ORTHOWALKATHON- Interview of Dr. Sailendra Bhattacharya

Vol 2 | Issue 1 |  Jan – June 2017 | Page 61-62 | Dr. Sailendra Bhattacharya

Author: Dr. Sailendra Bhattacharya

Dr. Kanchan Bhattacharyya, interviews the living legend of Orthopaedics in India, Dr. Sailendra
Bhattacharya and presents the pearls of the interview here


Dr. Sailendra Bhattacharya is a living legend in the field of Indian Orthopaedics. Born in Calcutta on
26th of January,1924, he graduated from RG Kar Medical College and Hospital in 1949 and after the mandatory PRCA, became the first Honorary house surgeon in Orthopaedic Surgery under Dr. Sarbadhikari, going on to be the Registrar, at the same institution.

In 1953 he was selected by the Indian Medical Association to visit the University of Oklahoma,USA, where he was accepted in the Orthopaedic residency program and incidentally one of his colleagues there, was the redoubtable Dr. Charlie Rockwood. He had barely spent a year and a half, when his father needed him, and Dr. Bhattacharya, realizing that a post graduate degree was a necessity, left Oklahoma for UK where he completed his FRCS, and returned to Calcutta in 1956. In U.K. he spent most of his time in Southampton with Mr. Alexander Law.

Back home, with a young family, life was not easy. He joined Sambhunath Pandit Hospital in an honorary capacity, and took care of Orthopaedic cases only, which was a first in that institution. Dr Bhattacharya had always been a keen surgeon, and during his short stint in that hospital he had performed several operations including skin interposition arthroplasty of the hip. What made him stand out, was his meticulous record keeping. He kept track of all his surgical cases starting from day one and never let up even when his volume had become prodigious.

During this period he was invited by Dr. S.R. Chandra, the HOD in P. G. Hospital, to join the teaching staff of Calcutta University at the University College of Medicine as a lecturer. In 1958 he went back to his alma mater as a lecturer, and stayed on for 18 years, leaving as an Assistant Professor, when he felt that the hospital was not moving forward at a pace of his liking.

He joined Calcutta Hospital, a newly inaugurated multi-specialty hospital in the city, which boasted of state of the art equipment and a modern infrastructure. Dr. Bhattacharya was a consultant for several years, and did his first THR there, which, incidentally was the first in this part of the country. He has more than 30 years of documented survival of his earliest THRs.

He was a perfectionist in every aspect of his practice. He had two sets of X-rays taken every time, of which one was for his records. He maintained his own instruments, like all surgeons of his era, with a big difference. His huge practice demanded a high volume of surgery and he had several sets of instruments for each procedure, so that he could carry out five or six similar surgeries without running out of pre autoclaved trays. This made it easy for him to comfortably operate into the small hours of the morning without relying on the limited infrastructure of the smaller nursing homes. The clock never bothered him and his surgery went on until he had it just so.

In Harrington Nursing Home, adjacent to the US consulate, and across the street from his consultancy, where he operated for years, it was customary for the last surgery to be completed at about the stroke of dawn, with the surgical team, the only people around. There seldom came a challenge he would not rise up to, and it is difficult to imagine a surgical procedure that he has not conducted and documented. He was replacing hips in the seventies and knees in the eighties, did spinal fixations and decompressions, and, of course, all routine surgeries of his era, but the orthopaedic community remembers him most, for his description and expertise in elbow arthrolysis in post traumatic elbow stiffness which he first presented in the ASI conference in 1971 and later published in JBJS in 1974. His previous publication ‘Abduction contracture of the shoulder due to contracture of the intermediate part of deltoid’ had appeared in JBJS in 1966.

Dr. Bhattacharya’s documentation and record keeping was so far ahead of his time, that he was asked to speak on this subject in Cuttack along with Dr. Shanmugasundaram. On starting his own hospital, BORRC, in 1992 he has had most of his handwritten records digitalized. Until a short time ago he still saw a select few patients every day, attended every meeting in the city, talked to everyone around him, addressing them by their first names and occasionally, personally, updating the contacts list in his latest I- phone.

A towering personality, who has been a role model to the generation next, Dr. Bhattacharya’s matchless skill and expertise, his phenomenal volume and enviable accomplishments has become part of folklore in this part of the world.

A little frail of body today, his mind is still just as sharp as it was during his heydays. His enviable appetite for knowledge has not ebbed al all, though that of food, has. However, as a host he is as keen as ever and you can never leave his room without eating all the savories that he will have lined up.

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Changing Trends in Fracture Fixation

Volume 2 | Issue 1 |  Jan – June 2017 | Page 2-3 | Sudhir Babhukar

Authors: Sudhir Babhukar [1]

[1] Sushrut Hospital, Research Centre and Post Graduate Institute of Orthopaedics, Nagpur.

Address of Correspondence

Dr. Sudhir Babhulkar
Emeritus Prof. of Orthopaedics Indira Gandhi Medical College, Nagpur. Director Sushrut Hospital, Research Centre and Post Graduate Institute of Orthopaedics, Nagpur.
Email: sudhirbabhulkar@gmail.com

Internal fixation requires a sound understanding of the principles and techniques of the use of implants. Proper understanding of mechanical and biological aspects of fracture repair is key to selection of implant for the treatment of a particular fracture. Fracture fixation is guided by results of various laboratory researches and is related to cellular biology, vascular physiology, biomechanics and our observation and experience from clinical practice. Due respect should be given to microcirculation of bone and soft tissues which is equally important while considering the internal fixation of fractures. One major factor for non-healing of fractures has been the association of the motion at the fracture site during the process of healing after internal fixation causing instability. In cases of internal fixation, this will affect the choice of implant and its principle of application.
Kuntscher first developed the technique of intramedullary nailing as early as 1939. Kuntscher’s work was marked by his extensive knowledge, his wealth of ideas and his understanding of the biological process of bone healing, which are impressively, documented in his monograph ‘The problem of consolidation and intramedullary nailing’. His contributions in this field include flexible intramedullary reamers, distraction device, intramedullary saw, and the detensor, which was the first type of interlocking nail. Kuntscher’s original nail was hollow, slotted; cloverleaf shaped and became progressively popular all over the world.
During the last 20-25 years interlocking nailing has been the golden standard in the treatment of diaphyseal long bone fractures. In 1972 Klemm and Schellmann from Frankfurt and Maine developed the first version of Interlocking nail. Subsequently at CTO Strasbourg around 1974-76 Grosse and Kempf modified, developed and improved the original nailing interlocking system. Lot of changes has occurred in this methodology of nailing-interlocking fixation. Second-generation Reconstruction nail, Gamma nail, PFN and very recent third generation telescoping locking nails are some recent newer modifications.
The treatment of open injuries during the course of fracture treatment dictate the use of methods believed to reduce the risk of complications, including urgent or emergent treatment and thorough debridement of wound and stabilisation by various methods of fracture stabilization, which includes markedly improved external fixators and intramedullary (IM) devices. External fixation devices were used as early as 1840 by Malgaigne to hold a fracture tibia in position and in 1843 a clamp to approximate fractures of the patella. Lambotte in 1907 is also credited with the use of monolateral system with threaded pins, which looks like the AO fixator. However the method failed to gain widespread acceptance till Hoffmann from Switzerland published his series in 1938 with good results. Today it is one of the best methods of fixation for open fractures especially grade III B and C. With the development of VAC system the prognosis of open injuries have improved. Another significant development in this area was the Ilizarov’s technique of ring fixators, which has revolutionized the treatment of infected nonunion and reconstruction of comminuted intra-articular fractures.
Stable reconstruction of the fractured bone minimizes the load to be carried by the implant. Stability of the fixation is therefore a critical parameter with respect to implant fatigue and corrosion. Fracture fixation once achieved should produce absolute quietness of fracture by way of stable or biological fixation. This was the basis of AO principles, the group formed in 1958 that promoted the treatment by internal fixation. However their principles are changing and they have moved from rigid fixation to biological fixation & stable fixation allowing micromotion. Stability in internal fixation is used to describe the degree of immobility of the fracture fragments. Stable fracture fixation (Osteosynthesis, term coined by Lambotte) means a fixation with little displacement. A special condition is described by the term absolute stability. This defines complete absence of relative displacement between fracture surfaces. Within the same fracture surfaces, areas of absolute and of relative stability may be present simultaneously. Over the years there has been a major change in the philosophy of the AO/ASIF group. It is now preferred to have a stable biologic fixation than a rigid fixation.
The principles of Biological Fixation may be summarized as: Repositioning and realigning by manipulation at a distance to the fracture site, preserving soft tissue attachments, leaving comminuted fragments out of the mechanical construct while preserving their blood supply, using low elastic modulus, biocompatible material, decreasing contact between the bone and the implant and limiting operative exposure when possible. The degree of stability achieved has a determining effect upon the amount of the load borne by the implant used for fixation. The load carried by the implant is critical with respect to possible fatigue failures and /or to fretting corrosion.
Today with the development of key-hole & minimally invasive surgery, arthroscopically assisted fracture reduction, reconstruction of articular surface & fixation is very much in vogue, especially for distal radius, tibial plateau and plafond fractures. The principle of indirect reduction has been developed lately for fracture fixation. The technique of plating as well as plate design has been modified. The AO principles, techniques and implants have changed considerably over the time. There is a shift of emphasis from mechanical to biological aspect of internal fixation with great emphasis being placed on the preservation of blood supply to the bones & soft tissues. Less Invasive Stabilisation System (LISS) and Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) represents a new generation of plates and principles, which act as internal fixators, minimising any surgical insult to the bone and approach related soft tissue damage.
Similarly, there have been lot of developments for the easy and safe technique of closed nailing and interlocking of femur, tibia and other bones. Use of ultrasound for control of passage of guide wire by closed technique is one of the latest developments. Ultrasound and Doppler studies are used for assessing the fracture healing. The technique studies the morphology of callus and neo-vascularisation to predict the progress of fracture healing. The test is non-invasive, cheap and easily accessible. Minimally invasive surgery and computer-aided techniques will influence future developments in the fracture management.
With the increase in the medicolegal issues related to the field of medicine, especially in orthopedics, there is no specific single method of treatment available, for a particular fracture/injury. Major changes are taking place around the world concerning fracture treatment. Change cannot be avoided and will, sooner or later, arrive. The specialty of orthopedics in particular has grown by leaps and bounds in the last 50 years, thanks to the modern day pandemics – road traffic accidents. From a neglected specialty that dealt with deformity, osteomyelitis and low energy trauma, it has become a specialty of demand and glamour, ever growing with quantum leaps. Improved metallurgy, asepsis, intensive care facilities, anesthesia, imaging and diagnostic methodology has allowed us to progress faster.

How to Cite this article: Babhulkar S. Changing Trends in Fracture Fixation. Journal of Clinical Orthopaedics Jan – June 2017; 2(1):2-3.

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Journal of Clinical Orthopaedics – an academic venture of Bombay Orthopaedic Society


Journal of Clinical Orthopaedics | Vol 2 | Issue 1 |  Jan – June 2017 | page:1 | Dr. Nicholas Antao, Dr. Ashok Shyam

Author: Dr. Nicholas Antao [1], Dr. Ashok Shyam [2, 3]

[1] Hill Way Clinic, Hill N Dale Building, 4th Floor, Hill Road, Bandra West, Mumbai – 400050
[2] Sancheti Institute for Orthopaedics and Rehablitation, Pune, India
[3] Indian Orthopaedic Research Group, Thane, India.

Address of Correspondence
Dr. Nicholas Antao
Head of Dept. of Orthopaedics, Holy Spirit Hospital, Mahakali Road, Andheri (E), Mumbai – 400093 India.
Email: narantao@gmail.com

Journal of Clinical Orthopaedics – an academic venture of Bombay Orthopaedic Society

Bombay Orthopaedic Society (BOS) has always been in forefront of academics and education. Academic courses and content of BOS have always been known for high quality and providing best education to the new generation of orthopaedic surgeon has been the central aim of BOS right from its inception decades ago. Taking ahead the same tradition, BOS had taken the decision of starting its own journal named Journal of Clinical Orthopaedics. This is the second issue of the Journal and the entire editorial team is proud to present it to our readers
As is the hallmark of all BOS activities, high quality content is hallmark of Journal of Clinical Orthopaedics (JCO). In this issue we have guest editorial by Dr Sudhir Babhulkar and a perspective article by Dr Shantaram Shetty. Dr GS Kulkarni, Dr Ashok Rajgopal, Dr Ramesh Sen, Dr Raju Vaishya and many more have contributed excellent review articles. Also the issue contains the usual potpourri features that includes, foot and ankle, arthroscopy, paediatric orthopaedics and tuberculosis. Lastly but most importantly the issue contains interview of Dr Sailendra Bhattacharya, the living legend of Orthopaedics. Thus the content of the issue is contributed by the best in orthopaedics from across the country and although the issue was delayed by a month, we could cover the shortcoming by providing excellent quality articles for our readers.
The format of JCO will continue to evolve in coming years, but the goal will always be to bring the best reading material which has balance of both experience and evidence based content. The focus would be to bring practically useful content which can be applied to day to day practice. We would like to request our readers to please submit clinically relevant articles, original research, case series, case reports and technical notes to JCO. The Journal has an excellent website and online article submission system which is simple to use and keep record of all your submissions. Preparation of JCO issue for WIROC 2017 is in full swing and we are hopeful to get articles from many more of our readers.
We thank our authors and editorial board members for their contributions to the journal. We look forward to making JCO a world recognised indexed journal and we solicit support from all of our readers

Dr Nicholas Antao – Editor JCO
Dr Ashok Shyam – Associate Editor JCO.

How to Cite this article: Antao N, Shyam AK. Journal of Clinical Orthopaedics – an academic venture of Bombay Orthopaedic Society . Journal of Clinical Orthopaedics Jan – June 2017; 2(1):1.

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Foot and Ankle in 2017: Some Questions Answered?

Vol 2 | Issue 1 |  Jan – June 2017 | Page 59-60 | Pradeep Moonot

Authors: Pradeep Moonot [1].

[1] Breach Candy Hospital, Mumbai, India

Address of Correspondence
Dr Pradeep Moonot
Orthopaedic Surgeon & Specialist in Knee, Foot and Ankle Surgery, Breach Candy Hospital, Mumbai
Sir H N Reliance Foundation Hospital, Wockhardt Hospital, Bombay Central, S L Raheja Fortis Hospital, Mahim, Hinduja Khar Hospital, Nanavati Multispecialty Hospital, Criticare Hospital, Juhu
Email: drmoonot@gmail.com


There are many ways in which a condition can be treated, especially in the foot and ankle speciality. There are also many queries and controversies in this field on various topics like tendoachilles tear, isolated lateral malleolus fracture, flat foot surgery, Mortons neuroma, gastrocnemius tightness, etc. I hope to answer some of the queries and suggest an update in the present article.


Treatment of Chronic rupture of Tendoachilles:
In India there are numerous patients which present late with tendoachilles (TA) rupture either because of neglect or due to misdiagnosis. These patients present with disability involving activities of daily living or a limp. Various surgical procedures have been reported for the reconstruction of a chronic Achilles tendon rupture; these involve resection of the interposed scar tissue and reconstruction using normal autologous tissue. Although these reconstructive surgical procedures have been shown to have good clinical results, they are time-consuming and difficult to perform compared with primary repair. In addition, procedures involving the use of a normal autologous tendon are associated with donor-site morbidity. Yasuda et al 1 studied the direct repair of chronic TA rupture using the scar tissue in 30 patients (30 feet). In 27 patients, the duration from injury to the time of the surgical procedure was >12 weeks, and the mean duration was 22 weeks.
Surgical technique: After the midline longitudinal incision, the scar and tendon tissue was inspected. The middle part of the scar tissue located between the tendon stumps was resected. After the resection, the approximation of the proximal and distal ends of the tendon was possible with the ankle in 200 to 300 of plantar flexion. If needed, the additional scar tissue was resected.
The results showed significant improvement in the AOFAS scores. At the time of the latest follow-up (minimum 24 months), none of the patients had experienced tendon reruptures or difficulties in walking or climbing stairs, and all except 2 patients could perform a single-limb heel rise. All athletes had returned to their pre-injury level of sports participation. Histologically, the interposed scar tissue consisted of dense collagen fibers.
In conclusion, shortening of the tissue between the 2 tendon ends that included healing scar and direct repair of healing tendon without allograft or autograft can be effective for treatment-delayed or neglected Achilles tendon rupture.

