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juniperpublishers-orthopedics · 2 years

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Surgical Management of Delayed Presentation of Osteochondral Knee Injuries in Adolescents - Case Series and Literature Review

Abstract

Objective:Osteochondral fractures (OCF) are injuries to the articular surface of a joint containing both cartilaginous and bone components. Various methods have been reported for the treatment of these fractures in the acute setting. There is limited data on delayed fixation. We report two cases of delayed presentation and primary fixation of OCF with bioabsorbable osteochondral dart.

Cases: The first case was of a sixteen-year old boy with a twisting knee injury resulting in a displaced 22 mm OCF on the medial facet of the patella, identified on Magnetic Resonance Imaging (MRI). The second case was of a fifteen-year old boy who presented five months following a soccer injury with persistent left knee swelling and pain. MRI identified a displaced 22.5mm OCF of the lateral femoral condyle. Both patients underwent arthroscopic inspection followed by arthrotomy and fixation of the OCF using osteochondral darts, 5 weeks post injury in the first patient, and 6 months post injury in the second. There were no intra-operative or post-operative complications. Post-operatively, both were initially kept non-weight bearing in extension for 4 weeks, with graded increase in range of motion and weight bearing. Clinically at final follow up at 12 months both had a pain free, full range of motion. MRI in the second patient demonstrated osseous union of the fragment with some superficial fibrillation of the cartilage.

Conclusion: OThese cases demonstrate that late presenting OCFs can be successfully treated by primary internal fixation using bioabsorbable osteochondral darts.

Abbreviations: OCF: Osteochondral fractures; MRI: Magnetic Resonance Imaging; MPFL: Medial Patella Femoral Ligament; BMAC: Bone Marrow Aspirate and Concentrate Cells; MCIC: Mesenchymal Cell Induced Chondrogenesis

Introduction

Intertrochanteric fractures are very common among elderly patients. These fractures are cause of significant morbidity and mortality in conservatively treated patients. Because of that the treatment of choice is surgery. The most commonly used surgical method is internal fixation which is associated with intraoperative blood loos and prolonged anesthesia. The elderly patients are high risk patients for surgery and conservative treatment is a bad alternative as it is associated with a high mortality rate. The aim of this retrospective study was to evaluate the results of the external fixation for the treatment of intertrochanteric hip fractures in a group of high surgical risk elderly patients.

Surgical treatments have been developed, and are based on either fixation, via several methods, or regenerative procedures such as microfracture, osteochondral transplantation (allograft or autograft) or autologous chondrocyte implantation. Procedures such as microfracture, osteochondral transplantation (allograft or autograft) and autologous chondrocyte implantation. The current literature is dominated by case studies and small case series reporting the use of different methods in the acute setting. The impact of time to fixation on results has been identified as an important question that has not been addressed [5]. This is a pertinent question due to challenging nature of diagnosis in these patients by plain radiographs [6], leading to a large proportion of late presentations. We describe the results of two cases of OCF with fixation by bioabsorbable osteochondral darts, following late presentation.

Case 1

A sixteen-year-old boy reported a twisting injury while playing soccer, resulting in an acutely painful and swollen left knee. He had no history of previous trauma to the knee. On examination in the emergency department, there was an acute haemarthrosis and limited range of movement with the knee held in 20 degrees of flexion. There was no medial collateral or lateral collateral ligament instability. Cruciate ligament exam was precluded by pain. Anterior-posterior and lateral knee radiographs showed a skeletally mature knee with a haemarthrosis, but no acute bony injury was identified. He was placed in to an extended cylinder cast. Due to ongoing pain, he underwent magnetic resonance (MR) imaging. This was conducted 5 weeks after injury and revealed a displaced 2.2cm OCF on the medial facet of the patella (Figure 1).

Seven weeks post injury; he underwent arthroscopic assessment followed by limited open arthrotomy and internal fixation of the fractured fragment. After confirming the presence of the fragment, he underwentmini-open arthrotomy. A tear of the Medial Patella Femoral Ligament (MPFL) was identified. The fragment was trimmed, and the base debrided of soft tissue, back to bleeding bone. The fragment was then reduced and fixed with four osteochondral darts (anthrax) (Figure 2), and stability checked in flexion. The MPFL was also repaired.

There were no intra-operative or post-operative complications. He was kept in an extension splint, with nonweight bearing mobilisation for 4 weeks. Under physiotherapist supervision, range of movement was progressively increased from 0 to 90 degrees, maintaining non-weight bearing for 6 weeks. He was then allowed flexion up to 90 degrees, with partialThere were no intra-operative or post-operative complications. He was kept in an extension splint, with nonweight bearing mobilisation for 4 weeks. Under physiotherapist supervision, range of movement was progressively increased from 0 to 90 degrees, maintaining non-weight bearing for 6 weeks. He was then allowed flexion up to 90 degrees, with partial

Case 2

This fifteen-year-old boy presented to fracture clinic with a five-month history of left knee pain and swelling following an injury while playing soccer. Examination revealed a joint effusion and a range of movement from 10 to 135 degrees. There was moderate lateral joint line tenderness, and no ligamentous instability. Antero-Posterior and lateral knee radiographs demonstrated a skeletally immature knee, with a lucency in the lateral femoral condyle suggestive of an OCF. Subsequent MR scan showed a 22.5 mm by 17 mm full thickness OCF on the lateral femoral condyle (Figure 4), with subchondral cysts present anteromedially. On further review his range of movement had deteriorated 30 to 135 degrees. He underwent open reduction and internal fixation six months following onset of symptoms.

He underwent initial arthroscopy, which confirmed the presence of the fragment, and proceeded to open arthrotomy and internal fixation. Via a lateral parapatellar incision, the fragment was identified, and trimmed. The base of the fracture was debrided back to bleeding bone. Five osteochondral darts (anthrax) were used to fix the fragment following reduction (Figure 5). Stability was checked prior to closure. There were no intra-operative or post-operative complications. Postoperatively he was kept non-weight bearing in an extension splint for 6 weeks. Following this, flexion was increased to 0-30,

maintaining non-weight bearing. He was then allowed to flex from 0-90 and progress to partial weight bearing, for 6 weeks. After this, he was allowed free flexion and full weight bearing mobilisation under physiotherapist supervision, avoiding contact sport, while encouraging swimming and cycling. MRI scan of the knee performed 10 months post operatively demonstrated osseous union of the fragment (Figure 6). There was also some superficial fibrillation of the chondral component, but at no point was this full thickness. Clinically at final follow up at 12 months, he had a pain free, full range of movement. He was discharged back to previous levels of activity and sport.

Discussion

These cases demonstrate that late presenting OCFs can be successfully treated by primary internal fixation techniques. Diagnosis of OCF at the time of presentation requires a high level of clinical suspicion. Plain antero-posterior radiograph should be carefully inspected in the presence of a twisting knee injury or patella dislocation and haemarthrosis in an adolescent. Any suspected abnormalities should prompt urgent knee specialist referral and MR imaging, to allow early identification and appropriate management. The use of bioabsorbable dart fixation has previously been reported in the acute setting [7, 8], with good results. Historically, it was felt that late presenting fractures could not be accurately repaired, and therefore should be excised [1]. However, the cartilage defect predisposes to the development of early osteoarthritis [9], and therefore this does not provide an ideal long-term option. We therefore felt that anatomic reduction and fixation of these lesions provided the best chance of a good long-term functional outcome in these active young adolescent patients

We elected to confirm the presence, size and placement of the fracture via arthroscopic inspection prior to open arthrotomy. This ensures that the fragment is present as described on MRI, and further guides the extent and position of the arthrotomy incision. We feel that arthrotomy is particularly necessary in late presenting cases to ensure that a thorough debridement of both fragment and fracture site can be conducted. This allowed accurate and stable reduction and fixation of the fragment using bioabsorbable screws. These preclude the risk of metalwork displacement and damage to articular surfaces, and the potential need for a second procedure to remove them. A cautious approach to weight bearing and mobilisation is essential in these patients to protect the fixation of the fragment, preventing displacement, as both boney and chondral healing occur. Although this can result in short term knee stiffness, graded increase in range of motion provides a reliable return to full movement in these young patients. There are a number of different surgical options for these patients that can broadly be divided in to fixation methods or regenerative therapies. Fixation methods include the use of bioabsorbable screws, as in this study, and conventional headless screws [10]. Regenerative procedures are designed to stimulate healing and repair of cartilage. These include microfracture, osteochondral transplantation and autologous chrondrocyte implantation.

Microfracture aims to stimulate new cartilage growth and repair. An awl is used to make multiple holes in the subchondral bone beneath the defect. Bleeding creates a healing response, with the goal of producing new healthy cartilage. Microfracture provides good early results; however, there is evidence to suggest that clinical outcomes following microfracture deteriorate after eighteen to twenty four months [11]. Osteochondral autograft transplantation (OAT) involves taking a plug of cartilage and subchondral bone from a non-weight bearing part of the knee and then implanting it in to the defect. This can either utilise a single transplant, or multiple small plugs in a ‘mosaicplasty’. OAT and microfracture have recently been compared in a metaanalysis [12]. This appeared to show better clinical results with a higher rate of return to sport and maintenance of their sports function from before surgery compared to microfracture. The authors suggested that OAT is appropriate for lesions smaller that 2cm2.

