research is needed to determine an optimum treatment guideline as the existing literature of poorer quality.

Intra articular calcaneal fractures are one of the most difficult fractures to treat due to associated complications. One important complication is the peroneal tendon instability, which is clinically difficult to evaluate due to pain and swelling. Ketz et al [5] in their study concluded that intra operative evaluation of the superficial peroneal retinaculum as well as pre operative imaging (CT scan) is useful in the operative management of intra articular calcaneal fractures. SPR and its confluence with the peroneal tendon sheath represent the primary restraint against displacement of peroneal tendons. They also suggested a new technique of reparing the superficial peroneal retinaculum with intra-osseus suture anchor placement into the posterolateral fibula.

Sacral fractures with spinopelvic dissociation are highly unstable injuries which often require surgical intervention with Iliosacral screw fixation &/or lumbopelvic fixation from L4 to Pelvis which is often associated with life threatening complications and higher infection rate due to the prolonged surgery and increased blood loss. Seth K. Williams et al [6] developed a minimally invasive percutaneous lumbopelvic fixation technique to reduce and stabilize these fractures. They concluded that this technique is not only time saving but the intra operative blood loss is less. The ability to immediately weight bear without restriction made the author use this technique in cases where sacro iliac screw fixation alone would have sufficed.

Fracture spine is a subtype of fracture that relies heavily on radiological imaging ( X-Ray MRI, CT- Scan) in assessment and planning. The treatment strategies of thoracolumbar fractures are largely dependant on the classification system, and recently most of them have stressed on the importance of assessing then integrity of posterior ligament complex due to the high instability of the fractures and the resultant functional deterioration. Rajasekaran et al [7] formulated an interesting radiological index based on plain radiographs and CT scan to detect PLC injury without the actual need for MRI. The injury was assessed with parameters like Superior Inferior End plate Angle (SIEA), Vertebral body Height (VBH), Local Kyphosis (LK), Inter Spinous distance (ISD), and Interpedicular distance (IPD).



1. Zhang J, Ji XR, Peng Y, Li JT, Zhang LH, Tang PF. New classification of lunate fossa fractures of the distal radius. J Orthop Surg Res. 2016 Oct 21;11(1):124.
2. Lin W, Su Y, Lin C, Guo W, Wu J, Wang Y, Zhang S, Liu S, Liu W, Chen L. The application of a three-column internal fixation system with anatomical locking plates on comminuted fractures of the tibial plateau. Int Orthop. 2016 Jul;40(7):1509-14.
3. Firoozabadi R, Schneidkraut J, Beingessner D, Dunbar R, Barei D. Hyperextension Varus Bicondylar Tibial Plateau Fracture Pattern: Diagnosis and Treatment Strategies. J Orthop Trauma. 2016 May;30(5):e152-7.
4. Ramasubbu RA, Ramasubbu BM. Surgical stabilization for open tibial fractures in children: External fixation or elastic stable intramedullary nail – which method is optimal? Indian J Orthop. 2016 Sep;50(5):455-463.
5. Ketz JP, Maceroli M, Shields E, Sanders RW. Peroneal Tendon Instability in Intra-Articular Calcaneus Fractures: A Retrospective Comparative Study and a New Surgical Technique. J Orthop Trauma. 2016 Mar;30(3):e82-7.
6. Williams SK, Quinnan SM. Percutaneous Lumbopelvic Fixation for Reduction and Stabilization of Sacral Fractures With Spinopelvic Dissociation Patterns. J Orthop Trauma. 2016 Sep;30(9):e318-24
7. Rajasekaran S, Maheswaran A, Aiyer SN, Kanna R, Dumpa SR, Shetty AP. Prediction of posterior ligamentous complex injury in thoracolumbar fractures using non-MRI imaging techniques. Int Orthop. 2016 Jun;40(6):1075-81.

How to Cite this article: Gala R, Dhar SB. Orthopaedic Trauma – Relevant articles in 2016. Journal of Clinical Orthopaedics July – Dec 2016; 1(1):36-37.

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Antibiotic Loaded Bone Cement in Orthopaedic Surgery

Vol 1 | Issue 1 |  July – Dec 2016 | Page 56-57 | Vikas Agashe, Aditya Menon

Authors: Vikas Agashe [1], Aditya Menon [1].

[1] P.D.Hinduja Hospital & Research Centre, , Mumbai, India.

Address of Correspondence
Dr. Vikas M. Agashe
Dr Agashe’s Maternity & surgical Nursing Home, Vrindavan, Off L.B.Shastri Marg, Kurla, Mumbai 400070
Email: agashefam@gmail.com

Antibiotic loaded bone cement (ALBC) is used for prevention as well as treatment of orthopaedic infections. Below is a short review of salient points and practical tips regarding antibiotic loaded cement

1. Antibiotics which can be used
i. Gram positive coverage
a. Vancomycin
b. Cefazolin
c. Clindamycin
d. Teicoplanin
e. Daptomycin

ii. Gram negative coverage
a. Gentamycin
b. Tobramycin
c. Colisitn
d. Tigecycline
e. Meropenem