Surgery for Flat foot in adults. Does it help?
Adult acquired flatfoot deformity (AAFD) could result in a painful progressive plano-valgus deformity. The most common cause of AAFD is posterior tibial tendon dysfunction (PTTD), which involves pathology of the posterior tibial tendon (PTT) and the spring ligament. In the initial flexible stage (Type II AAFD) shoe modification, ortrhosis and physiotherapy is helpful. Surgery becomes an option after failed non-surgical treatment. There are less than 20 published studies that evaluate the outcome of this type of surgery, most are small retrospective investigations with only postoperative data presented and only few use a prospective design. Coster et al evaluated 21 patients with a median age of 60 (range 37–72) years who underwent different surgical reconstructions due to stage II AAFD before and 6 and 24 months after surgery by the multiple patient questionnaires.
The surgical procedures varied but included medial displacement calcaneal osteotomy, FDL tendon transfer, spring ligament reconstruction, lateral column lengthening and gastrocnemius recession.
Before surgery the patients completed multiple scores which included SF-36 and Euroqol. The participants were before surgery markedly impaired in function and HrQoL and had substantial pain. All scores improved after surgery, with statistically significant improvement found from preoperative to 6 months after surgery. Three patients had severe but flexible flat foot deformities which required fusion. These patients also did well.
This study shows that surgery of AFFD due to PTTD results in improved pain, function and HrQoL. The high subjective satisfaction rate and the low complication rate support the usefulness of surgery in this condition. The improvement can take up to 2 years after surgery.
Is Gastrocnemius recession the answer to foot pain?
Isolated gastrocnemius contracture (IGC) is considered an etiologic factor for various complex foot diseases and symptoms such as hallux valgus, acquired flatfoot, hammertoe deformity, and plantar fasciitis. Holtmann et al3 studied the effect of IGC release in 64 neurologically healthy patients. The prevalence of foot disorders were pes planus (41%), hallux valgus (38%), metatarsalgia (19%), hammertoe deformity (13%), and symptomatic Haglund exostosis (11%). At a follow up period of 31 months, the patients had significantly benefited from increased ankle dorsiflexion. This resulted in improvement of the symptoms of pain and increase in the daily life functionality and patient satisfaction. Special attention is needed to identify the sural nerve as it is at risk during surgery. Early physiotherapy and muscle training is required to regain the strength.
Use of PRP in Foot and Ankle:
In recent years, the musculoskeletal benefits of PRP have been the focus of considerable interest, most notably in sports medicine and orthopedics. Most of the published data on PRP have focused on its effectiveness to treat degenerative tendinopathy or early-stage knee chondropathy and arthritis.
Repetto et al4 retrospectively evaluated the mid- to long-term clinical results (mean follow-up of 17.7 months) for platelet-rich plasma injections in 20 patients (20 ankles) with ankle osteoarthritis. They found a strong positive effect for 4 platelet-rich plasma injections (injected once a week) on pain and function, with 80% of patients very satisfied and satisfied, and only 2 patients (10%) required surgery because of early treatment failure. These results suggest that the use of platelet-rich plasma injection is a valid and safe alternative to postpone the need for surgery.
Alviti et al5 studied the use of PRP matrix in acute rupture of the Achilles Tendon (ATR). They analysed the biomechanical characteristics, stiffness, and mechanical work of the ankle during walking in patients who had undergone surgery after ATR with and without PRF augmentation in 20 patients. A gait analysis evaluation was performed at 6 months after surgery. The percentage of the stance time of the operated leg, double-support time of the healthy leg, and net work of the ankle during the gait cycle showed statistically significant differences between the no-PRF and the healthy group (p < .005). This may be due to a reduction of the effectiveness of the muscle work related to a weakness of the elongation and elastic return of the Achilles tendon during walking. There were no differences between the PRF and healthy groups. Treatment with suture and PRF augmentation could result in significant functional improvements in term of efficiency of motion.


1. Yasuda T, Shima H, Mori K, Kizawa M, Neo M. Direct Repair of Chronic Achilles Tendon Ruptures Using Scar Tissue Located Between the Tendon Stumps. J Bone Joint Surg Am. 2016 Jul 20;98(14):1168-75
2. Cöster MC, Rosengren BE, Bremander A, Karlsson MK. Surgery for adult acquired flatfoot due to posterior tibial tendon dysfunction reduces pain, improves function and health related quality of life. Foot Ankle Surg. 2015 Dec;21(4):286-9
3. Holtmann JA, Südkamp NP, Schmal H, Mehlhorn AT. Gastrocnemius Recession Leads to Increased Ankle Motion and Improved Patient Satisfaction After 2 Years of Follow-Up. J Foot Ankle Surg. 2017 May – Jun;56(3):589-593
4. Repetto I, Biti B, Cerruti P, Trentini R, Felli L. Conservative Treatment of Ankle Osteoarthritis: Can Platelet-Rich Plasma Effectively Postpone Surgery? J Foot Ankle Surg. 2017 Mar – Apr;56(2):362-365.
5. Alviti F, Gurzì M, Santilli V, Paoloni M, Padua R, Bernetti A, Bernardi M, Mangone M. Achilles Tendon Open Surgical Treatment With Platelet-Rich Fibrin Matrix Augmentation: Biomechanical Evaluation. J Foot Ankle Surg. 2017 May – Jun;56(3):581-585.

How to Cite this article: Moonot P. Foot and Ankle in 2017: Some Questions Answered?. Journal of Clinical Orthopaedics Jan – June 2017; 2(1):59-60.

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Commentary on meaningful and interesting arthroscopy articles around the globe, 2016-2017

Vol 2 | Issue 1 |  Jan – June 2017 | Page 56-58 | Arumugam S, Prakash A

Authors: Arumugam S [1], Prakash A [1].

[1] Department of Arthroscopy & Sports Medicine, Sri Ramachandra University, Porur, Chennai, India – 600116

Address of Correspondence
Dr. Arumugam S
Centre for Sports Science, Head, Dept. of Arthroscopy & Sports Medicine, Sri Ramachandra University, Porur, Chennai, India – 600116
email: drarumugam@csstrucoach.in

ACL Repair here to stay?

With the re-introduction of arthroscopic ACL repair, the arthroscopy community is visualising the resurgence of this previously abandoned procedure. Andreas Imhoff and Wolf Petersen’s group [1] has published their results comparing ACL reconstruction with quadrupled semitendinosus graft and primary ACL repair using knotless suture anchors and micro fracture in a followup period of 28months with comparable results in terms of IKDC and Lysholm score. However this group had a 15% failure rate in their repair group as opposed to the Danish & Norwegian registries cumulative report of 4% failure rate in ACL reconstruction. Although the results are promising only time will tell if ACL repair is here to stay.

J.P.Van der List [2] studied biomechanics of primary ACL repair in 12 cadavers knees and observed for gap formation during cyclic loading and found approximately 1mm gap formation with failure load of 243N. They emphasise careful ROM exercises and early second look arthroscopy to assess gap formation and healing in primary ACL repair.

Anterolateral ligament does exist
ALL Expert Group [3] consisting of leading proponents of the anterolateral ligament provides a comprehensive consensus on anatomy of this ligament of knee, along with comprehensive examination & imaging, also proposing their own surgical technique of ALL reconstruction to improve the outcome of the ACL injured patients. Their broad overview of this subject enables one to see the bigger picture in the enigmatic instability patterns of the human knee.

Etienne et al [4] studied a small cohort of patients with ACL tear and examined their knees clinically and using USG and MRI. Their study revealed the identification of ALL in all cases using USG, MRI could not pickup ALL tear in all cases and patient with ALL tear more often had a positive pivot shift. According to them USG is a better imaging modality to detect this pathology owing to its higher spatial resolution and its ability to examine knees dynamically.

Primary knee ACL, in depth analysis
Graft bending angle was studied by Tashiro et al [5] assessing dynamic knee motion after primary ACL reconstruction using quadriceps graft, comparing femoral tunnel created using rigid & flexible reamers. The striking finding of this study was higher bending angles at femoral aperture and correlating larger bone tunnel widening was observed as early as 6 months following surgery in the flexible reamer group. Suggesting increase stress the tunnel & graft at the femoral aperture.

J.H Wang et al [6] observed a 4% physeal violation by creating tunnels during ACL reconstruction in adolescents, 3.95% in distal femur & 3.65% in proximal tibia. They also observed that physeal violations less than 4% were not associated with growth disturbances.

Biochemistry of joint injury

D.J.Kaplan et al [7] interestingly studied synovial fluid biomarkers in acute ACL injured knee and found significantly higher concentration of 6 specific biomarkers (MMP-3, IL-6, MIP-1β, TIMP-1, TIMP-2,FGF-2) in the injured knee in comparison to the normal uninjured knee. This inquisitive study urges the scientists to look into joint fluid analysis to accurately describe intra-articular pathologies and future directions to involve biomarkers as a prognostic injuries post surgery.

Stem cells, think inside the box
A.W.Anz et al [8] confirmed the presence of viable stem cells in post injury knee effusion and in waste by products of cruciate ligament surgery, they think that these cells are derived from the synovium and fatpad. Their study will help us optimise and make us think about ways to capture viable tissues for stem cells further.

Complex meniscal tear, the unusual suspect
F.A.Barber et al [9] has published his series of 179 patients, in whom he observed 27.4% biconcave medial tibial plateaus and his study concludes that this phenomenon significantly associates itself with a complex medial meniscus tear than those knees without biconcavity. Although MRI was effective in identifying this anatomical variant, the authors believe that arthroscopy is the diagnostic standard to identify these variants.

Alignment and ligament surgery
A comprehensive review done by Tischer et al [10] on the impact of osseous malalignment and realignment procedures in knee ligament surgery makes us consider slope reducing osteotomies in patients revised multiple times for failed ACL reconstruction. They also recommend correction of varus alignment in case of chronic PCL and or PLC instability to reduce failure rate. The article recommends considering correction of mechanical axis in cases of instability accompanied by early unicompartmental osteoarthritis.

An unusual threat

E.Bonnet [11] from France has published an important case report on joint infection due to Raoultella planticola, a first of its kind in human joint in a patient following synovectomy and corticosteroid injection for calcium pyrophosphate crystal arthritis. The author provides comprehensive insight into identification of this species by mass spectrometry and a favourable outcome on treatment with antibiotics. He also warns new cases of bone and joint infection should be expected in coming years especially in patients with joint prostheses.

Cartilage regeneration is possible

A first of its kind study by B.Sadlik et al [12] from Poland tries to regenerate knee cartilage using umblical cord, Whartons’s jelly derived mesenchymal stem cells (WJ-MSC) embedded in collagen scaffold using dry arthroscopy technique in 5 patients who had not improved with standard therapy and showed favourable outcomes on the basis of clinical and MRI examination. Long term results can make this a viable option for cartilage repair.

Is it time for PRPP?

Meta-analysis of RCT’s done by Wen-li Dai [13] on efficacy of PRPP in the treatment of knee OA suggests that PRP injection have more benefit and functional improvement in patients with symptomatic knee OA at 1 year post injection, in comparison with HA and saline injections. Timothy J Hunt [14] in his editorial commentary in Arthroscopy journal writes “The time has come for those of us who have not tried PRPP injections in our patients with symptomatic knee osteoarthritis to do so”.

Meniscal root repair is better for the knee
As we see an increase in the identification and treatment of medial meniscal root tears, the efficacy of this procedure to prevent progression root tears have not been widely published. Michael Alaia et al [15] studied the discrepancy between radiographic and clinical outcomes at two year followup following transtibial medial meniscal root repair using two locking cinch sutures. This retrospective study of 18 patients showed improved clinical outcomes, however they observed only partial healing in majority of cases with increased extrusion and progression of medial compartment arthrosis on followup MRI.

Answer to the important question
When can I drive after ACL reconstruction? I’m sure all of us would’ve encountered the same question in our practice but, do we really know when? Kevin J [16] has studied the observer reported outcome measures to return to normal, measuring the brake response time and observed patients after Right knee ACL reconstruction exhibit a normal brake response time 4-6 weeks post-operatively and after Left knee ACL reconstruction exhibits a normal brake response 2 weeks post-operatively. The meniscectomy, chondroplasty and diagnostic arthroscopy group exhibit normal brake response time at the end of first week. As interesting it may seem this needs further elaborative effort to arrive at a conclusion and definitely require further investigation considering the other parameters involved.

Rehabilitation – A step ahead
A pilot study on Blood flow restriction training after knee arthroscopy done by David J Tennent [17] suggests BFR is an effective intervention after knee arthroscopy and found significant increase in quadriceps strength and thigh girth when compared to conventional therapy opening new avenues in rehabilitation after ACL reconstruction.

These articles are not just fuel that powers our scientific reasoning but also inspires action in the years to come.


1. Burks, R., 2017. Regarding “Acute Proximal Anterior Cruciate Ligament Tears: Outcomes After Arthroscopic Suture Anchor Repair Versus Anatomic Single-Bundle Reconstruction”. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(5), p.888.1. Burks, R., 2017. Regarding “Acute Proximal Anterior Cruciate Ligament Tears: Outcomes After Arthroscopic Suture Anchor Repair Versus Anatomic Single-Bundle Reconstruction”. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(5), p.888.2. van der List, J.P. and DiFelice, G.S., 2017. Gap formation following primary repair of the anterior cruciate ligament: A biomechanical evaluation. The Knee, 24(2), pp.243-249.3. Sonnery-Cottet, B., Daggett, M., Fayard, J.M., Ferretti, A., Helito, C.P., Lind, M., Monaco, E., Pádua, V.B.C., Thaunat, M., Wilson, A. and Zaffagnini, S., 2017. Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. Journal of Orthopaedics and Traumatology, 18(2), p.91.4. Cavaignac, E., Faruch, M., Wytrykowski, K., Constant, O., Murgier, J., Berard, E. and Chiron, P., 2017. Ultrasonographic Evaluation of Anterolateral Ligament Injuries: Correlation With Magnetic Resonance Imaging and Pivot-Shift Testing. Arthroscopy: The Journal of Arthroscopic & Related Surgery.5. Tashiro, Y., Sundaram, V., Thorhauer, E., Gale, T., Anderst, W., Irrgang, J.J., Fu, F.H. and Tashman, S., 2017. In Vivo Analysis of Dynamic Graft Bending Angle in Anterior Cruciate Ligament–Reconstructed Knees During Downward Running and Level Walking: Comparison of Flexible and Rigid Drills for Transportal Technique. Arthroscopy: The Journal of Arthroscopic & Related Surgery.6. Wang, J.H., Son, K.M. and Lee, D.H., 2017. Magnetic Resonance Imaging Evaluation of Physeal Violation in Adolescents After Transphyseal Anterior Cruciate Ligament Reconstruction. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(6), pp.1211-1218.7. Kaplan, D.J., Cuellar, V.G., Jazrawi, L.M. and Strauss, E.J., 2017. Biomarker Changes in Anterior Cruciate Ligament–Deficient Knees Compared With Healthy Controls. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(5), pp.1053-1061.8. Anz, A.W., Branch, E.A., Rodriguez, J., Chillemi, F., Bruce, J.R., Murphy, M.B., Suzuki, R.K. and Andrews, J.R., 2017. Viable stem cells are in the injury effusion fluid and arthroscopic byproducts from knee cruciate ligament surgery: An in vivo analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(4), pp.790-797.9. Barber, F.A., Getelman, M.H. and Berry, K.L., 2017. Complex Medial Meniscus Tears Are Associated With a Biconcave Medial Tibial Plateau. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(4), pp.783-789.10. Tischer, T., Paul, J., Pape, D., Hirschmann, M.T., Imhoff, A.B., Hinterwimmer, S. and Feucht, M.J., 2017. The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence. Orthopaedic Journal of Sports Medicine, 5(3), p.2325967117697287.11. Bonnet, E., Julia, F., Giordano, G. and Lourtet-Hascoet, J., 2017. Joint infection due to Raoultella planticola: first report. Infection, pp.1-2.12. Sadlik, B., Jaroslawski, G., Gladysz, D., Puszkarz, M., Markowska, M., Pawelec, K., Boruczkowski, D. and Oldak, T., 2017. Knee Cartilage Regeneration with Umbilical Cord Mesenchymal Stem Cells Embedded in Collagen Scaffold Using Dry Arthroscopy Technique.13. Dai, W.L., Zhou, A.G., Zhang, H. and Zhang, J., 2017. Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: a meta-analysis of randomized controlled trials. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(3), pp.659-670.14. Hunt, T.J., 2017. Editorial Commentary: The Time Has Come to Try Intra-articular Platelet-Rich Plasma Injections for Your Patients With Symptomatic Knee Osteoarthritis.15. Alaia, M., Strauss, E., Jazrawi, L., Campbell, K. and Kaplan, D., 2017. Discrepancy Between Radiographic and Clinical Outcomes at Two Year Follow-Up Following Transtibial Medial Meniscal Root Repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(6), p.e34.16. DiSilvestro, K.J., Santoro, A.J., Tjoumakaris, F.P., Levicoff, E.A. and Freedman, K.B., 2016. When can i drive after orthopaedic surgery? A systematic review. Clinical Orthopaedics and Related Research®, 474(12), pp.2557-2570.17. Tennent, D.J., Hylden, C.M., Johnson, A.E., Burns, T.C., Wilken, J.M. and Owens, J.G., 2017. Blood Flow Restriction Training After Knee Arthroscopy: A Randomized Controlled Pilot Study. Clinical Journal of Sport Medicine, 27(3), pp.245-252.