There is also evidence to suggest that clinical outcomes following microfracture deteriorate after eighteen to twenty four months [11].Osteochondral allograft transplantation is a similar procedure to autograft transplantation, however cadaveric bone is used. This technique is burdened by cost, and difficulty finding appropriate donors. However, good clinical and functional outcomes have been demonstrated in systematic review [13], and this is an appropriate technique in large defects. Autologous chondrocyte implantation is a two-stage procedure. Healthy cartilage tissue is removed via an arthroscopy and cultured for 3 to 5 weeks. An arthrotomy is then performed to allow preparation of the defect site and a covering patch of periosteum to be placed over the defect. The chondrocytes are then injected in to the defect underneath the periosteal sleeve. This is postulated to form ‘hyaline like’ cartilage that is histologically closer to healthy articular cartilage than microfracture techniques. This has been shown to have a successful outcome in 72% of cases at a mean of 10.2 years in a recent meta-analysis [14]. However it does appear that failure rate increases as the size of the lesion increases. The recently developed technique of autologous bonemarrow Mesenchymal Cell Induced Chondrogenesis (MCIC) using bone marrow aspirate and concentrate cells (BMAC) for treating chondral defects [15,16] shows promising early results, but requires long term studies to evaluate its efficacy.

Conclusion

Early diagnosis and management of these fractures is ideal. However, good results can be achieved using primary fixation with bioabsorbable screws in late presenting cases especially in young skeletally immature patients who have the best chance of cartilage healing.

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#Clinical Rheumatology #Orthopedic trauma #Hand surgery #Osteoarthritis

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juniperpublishers-orthopedics · 2 years

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Treatment of Intertrochanteric Hip Fractures in Elderly High Risk Patients with External Fixation

Abstract

In 6 elderly patients intertrochanteric fractures were treated, using FERN external fixation system. All fractures healed within 4 months. Three patients had a superficial pin tract infection and one deep infection. Shortening of 1cm or more was seen in 2 patients. Varus angulation of 5Âº or more was seen in 2 patients but this seems to be well tolerated by the elderly. External fixation represents an excellent alternative for the surgical treatment of high-risk, elderly patients.

Introduction

Patients and Methods.

Between 2012 and 2015, 6 elderly high-risk patients classified according to the American Society of Anesthesiologists (ASA) scale (Table 1) sustaining intertrochanteric fractures were treated using the FERN external fixation frame [1]. The fractures were classified according to the modified Evans classification [2] (3 of the fractures were unstable and 5 were stable). Four of these 6 patients were ASA grade III, and 2 were grade IV.

Operative technique

The operations were performed under local anaesthesia with sedation in 2 patients, in rest of the patients short spinal or epidural anaesthesia was used. After placing the patient on the fracture table a closed reduction of the fracture was performed under image intensification. Fracture was fixed with two 5 mm

diameter and 20-25 cm long thread pin with sharp tip passed from lateral aspect greater trochanter along the neck engaging the subchondral bone of head. Two or three more thread pins were passed in the proximal femur. All the pins were connected with an external rod (Figure 1). Stability of fracture fixation was checked under image intensifier using varus- vulgus stress. The patients were given prophylactic antibiotics, lowmolecular heparin, and analgesics. The patients were made to sit up immediately postoperatively and limited non-weight bearing ambulation for up to 6 weeks after which gradual increase from toe-touch to full weight bearing was instituted. Patient’s family was also educated for the physiotherapy (hip, knee and chest) and pin tract care. External fixator was removed without anaesthesia in outpatient clinic after radiological evidence of fracture union.

Results

No patient needed blood transfusion intra operatively or post operatively. The average follow up was 5.2 months ranging from 3 months to 18 months. The average operative time was 38 ± 2 minutes. The average duration of hospitalization was 5 days (range: 3 to 8). All fractures have radiological union at 4 months (Figure 2). One patient had died 9 months post-operatively due to causes unrelated to external fixator application. Pin tract infection was the most common complication, 3 patients were affected by superficial pin tract infection which resolved with cleaning and dressing with chlorhexidine, without administration of antibiotics. Shortening of 1cm or more was seen in 2 patients. Varus angulation of 5º or more was seen in 2 patients (Figure 3).

They followed their patients for an average of 26 months (12 -51 months). There were 2 non-unions; one patient was treated with cast and the other with a plate. There were 13 patients with open fractures. It is not clear how patients were allocated. However, the methods laid the foundation for the management of segmental tibial fractures. The implants have improved over the years but the principles of treatment have not changed dramatically over these years. In 1969, Zucman and Maurer [6] introduced the technique of unreamed tibial nailing in the management of both closed and open segmental fractures. There was no grading of open fractures as we know it today. They found that 19/36 (79%) of open fractures achieved union without complications. There were two cases of non-union of closed fractures. Deep sepsis developed in four cases (12%); two of these united without any surgical intervention. Tibial nailing was to be the major technique in the management of these fractures as will be evident in subsequent cases.

Functional outcome of segmental tibial fractures was not documented in the majority of previous reports. Oivind & Olav [7] reviewed 54 patients with the aim of documenting functional outcome. They found that 53.7% of their patients had full recovery and the rest had some form of functional impairment. Their assessment was to have great impact to subsequent authors: it was clear that closed segmental fractures should be viewed differently from open ones. It was Melis et al. [8] who, in their reviews of 38 patients separated the treatment of open and closed segmental tibial fractures. They used reamed K-nail- Hertzog nail. Open fractures were treated with antibiotics for 20 days plus continuous irrigation and suctioning for at least 10 days. Soft tissue coverage was done after 10 days. They clearly documented all complications which occurred that included skin breakdown, melanin and sepsis.

They noted that skin breakdown did occur in closed fractures as well. Woll & Duwelius [4] used Ender nails in both closed and open fractures. All fractures united. The few complications they encountered included superficial sepsis, DIC, shortening and melanin. Complications associated with this kind fracture were mal-union and shortening. But in our patient it was not the case. At follow up patient recovered well with no residual co morbidity. Giannoudis et al. [1] findings send a very important message that “66.6% of segmental tibial fractures require more than one surgical intervention”. It is therefore extremely vital to plan ahead so that should subsequent surgical interventions become necessary, the surgeon is well prepared for it. This planning ahead implies re-aligning the medullary cavity from the start.

Discussion

Hip fracture is a leading cause of death and disability among the elderly [3]. Delay in operation is associated with an increased risk of morbidity and mortality [4]. The mortality rate associated with these fractures is 10-30% in first year after trauma [5]. An increased mortality rate after fracture of the hip is associated among other factors with advanced age, untreated or poorly controlled systemic disease, and control of medical co morbidities [6]. Although internal fixation is the gold standard for fixation of these fractures, it may not always be possible to undertake this procedure elderly high risk patients In such circumstances, external fixation is a good alternative for fracture stabilization allowing for a quick, cheap and effective stabilization that can be undertaken even under local anesthesia [7].

External fixation was introduced for the management of trochanteric fractures at about the same time as the first sliding internal fixation devices [8,9] but its use has decreased considerably in recent years. Studies comparing external fixation to sliding hip screws have reported superior outcomes in favor of external fixation [10-12]. Complications related to external fixator include pin tract infection which can easily be controlled with meticulous local care. In our study superficial pin tract infection was the most common complication (3 patients) which resolved with cleaning and dressing with chlorhexidine, without administration of antibiotics. Varus angulation of 5º or more was seen in 2 patients. Collapse of the fracture into varus is commonly found in in grossly unstable fractures but this seems to be well tolerated by the elderly, possibly because of their low demands in activities of daily living or due to associated co-morbidities restricting excessive ambulation [13].

Conclusion

External fixation provided an excellent alternative for the treatment in elderly high risk patients with intertrochanteric hip fractures for open surgery which offers a low-risk operation with minimal blood loss, fast mobilization, few postoperative complications, and reduced cost because of the short hospitalization.

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#Hip replacement #Orthopedic trauma #Orthopedic oncology #osteoporosis

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juniperpublishers-orthopedics · 2 years

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Segmental Fracture of Both Bones with Ipsilateral Condyle of Tibia Fracture - A Case Report

Abstract

Segmental fracture both bone associated with lateral condyle fracture on the same side is very rare. Segmental tibia fracture is defined by the presence of two distinct fracture lines separating the cortical and completely isolating an intermediary segment of the tibia. Segmental tibia fractures are uncommon injuries that occur in about 12.8% of tibial fractures. Most are caused by high-energy trauma. It is estimated that almost more than half of these fractures are open fractures. They are often part of multiple injuries. It often is a challenge to manage such cases as they have a significant complication rate.

As such there are very few article on the management of segmental tibia fractures. There has been a significant change in the management of these injuries. This has been made possible by the development of new orthopedic implants. Few of them are intramedullary locking nail, external Fixators and Plaster of Paris. It is important to note that more than two-thirds of segmental tibia fractures will require more than one surgical intervention. The surgeon therefore, needs to plan ahead to make subsequent surgical interventions possible.

Introduction

A segmental fracture is defined as a fracture with two or more fracture lines with one or more cylindrical intercalary segment(s). The majority of segmental tibia fractures have one intercalary segment. These fractures are rarely encountered, accounting for only up about 12.8% of tibial fractures [1]. They are caused by high-energy injuries; motor vehicle and motorcycle crashes, falls from a height industrial and train accidents. Some are caused by low - energy injuries such as sports and twisting the leg. The incidence of open segmental fractures varies considerably from study to study; it ranges from 37.5% to 83.8% [2,3]. Segmental tibial fractures are often part of multiple injuries. Segmental fracture of both bones is quite a rarity. Along with that we have lateral tibial condyle fracture. Hence it was one of the challenging case for the treating Orthopaedic Surgeon.