2. Antibiotic must be
a. Water soluble
b. Powder form
c. Stable at temperatures up to 60 to 80degrees Celsius.

3. Effect of type of mixing
a. Manual:
More porous
Less mechanical stability
Higher chance of mantle fracture
Better elution of antibiotics due to high porosity

b. Vacuum mixing
Less porous
More stable
Less elution of antibiotics compared to manual preparation (not clinically significant)

4. Combination of two antibiotics in a spacer has a superior bactericidal activity and the antimicrobial effect lasts for a longer duration as compared to a spacer loaded with a single antibiotic [1]. This occurs due to enhanced elution of both the antibiotics, a phenomenon described as “passive opportunism” Coupling of a glycopeptides and aminoglycoside covers both gram positive and gram negative organisms thereby reducing the resistance rates.
The combination of teicoplanin with gentamycin is more superior than Vancomycin with gentamycin

5. Amount of antibiotic
a. Must not exceed 10% of the total volume of cement
b. Higher than 10 % may affect the mechanical strength of the cement mantle in arthroplasty
c. Higher concentration of antibiotics can be used if PMMA is used as a temporary spacer
d. Primary arthroplasty: Mix less than 2 grams of antibiotics with 40 grams of PMMA.
e. Temporary spacer in trauma or periprosthetic infections > 2grams (up to 6 to 8 grams) of antibiotic can be used with 40 grams of PMMA [2,3].

5. Biomechanical properties:
Studies show that addition of antibiotics to the commonly used brands (Simplex, Palacos, CMW1 and CMW 3) did not show any significant difference in the fatigue strength as compared to the same brand without any antibiotic [3]. Clinically significant differences in biomechanical properties are seen only when high doses of >4.5gm per 40 gms PMMA are used

6. Tips and tricks to prepare cement beads [4]
a. 22 or 24 gauge stainless steel wire is braided by holding a loop with clamps at either ends and twisting it.
b. Bead size must not exceed 8mm
c. Keep a gap between 2 successive beads
d. Surface area of the beads can be increased by making multiple pits on the surface using a 1.5mm k wire as the PMMA starts to set
e. Suction drain if used may be kept closed and opened every 6 to 8 hours for only 15 minutes to allow periodic drainage of the wound

7. Cement mixing recommendation
A. Sumant Samuel et al [4]
a. Add liquid monomer to methylmethacrylate powder in a bowl
b. Commence hand mixing with a spatula
c. Add appropriate amount of antibiotic powder to the cement when in early ‘dough’ phase immediately after wetting the cement
d. Mix in standard fashion at 1 revolution/ second to obtain a homogenous compound

B. Oschner et al [5]
a. Fill bowl with appropriate amount of antibiotic powder ( eg. 2grams)
b. Grind to a fine powder
c. Mix equal amount of cement polymer powder (2 grams) to the bowl
d. Mix thoroughly
e. Add an equal amount of cement polymer powder subsequently so as to double the total amount in the bowl till all the polymer powder is used up
f. Pour liquid monomer
g. Blend as usual

Careful attention has to be paid to dose and method of mixing for preparation of antibiotic loaded cement. It is an effective tool when used properly for proper indications


To conclude, lumbar disc herniations are major cause of lower back-related disability in working-age group. Fortunately, around 80 % of patients do well with non-operative treatment while surgery is reserved for a small and specific fraction of patients. There is a wide range of modalities in non-operative management of lumbar disc herniations inspite of lack of evidence for any specific modality better than other. In cases of clinico radiological mismatch epidural steroids is preferred modality of treatment. Whenever an operative treatment is opted we don’t believe in prophylactic fusion. Instability should be given a chance. Fusion is performed only in limited and specific patients. Pedicle screws fixation along with posterolateral fusion (PLF) is a preferred modality of treatment.


1. Hsu YM, Liao CH, Wei YH, Fang HW, Hou HH, Chen CC, Chang CH. Daptomycin-loaded polymethylmethacrylate bone cement for joint arthroplasty surgery. Artif Organs. 2014 Jun;38(6):484-92.
2. Bistolfi A, Massazza G, Verné E, Massè A, Deledda D, Ferraris S, Miola M, Galetto F, Crova M. Antibiotic-loaded cement in orthopedic surgery: a review. ISRN Orthop. 2011 Aug 7;2011:290851
3. Cancienne JM, Burrus MT, Weiss DB, Yarboro SR. Applications of Local Antibiotics in Orthopedic Trauma. Orthop Clin North Am. 2015 Oct;46(4):495 510.
4. Samuel S, Ismavel R, Boopalan PR, Matthai T. Practical considerations in the making and use of high-dose antibiotic-loaded bone cement. Acta Orthop Belg. 2010 Aug;76(4):543-5.
5. Oschner P, Borens O, Trampuz A, Zimmerli W. Infections of the musculoskeletal system: Basic principles, prevention, diagnosis and treatment: 1st edition, 2014. Swiss Orthopedic and Swiss society for Infectious diseases expert group “Infections of the musculoskeletal system”

How to Cite this article: Agashe V, Menon A. Antibiotic Loaded Bone Cement in Orthopaedic Surgery  Journal of  Clinical Orthopaedics July – Dec 2016; 1(1):56-57

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