How to Cite this article: Arumugam S, Prakash A. Commentary on meaningful and interesting arthroscopy articles around the globe, 2016-2017. Journal of Clinical Orthopaedics Jan – June 2017; 2(1):56-58.

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What is New in Total Knee Replacement

Vol 2 | Issue 1 |  Jan – June 2017 | Page 10-13 | Ashok Rajgopal, Vivek Dahiya

Authors: Ashok Rajgopal [1], Vivek Dahiya [1].

[1] Fortis Bone & Joint Institute. Fortis Group of Hospitals, Delhi, NCR

Address of Correspondence
Dr. Ashok Rajgopal
Email: a_rajgopal@hotmail.com


Introduction: Total knee replacement is a Gold standard for treatment of arthritis of knees. It has stood the test of time and has delivered excellent results. With time the number of knee replacement are increasing and the age of patients are decreasing. Technological advances have kept pace with the newer designs which have helped deliver better results to the patients.
Key Words: Total knee replacement, new updates, technology.


The knee is the largest joint of the human body and it is involved in almost all the activities of daily living. It is prone to repetitive micro trauma leading to wear and tear of the cartilage which in turn leads to osteoarthritis of the knee joint. Osteoarthritis makes a knee stiff, painful to walk on and inhibits an individual from performing activities of daily living. Exercises, physiotherapy and over the counter pain killers do help initially but with time it becomes imperative to think about knee replacement. Total knee replacement is the gold standard for treatment of knee arthritis and has shown predictably excellent results over the past 20 years [1,2]. In recent times due to increased awareness more and more patients are opting for this surgery not only to maintain but also to improve their quality of life. The patients hope to participate in all the activities and be physically active. They don’t want to adhere to the age old nuances of “Let it be , you are getting old”. In the past two decades the average age of the patients undergoing knee replacement surgery has come down resulting in an increased demand on the knee joint [3]. The challenges for the Orthopaedics surgeon are manifold. Not only does he need to correct the deformity, and enable the patient to get back to a normal life but also think about life of the prosthesis. This increased demand has forced the surgeons to deliberate and research extensively in order to overcome the drawbacks of the older conventional knee systems and also meet the challenges faced by them in their daily surgical practice.
Advances in the past two decades have been able to give the surgeons the tools to satisfy their patients over the whole spectrum. In this article we shall try to enumerate the recent advances in total knee replacement and how they help the patients.
As we know in 1860, Verneuil proposed interposition arthroplasty, involving the insertion of soft tissue to reconstruct the joint surface. Since then, pig bladder, nylon, femoral sheath, anterior bursa of the knee, cellophane, and many other materials have been used, but results were disappointing. The use of metallic interposition arthroplasty began in the late 1930s. Today implants are made of a highly polished cobalt chrome alloy which is a very strong alloy well tolerated and accepted by the human body. Zirconium implants (Fig.1) offer another bearing surface akin to ceramics with a very low coefficient of friction. The long term results of these implants are awaited and we shall then know if it is worth the high price [4]. The polyethylene insert which is placed between the two metal components is highly cross linked which prevents its wear and tear. Sterilization methods have helped reduce the wear and tear rate of the insert. Gamma sterilization in the past led to early catastrophic wear and breakdown of the insert. Now a days EtO sterilization has solved the problem. Addition of vitamin E in the substance of the insert is said to delay its degradation [5,6].

Design of the knee implant has a bearing on the result of the surgery-both in the survivorship of the implant and in terms of patient satisfaction. The knee joint has three bones that articulate with each other. For the implant to be successful the components have to be well synchronised with each other and also perform their own functions independently. The femoral component (part of the lower thigh forming the knee) should be well fitting on the host bone, and should not over hang the bone otherwise it will rub with the soft tissues causing pain. It should also provide a good and friendly surface for the knee cap (patella) to glide on. Modern designs take care of this aspect. The Persona implant (Fig. 2) from Zimmer has femoral components in 2 mm increments and each size comes with a standard and a narrow option. The number of sizes available are in 2 mm increments in both planes,a design which helps in providing a better fit of the implant. No two individuals are alike so why should two knees be the same? To facilitate this there are several permutations and combinations available to the surgeon which provide for the ideal fit. The Persona implant is also the most patella friendly implant available. This allows for ease of gliding of the patella on the femoral component helping to achieve a better and more efficient thigh muscle function. This in turn leads to better knee joint range of motion and gait pattern.
The Tibial component (part of the leg bone which participates in the knee) is also an important part of the knee. Traditionally they were made symmetric whereas the normal human anatomy is asymmetric [7].(Fig.3) What this means that the shape of the tibial component should closely approximate the original anatomy of the bone. In the Persona Knee system the tibial component comes in 9 sizes with 1mm increments again allowing the surgeon much more flexibility in choosing the exact size of the implant for the patient. As with the femoral component overhang is going to rub against the soft tissues and cause pain [8]. The question as to resurface the patella or to leave it alone is eternal. The proponents of either are numerous but so far no consensus has been formed [9]. So has been the case for posterior cruciate ligament retention or substitution. All implants are available in cruciate retaining and posterior stabilized designs.

Newer metals like Trabecular metal have in fact revolutionized the area of knee replacement. These metals are extremely porous and have elasticity of modulus approximating that of natural bone. The porosity allows for growth of bone into the implant(Fig.4). This helps in better integration of the implant to the bone and thus increasing the life of the implant [10,11]. Also there is no need to use bone cement to fix these implants to bone. It has found use in revision surgery of the knee too. Revision surgery is needed when the original total knee replacement fails and a new surgery is needed to address all the myriad issues where trabecular metal cones are helpful to reconstruct the lost bone. They are used to build up the defect in bones and allow for the host bone to grow into them to achieve a more biological end result.
Computer assisted surgery has been in use for a long time. Earlier devices were large in size (Brain Lab) and cumbersome to useresulting in an increase in surgery time. Newer devices are gravitating towards hand held devices such as the iASSIST (Zimmer)(Fig 5) or eNdtrac (Stryker)(Fig 6). These are surgical guidance systems engineered to improve the accuracy and alignment of total knee replacement surgery. They are also less invasive and more surgeon friendly. Once the learning curve is over there is hardly any change in surgery time as compared to before12. Among these devices is the Navio (Fig. 7) system from Smith & Nephew. It allows for intraoperative navigation and then the use of a handheld robot to perform the cuts of the bone. At present available only for the unicompartmental knee. The software for the total knee replacement is to be released soon.
Customized knee implants wherein the implant is designed for the patient after pre-operative imaging is also being used in the USA. Conformist manufactures these implants. Individualized fit and bone conservation are their hallmarks. These unfortunately are not available in India yet [13].
Awareness is leading to younger patients opting for knee surgery. Every knee arthritis does not need a total knee replacement. In case only one compartment is involved then only that part can be replaced. This is called unicompartmental knee replacement. Unicompartmental knee replacement is getting to be more widely used than before and is well accepted. It is a smaller procedure, allows the patient to recover faster and gives a more natural feel of the knee. It also allows the patient to continue with a fairly aggressive life style.

Blood loss following surgery is expected, but the quantity of blood loss leads to several problems [14]. Constant endeavours to lessen the blood loss are underway. Use of tranexamic acid perioperatively has helped reduce the blood loss after total knee replacement. It is being used both intravenously and by injecting into the tissues around the surgical site15. Autologous blood transfusion is also a way to deal with the dangers of blood transfusion. It allows for the patient to receive their own blood which was given 3 to 6 weeks prior to surgery.
Use of technology is increasing in this field. Navigation and customized implants are at one end of the spectrum. The other end is occupied by Big Data. The immense amount of data and surgeon experience that is available all around is being understood now. It will be used to fabricate protocols to increase the surgeons and hospitals efficiency while dealing with total knee replacement patients. Big data combined with the joint registries will help the surgeons to make an informed choice on their choice of implants, surgical techniques, pain management protocols and postoperative rehabilitation.
Experience and hospital management systems have helped us evolve faster rehabilitation programs. They consist of patient education prior to surgery, ultrasound guided nerve blocks to reduce the intensity of post-operative pain, earlier and more aggressive rehabilitation and earlier discharge from the hospital. Patient education makes the patient more aware of the procedure and their expectations. They learn about the normal course of recovery and hence are more involved in the whole process. The commonest cause for delay of surgery is the fear of pain. Once the anesthesia wears off the patients will have some pain. Analgesics be it non opiodal or opiods have their limitations. Increased pain aggravates the co- morbidities and less rehabilitation. Ultrasound guided nerve blocks and placement of femoral nerve catheters does help a long way to reduce the pain [16,17]. So does the ”Ipac”, which involves instillation of an analgesic cocktail in the posterior capsule and the surgical field anteriorly. Early rehabilitation and mobilization helps reduce the incidence of DVT and PE, allows for earlier patient confidence in walking and leads to an early recovery. All these contribute to making the whole process more patient friendly and efficient for the hospitals to manage.
These advances have helped surgeons to satisfy their patients and have allowed the patients to achieve their goals and expectations to a large extent.


1. Twenty-Five-Years and Greater,  Results  After Non modular cemented Total Knee Arthroplasty. Ritter MA, Keating EM, Sueyoshi T, Davis KE, Barrington JW, Emerson RH.1. Twenty-Five-Years and Greater,  Results  After Non modular cemented Total Knee Arthroplasty. Ritter MA, Keating EM, Sueyoshi T, Davis KE, Barrington JW, Emerson RH.J Arthroplasty. 2016 Oct;31(10):2199-202. doi: 10.1016/j.arth.2016.01.043. Epub 2016 Feb 4.2. How do knee implants perform past the second decade? Nineteen- to 25-year followup of the Press-fit Condylar design TKA.Patil S, McCauley JC, Pulido P, Colwell CW Jr.ClinOrthopRelat Res. 2015 Jan;473(1):135-40.3. Total knee replacement in young, active patients: long-term follow-up and functional outcome: a concise follow-up of a previous report.Long WJ, Bryce CD, Hollenbeak CS, Benner RW, Scott WN.J Bone Joint Surg Am. 2014 Sep 17;96(18)4. Twelve-Year Outcomes of an Oxinium Total Knee Replacement Compared with the Same Cobalt-Chromium Design: An Analysis of 17,577 Prostheses from the Australian Orthopaedic Association National Joint Replacement Registry.Vertullo CJ, Lewis PL, Graves S, Kelly L, Lorimer M, Myers P.J Bone Joint Surg Am. 2017 Feb 15;99(4):275-283. 5. Contribution of Surface Polishing and Sterilization Method to Backside Wear in Total Knee Arthroplasty.Teeter MG, Lanting BA, Shrestha KR, Howard JL, Vasarhelyi EM.J Arthroplasty. 2015 Dec;30(12):2320-2.6. The influence of sterilization method on articular surface damage of retrieved cruciate-retaining tibial inserts. Greulich MT, Roy ME, Whiteside LA.J Arthroplasty. 2012 Jun;27(6):1085-93. 7. How Much Does the Anatomical Tibial Component Improve the Bony Coverage in Total Knee Arthroplasty ? Jin C, Song EK, Prakash J, Kim SK, Chan CK, Seon JK. J Arthroplasty .2017 Jun; 32(6):1829-18338. Gait Parameters and Functional Outcomes After Total Knee arthroplasty Using Persona Knee System With Cruciate Retaining and Ultracongruent Knee Inserts. Rajgopal A, Aggarwal K, Khurana A, Rao A, Vasdev A, Pandit H. J. Arthroplasty. 2017 Jan ;32(1):87-919. Is Selectively Not Resurfacing the Patella an Acceptable Practice in Primary Total Knee Arthroplasty?Maradit-Kremers H, Haque OJ, Kremers WK, Berry DJ, Lewallen DG, Trousdale RT, Sierra RJ.J Arthroplasty. 2017 Apr;32(4):1143-1147. 10. Trabecular metal tibial knee component still stable at 10 years.Henricson A, Nilsson KG. Acta Orthop. 2016 Oct ;87(5) : 504-1011. Mid-term results of total knee arthroplasty with a porous tantalum monoblock tibial component.Hayakawa K, Date H, Tsujimura S, Nojiri S, Yamada H, Nakagawa K. Knee. 2014 Jan;21(1):199-203. 12. Total knee arthroplasty with computer-assisted navigation more closely replicates normal kneebiomechanics than conventional surgery.McClelland JA, Webster KE, Ramteke AA, Feller JA.Knee. 2017 Jun;24(3):651-656. 13. Evolution of customization design for total knee arthroplasty.Slamin J, Parsley B. Curr Rev Musculoskelet Med. 2012 Dec;5(4):290-5. 14. Enhanced recovery protocol and hidden blood loss in patients undergoing total knee arthroplasty.Dhawan R, Rajgor H, Yarlagadda R, John J, Graham NM. Indian J Orthop. 2017 Mar-Apr;51(2):182-18615. Effect of Tranexamic Acid on Transfusion Rates Following Total Joint Arthroplasty: A Cost and Comparative Effectiveness Analysis.Evangelista PJ, Aversano MW, Koli E, Hutzler L, Inneh I, Bosco J, Iorio R.OrthopClin North Am. 2017 Apr;48(2):109-115.16. Does Addition of Adductor Canal Blockade to Multimodal Periarticular Analgesia Improve Discharge Status, Pain Levels, Opioid Use, and Length of Stay after Total Knee Arthroplasty? Gwam CU, Mistry JB, Richards IV, Patel D, Patel NG, Thomas M, Adamu H, Delanois RE. J Knee Surg. 2017 May 2. 17. Multimodal infiltration of local anaesthetic in total knee arthroplasty; is posterior capsular infiltration worth the risk? a prospective, double-blind, randomised controlled trial. Pinsornsak P, Nangnual S, Boontanapibul K.Bone Joint J. 2017 Apr;99-B(4):483-488. .

How to Cite this article: Rajgopal A, Dahiya V. What is New in Total Knee Replacement. Journal of Clinical Orthopaedics Jan – June 2017; 2(1): 10-13.