Case Report

A 38 year old male presented to the casualty with history of RTA. He came to our institute with complaints of swelling of the right lower limb. There were no external wounds, but there were extensive grazed abrasions on the anterior aspect of right leg. His vitals were normal. No head injury or any other solid organ injury. Plain X-ray showed a Segmental fracture of both bone along with lateral condyle fracture of tibia (Figure 1). He was assessed for other co morbid conditions [4]. He was fit for the surgical procedure. He was taken up for surgery. Treated by closed reduction and internal fixation by using interlocking tibial nail. Fibula was fixed with a rush pin. Lateral condyle fracture of tibia was fixed with cannulated cancellous screw along with a washer. Post operative recovery was uneventful. Immediate post op x-ray showed a satisfactory reduction of fracture (Figure 2). Later he was put on non weight bearing of right leg for 6 weeks. Later x-ray was taken at 1 year post operative (Figure3).

Discussion

Boylston et al. [5] forty years ago reviewed 28 patients and outlined treatment options for segmental tibial fractures. The options werefew technique and implants like:

Cast immobilization

Plating

Rods

Single screw

Rod and plate

Fibular rod

Conclusion

As per the literature no cases has been reported with segmental fracture of both bones with lateral condyle fracture. And currently there is no comprehensive classification of this type of fracture. An ideal classification needs to take into account the extend of soft tissue damage and offer a guideline in the management. We need a large series of cases to be able to assess the functional outcome of segmental both bone fracture. We must use a validated outcome measure or scale. There is a need to do multi-centre collaboration because these fractures are rare. Future clinical studies need to address all outstanding issues discussed above. There are no clear therapeutically relevant guidelines regarding classification of segmental both bonefractures, treatment approaches and evaluation of functional outcome using validated scales. These are the crucial issues or challenges facing future clinical research studies.

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#Clinical Rheumatology #Orthopedic trauma #Bone & Osteoarthritis #orthopedic disorders

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juniperpublishers-orthopedics · 2 years

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How Long Do I Need To Suffer Pain and Invalidity?

Editorial

Osteoarthritis in hips, knees and other major large joints is a progressive and chronic debilitating disease characterized by pain and limitation of movements. Worldwide this disease is on the increase due to people living longer and more active lives.

When first symptoms appear, doctors will offer palliative treatments to kill pain, which will help for awhile, and in many cases patients develop health complications due to taking anti-inflammatory or pain killers.

In many countries of the third world and even in the developed world, patients have to suffer pain and limitations for months or years, waiting while their joints are destroyed and in need of the old, dreaded, expensive and not free from severe complications joint prosthesis surgery. By the time patients are operated, their muscles have weakened and lost strength needing prolonged rehabilitation for their limbs to function properly.

Mr. Mc Kee FRCS, and his Assistance Mr. Farrar in Norfolk - England initiated total hip prosthesis replacement as a new era for treating hip osteoarthritis in the 60s., this was improved after Mr. John Charnley introduced plastics and acrylic cement. Total Hip Prosthesis (THP) has helped millions of people worldwide and today there are on the market dozens of different types of hip prosthesis joints.

At the XIX World congress of Surgery of the International College of Surgeons (ICS), in March 1974, the most renowned surgeons of the day; like Mr. Mc-Kee, Mr. Ring, Mr. Wilson from England, together with the very few surgeons performing this surgery in Europe, Latin America and Australia communicated their experiences in this field. The problem of infection, metal rejection, loosening of prosthesis and metallic particles appearing around operated areas were already causing concern, especially in my case, as I was performing this surgery in private hospitals since 1972. After this congress the FDA in the USA allowed the use of acrylic cement in humans, since then very little has changed. We have almost the same complications as 50 years ago as the method of introducing a stiff metallic element (prosthesis) into a constant remodelling bone structure is the same.

Total Hip prosthesis so far has been the treatment for destroyed hip joints, ignoring other solutions for treating the initial lesions in the articular cartilage, that trigger osteoarthrosis that needs replacement by a metallic prosthesis. This kind of surgery is very expensive, not free from complications and by increasing Revision surgery, which is the proof of device failure or surgical procedure, thus creating a huge business and increasing expenditure for patients and society.

We should follow the dental method of treating caries avoiding the destruction and removal of the tooth by resurfacing the decay. By resurfacing lesions in the articular cartilage as soon as diagnosed, it is possible to avoid the rough surface contacting healthy cartilage, which triggers changes in the joint, facilitating its destruction.

New advances in X ray visual devices. Arthroscopy, bio-materials, stem cells therapies, etc, innovative methods to approach joints avoiding puncturing the capsule etc , can make it possible in the near future to resurface initial lesions to save joints and save funds to National Health Authorities and patients. See: biototalhip.com.

We need to mobilize the medical world, research centers, orthopedic manufactures, Governments and Health Authorities to find new methods using new biotechnology to resurface with biomaterials lesions in joints to avoid the appearance of osteoarthritis.

With the economical crisis that societies are facing and worldwide increase of osteoarthritis, it is extremely important to save funds for other diseases. $83 billion will be expend in the next 10 years in the USA in joint prosthesis surgery. This amount of money will increase due to increase of Revision surgery in operated younger patients. Worldwide is the same situation.

The amount of energy consumed to manufacture prosthesis due to materials and metals used, make this production unfriendly to the environment and pollute the soil when patients are buried with them.

We need to open a line of discussion among experts to direct all our resources to find a more modern and biological way of treating osteoarthritis at its different levels of disease.

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#Hand surgery #Osteoporosis #Orthopedic oncology #pediatric orthopedics

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juniperpublishers-orthopedics · 2 years

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Adjacent Segment Disease after Anterior Cervical Inter body Fusion using Conventional Plate versus Zero-Profile Implant - A Preliminary Report

Abstract

Background: Anterior cervical discectomy and interbody fusion is a common surgical method used for treatment of single or 2 level cervical lesion. Recently, zero-profile implant, which lessened irritation of adjacent structures by preventing the contact with them, was design for anterior cervical fusion, and was assumed that it would reduce the occurrence of adjacent segment disease. Thus, authors compared the occurrence of adjacent segment disease after using conventional plate or zero-profile for anterior cervical interbody fusion.

Methods: 48 consecutive cases that underwent single-level anterior cervical discectomy and fusion for lesions of cervical spine that did not respond to nonsurgical treatment and were able to follow up for at least 1 year were included in this study. Clinical and radiologic features of 25 cases (group A) that used conventional plate from April 2007 to January 2011 and 23 cases (group B) that used zero-profile plate from March 2011 to February 2014 were retrospectively compared.

Results: Adjacent segment degeneration was present in 10 cases in group A and 6 cases in group B. The occurrence of the degeneration was statistically insignificant. In aspect of grade of ossification, group A consisted of 6 cases of grade 1, 2 cases of grade 2, and 1 case of grade 3 while group B consisted of 5 cases of grade 1, 1 case of grade 2, and no case of grade 3.

Conclusion: It is considered rather than the insult to adjacent structures by implants, natural degeneration or increased loading to the adjacent segment after interbody fusion are more important factors for occurrence of adjacent segment degeneration.

Keywords: Adjacent segment disease; Anterior cervical inter body fusion; Zero-profile implant

Introduction

Anterior cervical discectomy and fusion is a widely used technique for cervical spine disease and trauma such as herniation of intervertebral disc, cervical spondylotic radiculopathy, cervical fracture, and etc [1]. The technique requires relatively short operation time, has less blood loss and complication, shows immediate symptom relief, and high union rate of over 90% compared to lumbar spine [2]. Though the technique has become popular due to such merits, there are a few possible complications at risk, for example, dysphagia and adjacent segment disease. Adjacent segment disease refers to a radiologic degeneration on the segment adjacent to previous arthrodesis with accompanied symptom due to such degeneration and adjacent segment degeneration refers to only radiologic degeneration. However, the correlation between the degree of degeneration and occurrence of symptom due to degeneration is not well established [3,4]. According to Hilibrand et al, the annual occurrence of adjacent segment disease after anterior cervical discectomy and interbody fusion is about 2.5% [3]. In the other hand, some clinical and mechanical studies reveal that there are no increased motion or pressure of adjacent level after interbody fusion [5,6].

Another study showed that cases with postoperative kyphotic angulation are more likely to have adjacent segment disease [7,8]. As indicative above, numerous studies reported that various factors influence the occurrence of adjacent segment disease and results whether it is brought about due to trauma by surgery or natural history is inconsistent. Based on studies that concluded that adjacent segment degeneration was more frequently occurred and accelerated by insult of tissue due to surgery [9-11], authors investigated the occurrence of adjacent segment disease after anterior cervical discectomy and fusion using zero-profile plate and conventional plate hypothesizing that group using zero-profile plate will show lower occurrence.

Materials and Methods

The study was conducted after the approval of the institutional review board (IRB file no. 2015-08-015). All patients signed consent that they will be enrolled in clinical study. Medical records and radiologic evaluation of 48 consecutive cases that underwent a single level anterior cervical discectomy and fusion due to degenerative change from April 2007 to February 2014 were retrospectively analyzed. All cases had been followed up for at least 12 months clinically and radiologically. Surgery was performed for cases refractory to adequate nonsurgical treatment of at least 6 weeks with a diagnosis of single level cervical radiculopathy or myeloradiculopathy with subtle myelopathy symptoms such as mild numbness on the hand. Patients’ symptoms were well correlated with the conventional radiograph and magnetic resonance images with evident stenosis (Figure 1). The senior author (JS Ahn) performed every surgery and Smith-Robinson technique was used for surgical approach for all patients.

Before the introduction of zero-profile plate on February 2011, a conventional plate (Vectra-T plate, Synthes, Switzerland) was used and ever since, zero-profile plate (Zero-P plate, Synthes, Switzerland) was used for degeneration cases (Figure 2). For postoperative care, soft cervical collar (Philadelphia brace) was applied for 1 day and then all neck motion was allowed without brace. Conventional radiograph was performed on the final follow up for each case (Figure 3). To eliminate the difference of loading due to difference numbers of fused segment, multi segment fusion cases were excluded from the study. In addition, since compromised soft tissues such as anterior longitudinal ligament and bony structures could accelerate degeneration of the adjacent segment, trauma or tumor cases were also excluded [11,12]. Also, cases without radiological follow up at least 12 months after surgery were not included.

Clinical factors such as sex, age, alcohol, smoking, and index level of every patient were checked. The preoperative and postoperative curvature of the index level was measured using simple radiograph. Diagnosis of adjacent segment degeneration and classification of ossification was made according to Katsuura et al. and Nassr et al. [8,9]. Patient was diagnosed as adjacent segment degeneration if at least 1 of the following findings was present:

Evident intervertebral disc space narrowing

Newly developed instability on flexion-extension radiographs

Vertebral anterior or posterior spur formation. Cases were also were classified by the degree of ossification as following:

Grade 0: no ossification

Grade 1: extending across less than 50% of adjacent disc space

Grade 2: extending across more than 50% of adjacent disc space

Grade 3: complete bridging of adjacent disc space [13].

For evaluate the clinical judgment after surgery, Odom’s criteria along with symptom and sign of each patient were investigated. Odom’s criteria are as follows:

Excellent: all preoperative symptoms relieved; abnormal findings improved

Good: minimal persistence of preoperative symptoms; abnormal findings unchanged or improved

Fair: definite relief of some preoperative symptoms; other symptoms unchanged or slightly improved

Poor: symptoms and signs unchanged or exacerbated.

1 for Excellent,

2 for Good,

3 for Fair, and

4 for Poor

As a result, group A showed 1.96±0.73 points while group B showed 1.65±0.88 points which showed no significant difference between 2 groups (p=0.092). Authors emphasized to keep

For the comparison of diverse clinical factors between two groups, the Mann-Whitney U and chi-squared tests were used. Various pre and postoperative findings were analyzed using the Mann-Whitney U-test, Chi-square test, and Fisher’s exact test. All statistical analysis was performed using the SPSS analytical software version 18.0 (SPSS Inc., Chicago, Ill., USA). In all analyses differences were considered significant at a level of p < 0.05.

Results

Total of 48 cases were included in the study. 25 cases used conventional plate with cage insertion (group A) and 23 cases used zero-profile plate (group B) for cervical interbody fusion. The demographic data of both groups are descripted on (Table 1). All factors mentioned above showed no statistically significant difference between the 2 groups. Cases’ clinical improvements were graded according to Odom’s criteria:

lordosis of the index level, and as a result, postoperatively, sagittal angle was maintained as a lordotic curve (group A: 5.19±6.00, group B: 5.38±4.96) (+; lordosis, -; kyphosis). Adjacent segment degeneration was present in 10 cases in group A and 6 cases in group B. Specifically, spur formation, disc space narrowing, and instability was found in 9 cases, 2 cases, and 1 case in group A and 6 cases, 0 case, and 2 cases in group B.

The occurrence of the degeneration was statistically insignificant. (p=0.307) In aspect of grade of ossification, group A consisted of 6 cases of grade 1, 2 cases of grade 2, and 1 case of grade 3 while group B consisted of 5 cases of grade 1, 1 case of grade 2, and no case of grade 3. There were 1 cases of each group that had new radiculopathic symptom (tingling sensation) apart from preoperative symptoms, however, both cases were able to be managed non-surgically (Tables 2 & 3). Each clinical and radiological factor (age, sex, smoking, alcohol drinking, index level, and preoperative and postoperative sagittal angle of the index level) were statistically analyzed for influence to the adjacent segment degeneration. As a result, cases that have smoked and regular alcohol drinker showed a statistically significantly higher occurrence rate of adjacent segment degeneration.

Discussion

Anterior cervical discectomy and fusion is a common procedure for single or two level cervical spondylotic changes or disc disease. Rarely, however, complications of the technique such as postoperative dysphagia, hematoma, recurrent laryngeal nerve, and adjacent segment disease could occur. Specifically, 58.4% of the patients that underwent anterior cervical discectomy and fusion suffered from symptoms related to swallowing difficulty immediately after surgery [2] and among them, 6.6% had the symptom continued until 2 years follow up, [14,15] and adjacent segment disease is reported that the annual occurrence is about 3% [6]. It is assumed that anterior cervical plating bring about dysphagia and adjacent segment disease [16].

However, even with such evidence, most of the anterior cervical discectomy cases are augmented with plating rather than using cage alone since plate augmentation shows higher union rate and preservation of intervertebral disc height [6,17,18]. Thus, to minimize complications while maintain firm fixation with plate, recently a zero-profile plate has been developed and promising results, especially in aspect of dysphagia, are being reported [19-22]. Though the causes of adjacent segment disease is multivariate, however, the issue is that whether it is a result of natural course of degeneration or due to insult after interbody fusion of the cervical spine. Some reports are conflicting with the theory of accelerated adjacent segment degeneration after fusion surgery.

Biomechanical studies by Reitman et al. [5] reported no increased motion of cephalad segment after anterior cervical interbody fusion, and Fuller et al. [23] found that sagittal rotation of the immediately adjacent segment of arthrodesis was not statistically significantly increased. However, there are other studies show contrary results with accelerated degeneration and motion of the adjacent segment after fusion, for example, Eck et al. [24] reported significantly higher intervertebral pressure and motion of the segments adjacent to arthrodesis. Since Park et al. [10] reported that adjacent segment degeneration is prone to occur when the distance of plate end and adjacent disc is less than 5mm and Mahrling [25] reported accelerated degenerative change after wider resection of anterior longitudinal ligament, zero-profile plate was considered to minimize such problems which in order will decrease the occurrence of adjacent segment disease.

However, against to our expectation, according to the result of our study, the difference of occurrence rate between cases using conventional plate and zero-profile plate was statistically insignificant. In view of such result, it is considered that rather than insult to the adjacent segment caused by plating, increased loading to the adjacent segment due to interbody fusion is the major factor for degeneration. In addition, since there are some reports of accelerated degeneration after postoperative kyphotic sagittal alignment [8,26], postoperative sagittal balance should be carefully considered.

There are some limitations of this study, which are small numbers of cases and the results are obtained after a shortterm follow up. Since there is chance of development of adjacent segment problems in longer follow up, which is necessary to make a final conclusion of our study? In addition, as Cherubino et al. [27] described, the degree of degeneration and clinical symptom showed no correlation thus, factors influencing clinical symptoms of adjacent segment was not established. Further evaluation to investigate the factors that cause symptoms due to adjacent segment degeneration is necessary. However, the strength of our study is that, to the best of our knowledge, this is the first study comparing the zero-profile plate with conventional plate in aspect of adjacent segment disease.

Contrary to our expectation, surgery using both implants showed similar results in aspect of adjacent segment degeneration. It is considered rather than the insult to adjacent structures by implants, other factors such as natural degeneration or increased loading to the adjacent segment after interbody fusion might be more important factors for occurrence of adjacent segment degeneration. In short-term after surgery, adjacent segment disease is not a frequently complication, however, longer term follow up is necessary since degeneration of adjacent segment is accelerated.

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juniperpublishers-orthopedics · 2 years

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Assessment of Knowledge about the BARC Centre and Satisfaction with the Educational Services Available

Abstract

The aim if this proposal is to determine knowledge in the general population about arthritis and immunology disorders ; to ascertain if this has improved in the decade since our Needs Assessment; and the satisfaction with the educational material now available to support communities and arthritis sufferers.

Background

BARC (Birmingham Arthritis Resource Centre) was set up to provide education and support to people with arthritis and their carers, based on a formal Needs Assessment. BARC aims to promote self-coping to help people to deal with the physical and social disabilities caused by their disease. It is cited in the city centre public library and works alongside the regular medical NHS service provision. Services for Rheumatology have always had lower priority and funding than those for acute services such as Cancer and Heart disease. In addition they have historically been somewhat restricted in the West Midlands (the UK region where Birmingham is the central city) compared to the rest of the UK. The picture is also complicated by the high percentage of ethnic minority groups locally (generally referred to as BME groups- Black and Minority Ethnic). Birmingham is set to become the first major UK city where BME groups will become the majority within the next ten years. There is evidence that “excluded groups” - such as immigrants, the poor and the less-well educated have poorer health but do not access the NHS in the same way as the white middle-class population for a variety of reasons, including cultural, language and poverty barriers. This is clearly relevant to the wider European scene where there is increasing pressure from immigration while currently both health and social programs are threatened by the financial recession.

The BARC project was started a decade ago with a formal research process to determine the extent of current services and what people wanted. This “Needs Assessment” showed that both medical profession and public perceived a need for more information provided in an informal setting (ie a non-medical setting) - and wanted it in a range of languages Adab et al. [1]. There was also a widespread desire for more support services for patients. The BARC centre was set up on the basis of this in space provided by the City in the Central Library and is manned by volunteers. These have been selected and trained by the Centre manager, Chan Gordhan, who has a long background in social and voluntary work. The volunteers come from a range of ethnic backgrounds and importantly they have all had some personal rheumatic problem. Thus they fit what the UK government is now calling “expert patients” - and promoting the idea that they are best placed to help others since they have learnt how to cope. Interestingly our experience shows that volunteering to help others also empowers them to deal with their own lives, so they should also be the best placed group to teach us how to empower our clients. Our data also shows that the BARC service is wanted as well as needed locally.