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A Critical Review of the Management of Partial Tears of Anterior Cruciate Ligament

Vol 2 | Issue 1 |  Jan – June 2017 | Page 27-30 | Raju Vaishya, Vipul Vijay, Abhishek Vaish, Amit Kumar Agarwal

Authors: Raju Vaishya [1], Vipul Vijay [1], Abhishek Vaish [1], Amit Kumar Agarwal [1].

[1] Department of Orthopaedics and Joint replacement Surgery Indraprastha Apollo Hospitals Sarita Vihar, New Delhi 110076, INDIA

Address of Correspondence

Dr. Raju Vaishya
Department of Orthopaedics and Joint Replacement Surgery Indraprastha Apollo Hospitals Sarita Vihar, New Delhi 110076, India.
Email: raju.vaishya@gmail.com


Anterior cruciate ligament (ACL) injuries are common sports injuries. While the treatment of complete ACL tear is clearly delineated and are often treated with ACL reconstruction, the treatment of a partial injury to the ACL is still a matter of debate.
Partial tear of an ACL is a relatively rare injury. The reported incidence of partial ACL injuries ranges from 10-28% (1). There are studies which have tried to outline the natural history of partial ACL tears. It is reported that there is a 15% to 66% chance of this lesion to progress to a complete tear. The incidence of secondary cartilage injuries has been estimated to be between 15% to 86% (2,3). Even though there is consensus on the progression of the instability and the occurrence of secondary cartilage injuries, the management, including the timing and type of intervention, are still under debate.
In the present article, we have done a critical review of the literature regarding the management of partial ACL tears.


A precise definition of a partial ACL tear is lacking. Hong et al. described a partial ACL tear as one where less than 50% ligament is torn (4). On the other hand, Noyes et al. described the partial ACL injury by the ACL left after the tear (5). It was based on the finding that the loss of 50-75% diameter of the ACL would lead to the significant incidence of clinical failure. Some authors have also tried to assess the grading of the injury by arthroscopic findings (6).DeFranco and Bach have attempted to define the partial ACL tear by a combination of clinical, knee laxity and arthroscopic criteria (7). Barrack et al. defined a partial ACL as a lesion in which the three criteria were fulfilled.  These included a pivot shift test being negative, the Lachman test being 0 or 1+ and a significant portion of any of the two bundles being intact on arthroscopy and found to functionally active, as confirmed by arthroscopic anterior drawer test (8).Functional anatomy of ACLThe ACL has been found to be comprising of two bundles, namely the anteromedial (AM) and posterolateral (PL) bundle. The two bundles have been labeled by their insertion of the femur. The AM bundle is isometric whereas the PL bundle is anisometric and changes length as per the position of the knee. The anterior fibers of the AM bundle are taut during 30 to 130 degrees of flexion. Conversely, the posterior fibers of PL are completely taut in extension and beyond 90-degree flexion.This unique configuration is responsible for the differential effects on knee stability of the injury of the two bundles. The AM bundle contributes majorly to the anterior stability of the knee in normal activities of daily living. The PL bundle contributes more to the rotator stability and is responsible for stability during activities involving pivoting. The differential functions of the two bundles lead to different sets of presentation in patients with partial ACL injury depending on the bundle which is injured.The AM bundle is easily visualized in all knee positions, and it is this reason that some isolated PL bundles are often missed. To clearly assess the integrity of the both the AM and the PL bundles, the Cabot’s position (Figure of four position) was described (Figure 1).

In the Cabot’s position, the AM bundle can be visualized wrapping around the PL bundle and hence the integrity of both the bundles can be individually assessed (9).Advantages of retaining a native ACLThere are various potential benefits of retaining the intact portion of the ACL: 1. The retention of the native ACL helps in preserving the blood supply to the ligament and may lead to potentially better healing capacity (10).2. The presence of mechanoreceptors in the remnant can also help postoperative ACL function (11).3. There are chances of increased biomechanical strength.4. A study by Bak et al. reported significantly decreased immediate postoperative pain during rehabilitation in patients in whom the ACL remnant was preserved (12). They also concluded that the ACL remnant gives protection to the graft while it is still in its healing phase.5. Also, the preserved ACL remnant acts as a guide for the creation of the bony tunnels and helps in the anatomic reconstruction of the ligament.
Diagnosis The diagnosis and identification of a partial ACL tear is a challenge. The diagnosis is usually based on a combination of clinical, radiological and knee laximetric findings along with an arthroscopic correlation.A) ClinicalThe injury is common in young individuals, usually 20-30 years of age. The symptoms may vary with the type of bundle which is injured, varying from feeling of instability in the anteroposterior plane (isolated AM bundle injury) to a rotatory instability in pivoting activities (isolated PL bundle injuries). The clinical examination reveals a Lachman’s test which has a firm end point and has less than 5mm translation. The pivot shift test is usually negative.B) RadiologicMRI findings cannot be completely relied on for making a diagnosis of partial ACL tear (Figure 2).

However, it may provide subtle clues to the diagnosis when assessed along with arthroscopic and clinical findings. There are special axial or perpendicular cuts in the MRI which have been described for clearly assessing partial ACL injuries in MRI (13). Colombet et al. described three type of orientation of the partially torn ACL fibers on MRI (14). The “straight fibers” had an orientation which was parallel to the Blumensaat’s line, the “lying down” fibers had fallen and were lying down in the intercondylar notch, close to the PCL and the “disorganized” fibers, which had no structural pattern and had disappeared.C) ArthroscopicArthroscopy helps in the identification of the lesion under direct vision. There have been authors who have suggested the use of arthroscopy for the identification of partial ACL tears (15). However, with the improved understanding of the imaging and clinical findings, arthroscopy should only be used for confirmation of the diagnosis and the surgeon should be ready with the option of reconstruction at the time of arthroscopy. The important thing to underline during an arthroscopic examination of the knee is the essentiality of examination of the knee in the Cabot position (Figure 3), wherein both the ACL bundles can be identified separately.D) Objective laxity measurementThere are many studies which have studied the anteroposterior plane laxity for complete ACL injuries using KT 1000. Since partial ACL ruptures may sometimes lead to pure rotational instability; the diagnosis may be difficult to identify using the conventional laximeters. The usual translation in the AP plane for non-ACL injured knee is less than 3 millimeters (mm). A translation greater than 5 mm is suggestive of a chronic and complete ACL tear. Translation between 3-5 mm is suggestive of a partial ACL tear. There have been studies using special laximeters like GNRB® which can diagnose isolated PL bundle damage (16).

Treatment – The treatment of partial ACL tears needs to be individualized as per the requirements of the patient. A certain subset of patients may be treated with conservative means. These subgroup of patients include those who are diagnosed by radiologic findings and lack any clinical examination findings. Also, the patients in low demand jobs, involved in activities not involving torsional strain on the knee and sedentary lifestyles may be candidates for conservative treatment (17). Patients who have mechanical signs and symptoms of instability and are involved in high demand physical activities which are likely to put a torsional strain on the knee are candidates for surgical intervention (18). A) Conservative treatmentConservative treatment consists of immobilization immediately after the acute phase of injury till the pain subsides. Further treatment usually is followed along the course of rehabilitation of ACL reconstruction. The exercises focus on muscle strengthening along with proprioceptive training and adaptive training. The most important aspect of the conservative treatment of ACL injuries is a regular and systematic follow-up assessment of instability since there have been reports of conversion of up to 25% partial ACL tears to complete tears (19).B) Surgical treatmentThe surgical treatment entails the use standard arthroscopic techniques and creation of the standard anteromedial and anterolateral portals. The graft selection depends on the choice of the surgeon. Some authors have suggested creating a high anterolateral portal so that there is minimum obstruction of the Hoffa’s fat pad (9). After the assessment of the associated lesions along with the partial tear, they are managed as per the standard protocols. The assessment of the partial ACL tear is done arthroscopically and also through stability tests in both the semi-flexed and the Cabot’s figure. There are certain steps which are specific for the creation of the AM and PL bundles.Anteromedial bundleThe entry point for the creation of the tibial tunnel for the AM bundle begins approximately 1.5 cm medially to the tibial tuberosity and is angulated at an angle of 60 degrees (20). The femoral tunnel is along the fibers of the femoral remnant. Care is taken to avoid excessive debridement of the remnant bundle to provide a scaffold for faster healing.
Posterolateral bundleThe entry point of the PL bundle lies more medially and is usually situated 3.5 cm medially to the anterior tuberosity. The intra-articular exit point is located 5 mm medial to lateral tibial intercondylar eminence. Similar to AM bundle, excessive debridement of the remnant should be avoided.Future trendsApart from the role of the single bundle reconstruction, there has been a renewed interest in the use of biologics in the healing of partial ACL tears. The more recently used techniques include the use of growth factors, Platelet rich plasma, stem cells and bio-scaffolds (21). Their use in the presence of partial ACL tears has given good short to medium term results, but further studies to assess their role in long-term is needed.ConclusionsA partial tear of ACL is rare, but a distinct clinical entity, which is hard to diagnose and manage. The clinician and radiologist require awareness about this entity, and a high index of suspicion is necessary to be able to make an early diagnosis of partial ACL tears. Direct examination of the knee by arthroscopy is the most accurate and invaluable modality in the diagnosis and management of these lesions. In low-demand individuals, conservative treatment is effective, whereas symptomatic high-demand and athletic individuals are the candidates for surgical intervention. A single bundle ACL reconstruction is the treatment of choice in these symptomatic patients. Regenerative treatment seems to be a likely option, but lack long-term follow-up to advocate their efficacy, at present..


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3. Casteleyn PP. Management of anterior cruciate ligament lesions: surgical fashion, personal whim or scientific evidence? Study of medium- and long-term results. Acta Orthop Belg 1999;65:327—39.
4. Hong SH, Choi JY, Lee GK, Choi JA, Chung HW, Kang HS. Grading of anterior cruciate ligament injury. Diagnostic efficacy of oblique coronal magnetic resonance imaging of the knee. J Comput Assist Tomogr. 2003 Sep-Oct;27(5):814-9.
5. Noyes F.R., Mooar L.A., Moorman C.T., 3rd, McGinniss G.H. Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency. J Bone Jt Surg Br. 1989;71(5):825–833.
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13. Roychowdhury S, Fitzgerald SW, Sonin AH, Peduto AJ, Miller FH, Hoff FL. Using MR imaging to diagnose partial tears of the anterior cruciate ligament: value of axial images. AJR. American journal of roentgenology. 1997 Jun;168 (6):1487-91.
14. Colombet P, Dejour D, Panisset JC, Siebold R. Current concept of partial anterior cruciate ligament ruptures. Revue de Chirurgie Orthopédique et Traumatologique. 2010 Dec 31;96(8):S329-38.
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19. Pujol N, Colombet P, Cucurulo T, Graveleau N, Hulet C, Panisset JC, et al. Natural history of partial anterior cruciate ligament tears: a systematic literature review. Orthop Traumatol Surg Res. 2012;98(8 Suppl):S160–4.
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How to Cite this article: Vaishya R, Vijay V, Vaish A, Agarwal AK. A Critical Review of the Management of Partial Tears of Anterior Cruciate Ligament. Journal of Clinical Orthopaedics Jan – June 2017; 2(1):27-30.

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Terrible Triad – Is no More Terrible!

Vol 2 | Issue 1 |  Jan – June 2017 | Page 14-26 | G S Kulkarni, Vidisha Kulkarni, Ruta Kulkarni, Sunil Kulkarni, Milind Kulkarni

Authors: G S Kulkarni [1], Vidisha Kulkarni [1], Ruta Kulkarni [1], Sunil Kulkarni [1], Milind Kulkarni [1].

[1] Swasthiyog Prathisthan, Miraj, Maharashtra India.

Address of Correspondence
Dr. G S Kulkarni
Swasthiyog Prathisthan, Miraj, Maharashtra, India.
Email: gskorth@gmail.com


Terrible triad (TT) is traditionally an injury that is been well know but poorly understood. Most of the poor results are due to lack of understanding of the pathoanatomy and formulate a plan for individual cases. Bony articulations as well as the ligamento-tendious structures are injured along with added complexity of the elbow joint, the terrible triad is not a simple injury to comprehend. The current review focusses on the basics of pathoanatomy and relevant decision making protocols along with details of various treatment modalities. we also share our personal experience of 20 cases of terrible triad and also our preferred method of treatment
Keywords: terrible triad, radial head, medial collateral ligament, external fixator, functional outcomes.


Terrible triad (TT), a complex elbow dislocation, is a combination of a radial head fracture, dislocation and a coronoid process fracture. Historically, TT has had consistently poor results; for this reason, it is called the terrible triad injury. The eponym is coined by Hotchkiss[1]. The rate of subluxation or dislocation after operative treatment of these injuries has ranged from 8% to 45%[2].
In a simple fracture without dislocation elbow, medial collateral ligament (MCL), lateral collateral ligament (LCL), capsule, muscular elements are torn and there is dislocation of ulno-humeral and radio-carpal joint. When both joints are reduced closely, all ligaments and capsule heal well; but not so with TT which needs surgical repair of all torn tissues. TT injuries are seen more commonly in adults and are rare in children’s.
During the last 2 decades better understanding of relevant anatomy and biomechanics of stability, restoration of injured primary and secondary stabilizers of elbow, improved surgical technique have given excellent results; and operative treatment of this injury has evolved to include restoration of radiocapitellar contact (via fixation or replacement of the radial head), reattachment of the origin of the lateral collateral ligament (LCL) to the lateral epicondyle, with fixation of the coronoid fracture, and medial collateral ligament (MCL) repair when indicated[2].
These techniques have decreased the occurrence of subluxation or dislocation after operative treatment of a terrible triad injury[3-5].
TT is now no more terrible; however, despite best attempts of reconstruction by even experienced specialists final outcome may not be so satisfactory. Tanna[6] has published a series of 9 cases. He presented cases in which the radial head could not be repaired due to comminution, head was resected and elbow was immobilized for 6 weeks with satisfactory results. We also did resection of radial head in 7 cases with repair of LCL, coronoid, MCL and of both flexor and extensor muscles, with repair of all other primary and secondary stabilizers(except radial head) and elbow was stabilized by orthofix hinged external fixator for 6 weeks, with comparable results. Perhaps head resection is indicated in developing countries, where head could not be repaired or replaced due to various specific conditions in developing countries, described below. Planned post-operative care is needed to reduce complications. The goal of treatment for terrible triad injuries is restoring the bony anatomy and reconstructing the ligamentous restraints of the elbow to provide enough stability for early elbow range of motion and prevent elbow stiffness. Early management has a favorable prognostic factor for outcome. Delayed presentation> 2 weeks has poor outcomes. Understanding the patho-mechanics of this complex elbow dislocation may improve diagnosis and treatment of these injuries.
The purpose of this paper is to review current management of TT, especially, our experience and the results of resection of radial head in TT

Relevant Anatomy
An understanding of the anatomy of the structures of elbow is paramount to the successful treatment of TT. The coronoid process provides an important anterior and varus buttress to the elbow joint. Ulno-humeral joint is the key element of elbow stability. The coronoid is thought to be the most significant determinant of stability of the elbow joint[7].
Although the coronoid fracture was once described as an avulsion fracture, it is now considered most often to be the result of shear forces caused by posterior translation against the humeral trochlea. Tip of coronoid does not have any muscular attachment.

The anterior bundle of MCL, a primary stabilizer of elbow stability originates from the antero-inferior aspect of the medial epicondyle, and is inserted in to the sublime tubercle at the base of the coronoid process [8]. Lateral ulnar collateral ligament (LUCL) is inserted in the supinator crest, distal to sigmoid notch and it originated at lateral epicondyle, which is the isometric point[9]. The radial head is a slightly elliptical structure. With the forearm in neutral rotation, the lateral portion of the articular margin of the radial head is devoid of hyaline cartilage. This is the safe zone for plating from radial head to shaft, when the forearm is in mid pronation position.
The flexor and extensor muscle and the joint capsules are secondary stabilizers of the elbow. The muscular system provides dynamic stability against valgus and varus forces.