The key point in developing any new service is to provide an evidence base for it. BARC set out to do this from the outset. Following the initial “Needs Assessment” We carried out a focus group study to determine what patients from BME groups were looking for from the local health services Bacon et al. [2]. A key factor expressed by the participants was the desire to be listened too. They were dissatisfied with their doctors who were seen to lack time to take in the patients broader complaints. This echoes wider concerns about poor doctor patient communications an area which the Royal College of Physicians is holding an enquiry into at present.

BARC has set up sympathetic listening as one of the basic parts of the service Gordhan [3,4]. This is provided by trained volunteers. They are themselves patients and come from a range of ethnic and linguistic backgrounds, so that they are able to provide culturally sensitive guidance to clients. We have collected data on who has attended and how satisfied they are with the service provided Treharne [5]. Approximately 40% of attendees come from the BME groups, similar to the general population. Thus we are getting through to target populations - but not in large enough numbers. We have also had high gradings for client satisfaction.

We have also addressed the need for relevant patienteducation material understandable to those for whom English is not their mother tongue. We recently completed a set of educational leaflets, designed as “bottom-up” material that is based on questions people actually ask rather than information doctors think patients ought to know. They are in simple English, avoiding technical terms, so as to be easily understood. The first six have been translated into Urdu and recorded on CD’s in both languages, as well as in print format with a few cartoons to illustrate them. A preliminary piece of market research in the BARC Centre shows that the volunteers think they are what is needed and a small sample of clients listening to the first one agreed. The Urdu translation has also been approved by a range of Indian colleagues as being both true to the English information and understandable by a range of local language speakers. The translation is not strict Urdu but includes phrases used in Bollywood films (watched by all the local S. Asian groups) as well as some English words generally used in the version of “Urdu” widely used around Birmingham.

A questionnaire-based assessment of the first of these CD’s – on Understanding Arthritis – showed that clients gave it high scores for clarity of information and obtaining information that they wanted. In general they found the CD helped them to cope Sharif [6]. We are just completing an assessment of the CD on rheumatoid arthritis and the outcome is very exciting. The challenge was far greater here as the usefulness of the CD was examined in a specialist RA clinic which already had a highly trained specialist nurse providing explanations and support to patients. Despite this the comments made at the focus groups demonstrated that the study participants had found the additional BARC service a major help Kumar et al. [7]. There is now patient pressure to set up such a service on a regular basis in the hospital setting. This would be in line with the recent Report from the influential Kings Fund which noted a lack of understanding on the quality of RA care and the struggle many RA patients have to access quality care Kings Fund [8].

In the same way, we have struggled to reach our target for new attendees at the BARC centre, despite the evidence for the need for and the success of the BARC service. Total numbers accessing the BARC service, including phone calls and web-site hits, have increased year-on year but surprisingly there has been no increase in personal visitors. A number of community centres have asked for the manager to go out to specific groups with promotional and educational talks. This alternative approach has proved very popular but many attendees have said they were not aware of the BARC centre. These outreach sessions are demanding on Chan Gordhan’s time and there is an excellent service available at the library. Thus the next essential step is a study of why people are not coming in the predicted numbers.

Hypothesis

We propose that the population in general tend to downplay the importance of their musculo-skeletal problems. This is reinforced by the poor publicity that arthritic diseases get compared to some others. Analysis of the relative importance given by press or TV showed that heart disease and cancer got far more attention and were treated as serious scientific problems. Rheumatic diseases by contrast were seen as “lifestyle problems” for which there was no real medical treatment. The existence of a ground-breaking local service does not appear to have changed that mould to any major extent. Each time that the BARC Centre has been discussed on local radio there has been a sharp rise in client enquiries – but only for a short period. We intend to analyse the degree of local awareness of the BARC and at the same time look further into the responses of those who do actually come to seek help.

Methods

The first aspect will be carried out by collecting data about knowledge of BARC and satisfaction with current educational support using standardised questionnaires. This will target both a random population (people accessing the Central Library for any purpose) and specific communities such as local Sikh and Somali populations who have already identified a perceived need for an increased service for their groups. A minimum of 200 library people will be sampled at random in each grouping. The second part (analysis of satisfaction with current services) will be completed by analysis of the data collected over the past two years from attendees at the Centre, who are all asked to complete such a form. The data from this project will be compared to that obtained 10 years ago in the original Needs Assessment

Broader aspects of Fellowship

The advantages of taking on this project would be to widen your experience into qualitative research and introduce you to a new but important area of rheumatology, patient education. The latter has many messages for someone practicing in a major city with an immigrant population and you have already reported working with several ethnic minority groups in Kosova. We have been thinking about this project for some time, so there are some things already in place to facilitate your research. We have already trailed a simple questionnaire for these assessments. A sociology student is currently using these to collect some preliminary data from library visitors. That experience will focus the further development of the project. A trained health psychologist is available to help with analysing the questionnaires and the unstructured material coming from the “free comment” section at the end of each form. In the same way, the set of forms collected from clients attending the Centre in its early years have been analysed and will form a useful comparison with the planned analysis of the comments collected from recent clients.

This exercise will definitely lead to at least one published paper. The methodologies used will be of value to you in assessing the worth of conventional treatment options across the field of rheumatology. Our speciality deals with incurable chronic disease and there is increasing evidence that patients have a different perspective on the outcome to their doctors Hewlett [9]. Helping people to cope with chronic disability, improving their life by addressing their real concerns rather than measuring “medical outcomes” like degree of swelling or ESR, is becoming increasingly important. Finding ways of reaching out to the large percentage of the population who have a disability related to a rheumatic problem is also essential to persuade politicians to take the subject seriously and invest in it. Thus the experience gained from this would be advantageous to your career in many ways – and I believe you would find working in BARC both interesting and rewarding. Once in place here you can join in all the usual University Rheumatology Departmental activities, from seminars to clinical meetings. We would also work to get you some exposure to Rheumatoid Arthritis clinics as an observer on an informal basis. That will be easier to do with colleagues on the ground than to set up formally in advance with the current NHS bureaucracy [10].

Conclusion

You will have free time to catch up on your reading, particularly on the fairly large literature on self-coping and on what people expect from health services. You would need this to write a good paper and I would expect you to write up a comprehensive introduction and methods section well before data collection has been completed. Of course we will be available to discuss that with you but it will be your responsibility to produce the first version. I believe that an important part of such a fellowship is learning how to plan and write up your own research projects for the future.

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juniperpublishers-orthopedics · 3 years

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Total Knee Arthroplasty Following Mycobacterium Kansasii Septic Arthritis in a Patient with Systemic Lupus Erythematosus and Essential Thrombocythemia

Abstract

Mycobacterium kansasii, like other non tuberculosis mycobacterial (NTM), is rare opportunistic infection that can lead to septic arthritis in immune suppressed patients. We report the case of a 56‐year‐old His panic female with systemic lupusery the matosus (SLE) and scleroderma on long‐term immune suppression, who developed an M.kansasii septic arthritis of the left knee in the setting of chronic lupus arthritis. Total knee arthroplasty (TKA) was delayed as the infection progressed into osteomyelitis of the distal left femur with an associated chronic, draining wound in the popliteal fosse. There are no reports in the literature documenting the treatment of this manifestation of M.kansasii in a patient with SLE, prior to TKA. Diagnosis requires a high index of suspicion, and was accomplished with synovial fluid culture and tissue biopsy. Treatment was accomplished with staged debridement and anti‐mycobacterial drug therapy along with tapering of immune suppressive regimen. Wound closure was achieved with a combination of a split thickness skin graft and negative pressure wound therapy (NPWT). Wound healing was augmented with hyperbaric oxygen therapy HBOT. A TKA was then performed, which yielded excellent results.

Keywords: Mycobacterium Kansasii; Chronic Wound; Knee; Total knee Arthroplasty

Abbreviations: SLE: Systemic Lupusery Thematosus; TKA: Total Knee Arthroplasty; NPWT: Negative Pressure Wound Therapy; AFB: Acid Fast Bacteria; ESR: Erythrocyte Sedimentation Rate; CRP: C‐Reactive Protein; OR: Operating Room; PICC: Peripherally Inserted Central Catheter

Introduction

Arthritis and arthralgias are noted in up to 95% of patients with systemic lupus erythematosus (SLE) but they are typically responsive to immune suppression and are often transient [1]. The arthritis of SLE is characterized by a non‐erosive inflammatory arthropathy (Jacouds Arthropathy); however, in the knee joint osteonecrosis can occur leading to accelerated articular degeneration. Studies show that patients with SLE require TKA at an average age of 56 compared to age 69 in matched controls, without auto immune disease [2].

The increased morbidity and mortality in SLE is well recognized and infection is a major cause of death, accounting for approximately 25% of deaths in a British cohort at a large tertiary care center [3]. In‐hospital post operative mortality for patients with SLE undergoing hip and knee arthroplasty was recently investigated using data from the Nationwide Inpatient Sample. The investigators found that patients with SLE had an odds ratio of 4.0(95%CI1.9‐8.0) for postoperative mortality with hip replacement and odds ratio of 1.2(95%CI0.2‐7.5) for mortality with knee replacements. In contrast, mortality risk for RA patients was similar to controls [4].

Non‐tuberculosis mycobacterial infection has been reported in patients with SLE [5], and typically presents later in the disease course and in patients receiving more potent immune suppression. M. kansasii is a typical mycobacterium that usually causes pulmonary infections, but has a predilection for the joints and soft tissue in patients with SLE [5,6]. It is particularly challenging to culture, and a prolonged period of time may pass before a definitive diagnosis is established, thus, leading to treatment delay and the potential for poor outcomes. Wound healing is known to be impacted by autoimmune diseases including lupus [7] and scleroderma [8].

Immunosuppressive therapies used to manage SLE can further impair immune defense and clearance of M. kansasii infections. The authors have obtained the patient’s informed written consent for print and electronic publication of the case report.

Case Studies

The patient is a 56‐year old female with long standing SLE overlap with scleroderma who had been taking chronic prednisone for management of interstitial lung disease and recurrent pericarditis. She initially presented with chronic recurrent left knee effusion at an outside hospital.

Synovial fluid analysis was initially benign, with a white cell count of 2100 and no crystals present. Anti‐inflammatory agents and a trial of intra‐articular corticosteroid injections failed to relieve her pain , and the patient was referred for an exploratory arthroscopy. Post‐operative analysis of the synovial fluid revealed 56,000 white cells and synovial cultures were positive for acid‐fast bacilli (AFB) after 10 days of incubation. It was believed at the time to be an external contaminant. Without a definitive pathogen, the patient was treated empirically with a four‐week course of vancomycin and piperacillin‐tazobactam.

Her pain slightly improved and she continued to have difficulties with ambulation. One year later, she developed a new, painful swelling in her left popliteal fossa. An MRI was suggestive of a Baker’s cyst; however, no fluid could be a spiraled by interventional radiology. An aggressive attempt at arthroscopic synovectomy and closure of the popliteal wound then followed.

The wound broke down two days later. Four further attempts at surgical closure of the wound resulted in dehiscence. One‐year after initial presentation, the surgical wound had transformed into a recalcitrant, painful, non‐healing fistula a with malodorous, grey drainage. The patient was reporting fevers, fatigue, and an eight-pound weight loss. No definitive pathogen had been cultured.

At the time of presentation, the patient’s medications included azathioprine 150 mg daily, cholecalciferol 5000 units once a day, calcium citrate‐vitamin D 1000 units daily, aspirin 81 mg once daily, acetaminophen 500 mg daily, dexlansoprazole 60 mg once daily, prednisone 4.5 mg daily, zoledronic acid 5mg yearly infusions, topical diclofenac sodium gel, and tramadol 50 mg every six hours.

On examination, vital signs, cardiac and pulmonary exams were within normal limits. The patient had a swollen left knee that was red and warm to the touch. There was an open, exudative, mildly malodorous, 1.5 x 0.4 x 2.5 cm wound in the left popliteal fosse with surrounding erythema. Edema was 1+, extending downward into left lower limb. Dorsalis pedis and posterior tibial pulses were 2+. No neurological deficits were appreciated.

Laboratory studies revealed mild normocytic anemia with a hemoglobin count of 8.1 g/dL, an elevated white cell count of 27.4 x 103 uL, a creatinine 0.52 mg/dl, and an albumin of 2.6. Transaminases were within normal limits. Her erythrocyte sedimentation rate (ESR) was 98 mm/hr and the serum Creactive protein (CRP) level recorded as 15.9 mg/L. Blood, urine and stool cultures were negative.

Management and Outcome

Our initial impression was that she suffered from septic left knee arthritis, likely related to a history of SLE and immune suppression. We were concerned that the popliteal wound tracked into the joint. A multidisciplinary team of infectious disease, orthopedics, rheumatology and plastic surgery proceeded with a management strategy beginning with staged debridement and serial cultures to determine a pathogen for targeted antibiotic therapy.

The patient would then be closed surgically with the aid of a graft or soft tissue reconstruction. TKA would follow after stabilization of the soft tissue. Optimization of her SLE medication regimen was paramount for successful management at all stages.

The patient under went three excision a debridement and final closure of the wound. Multiple, purulent deep tissue abscesses were identified within the wound in popliteal fosse, and were incised and drained. The wound bed was derided down to healthy appearing tissue, leaving a 9 x 3 cm defect. Copious irrigation prepared the wound for placement of a NPWT device. Cultures of the wound were obtained before and after debridement to determine organism speciation, sensitivities, and assess for clean margins. Cultures from the first two debridements were positive for methicillin resistant’s resistant staphylococcus aureus (MRSA) but not AFB.

The infectious disease team was consulted and the patient was place on intravenous vancomycin and cefepime. Three days later the patient was taken to the OR for a final debridement and closure with a split thickness skin graft. A peripherally inserted central catheter (PICC) line was placed and the patient was discharged one day later to receive daptomycin 300mg IV daily for 30days. Azathioprine and prednisone were continued for management of SLE, per rheumatology. Post‐debridement cultures including AF yielded no growth.

She required another “take‐back” one month later due to poor graft adherence and renewed drainage. Cultures remained negative.

After 5 months of follow up and difficulty healing, the patient was reevaluated for new drainage from the wound. An MRI of the left lower limb was concerning for osteomyelitis in the distal femur. The patient was taken back to the OR for debridement and culture of the involved tissues. Methylene blue was injected to identify the joint‐space during the surgical approach. A posterior knee incision was made into the popliteal fosse, and multiple specimens, including the capsule, were sent for culture and pathology. 3 x 2 cm, cheesy, caseating mass, adjacent to the left medial femoral condyle was evacuated (Figure 1).

Two draining sinuses within the 10 x 2 cm wound bed were debrided with sharp curettage. The gram stain was unhelpful and the cultures again returned with no growth on AFB media. The patient was sent home on moxifloxacin 400 mg PO daily and instructed on daily dressing changes with gauze dressings.

She presented one month later with a fever, and was reevaluated to for the source of this indolent and here to fore unexplained infection. There was a suspicion that mycobacterium could be involved because mycobacterium species are known to cause a tenosynovitis and persistent wounds, with cultures often being negative. This hypothesis was supported, by the caseous nature of the drainage, the history of chronic immunosuppressive therapy, and the priorpositive AFB culture from the outside hospital. Mycobacterial infection had long been suspected but without subsequent cultures, a definitive diagnosis could not be made. A decision was made to discontinue azathioprine, and the patient underwent subsequent evacuation of there‐accumulated as eating mass from the joint space in the left knee. AFB cultures were sent again; this time the cultures returned positive for M.Kansasii, and the patient was started on a triple therapy with rifampin 150mg BID, isoniazid 300mg daily, and azithromycin 500mg daily. NPWT was maintained after discharge.

She presented one month later with a fever, and was reevaluated for the source of this indolent and heretofore unexplained infection. There was a suspicion that mycobacterium could be involved because mycobacterium species are known to cause a tenosynovitis and persistent wounds, with cultures often being negative. This hypothesis was supported, by the caseous nature of the drainage, the history of chronic immunosuppressive therapy, and the prior positive AFB culture from the outside hospital. Mycobacterial infection had long been suspected but without subsequent cultures, a definitive diagnosis could not be made. A decision was made to discontinue azathioprine, and the patient underwent subsequent evacuation of the re-accumulated caseating mass from the joint space in the left knee. AFB cultures were sent again; this time the cultures returned positive for M. kansasii, and the patient was started on a triple therapy with rifampin 150mg BID, isoniazid 300mg daily, and azithromycin 500mg daily. NPWT was maintained after discharge.

The antimycobacterial drugs were discontinued two weeks later due to a drug reaction, which manifested as a severe pruritic rashm flu-like symptoms, and fatigue. Four months later, a sinus within the wound re-opened and was treated with iodosorb and acetic acid dressings. AFB cultures at this time were negative. The patient was referred to hyperbaric medicine team for hyperbaric oxygen therapy (HBOT). She underwent a total of 30 dives over the course of 45 days, at 2.0 atmospheres for 90 minutes each. Three months later, the left posterior knee wound had completely healed and the patient was ambulating well with the aid of a knee brace and a cane (Figure 2).

She was restarted on antimycobacterial therapy, with a new regimen of rifampicin 300 BID and ethambutol 400 mg TID.

She remained on ethambutol for 25 month until it was discontinued due to ocular findings, one month prior to TKA. Almost four years after the initial presentation, the patient successfully underwent TKA. Following aggressive physical therapy she has full range of motion of the knee and is ambulating without significant pain. Rifampin was continued perioperatively, and discontinued six months after TKA, after a total of 33 months of treatment.

Discussion

This case demonstrates the challenging diagnosis and treatment of M. kansasii septic arthritis, osteomyelitis, and a fistulous chronic wound in a patient with SLE. There should be a high degree of suspicion for atypical mycobacterial disease in patients presenting with persistent septic arthritis with autoimmune disease, and who are significantly immunosuppressed [9].

A study by Mok et al analyzed a cohort of 725 SLE patients with previous NTM infections and found that compared to mycobacterium tuberculosis infections, NTM infections such as M. kansasii, were more likely to present in extra pulmonary sites (P=0.006), in those with a longer duration of SLE (P<0.001), and in those with a cummulative higher dose of corticosteroids (P=0.01)[5].

M. kansasii infections typically involve soft tissues tissues, bones, bursae, tendon sheaths and large or medium joints [10]. Patient with SLE are especially predisposed to extrapulmonaryinvolvement [11]. Seeding of deep tissues by ,M. kansasii?, can occur via hematogenous spread, but is more frequently caused by trauma and contaminated medical instrumentation or solutions, such as local anesthetics and steroids [10,12,13].

Tap water is believed to be a major reservoir and source of contamination for M. kansasii [13,14] Diagnosis of M. kansasii septic arthritis is made with culture of synovial fluid or biopsy of the synovium; however, cultures are often negative. This may be due to poor inoculums yielded from synovial fluid or the fact that M. kansasii is slow growing and fastidious in vitro[11]. An abundance of neutrophils are often the only findings on diagnostic work up of affected tissues, and thus diagnosis can be difficult [14].

Corticosteroids and immunosuppressive agents, which are commonly used to manage SLE, can mask the inflammatory response, which may further delay diagnosis. There are documented reports of patient with destructive arthritis of unknown origin persisting for 11 years after presentation, until the infection converted to a granulomatous lesion, from which positive cultures were ultimately obtained [11].