Fracture classification
Fracture classification is important from management of TT point of view. Mason[10] classified radial head fractures into three categories: type I, non-displaced fracture; type II, displaced partial articular fracture with or without comminution; and type III, comminuted radial head fracture involving the whole head.
Regan and Morrey[11] classified coronoid fracture (Fig.1) into following 3 types –
Type I – Fracture involved an ‘Avulsion’ of the tip of the coronoid process.
Type II – Fracture involved a single or comminuted fracture representing <50% of the coronoid process.
Type III – Fracture involved a single or comminuted fracture of >50% of the coronoid process. Currently, the simple modification of the original classification includes medial and lateral oblique fractures. However, it has been recently shown that for practical matters, the original classification system is probably adequate as a basis of our clinical decisions[12].

O’Driscoll’s classification is more applicable to management as it emphasizes the importance of the anteromedial facet injury, which causes instability.
His classification is as shown in table 1: (Modified from Tarassoli) [13]

Fractures of the anteromedial facet are divided into three subtypes. Anteromedial subtype 1 fractures do not involve the coronoid tip and extend from just medial to the tip to just anterior to the sublime tubercle. Subtype 2 fractures are subtype 1 with involvement of the coronoid tip. Subtype 3 fractures involve the anteromedial rim of the coronoid and the sublime tubercle.
Doornberg and Ring Demon[14]- stated that fractures of the antero-medial facet of the coronoid could result in increased instability, even without a significant overall loss of height. They recommend fixation of these fractures through an alternative medial approach, even when the fracture is very small[14].

Understanding of biomechanics of elbow instability is of paramount importance to treat TT. The elbow’s stability depends on static and dynamic stabilizers. Static stability is maintained by osseous and capsule -ligamentous restraints, whereas muscles crossing the elbow provide dynamic stability.
Beyond 30° of flexion, the coronoid process provides substantial resistance to posterior subluxation or dislocation[15].

Elbow stability is due to primary and secondary stabilizers due to symbiosis of bony and ligamentous anatomy. (See Fig.2.)
Primary stabilizers are
(1) The ulno-humeral articulation
(2) MCL (the anterior bundle),
(3) LCL complex (the ulnar lateral collateral ligament).

The secondary stabilizers are
(1) The radio-humeral articulations,
(2) Common flexor tendons, Common extensor tendons,
(3) The capsule.

Small fractures of the tip involving 10% of the coronoid process have been shown to have little effect on elbow stability in cadaveric biomechanical studies and may be neglected.
When residual instability was present after LCL repair and radial head repair or replacement, repair of the MCL was more effective than fixation of small coronoid fractures in restoring elbow stability[16]. Posterior displacement of the ulno-humeral joint is not affected until 50% of the total coronoid height is removed when the ligaments are intact[17], but smaller fractures can result in instability if there is a deficiency of the MCL[18]. Coronoid fragments more than 10% of coronoid process require surgical fixation.

Functions of radial head are – (1) Radial head is an important, anterior and valgus to buttress, (2) It also tightens the lateral, collateral ligament and provides varus stability indirectly. (3) In the absence MCL radial head, if it is intact, replaced or repaired, provide stability to the elbow. (4)The radial head also provides axial support to the forearm and acts as an anterior buttress resisting posterior dislocation or subluxation.(5) Resection of radial head may result in ulna minus and disturb distal radio-ulnar joint When fragments are very small, less than 25% may be discarded and head need not be repaired. In the absence of radial head, over a time, MCL stretches out and LCL collapses, contracts and dynamic valgus deformity of elbow results.

Morrey et al[7] did cadaveric studies regarding the relationship of MCL and radial head. In the presence of an intact MCL, radial head resection did not cause any significant valgus instability. However, the removal of the MCL caused valgus instability even with an intact radial head. Removal of both resulted predictably in gross subluxation and severe valgus instability. They concluded that the radial head is an important secondary stabilizer of the elbow, as it contributes significantly to valgus stability in elbows with a deficient MCL. Corollary of this i.e. with absent radial head and restoration of MCL, LCL, coronoid, flexor – extensor muscular attachment and application of hinged external fixator, the elbow may be stable enough[6]; however this has not been studied biomechanically.

Fractures of antero-medial facet instability is due to the attachment anterior bundle MCL at sublime tubercle. The mechanisms of TT injuries can be divided into low-energy falls from standing height and high-energy accidents usually due to vehicular accidents. Most of the low-energy mechanisms are usually in elderly person with osteoporosis. The mechanism of failure is according to the “Horii” circle, where the sequential failure of soft-tissue constraints starts from the lateral side and moves anteriorly and posteriorly to the medial side.

Material and Methods
Twenty patients sustaining elbow dislocation with associated radial head and coronoid process fracture, over a period of 7 years between 2009-2016 were enrolled in the study and their clinical results were assessed. The series included 13 males and 7 females of mean age of 35 years (range, 15-58 years) at the time of trauma.
14 patients had sustained the initial trauma during a road traffic accident and 6 had a fall from height. 18 dislocations were closed injuries with no neurovascular deficits and 2 were open. The initial assessment included high quality antero-posterior(A/P) and lateral radiographs of the elbow. Diagnosis of TT can be easily made by noting elbow dislocation, fractures of coronoid and fracture of radial head by good radiographs. Prompt closed reduction of TT should be attempted. This will reduce pressure on the soft tissues and decrease the chance of subsequent secondary neurovascular compromise or compartment syndrome.
CT scan was performed routinely in all the cases to rule out any occult coronoid process fragment. CT helps to understand morphology, size, shape and displacement of all fragments and to plan surgical technique.
In all cases, it was a postero-lateral dislocation of the elbow joint associated with fractures of the radial head and coronoid process. We had 2 cases of TT associated with trans olecranon fracture dislocation. Both were approached through a long posterior approach. Our series included 6 type I fractures, 4 type II fractures, 10 type III fractures. When there is complete posterior dislocation, all the ligaments, anterior capsule and medial and lateral muscular attachments are torn.

Operative Technique
Dislocations were reduced by closed method in 8 patients and 12 were reduced by open technique under general anaesthesia and image intensifier. Final reconstructive surgery is done as early as possible.
Either a posterior global incision or a lateral incision was used. For a lateral approach supine and for posterior approach lateral decubitus position was used. In 14 cases lateral surgical approach was carried out through the Kocher[19] interval, between extensor carpiulnaris and anconeus muscle. In addition, a medial approach in 8 cases, which provides better access to the coronoid process and the medial collateral ligament. Posterior approach was performed in 6 cases.
TT with trans-olecranon fracture needed a long posterior approach. When posterior approach was used, a thick flap was raised to prevent skin necrosis. Proximal fragment of olecranon along with triceps was lifted up proximally, similar to olecranon osteotomy approach. The coronoid fragment can be approached through fracture site for passing ‘lasso’ sutures or lag screw/s. Radial head was repaired or replaced or resected as indicated. MCL and LCL also were repaired through the posterior approach.
Exploration revealed persistent damage to the lateral collateral ligament in all cases. In 8 cases, decision to reconstruct MCL was taken because at the end of surgery extension test showed some subluxation or doubtful stability.
In 5 cases of non-re- constructible type III radial head, excision was performed and no prosthesis was used, hinged ex fix was applied.
In 2 cases, the radial head was excised by outside surgeon. He missed the diagnosis of TT and thought the case to be just a case of isolated radial head fracture. At 2 weeks, both patients had instability and were referred to us. In these 2 cases with absent radial head, after reconstruction of all ligaments including MCL and coronoid, orthofix type hinged external fixator (Pitkar Orthotools Pvt. Ltd. Pune) was applied.
When one applies hinged external fixator, it is very important to see that the axis of external fixator is collinear with axis of the elbow joint. Axis of elbow joint passes through centre of lateral epicondyle laterally and through a point just anterior distal to medial epicondyle. We have developed a technique of matching axis of hinge and elbow. In a dead lateral view of elbow on image intensifier, the centre of the circle of capitulum represents the point of axis elbow on the lateral side. Axis point on the medial side is just distal and anterior to the medial epicondyle. Two K-wires are passed- one through the centre of lateral condyle and one through the point on the medial side described above (See fig.3.) The wires were cut 1 cm away from bone. When applying external fixator, the centre of external fixator is in line with both K-wires. After applying external fixator k-wire were removed from both sides.

Repair of radial head with 2.4mm Herbert screw (Synthes) was performed in 7 cases of type II fractures. Resection of radial head was done in 7 cases and in all these cases hinged external fixator was applied. Replacement was done in 6 cases.
Five type I coronoid fractures were neglected. Eight type II coronoid fractures were treated with suturing the capsule with no.1 non-absorbable sutures. In one delayed case coronoid fragments were completely absorbed and was reconstructed with a piece from iliac crest (Fig.4.). All lateral and medial collateral ligaments were repaired with no.1 non-absorbable sutures.
At the end of the surgery, flexion – extension was tested from 30° to 110° of flexion. If there was instability during extension, MCL was repaired. In cases when MCL, LCL and coronoid were repaired and still there was some instability, orthofix type external fixation was applied. Indications for external fixator were radial head excision or instability at the end of surgery. Structures were generally addressed in a deep to superficial manner (coronoid first, then radial head, finally LUCL).
The coronoid was addressed with a suture ‘lasso’, suture anchor, or lag screw technique, depending on the size and comminution of the fracture fragment. Stability of the elbow was tested with the hanging arm test.

Post Operative Management
Elbow maintained at 90° in a posterior plaster splint. Elbow was mobilized passively from 45° to 100° flexion, 3 times in a day. Sutures were removed at 2 weeks. Patient was taught to do flexion-extension exercises passively from 45° – 100°. At 3 weeks active exercise were allowed and to slowly increased the range of motion.
When hinged external fixator was applied, during day the elbow mobility was allowed with hinge kept loose, and during one night hinge was tightened to maintain flexion at 90° and the next night it was tightened to maintain extension up to 135° (i.e. 45° short of full extension). This protocol has given excellent results.
When external fixator was not applied, continuous passive motion was started on post operative day 2 as per patients’ tolerance. Active pronation-supination movements were allowed with the elbow placed in 90° of flexion. Up to 6 weeks extension was limited to 30°-60° according to the elbow stability and to prevent the risk of dislocation. External fixator was removed at 6 weeks. At 3 months, muscular rehabilitation programme is initiated to strengthen the periarticular stabilizing muscles.

Devid Ring et al[20] to avoid varus stress of the elbow (shoulder abduction), used temporary external fixation (static or hinged) or temporary cross pinning of the elbow joint. When fixation is secure, stretching exercises can be started as soon as the patient is comfortable. Active self-assisted stretching exercises are key to regaining elbow and forearm motion. Static or dynamic splints may be used. Problems with internal fixation are stiffness, instability, or ulnar neuropathy. Infection is uncommon[20].

17 patients were reviewed at a mean follow up of 33 months (range, 18 to 60 months) and were clinically and radiologically evaluated. 2 patients were lost to follow up. One patient was followed up only up to 6 months. He had no pain and had functional range of motion from 30° flexion to 120°. Patients were clinically assessed according to the Mayo Elbow Performance score, on the basis of pain, mobility, stability and functional evaluation. Radiographic assessment of the elbow, based on A/P and lateral views was performed at last follow up.

The mean Mayo Elbow Performance Score, at evaluation 18 patients was 86 (range, 75 to 100). The outcomes were classified as excellent in five elbows and good in 7, fair 5 and poor 1.
However, of great significance, delayed reconstruction the satisfactory outcomes decreased to 50%[21].
Ten patients had no pain while five reported to have mild pain on lifting heavy weights. 3 had negligible pain. None of the patients suffered from severe pain. Mean flexion at last follow up was 110°, ranging from 90° to 140°. Mean extension loss was 14, ranging from 0° to 80°. Mean pronation was 70° (range, 30° to 80°) while mean supination was 60° (range, 30° to 80°). Elbows were stable in flexion extension and varus-valgus in all the cases. One patient (See Fig.5.) returned 3 years after with pain on the lateral side of elbow. X ray showed reduced joint space at radio-capital joint. The radial head was excised. 2 years later after excision of head of radius, patient had no pain at elbow nor at distal radio ulnar joint.

Early complication was in a 22 year old male patient who had a persistent instability in the sagittal and frontal plane, after suturing type III coronoid fracture with ethibond and no surgical intervention for type I radial head fracture and lateral collateral ligament was repaired. At one month, this persistent instability required surgical revision performed through a medial approach and revealing cut through of ethibond sutures used for coronoid process fracture, which required screw fixation and repair of MCL. An orthofix ex fix was applied at the end of the operation to stabilize the whole reconstruction. He did well but had some amount of stiffness. 11 patients also had reduced range of movements between 30° to 120°. Other complications like heterotopic ossification, ulnar neuropathy, errant hardware, or malunion were not noticed in any of the patients.
A late complication occurred in a 50 year old female patient with type III radial head fracture and type I coronoid process fracture operated through posterior approach and excision of radial head was performed. The patient developed posterior interosseous nerve palsy for which flexor carpiradialis tendon transfer was performed at 12 months after electrodiagnostic testing showed no signs of progression of regeneration. Wrist movements were restored (Fig.6).

A systematic approach to management of TT injury of elbow that surgically addresses each individual component of pathoanatomy has resulted in improved results. The 3 components -coronoid, LCL and radial head are repaired. Adequate coronoid fixation in terrible triad injuries is of paramount importance. Radial head is either reconstructed with ORIF or replaced. Radial head resection has not been advocated in literature; however, Tanna’s [6] and our experience has shown that in Indian scenario, head can be resected in some situations (described below) with good results
Terrible triad injuries of the elbow have been described by Hotchkiss[1] in 1996 as a clinical entity. This condition accounted for 4% of adult radial head fractures and 31% of elbow dislocations in a study by van Riet and Morrey[22]. Complete dislocations of the elbow joint with radial head fracture should be considered as TT injury unless proven otherwise. This entity was named as ‘Terrible Triad’ by Hotchkiss because of the serious complications like recurrence of instability, stiffness, pain and chronic osteoarthritis. However, during the last 2 decades understanding the biomechanics of injury, complex pathoanatomy improved surgical technique, and primary and secondary factors, which stabilize the elbow, results, have improved considerably. Associated lesions represent a significant diagnostic and therapeutic issue.
CT scan assessment should be performed in every case. C.T gives excellent information regarding size, shape and displacement of each fragment and guide the surgeon to plan the surgery with most adapted therapeutic management.
Several retrospective series have been reported, with each reflecting differing injury patterns, operative strategies, and outcomes.
Most of these injuries are managed surgically. The principle of surgical management is based on two main objectives: Restoration of bony stabilizing structures (radial head and coronoid process) and lateral collateral ligament repair.

The commonly used surgical protocol for TT of the elbow injuries is well established as follows:
(1) (a) Coronoid plays a vital role as an anterior buttress therefore reduce and fix the coronoid fracture first, if it is more than 10% of coronoid height. Coronoid tip fracture with height < 2 mm may be neglected. (b) Coronoid fracture, type 2 O’Driscollis fixed with a screw or coronoid plate through medial approach.
(2) Radial Head; (a) repair if 3 or less pieces b) if comminuted replace or resect. If radial head is excised MCL, LCL and coronoid must be repaired with hinged external fixator applied. Head resection is controversial
(3) LCL complex and the common extensor origin are always repaired.
(4) MCL is not routinely repaired. Repaired when elbow is unstable as detected by tests at the end of surgery.
(5)If residual instability of the elbow joint persists, apply a hinged external fixator is applied.
Although this treatment protocol has been proved effective, instability, contracture, re-operation, and progression to arthrosis still may be significant problems. Proper counseling must be done.

Commonly used approach is by a long posterior incision. Advantages claimed are that it allows access to both the medial and lateral aspects of the elbow, and it precludes the need for a second medial skin incision; also it is cosmetic, less seen; Morrey[6] assumed that any coronoid fracture must cause some injury to one or both of the collateral ligaments. Hence, exposure usually involves a posterior incision from which surgeon can inspect each ligament complex as necessary. Ligament will typically heal if the ulnohumeral joint is reduced and stable[12].