Combination pharmacotherapy is the cornerstone of treatment of mycobacterial infections and monotherapy is not recommended due to the potential for development of drug resistance [15] M. kansasii is usually susceptible to isoniazid, ethambutol, rifampin, ethionamide, streptomycin, and clarithromycin. Combining rifampin specifically with the other drugs significantly improves the potency of the regimen, and lowers rates of resistance and subsequent relapse [14].

The recommended treatment for patients with rifampin susceptible M. kansasii is a daily regime of rifampin 10 mg/kg/ day (maximum 600 mg), ethambutol 15 mg/kg/day, isoniazid 5 mg/kg/day (maximum 300 mg), and pyridoxine 50 mg/day until 12months of negative cultures are obtained. Rifampin resistant M. kansasii should be treated with a three‐drug regimen consisting of clarithromycin or azithromycin, moxifloxacin, ethambutol, sulfamethoxazole, or streptomycin as the susceptibility data allows [14].

Often times, the microbiology data in the immunocompromised host can be unclear, with multiple microbes contributing to the overall clinical presentation. Bacteria can form dense colonies within bio film that can subvert host defenses and antibiotic drugs. Further, corticosteroids used to treat SLE, aside from impairing wound healing [16] and systemic response to infection, have been found alter bio film formation in animal models. While the total production of biofilm can be reduced with corticosteroid use, such therapy may alter the biofilm in such a way that resistance of bacteria to to certain antibiotics is enhanced [17]. As a result, patients with deep tissue involvement should be managed pharmacologically and surgically, with aggressive antimicobacterial therapy, staged debridement, and wash out of all compromised tissues [17-20].

Conclusion

In conclusion, although rare, M. kansasii should be added to the differential diagnosis in patients with SLE and other immune diseases, and persistent septic monoarthritis. This diagnosis should especially be considered in patients receiving chronic immunosuppressive therapies. Since immune diseases are known to impact wound healing, and immune suppression can contribute to impaired host defenses, it is crucial to both optimize immune therapy and aggressively treat the infected joint. A multidisciplinary approach to the care of patients with autoimmune disease and septic arthritis can be used to minimize risks and improve outcomes in this patient population.

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Hip Abductor Tendinopathy: Work-Up and Open Versus Arthroscopic Repair of Hip Abductor- Juniper Publishers

Abstract

The abductors of the hip notably the gluteus medius and gluteus minimus are paramount to hip stability and function, so much so they have been aptly termed the rotator cuff of the hip [1,2]. Tendinopathy of these structures is classified among a group of other diseases that also present as lateral sided hip pain called greater trochanteric pain syndrome (GTPS); this also encompasses snapping hip and trochanteric bursitis. Historically, patients with lateral sided hip pain have been presumed to have trochanteric bursitis and treated with anti inflammatory medications, physical therapy and corticosteroid injections [3]. Failure of conservative therapy, in many cases, can be attributable to tears in the abductors sometimes necessitating surgical intervention. Both arthroscopic and open repairs of the abductors have been shown to be effective treatments if conservative measures fail [1-4].

Introduction

Hip abductor tendinopathy encompasses a constellation of etiologies all of which present with the chief complaint of lateral hip pain. It is four times more common in women and is usually seen between the fourth and sixth decades of life [5,6]. Patients with osteoarthritis, iliotibial band tenderness, low back pain, and obesity are at an increased risk [7,8]. Hip abductor tendinopathy falls under a broader classification of greater trochanteric pain syndrome (GTPS). Etiologies of GTPS include gluteus medius and minimus tendinopathy, external coxa saltans (hip snapping), and greater trochanteric bursitis [9,10]. Domb et al. & Williams et al. [7,11] relate the incidence of GTPS is approximately 1.8 per 1,000 people and classically presents as pain on the lateral aspect of the hip that can radiate to the thigh and posteriorly. Chronic, progressive pain is more common than acute-onset pain from an identifiable traumatic event [12,13].

Historically, the etiology of GTPS has been mistaken for trochanteric bursitis. It was not until several decades after Stegemann et al. & Leonard et al. [7,14] described the symptoms of what is now known as GTPS in the vicinity of the trochanter major as “trochanteric syndrome” in the Journal of the American Medical Association. Since Stegemann and Leonard, advancements in clinical imaging techniques such as magnetic resonance imaging (MRI) and ultrasound have permitted more definitive diagnosis of lateral hip pain as GTPS and not a true trochanteric bursitis. As recently as 2008, Silva et al. [15] in the Journal of Clinical Rheumatology maintains that no histologic study of trochanteric bursitis has been reported in the literature.GTPS includes several potential causes, one of which is hip abductor tendinopathy, insufficiency, and tears.

Anatomy

The four hip abductor muscles accomplish hip abduction: gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae. The superior gluteal nerve innervates all but the gluteus maximus, which is innervated by the inferior gluteal nerve. The gluteus medius and gluteus minimus are the most frequently injured and thus the focus of hip abductor insufficiency. They are so commonly the culprit that the two have been termed the “rotator cuff tears of the hip” [1,2]. The gluteus medius is comprised of an anterior, middle and posterior portion. The anterior and middle portions are involved in initiating hip abduction while the anterior segment alone is the primary pelvic rotator [16]. The posterior portion of the gluteus medius stabilizes the hip from the heel strike to full stance during normal gait [16]. The gluteus minimus also stabilizes the hip joint during the gait cycle - specifically during the mid and late stages of gait [16].

Differential diagnosis

Abductor insufficiency tends to present as one of three clinical scenarios. First, older patients may present with lateral hip pain and abduction weakness without a history of arthritis [16,17]. In these patients, chronic, degenerative abductor tears should be considered - particularly in those who have failed conservative therapy [16,17]. A minority of patients may recall a traumatic event and in such cases history of such an event is helpful in categorizing the tear in this first group [16,17]. These degenerative and symptomatic tears will be the focus of our discussion. Abductor tears in the second group of patients are found incidentally at the time of a hip arthroplasty and are asymptomatic [16,18]. The last group presents with symptoms of abductor tendon insufficiency following hip arthroplasty [16,19,20]. As the hip abductor tendons are partially or fully released to facilitate adequate exposure and then repaired prior to closure, the failure of repair can be responsible for abductor insufficiency [16,19,20]. In addition to the expected damage and subsequent repair of the hip abductors requisite of a THA, Hardinge et al. [16,19,20] underscores that the anterolateral approach used in the procedure has been implicated in injury to the superior gluteal nerve - responsible for innervation of the gluteus medius and gluteus minimus - and its vessels.

Other etiologies of GTPS should be considered in the differential diagnosis. If snapping of the iliotibial band can be elicited on physical exam, a diagnosis of external coxa saltans should be considered. The maneuver is executed by moving the leg from a position of flexion, abduction, and external rotation to a position of extension, abduction, and internal rotation [9]. Outside of GTPS, pain that begins in the lower back and radiates to the lateral hip and thigh can be radicular and indicate lumbar spine pathology such as stenosis or spondylosis [16]. Other extra-articular diagnoses on the differential could include occult proximal femur fracture, injury to the superior gluteal nerve, or meralgia paresthetica. Decreased passive range of motion could indicate osteoarthritis of the hip, particularly if pain is also present in the groin. Other intra-articular pathologies on the differential include femoroacetabular impingement, labral tears, capsular laxity, chondral damage, and ligamentum teres rupture [9].

History and physical

A relevant history in the evaluation of a patient with suspected abductor tendinopathy will include a history of present illness detailing time-course of pain, characterization of pain, and interventions the patient has tried which either relieve or worsen pain. One should inquire of the use of steroid injections for presumed “trochanteric bursitis.” In a history indicative of neuropathy, myelitis should be suspected. An experience of snapping, catching, clicking, locking, and popping should also be solicited [9]. A patient’s past surgical treatment of the hip is important as certain surgeries can cause abductor insufficiency secondary to the approach as mentioned previously. As well, any history of attempted treatment - nonsurgical included - should be documented as this will impact future treatment options.

Patients presenting with GTPS secondary to hip abductor insufficiency endorse pain with weight bearing and difficulty ascending and descending stairs [5,12]. Narrowing the diagnosis, the examiner will notice point tenderness in the posterolateral area of the greater trochanter as well as pain with resisted hip abduction [5,12,13,17]. The examiner can also expect gait disturbances such as antalgic gait with or without Trendelenburg gait [5,7,12,13]. A 2001 study by Bird et al. [5] published in Arthritis and Rheumatology found Tendelenburg’s sign to be the most sensitive and specific physical exam finding to gluteus medius tears. Physical exam results were assessed against MRI as a surrogate gold standard in 24 patients recruited for clinical features suggestive of GTPS [5]. Trendelenburg’s sign was found to be 72.7% sensitive and 76.9 % specific in detecting gluteus medius tears [5]. The Trendelenburg sign is elicited by having the patient lift the nonaffected foot; the pelvis subsequently drops or tilts to the nonaffected hip denoting insufficiency of the abductors to keep the pelvis level.

The Trendelenburg gait is a compensatory mechanism in which the patient leans to the affected side when elevating the opposite leg in an attempt to keep the pelvis level during ambulation to compensate for abductor insufficiency as shown in (Figures 1 & 2) [9,21]. This physical finding was evaluated alongside pain findings with resisted hip abduction and resisted hip internal rotation. Utility of Trendelenburg’s sign eclipsed that of the other two maneuvers where pain experienced in resisted hip abduction demonstrated 72.7 % sensitivity though only 46.2 % specificity and pain on resisted hip internal rotation sported only 54.5 % sensitivity and 69.2 % specificity [5]. Diagnosis can also be confirmed with peritrochanteric injections where the patient’s pain is relieved while weakness of hip abduction persists [12,22].