However, posterior approach is associated with complications of skin edge necrosis, seroma, hematoma and a possible infection. Lateral approach has the advantage of a small incision and repair of coronoid, radial head and LCL can be safely managed; usually medial incision is not required, occasionally indicated to reconstruct MCL or medial wall fracture of coronoid. Stabilizing coronoid fracture is easier from medial side. Zhang et al[23] used an extended lateral approach in combination with a separate medial approach in every patient. An anteromedial skin incision was made and an ”over- the-top” approach was used to expose most of the coronoid fracture[23].

Resection of the head: Most of the authors suggest to repair or replace the radial head in the management of TT. The function of the radial head is to prevent valgus instability in the absence of MCL by abutting against capitulum. If radial head is excised and if there is MCL deficiency, gross valgus instability occurs. In isolated fractures of the radial head with comminution if excised, instability does not occur. Another important function of radial head is to tighten the LCL. In the absence of radial head LCL becomes loose. Morrey[18] has shown when the radial head is present and the collateral ligaments are intact up to 50% of the coronoid may be absent and the elbow will remain stable. Hence the value of either fixing the radial head fracture, if possible, or replacing the head with a prosthesis is clear in the presence of these specific associated injuries[12].
When the radial head is resected and even if the MCL, LCL, and coronoid both extensor or flexor muscles are repaired valgus instability may occur, if elbow is not fully immobilized because the repaired MCL, LCL are not strong enough to resist the valgus forces. In due to course of time MCL is stretched out and LCL is lax, valgus instability occurs. However, this can be prevented by a hinged external fixator, which protects the repair of the MCL, LCL and coronoid, till complete healing of all the reconstructions (MCL, LCL, and coronoid). They heal well at 6 weeks, when the external fixator can be removed.
If external fixator is not available, elbow should be immobilized by bridge plating as is done for distal end of radius or cross pinning is done. When all the repaired structures heal, elbow is stable even in the absence of radial head, a situation similar to resection of head for isolated radial head fracture. Thus, in management of TT the radial head can be excised provided all stabilizers are repaired and a hinged external fixator is applied properly as described above. Hinged elbow braces have a limited application as they rarely fit exactly, do not match the axis of elbow, and are prone to instability13. Cast immobilization is often insufficient.
In the Indian scenario,
1. Patients come late after injury, often >2 weeks
2. Proper sized radial head implants are not available
3. Patient cannot afford imported implants
4. Surgeon may not have the training of implant surgery
Prosthetic surgery has a high learning curve.
5. Poor infra structure
This situation made us to try resection and repair other structures with application of a hinged external fixator; it has given satisfactory results. Results of replacement are far from satisfactory, even in the hands of experienced surgeon and using modern modular prosthesis. Replacement needs refinement. Redial head repair is also associated with complications of stiffness of elbow and technically not so easy. Our results of excision of radial head with bony and ligamentous reconstruction are comparable. In our series, 7 radial heads were resected, with repair of all other primary and secondary stabilizers. Of the 7 cases, 6 had good stability and one resulting in intra-operative instability requiring additional stabilization with humeroulnar cross-pinning. In all other 6 cases, hinged external fixator (Ortho.fix) was applied. Two patients came with radial head already excised, by the previous surgeon who missed the diagnosis of TT and thought it just simple fracture of radial head (Fig.7).

In most of the literature, radial head excision is not advocated; However Tanna’s [6] and our small experience has shown that in Indian scenario, we suggest radial head excision with reconstruction of all 3 primary and 2 other secondary stabilizers with application of hinged external fixator, when it is not possible to repair or replace, though the literature does not support and the number of cases treated with excision is too small. Further study of resection of head in TT is strongly recommended.

Radial head repair
Radio-capitellar contact along with LCL repair is crucial to restore stability the management of Tt2.
2 or 3 large pieces of head of radius can be reduced and fixed with mini fragment countersunk lag screw/s 2.7 or 3 mm headless or Herbert screws are used. If associated with radial neck fracture, plate may be applied in the “Safe Zone” – lateral surface of head as seen when the forearm is neutral (mid prone) position.

Radial head replacement
Radial head replacement is technically a difficult procedure in the treatment of TT injuries. Height, shape and size of the radial head should correspond to the height of the excised fragments; in cases of radial neck comminuted fractures under sizing of the removed head fragments is common, which can result in elbow valgus instability if accompanied by MCL injury. On the other hand, over sizing of the head fragments may cause overstuffing of the humero-radial joint, with the potential risk of stiffness and capitular erosion. Over stuffing of radial prosthesis necessitates reoperation. Properly sizing the radial head prosthesis can be challenging; and is performed with the elbow in extension, but the radiocapitellar joint is tighter in flexion than extension, which can lead to overstuffing. Also, biomechanical study has shown that no type of radial head prosthesis can restore elbow valgus stability to the same degree as was provided by the native radial head[24]. Arthrosis was more common in the arthroplasty group than in the ORIF group[25].

Tyler S Watters et al[25] reported that radial head arthroplasty has been shown to be a reliable technique for reconstruction of the radial head. The radial head prostheses interestingly were more stable and had a greater ROM when compared to ORIF. There was a learning curve for radial head replacement for proper head size selection, may result in overstuffed radiocapitellar joints. Excision of the radial head was strictly avoided without replacement[25].

The complications associated with prosthetic radial head replacement are similar to those for any prosthetic intervention; infection, loosening and osteoarthritis. The radial head implant impacts on the capitellar side of the joint resulting in erosion of the articular surface. The reasons for revision of prosthetic radial head replacement have recently been reviewed by van Riet et al[22]. The most common causes for subsequent intervention include loosening, instability and problems with articulation all of which are considered mechanical-type failures. The most common technical problem associated with these complications is failure to secure solid fixation of the stem. “Overstuffing” of the joint is one of the most common technical errors and leads to capitellar erosion and pain. It is also now recognized that the use of a radial head implant in the setting of a reconstructive surgery, or when there is associated injuries, is also associated with an increased incidence of complications[12].

Coronoid: The coronoid is clearly the most important articular stabilizer and key element in the humero-ulnar joint stability. 50% of the height of the coronoid process is necessary to ensure humero-ulnar sagittal stability. In TT injuries of the elbow, most coronoid fractures are type I fractures as confirmed by the series of Doornberg et al[14]. The anterior capsular attachment to the coronoid fragment or fragments should not be released because protecting the attachment enhances stability. Type II and III fractures require stable osteosynthesis, which might be performed through a lateral approach after radial head excision, or via a medial approach. In our series 6 type I fractures were ignored, 11 type II fractures were sutured to the capsule and 6 type III were fixed with screws or a plate through medial approach.

Isolated tip fracture: A tip fractures are sutured if fragment size amenable to repair (larger than 10% of coronoid height) via a lateral approach. If MCL was to be repaired, a medial approach was used. If the fragment is large (>10% coronoid height) it is fixed with a screw.
Anteromedial facet fracture: Fracture of the anteromedial facet of the coronoid process typically results from a varus posteromedial rotation injury force and is usually accompanied by an avulsion injury of the LCL [20].
Small anteromedial facet fractures are best repaired with a suture that engages the capsular attachment through a medial exposure. Open reduction and internal fixation (ORIF) of antero-medial facet is reliably stabilized with a screw or buttress plate that pushes the fracture fragment against the intact coronoid and deficient MCL is repaired. Medial approach is taken by separate medial skin incision. Pre-contoured buttress plate may be applied for comminuted fracture.

If the coronoid is severely comminuted and the fragments are loose or absorbed in the soft tissue, the coronoid is reconstructed by a tri-cortical graft from iliac crest. This usually occurs in patients with delayed presentation. (Fig.3.)
Basal coronoid Fracture:
Sub type I : Basal coronoid fracture is treated by ORIF by screw or a pre-contoured plate.

Controversy of coronoid tip fracture – Repair or not to repair?
Coronoid tip fractures are often associated with TT injuries, and rarely occur in isolation[26]. In many centres it is fixed [14], others have challenged this with biomechanical evidence suggesting that small (<10% of coronoid height) fractures contribute very little to stability, and any valgus instability should be addressed by repair of the MCL instead [14,26,27]. We have fixed tips only when it is > 10 %.

Terrible Triad with transolecranon fracture
Terrible triad transolecranon is a severe injury. The anterior translation of the forearm is the hallmark of this instability pattern and hence this injury is often referred to as a trans-olecranon fracture dislocation [28,29]. This is a Sub type II basal coronoid fracture of O’Driscoll classification. A large basilar fracture of the coronoid are nearly always associated with olecranon fracture–dislocations. Usually have a fracture of the radial head as well. Both the fractures are approached though the traumatic window of the olecranon by a long incision. A thick flap is raised to prevent skin necrosis. Care must be taken during handling of the ulnar nerve and while fixing coronoid for screw penetration into the ulnohumeral or proximal radioulnar joints. Olecranon fracture is fixed with a long plate [20] .

ULCL: The most important step in achieving stability is repair of lateral collateral ligament which is the primary stabilizer. Successful isometric repair is by placing the sutures at the centre of rotation of the elbow, which is located at the center of the capitular curvature on the lateral epicondyle and at supinator crest, to prevent the occurrence of any varus or postero-lateral instability.

Systematic approach of medial collateral ligament remains controversial. Injuries to the MCL, which have been reported in 50–60% [13] of TT injuries, are not universally repaired. Forthmann [30] argues that MCL injuries tend to heal by scarring in simple elbow dislocations, and the repair of articular (and LCL complex) injuries in TT will effectively transform this injury into that of a simple dislocation, thereby rendering MCL repair unnecessary.
After repair of the coronoid process, radial head and lateral collateral ligament, the elbow should be fluoroscopically examined for stability, while it is flexed and extended with the forearm insupination, neutral position and pronation.
In 2004, Pugh et al [27] reviewed 36 TT injuries out of which isolated lateral approach was used in 26 cases. Radio-capitellar contact along with LCL repair is crucial to restore stability [2].

Their surgical protocol included fixation or replacement of the radial head, fixation of the coronoid fracture if possible, repair of associated capsular and lateral ligamentous injuries. After reconstruction of the lateral ligament complex, stability of elbow was evaluated in flexion-extension. In the absence of instability, the medial approach was not performed. In case of instability, a medial approach was chosen for reconstruction of the ligament complex and an external fixator was placed in some patients. The authors advocate that a medial approach should be performed only in case of persistent sagittal instability after reconstruction of bony structure and lateral collateral ligament. They recommend that isolated valgus instability in the coronal plane does not require medial collateral ligament repair as far as the elbow remains stable in flexion-extension.
Mathew et al [31] advocated that if the elbow remains congruous from approximately 30 degrees to full flexion in one or more positions of forearm rotation, repair of medial collateral ligament is not necessary. In our series, thirteen out of fifteen elbows treated through a medial approach reported damage to the medial collateral ligament. When radial head is excised MCL repair is mandatory

External Fixator
If instability persists despite repair of radial head and repair of the coronoid process, medial collateral ligament, or lateral collateral ligament, a static or hinged external fixator should be applied to maintain a concentric reduction of the elbow. Zeiders et al [32] have recommended the use of the external fixator in case of insufficient stability to allow complete mobilization after reconstruction of bony and ligamentous structures. These standard hinged external fixators are centered on the elbow centre of rotation. The external fixator allows early mobilizations within a protected range of motion to reduce the risk of secondary stiffness. In our series, we have invariably used hinged external fixators and reported that it prevents recurrent instability and protects reconstructed ligaments and soft tissue. External fixator is also indicated when radial head is excised. As shown in fig 4, fixators are also useful in neglected cases of terrible triad where the elbow is stiff [33].

Literature review
Zhang [2] from MGH Boston published an excellent paper on TT in July JOT 2016. One hundred of the 107 patients (93%) treated with open fixation of terrible triad injuries had no radiographic subluxation, so called drop sign. Five patients (5%) had persistent radiographic subluxation, 3 treated with a second surgery (3%). They concluded that Radiographic subluxation is very uncommon (2%) with current operative management of terrible triad injuries of the elbow within 2 weeks. They identified 2 risk factors or post-operative instability – (1) Delay of >2 weeks after injury, (2) Obesity. They suggested Patients treated more than 2 weeks after injury might benefit from ancillary fixation to limit subluxation (ie, cross pinning, hinged external fixation, or bridge plating).Modern techniques have decreased the incidence of post patient instability and other complications. Patients with higher BMI may be at risk for postoperative subluxation.
Yang et al[34] in 2013 reviewed 11 patients with TT of the elbow treated with hinged external fixator combined with mini-plate followed up to 12-20 months(mean, 15 months). According to Mayo elbow function evaluation standard, the results were excellent in five cases and good in four cases, and fair in two cases, with an excellent and good rate of 81.8%[4]. In 1 study, 11 patients with a terrible triad pattern, five of the elbows re-dislocated after operative treatment (including all 4 that had a radial head resection). The suture lasso technique was more reliable than the other techniques. The repair progresses from deep to superficial (coronoid, radial head, LCL) on the lateral side. The authors therefore favor fixation of the coronoid with a suture lasso except in the unusual case where the coronoid fracture is relatively undisplaced or stable[20].
In 2010 Chemama et al[35] published the results of 14 patients who were examined on an average of 63 months after injury. Several medial-sided ligament repairs were performed and motion results were similar to those of the current study, with an average flexion-extension arc of 18° to 127°. Mayo elbow performance score was 87 classified as excellent in 4 cases and good in 10.
There are limitations of this study. First, the number of patients was relatively small. Second, the study is not a randomized study. Third, though we have suggested radial head resection, the number of cases is too small and there are no biomechanical studies. On the other hand, the results showed that the technique provided good results with minimal morbidity. Considering review of literature and our own satisfactory experience, the TT of elbow is now no more terrible.

“Terrible triad” elbow fracture dislocation remains an unusual and challenging injury to treat. CT scan should be performed in all the cases to identify fracture patterns, comminution, and displacement. Surgical management is based on restoring the bony anatomy (radial head and coronoid process) and reconstructing (lateral collateral ligament) of the elbow to provide enough stability. A medial ligament reconstruction is indicated in cases of persistent instability. Although posterior approach has low risk of skin necrosis and is popular, we prefer lateral approach and when needed medial approach. Radial head excision is indicated in severely comminuted head in the situation prevailing in developing countries, mentioned above. Careful fluoroscopic examination of the elbow to assess any residual instability at the end of surgery and to determine the best position for immobilization as well as the safe arc of motion; Use of hinged external fixator is indicated when residual instability is detected at the end of surgery and in cases when radial head is resected; since it maintains reduction of the elbow and offers early mobilization. Optimal rehabilitation protocol is useful in allowing early motion while maintaining stability. With this modern treatment, the results of TT are satisfactory and TT is no more a terrible triad.


1. Hotchkiss RN. Fractures and dislocations of the elbow. In: Court-Brown C, Heckman JD, Koval KJ, Wirth MA, Tornetta P, Bucholz RW, eds. Rock-wood and Green’s Fractures in Adults. Philadelphia, PA: Lippincott-Raven; 1996.
2. Dafang Zhang, Matthew Tarabochia, Stein Janssen, David Ring, Neal Chen. Risk of Subluxation or Dislocation After Operative Treatment of Terrible Triad Injuries. J Orthop Trauma 2016;30(12):660–663.
3. McKee MD, Pugh DM, Wild LM, et al. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg. Am. 2005;87:22–32.
4. Gupta A, Barei D, Khwaja A, et al. Single-staged treatment using a standardized protocol results in functional motion in the majority of patients with a terrible triad elbow injury. Clin Orthop Relat Res. 2014;472:2075–2083.
5. Chen NC, Ring D. Terrible triad injuries of the elbow. J Hand Surg. Am. 2015;40:2297–2303.
6. DilipTanna. Elbow dislocation with irreparable fracture radial head. I.J.O. May 13;47(3);283-7.
7. Morrey BF, An KN. Stability of the elbow: osseous constraints. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2005;14(1 Suppl S):174S-8S.
8. Cohen MS: Fractures of the coronoid process. Hand Clin 2004;20:443-453.
9. Fornalski S, Gupta R, Lee TQ: Anatomy and biomechanics of the elbow joint. Tech Hand Up Extrem Surg. 2003;7:168-178.
10. Mason ML: Some observations on fractures of the head of the radius with a review of one hundred cases. Br J Surg. 1954;42:123-132.
11. Regan W, Morrey B. Classification and treatment of coronoid process fractures. Orthopedics 1992;15(7):845–8.
12. Bernard F. Morrey. Fractures of the Coronoid. Chapter 7 in Masters techniques in Orthopaedic Surgery; The Elbow, 3rd Edition (2015); Wolters Kluwer Pg.105 – 116.
13. Payam Tarassoli, Philop McCann, Rouin Amirfeyz. Complex instability of the elbow. Injury Int. J. Care Injured 48 (2017) 568-577.
14. Doornberg JN, Ring DC. Fracture of the anteromedial facet of the coronoid process. J Bone Joint Surg. Am 2006;88(10):2216–24.
15. Mezera K, Hotchkiss RN: Fractures and dislocations of the elbow, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA: Lippincott-Raven, 2001, pp 921- 952.
16. Beingessner DM, Stacpoole RA, Dunning CE, Johnson JA, King GJ: The effect of suture fixation of type I coronoid fractures on the kinematics and stability of the elbow with and without medial collateral ligament repair. J Shoulder Elbow Surg. 2007;16:213- 17.
17. Closkey RF, Goode JR, Kirschenbaum D, et al. The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint Surg. Am. 2000; 82 A: 1749–1753. 187–195.
18. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow: a definition of primary and secondary constraints. Clin Orthop Relat Res. 1991;265.
19. Kocher T. Operations at the elbow. In: Kocher T, ed. Textbook of Operative Surgery. London: Adam and Charles Black; 1911:313–318.
20. David Ring, Taylor Horst. Coronoid fracture. J Orthop Trauma 2015;29:437–440.
21. Bernard F. Morrey. Radial Head Prosthesis. Chapter 6 in Masters techniques in Orthopaedic Surgery; The Elbow, 3rd Edition (2015); Wolters Kluwer Pg.95-104.
22. Van Riet RP, Morrey BF. Documentation of associated injuries occurring with radial head fracture. Clinical orthopaedics and related research. 2008;466(1):130-4.
23. Chi Zhang, Biao Zhong, Cong-Feng Luo. Treatment strategy of terrible triad of the elbow: Experience in Shanghai 6th People’s Hospital. Injury Int. J. 45(2014) 942 – 948.
24. Leigh WB, Ball CM. Radial head reconstruction versus replacement in the treatment of terrible triad injuries of the elbow. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2012;21(10):1336-41.
25. Tyler Steven Watters, Grant E. Garrigues, David Ring, and David S. Ruch. Fixation Versus Replacement of Radial Head in Terrible Triad: Is There a Difference in Elbow Stability and Prognosis? Clin Orthop Relat Res. 2014;472:2128–2135.
26. Ring D. Fractures of the coronoid process of the ulna. J Hand Surg. Am 2006;31(10):1679–89.
27. Pugh DM, Wild LM, Schemitsch EH, King GJ, McKee MD. Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. The Journal of bone and joint surgery American volume. 2004;86-A(6):1122-30.
28. Ring D, Jupiter JB, Sanders RW, Mast J, Simpson NS. Transolecranon fracture dislocation
of the elbow. J Orthop Trauma 1997;11(8):545–50.
29. Mouhsine E, Akiki A, Castagna A, Cikes A, Wettstein M, Borens O, et al. Transolecranon anterior fracture dislocation. J Shoulder Elbow Surg. 2007; 16(3):352–7.
30. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. J Hand Surg. Am 2007;32(8):1200–9.
31. Mathew PK, Athwal GS, King GJ. Terrible triad injury of the elbow: current concepts. The Journal of the American Academy of Orthopaedic Surgeons. 2009;17(3):137-51.
32. Zeiders GJ, Patel MK. Management of unstable elbows following complex fracture-dislocations–the “terrible triad” injury. The Journal of bone and joint surgery American volume. 2008;90 Suppl 4:75-84.
33. Kulkarni GS, Kulkarni VS, Shyam AK, Kulkarni RM, Kulkarni MG, Nayak P. Management of severe extra-articular contracture of the elbow by open arthrolysis and a monolateral hinged external fixator. J Bone Joint Surg Br. 2010 Jan;92(1):92-7.
34. Yang Y, Wang F. Hinged external fixator with mini-plate to treat terrible triad of elbow. Chinese journal of reparative and reconstructive surgery. 2013;27(2):151-4.
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How to Cite this article: .Kulkarni GS, Kulkarni V, Kulkarni R, Kulkarni S, Kulkarni M. Terrible Triad – Terrible Triad is no more terrible! Journal of Clinical Orthopaedics Jan – June 2017; 2(1):14-26.

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Review of Important Recent Articles in Pediatric Orthopaedics

Vol 2 | Issue 1 |  Jan – June 2017 | Page 52-55 | Rujuta Mehta, Kailash Sarathy

Authors: Rujuta Mehta [1], Kailash Sarathy [1].

[1] Department of Pediatric Orthopaedics, B J Wadia Hospital For Children, Parel, Mumbai India

Address of Correspondence
Dr Rujuta Mehta
HOD, Dept. of Paediatric Orthopaedics, B J Wadia Hospital,
Nanavati Hospital, Jaslok Hospital & Shushrusha Hospital.
Email: rujutabos@gmail.com


Paediatric orthopaedics as a super speciality has evolved in the last 3 decades to become a vast ocean of changing concepts and rethinking of treatment strategies and hence, is abundant in evidence based literature. In the last year over a 100 good articles and research papers have been published on various subjects. In this commentary, we have sifted out a few of the most relevant ones to the day to day clinical practice and some which are relevant to both the general orthopaedic surgeon and paediatric orthopaedic surgeon. The following is a compilation according to categories which we think will interest the reader. The summary has been enlisted here along with a short comment on the utility of the article. The reader is advised to go into the full text of any selected article if any particular article meets their requirements: as providing full text of each article is beyond the purview of this review , making it over lengthy.
Aim:To analyse the important articles published in the field of Pediatric Orthopaedics in the recent past which would have a significant impact in the understanding and management of various common Pediatric Orthopaedic disorders.


1. “Pediatric Supracondylar Fractures: Variation in Fracture Patterns and the Biomechanical Effects of Pin Configuration.” by Jaeblon et al.(J Pediatr Orthop 2016;36:787–792) [1] REMARKS –This is one of the very few studies providing an insight on the biomechanical stability of pin configurations in various patterns of supracondylar fractures, showing the all lateral pin construct to provide favourable outcomes in most of the fracture patterns with fewer complications.
2. “Treatment of flexion-type supracondylar fractures in children: the ‘push–pull’ method for closed reduction and percutaneous K-wire fixation.”  by Chukwunyerenwa and his colleagues.(Journal of Pediatric Orthopaedics B 2016, 25:412–416)[2]Remarks- This is a research paper describing a new, simplified technique in treating flexion-type supracondylar humerus fractures (by push-pull technique) in pediatric population with optimal clinical and radiological outcomes. This technique would help the general orthopaedic surgeon to treat this difficult injury with ease.
3. “Conservative Management of Minimally Displaced (<2mm) Fractures of the Lateral Humeral Condyle in Pediatric Patients: A Systematic Review”.  A review article by Knapik et al. (J Pediatr Orthop 2017;37:e83–e87) [3]Remarks – This is paper provides a review of various published research papers regarding the management of minimally displaced lateral humeral condyle fractures, which is still a pandoras box to the orthopaedic surgeons. A conservative management can be attempted for minimally displaced fractures (<2mm) provided a close radiographic follow up is carried out.
4. “Closed Reduction and Percutaneous Pinning Versus Open Reduction and Internal Fixation for Type II Lateral Condyle Humerus Fractures in Children Displaced >2mm”. by Pennock et al. (J Pediatr Orthop 2016;36:780–786)[4]Remarks– This research paper describes about the surgical management in displaced lateral humeral condyle fractures (> 2mm) but with minimal joint incongruity, reported similar results with closed reduction and percutaneous pinning as well as open reduction with internal fixation. Closed reduction can be preferred due to its less invasiveness and operative time, only if joint congruity is confirmed. It outlines objective criteria for the different lines of management however the clinician must not forget the significant learning curve in the judgement of the displacement.
5. “Does operative fixation affect outcomes of displaced medial epicondyle fractures?”. By Stephanovich et al. (J Child Orthop (2016) 10:413–419) [5]RemarksAlthough this study provides a small cohort, reports higher union rates, less complications and early return activity especially sports, with operative management for displaced medial humeral condyle fractures. It deserves merit for attempting to study a large cohort for a rare injury, most clinicians are still unclear on its diagnosis and management and hence we recommend it as a must read.
6. “Compartment syndrome in infants and toddlers”. Research paper published by Broom et al. (J Child Orthop (2016) 10:453–460) [6]Remarks– This paper provides an insight on the incidence of compartment syndrome in children less than 3 yrs of age, as diagnosis is often delayed. It has been reported that, even with a delay in diagnosis (48-72 hrs after injury) the outcomes are favourable after fasciotomy especially in toddlers.


1. “Kocher Criteria Revisited in the Era of MRI: How Often Does the Kocher Criteria Identify Underlying Osteomyelitis?” , A research paper published by Nguyen and his colleagues.(J Pediatr Orthop 2017;37:e114–e119) [7]Remarks–This is one of the recent landmark papers in musculoskeletal infections showing the importance of the additional investigation of MRI in children with the diagnosis of septic arthritis according to the Kocher’s criteria, as there is a high chance of concomitant osteomyelitis.
2. “Laboratory predictors for risk of revision surgery in pediatric septic arthritis.”Research workby Telleria et al.(J Child Orthop (2016) 10:247–254) [8]Remarks –This research paper throws light on the predictors of revision surgery following index surgery for septic arthritis in children, and predicts a positive blood culture and a high CRP at initial presentation to be statistically significant risk factors.
3. “Tubercular dactylitis in children”. By Balaji and his colleagues. (Journal of Pediatric Orthopaedics B 2017, 26:261–265) [9]Remarks– This research paper provide light on the delay in diagnosing TB dactylitis as there are various mimickers, and prompt multi-drug therapy as the treatment of choice.
4. “Hand and wrist tuberculosis in paediatric patients – our experience in 44 patients”, By Prakash et al. (Journal of Pediatric Orthopaedics B 2017, 26:250–260) [10]Remarks – This research provides a large cohort of patients with tuberculosis of upper limb especially, wrist and hand. A prompt early diagnosis and management in the form of ATT is essential to get favourable outcomes and prevent morbidities in the form of residual stiffness and pain due to the development of arthritis.


1. “Avascular necrosis following closed reduction for treatment of developmental dysplasia of the hip: a systematic review”, by Bradley and his colleagues.(J Child Orthop (2016) 10:627–632) [11]Remarks – This is a review article on the incidence of AVN following closed reduction for DDH, with a significantly large follow up, showing a significant amount of AVN (10%).
2. “Long-term outcome following medial open reduction in developmental dysplasia of the hip: a retrospective cohort study”,a study by Gardner and his colleagues.(J Child Orthop (2016) 10:179–184) [12]Remarks– This study provides an evidence based review of medial open reduction in the treatment of dysplasia of hip, showing a significant amount of AVN and unsatisfactory outcome on long term follow up of these cases although initial short term results are satisfactory. This would probably explain why this operative approach is not so popular over the conventional Somerville anterior approach(bikini) which is accepted worldwide besides being a cosmetic approach
3. “MRI versus computed tomography as an imaging modality for post reduction assessment of irreducible hips in developmental dysplasia of the hip: an inter-observer and intra-observer reliability study”. A study conducted Barkatali and his colleagues.(Journal of Pediatric Orthopaedics B 2016, 25:489–492) [13]Remarks – This is one of the very few papers showing a definite comparison between the use of MRI and CT scan for the assessment of irreducible hips post reduction and provides a clear recommendation of using MRI over CT scan.
4.“The alpha angle as a predictor of contralateral slipped capital femoral epiphysis”,by Boyle and his colleagues.(J Child Orthop (2016) 10:201–207) [14]Remarks– This is one of the recent studies throwing a highlight on development of SCFE in the contralateral hip which could be prevented by measuring the alpha angle and assessing the risk during the index surgery with a statistically significant correlation. It is an excellent article which provides very useful guidelines to judge the angle of slip accurately.
5. “Delay in the Diagnosis of Stable Slipped Capital Femoral Epiphysis”. A study conducted by Iwinski and his colleagues.(J Pediatr Orthop 2017;37:e19–e22) [15]REMARKS –This is one of the recent articles that provides a brief information the factors contributing to the delay in the diagnosis of stable SCFE. A significant delay has been reported when the patient is seen by a non-orthopedic provider and when the patient presents with knee pain instead of hip.


1. “Ponseti method compared to previous treatment of clubfoot in Norway. A multicenter study of 205 children followed for 8–11 years”. A study conducted by Saetersdal K and his colleagues.(J Child Orthop (2016) 10:445–452) [16]Remarks– This article throws a significant light on the Ponseti method with a good amount of follow up, showing the significance and merits of using Ponseti method in comparison to other casting methods. It also highlights the paradigm shift that has occurred with respect to approachto  club foot  treatment.
2. “Treatment of complex idiopathic clubfoot using the modified Ponseti method: up to 11 years follow-up”. A study conducted by Matar H E and his colleagues.(Journal of Pediatric Orthopaedics B 2017, 26:137–142) [17]REMARKS – This is one of the few long term studies on the use of modified Ponseti method for the management complex idiopathic clubfoot showing effective and reliable results, but with a small sample size as compared to the Indian sub- continent.
3. “Tarsal Bone Dysplasia in Clubfoot as Measured by Ultrasonography: Can it be Used as a Prognostic Indicator in Congenital Idiopathic Clubfoot? A Prospective Observational Study”. A study by Chandrakanth U and his colleagues.(J Pediatr Orthop 2016;36:725–729) [18]Remarks– Excellent article. This is one of the new areas of research in the management of clubfoot, using the amount of tarsal bone dysplasia as a marker for prognostication in children with clubfoot. Although a short term study, has paved the way for this new area of research and analysis in the management of clubfoot.


“What’s New in Pediatric Flatfoot?”. This was a POSNA review article reported by Bauer K, Mosca V S and Zionts L E. (J Pediatr Orthop 2016;36:865–869) [19]Remarks–This paper deserves a lot of merit for being an eye opener especially regards with non uniformity of clear definitions and management protocols .Here the authors have described about the proponents of managing various causes of pediatric flatfoot like flexible flat foot, Tarsal Coalition and CVT, and the latest concept regards to the management of the above conditions.


1. “Stepwise surgical approach to equino-cavovarus in patients with cerebral palsy”. This article was published by Won H S and his colleagues. (Journal of Paediatric Orthopaedics B 2016, 25:112–118) [20]Remarks –This article provides a brief and clear outline about the step wise management of common foot deformities encountered in Cerebral Palsy.
2. “A balanced approach for stable hips in children with cerebral palsy: a combination of moderate VDRO and pelvic osteotomy”, published by Reidy K et al.(J Child Orthop (2016) 10:281–288) [21]Remarks – Providing a moderate but adequate amount of varus along with acetabular procedure, gives a favourable outcome especially in CP children with GMFCS IV and V.


1. “Correction of elbow flexion contracture by means of olecranon resection and anterior arthrolysis in obstetrical brachial plexus palsy sequelae”. A study conducted by Senes and his colleagues.(Journal of Pediatric Orthopaedics B 2017, 26:14–20) [22]Remarks- This is a pilot study which provides information on a new technique of olecranon tip resection with elbow arthrolysis in young patients with OBPP sequelae with reliable outcomes. However this is not a widely practised procedure we would advise the novice reader to interpret and adopt with caution as it is meeting with scepticism even in expert hands.
2. “Evaluation of functional outcomes and preliminary results in a case series of 15 children treated with arthroscopic release for internal rotation contracture of the shoulder joint after Erb’s palsy”. A study conducted by Elzohairy and his colleagues. (J Child Orthop (2016) 10:665–672) [23]Remarks–This article describes a new minimally invasive technique for the management of internal rotation contracture in the children with OBPP at a younger age with favourable mid-term results.


1. Jaeblon T, Anthony S, Ogden A, Andary JJ. Pediatric Supracondylar Fractures: Variation in Fracture Patterns and the Biomechanical Effects of Pin Configuration. J Pediatr Orthop. 2016 Dec;36(8):787-792.
2. Chukwunyerenwa C, Orlik B, El-Hawary R, Logan K, Howard JJ. Treatment of flexion-type supracondylar fractures in children: the ‘push-pull’ method for closed reduction and percutaneous K-wire fixation. J Pediatr Orthop B. 2016 Sep;25(5):412-6.
3. Knapik DM, Gilmore A, Liu RW. Conservative Management of Minimally Displaced (≤2 mm) Fractures of the Lateral Humeral Condyle in Pediatric Patients: A Systematic Review. J Pediatr Orthop. 2017 Mar;37(2):e83-e87.
4. Pennock AT, Salgueiro L, Upasani VV, Bastrom TP, Newton PO, Yaszay B. Closed Reduction and Percutaneous Pinning Versus Open Reduction and Internal Fixation for Type II Lateral Condyle Humerus Fractures in Children Displaced >2 mm. J Pediatr Orthop. 2016 Dec;36(8):780-786.
5. Stepanovich M, Bastrom TP, Munch J 3rd, Roocroft JH, Edmonds EW, Pennock AT. Does operative fixation affect outcomes of displaced medial epicondyle fractures? J Child Orthop. 2016 Oct;10(5):413-9.
6. Broom A, Schur MD, Arkader A, Flynn J, Gornitzky A, Choi PD. Compartment syndrome in infants and toddlers. J Child Orthop. 2016 Oct;10(5):453-60.
7. Nguyen A, Kan JH, Bisset G, Rosenfeld S. Kocher Criteria Revisited in the Era of MRI: How Often Does the Kocher Criteria Identify Underlying Osteomyelitis? J Pediatr Orthop. 2017 Mar;37(2):e114-e119.
8. Telleria JJ, Cotter RA, Bompadre V, Steinman SE. Laboratory predictors for risk of revision surgery in pediatric septic arthritis. J Child Orthop. 2016 Jun;10(3):247-54.
9. Saibaba B, Raj Gopinathan N, Santhanam SS, Meena UK. Tubercular dactylitis in children. J Pediatr Orthop B. 2017 May;26(3):261-265.
10. Prakash J, Mehtani A. Hand and wrist tuberculosis in paediatric patients – our experience in 44 patients. J Pediatr Orthop B. 2017 May;26(3):250-260.
11. Bradley CS, Perry DC, Wedge JH, Murnaghan ML, Kelley SP. Avascular necrosis following closed reduction for treatment of developmental dysplasia of the hip: a systematic review. J Child Orthop. 2016 Dec;10(6):627-632
12. Gardner RO, Bradley CS, Sharma OP, Feng L, Shin ME, Kelley SP, Wedge JH. Long-term outcome following medial open reduction in developmental dysplasia of the hip: a retrospective cohort study. J Child Orthop. 2016 Jun;10(3):179-84.
13. Barkatali BM, Imalingat H, Childs J, Baumann A, Paton R. MRI versus computed tomography as an imaging modality for postreduction assessment of irreducible hips in developmental dysplasia of the hip: an interobserver and intraobserver reliability study. J Pediatr Orthop B. 2016 Nov;25(6):489-92.
14. Boyle MJ, Lirola JF, Hogue GD, Yen YM, Millis MB, Kim YJ. The alpha angle as a predictor of contralateral slipped capital femoral epiphysis. J Child Orthop. 2016 Jun;10(3):201-7.
15. Hosseinzadeh P, Iwinski HJ, Salava J, Oeffinger D. Delay in the Diagnosis of Stable Slipped Capital Femoral Epiphysis. J Pediatr Orthop. 2017 Jan;37(1):e19-e22.
16. Sætersdal C, Fevang JM, Bjørlykke JA, Engesæter LB. Ponseti method compared to previous treatment of clubfoot in Norway. A multicenter study of 205 children followed for 8-11 years. J Child Orthop. 2016 Oct;10(5):445-52.
17. Matar HE, Beirne P, Bruce CE, Garg NK. Treatment of complex idiopathic clubfoot using the modified Ponseti method: up to 11 years follow-up. J Pediatr Orthop B. 2017 Mar;26(2):137-142.
18. Chandrakanth U, Sudesh P, Gopinathan N, Prakash M, Goni VG. Tarsal Bone Dysplasia in Clubfoot as Measured by Ultrasonography: Can It be Used as a Prognostic Indicator in Congenital Idiopathic Clubfoot? A Prospective Observational Study. J Pediatr Orthop. 2016 Oct-Nov;36(7):725-9
19. Bauer K, Mosca VS, Zionts LE. What’s New in Pediatric Flatfoot? J Pediatr Orthop. 2016 Dec;36(8):865-869.
20. Won SH, Kwon SS, Chung CY, Lee KM, Lee IH, Jung KJ, Moon SY, Chung MK, Park MS. Stepwise surgical approach to equinocavovarus in patients with cerebral palsy. J Pediatr Orthop B. 2016 Mar;25(2):112-8.
21. Reidy K, Heidt C, Dierauer S, Huber H. A balanced approach for stable hips in children with cerebral palsy: a combination of moderate VDRO and pelvic osteotomy. J Child Orthop. 2016 Aug;10(4):281-8.
22. Senes FM, Catena N, Dapelo E, Senes J. Correction of elbow flexion contracture by means of olecranon resection and anterior arthrolysis in obstetrical brachial plexus palsy sequelae. J Pediatr Orthop B. 2017 Jan;26(1):14-20.
23. Elzohairy MM, Salama AM. Evaluation of functional outcomes and preliminary results in a case series of 15 children treated with arthroscopic release for internal rotation contracture of the shoulder joint after Erb’s palsy. J Child Orthop. 2016 Dec;10(6):665-672.

How to Cite this article: .Mehta R, Sarathy K. Review of Important Recent Articles in Paediatric Orthopaedics Journal of Clinical Orthopaedics .Jan – June 2017; 2(1):52-55.

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Potpourri – Recent and relevant literature in Shoulder Arthroplasty, Arthroscopy and Trauma

Vol 2 | Issue 1 |  Jan – June 2017 | Page 49-51 | Vivek Pandey, Sandesh Madi, Naveen Mathai

Authors: Vivek Pandey [1], Sandesh Madi [1], Naveen Mathai [1].

[1] Kasturba Medical College, Manipal University, Karnataka, India- 576104

Address of Correspondence
Dr. Vivek pandey
Kasturba Medical College, Manipal University,
Karnataka, India- 576104
Email: vivekortho@gmail.com

1. Slow or accelerated Rehabilitation after cuff repair, A matter of time or is it?
There exists lot of ambiguity in rehabilitation protocols among shoulder surgeons following arthroscopic rotator cuff repairs. It is an overwhelming task to balance between initiating early range of motion without disturbing the integrity of the cuff repair. Following arthroscopic single-tendon rotator cuff repair, Mazzocca et al [1] revealed that no differences in quality of life scores or rotator cuff healing were identified after comparing two groups of patients undergoing either immediate (within three days) or delayed (after twenty eight days) postoperative rehabilitation protocols. Other factors such as age of the patient, cuff and bone quality, tear geometry, repair techniques and implants play vital role in determining the rehabilitation regime and probably needs to be tailored accordingly. Moreover, recent meta-analysis by Chang et al [2] comparing early versus delayed mobilisation protocols revealed hardly any differences in rotator cuff healing, final shoulder range of motion or patient outcomes.

2. Massive cuff tears: approaches for a costly affair
Presently, there are three possible strategies for the management of massive cuff tears with pseudopalsy without Osteoarthritis: 1) Arthroscopic Rotator Cuff Repair (ARCR) with option to arthroscopically revise once. 2) ARCR with immediate conversion to Reverse Total Shoulder Arthroplasty (RTSA) on potential failure, or 3) Primary RTSA. In an economic and decision based analysis (Markov decision model), Dornan et al have concluded that Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy in such cases [3]. An important observation was this result independent of age of the patient. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy. RTSA is not the panacea for massive cuff tear management and should be offered only as a last resort after exhausting available repair options.

3. Predictors of Re-tears after cuff reapir
There are diverse factors that determine the healing of repaired rotator cuff tears. Reported rates of re-tear after rotator cuff repair widely varies from 11% to 94% [4,5] . In a prognostic case series, Kim et al [6] attempted to identify pre-operative factors that can predict the rate of re-tears following rotator cuff repairs. The observations made are noted in table 1 and included mostly the charaterictic of the tear and duration of symptoms. Surprisingly comorbidities like old age, diabetes, smoking and fatty degeneration of tendons did not significantly predict re-tears.

4. Does the repair of cuff stays for long?
A Long term outcome after rotator cuff repair, 2-10 year long study. After the repair of the rotator cuff, it has always been intriguing that what happens to the repair in long term? Does the repair remains intact long enough and does the clinical results do not deteriorate over time? Heuberer et al [7] published their short and long term data recently involving arthroscopic repair of full thickness supraspinatus tear with/without partial infraspinatus tear. They followed 30 patients at 2- and 10 year with clinical scores ((Constant Murley and UCLA) and MRI for structural healing. MRI at two year follow up revealed 42% of patients with a full-thickness re-rupture, while 25% had a partial re-rupture, and 33% of tendons remained intact. The 10-year MRI follow-up (129 ± 11 months) showed 50% with a total re-rupture, while the other half of the tendons were partially re-ruptured (25%) or intact (25%). The UCLA and constant score remained high at 2- and 10 year follow up as compared to preop status. The constant total score and strength subscore remained high in patients with intact tendon versus those with retear. Majority patients (83.3%) rated their satisfaction as excellent. However the complete retear rates are almst 50% with single row. It would be interesting to analyse the repair of similar tears with double row and look at the outcome.

5. What is the critical Glenoid bone loss after which soft tissue bankart repair does not restore glenohumeral biomechanics and movement?
It was Itoi et al who brought the concept of critical bone loss of 21% in glenoid beyond which a soft tissue Bankart repair may not suffice to provide stability [8]. This brought the concept of bone augmentation using Latarjet procedure, Iliac crest graft or distal tibia allograft. However, recently Shin et al [9] challenged this concept of reconsidering this 21% bone loss as critical limit. In their study on eight cadaveric shoulder, they created 10%, 15%, 20% and 25% anteroposterior glenoid bone loss. After the soft tissue Bankart repair, the shoulder were subjected to range of motion, translation and humeral head position at 600 abduction with 40N rotator cuff muscle loading. They concluded that critical bone loss after which the biomechanics of the shoulder cannot be restored is 15%, and not 20-25% which has been the current recommendation for bone augmentation.

6. RSA versus conservative treatment in 3- or 4-part fracture of proximal humerus in elderly. Which is better?
Since the advent of RSA and its expanding indication, there has been a debate about the use of RSA in the treatment of proximal humeral fracture especially elderly patients. ORIF and hemiarthroplasty (HA) remained two essential form of treatment in these patients. However, ORIF carried a higher complications like implant failure due to osteoporosis and comminution whereas HA caused problem due to tuberosity nonunion. Hence, RSA became increasingly a popular option for the treatment of such challenging fracture. However, Roberson et al [10] did a two year retrospective review of patients older patients (>70 year) who underwent RSA for 3- or 4-part fracture of proximal humerus versus conservative treatment. They reported minimal benefits of RSA over conservative treatment at two years. The RSA group was no better than conservative group whether it was achievement of range of movement or patient reported outcomes.

7. Can local application of Vancomycin powder reduce the infection rate after total shoulder replacement?
Despite all the aseptic measures, the Methicillin resistant and Propionibacterium infection after the total shoulder replacement is a nightmare for the surgeon. The cost to treat postoperative infection till revision can range up 47260$ in USA. Any measure which can reduce the infection rate and cost to treat such problem will be a great idea. Based upon prevalent rates of infection in shoulder arthroplasty, Daniel Hatch et al [11] did an analysis of cost effective of local use of Vancomycin powder (2-18$/1000 mg) usage over the local wound to prevent such infection, and concluded that local application of Vancomycin powder is going to be highly cost effective in preventing such infection.


1. Mazzocca AD, Arciero RA, Shea KP, Apostolakos JM, Solovyova O, Gomlinski G et al. The effect of early range of motion on quality of life, clinical outcome, and repair integrity after arthroscopic rotator cuff repair. Arthroscopy. 2017 Jun; 33(6):1138-1148.
2. Chang K, Hung C, Han D, Chen W, Wang T, Chien K. Early versus delayed passive range of motion exercise for arthroscopic rotator cuff repair: A meta-analysis of randomized controlled trials. Am J Sports Med 2014; 43: 1262-1273.
3. Dornan GJ, Katthagen JC, Tahal DS, Petri M, Greenspoon JA, Denard PJ et al. Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplasty for the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders. Arthroscopy. 2017 Apr 30; 33(4):716-25.
4.Le BT, Wu XL, Lam PH, Murrell GA. Factors predicting rotator cuff retears: An analysis of 1000 consecutive rotator cuff repairs. Am J Sports Med 2014; 42: 1134-1142.
5.Wang VM, Wang FC, McNickle AG, et al. Medial versus lateral supraspinatus tendon properties: Implications for double-row rotator cuff repair. Am J Sports Med 2010; 38: 2456-2463.
6. Kim IB, Kim MW. Risk factors for retear after arthroscopic repair of full-thickness rotator cuff tears using the suture bridge technique: Classification system. Arthroscopy. 2016. Nov 30;32(11):2191-200.
7. Heuberer PR, Smolen D, Pauzenberger L, Plachel F, Salem S, Laky B, Kriegleder B, Anderl W. Longitudinal Longterm Magnetic Resonance Imaging and Clinical Follow-up After Single-RowArthroscopic Rotator Cuff Repair: Clinical Superiority of Structural Tendon Integrity. Am J Sports Med. 2017 May;45(6):1283-1288
8. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000 Jan;82(1):35-46
9. Shin SJ, Koh YW, Bui C, Jeong WK, Akeda M, Cho NS, McGarry MH, Lee TQ. What Is the Critical Value of Glenoid Bone Loss at Which Soft Tissue Bankart Repair Does Not Restore Glenohumeral Translation, Restricts Range of Motion, and Leads to Abnormal HumeralHead Position? Am J Sports Med. 2016 Nov;44(11):2784-2791.
10. Troy A. Roberson, Charles M. Granade, Quinn Hunt, James T. Griscom, Kyle J. Adams, Amit M. Momaya, Adam Kwapisz, Michael J. Kissenberth, Stefan J. Tolan, Richard J. Hawkins, John M. Tokish. Nonoperative management versus reverse shoulder arthroplasty for treatment of 3- and 4-part proximal humeral fractures in older adults. Journal of Shoulder and Elbow Surgery, 2017-06-01, Volume 26, Issue 6, Pages 1017-1022,
11. The cost-effectiveness of vancomycin for preventing infections following shoulder arthroplasty: a break even analysis. M. Daniel Hatch, Stephen D. Daniels, Kimberly M. Glerum, Laurence D. Higgins. Journal of Shoulder and Elbow Surgery, 2017-05-01, Volume 26, Issue 5, Pages e144-e145

How to Cite this article: Pandey V, Madi S, Mathai N. Potpourri – Recent and relevant literature in Shoulder Arthroplasty, Arthroscopy and Trauma . Journal of Clinical Orthopaedics Jan – June 2017; 2(1):49-51.

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