Imaging

Radiographs are typically unremarkable in patients with abductor tears, but are often the first step in evaluating for other pathologies on the differential, such as osteoarthritis of the hip or fracture [16]. MRI has proven to be a highly specific diagnostic tool in the work-up of GTPS. In a 2004 retrospective study published in the American Journal of Roentgenology, 74 hips - 15 surgically confirmed abductor tendon tears and 59 confirmed intact tendons - were evaluated to determine the accuracy of MRI in diagnosing abductor tendon insufficiency [6]. Cvitanic et al. [6] showed that MRI findings with an area of T2 hyperintensity superior to the greater trochanter was 73 % sensitive and 95 % specific to tears of the gluteus medius and gluteus minimus tendons. MRI can also be used in a patient suspected of GTPS to evaluate tendinosis, partial-thickness tear, or a full-thickness tear with loss of continuity [6,12].

A thickened tendon and increased signal intensity on T2 weighted images were characteristic of tendinosis. Partial thickness tears were indicated by focal discontinuity of gluteus medius fibers, and complete tears were defined as those involving retraction of the tendon [9]. Abductor tears may also show hypertrophied tensor fasciae latae compared with contralateral side as a result of compensation for decreased abductor strength [9,23]. Redmond et al. [9] explains ultrasound has been shown to be an effective tool for GTPS and diagnosing abductor tendinopathy with a sensitivity ranging from 79 % to 100 % with a positive predictive value ranging from 95 % to 100 %. Ultrasound as a dynamic evaluation modality can visualize external snapping of the hip. In a study of 877 patients with GTPS, Long et al. [24] used ultrasound to identify gluteal tendinosis in 50 % of patients, a thickened iliotibial band in 28.5 % of patients, a gluteal tear in 0.5 % of patients, and trochanteric bursitis in 20 % of patients. Incidentally, Long et. al concluded that only a minority of patients (20.2 %) were determined to have trochanteric bursitis [24].

Treatment

In patients with GTPS, including degenerative abductor tears, non-surgical management is the mainstay of treatment. Nonoperative treatment involves physical therapy, cortisone injections, local anesthetic injections, and nonsteroidal antiinflammatory medications [12,25]. Non-surgical management has been largely successful in patients with GTPS; trochanteric bursitis touts a similar response [9,26]. Adjuncts like plateletrich plasma injections continue to be investigated for many musculoskeletal diseases including tendinopathies but have not shown promise [12,27,28].

Failure of non-surgical management of GTPS should raise suspicion of abductor tendinopathy and lower the threshold for obtaining advanced imaging. Patients who fail conservative management with degenerative tears diagnosed on MRI may be candidates for surgical repair. Early surgical repair should be considered before the onset of fatty muscular atrophy [16]. Open surgical repair has been the classic technique for treating abductor tendon tears since Kagan et al. [4,17] published the first case series of open repairs for GTPS in 1999. Historically, the open technique has championed a high level of patient satisfaction with objective merits such as quantifiable improvements in abductor tendon strength and gait [12,29- 31]. In 2009, Voos et al. [4,32] published the first case series that detailed treatment of hip abductor tears arthroscopically. Since that time, few studies have objectively compared the two techniques in the treatment of GTPS.

Two systematic reviews published in 2015 in Arthroscopy: The Journal of Arthroscopic and Related Surgery by Alpaugh et al. and Chandrasekaran et al. [1,4] are among the first to discern between outcomes of open and arthroscopic surgical repair of the hip abductors. Alpaugh et al. [4] database search and inclusion criteria yielded 8 articles. A total of 174 hips were reviewed; 135 underwent open repairs and 39 received arthroscopic repairs [4]. No significant differences were noted between the two techniques in postoperative outcomes such as the modified Harris Hip Score, Oxford Hip Score, Hip Outcome Score, and pain reduction after open and endoscopic reapir. 4 However, complication rates were found to be higher in the open repair group where the rate of tendon retear after open surgical repair was 9 % (12 of 135 hips) versus no reported tendon retears following arthroscopic repair. 4

Chandrasekaran et al. [1] conducted a review of 7 of the 8 articles examined by Alpaugh et al. and arrived at similar conclusions of no significant differences between open and closed techniques as measured functionally by measures such as the Merle d’Aubigne-Postel score, Hip Outcome Score, modified Harris Hip Score, and visual analog pain scale. Chandrasekaran et al. [1] did identify a significant retear rate in patients receiving open repair where 10 out of 128 patients versus 0 reported retears in endoscopic cases. As well, 4 of the 128 open cases were complicated by infection or hematoma compared to 0 such complications in the endoscopic group [1]. While these findings and sample sizes merit further exploration, this data indicates a benefit afforded by arthroscopic repair that should impact selection of surgical technique in treating GTPS.

Our Approach

The vast majority of patients with GTPS can be treated conservatively by the methods described. Our general approach involves steroid injection and physical therapy. We will repeat the injection if necessary, but those patients that require early repeat injections often will have significant tears in the abductors. For those patients we will obtain an MRI. We also will obtain an early MRI for those patients with a positive Trendelenburg sign and gait. If the MRI demonstrates partial tears or mild degeneration, we will continue with nonoperative treatment. For those that do not respond to nonoperative management or demonstrate a full thickness tear, we proceed with arthroscopic intervention provided there is no significant fatty atrophy within the muscle. The results of arthroscopic treatment have been good, but there is a significant learning curve compared to the open procedure.

Conclusion

Lateral sided hip pain is a common orthopaedic complaint that should be specifically diagnosed through history of present illness, physical exam, and potentially imaging. GTPS occurs with an incidence of 1.8 per 1000 people and encompasses several diseases including trochanteric bursitis, abductor tears, and hip snapping [7-11]. Common intraarticular pathologies such as labral tears, femoroacetabular impingement, and osteoarthritis must be excluded. Abductor tears represent a common cause of GTPS that can be accurately diagnosed on physical exam with a positive trendelenburg’s sign, which is 72.7% sensitive and 76.9% to detecting gluteus medius tears [5-12]. Peritrochanteric injections that relieve pain but not weakness of the abductors may also indicate abductor insufficiency [22]. The mainstay of treatment for GTPS is non-operative which includes antiinflammatories, physical therapy, and injections [12]. Failure of conservative therapy may warrant further investigation including imaging. MRI findings of T2 hyperintensity superior to the greater trochanter are 73% sensitive and 95% specific to tears of the gluteus medius and minimus tendons [6]. Once a diagnosis of abductor tear is made, surgical treatment can include open and arthroscopic repair.

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juniperpublishers-orthopedics · 3 years

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Outcome of Endoscopic Calcaneoplasty in Insertional Achilles Tendinopathy with Retrocalcaneal Bursitis. A New Prospective Study

Abstract

Introduction: The aim of this study in to analyze the outcome of Endoscopic Calcaneoplasty Technique for the treatment of Insertional Achilles Tendinopathy with Retrocalcaneal Bursitis.

Methods: This prospective study consists of 6 patients (3 men, 3 women) with mean age of 44.3 years who were operated by a single surgeon from March to November 2014. The bone cutter shaver was used to remove sufficient amount of inflamed retrocalcaneal bursa and superior part of calcaneum under fluoroscopy guidance. All patients were discharged on the following day and allowed weight bearing as tolerated. American Orthopedic Foot and Ankle Society (AOFAS) score, SF-36 health survey score and Ogilvie-Harris score were documented at 3rd and 6th months follow up.

Results: All patients were followed up for at least 6 months. AOFAS scores showed significant improvement at 3rd and 6th months with p value of 0.028. SF-36 scores showed overall significant changes for physical functioning (p=0.04), physical role limitation (p=0.035), emotional wellbeing

Conclusion: Endoscopic calcaneoplasty is a safe and effective technique for the treatment of Insertional Achilles Tendinitis with Retrocalcaneal Bursitis.

Keywords: Endoscopic; Calcaneoplasty; Achilles Tendinitis; Fluoroscopy; Bursa

Abbreviations: AOFAS: American Orthopedic Foot and Ankle Society; SF: Short Form; SPSS: Statistical Package for the Social Science; ESWT: External Shockwave Therapy

Introduction

Achilles tendinopathy is a common hind foot disorder which affects both the active and non-active population. It’s occurence among Asians has shown an increasing trend due to their active involvement in sporting activities but limited literature is available documenting on Achilles tendinopathy. It can be classified as insertional and non- insertional tendinopathy [1]. Insertinal tendinopathy is responsible for 20% to 25% of total Achilles tendon related disorders [2] and usually associated with retrocalcaneal bursitis. Insertional Achilles tendinopathy is a clinical syndrome consisting of pain, swelling and impaired performance. The pathology is located at the insertion of Achilles tendon on the postero-superior part of calcaneum and commonly associated with formation of bone spurs and calcifications of Achilles tendon.

Insertional Achilles tendinopathy is purely a clinical diagnosis. Patients presents with complaint of pain, appear at the beginning and ending of walking session, stiffness and occasionally swelling of the hind foot. Examination findings include visible swelling, tenderness at postero-lateral aspect of the calcaneum and a palpable bony spur. Imaging like plain radiography and MRI can be used to support the diagnosis and exclude the differential diagnosis. Plain radiography may show ossification, a bone spur at the tendon’s insertion or radio-opacity of the retrocalcaneal recess. Meanwhile, MRI may reveal any bone formation or hyper intense signal at tendon insertion or retrocalcaneal recess.

The scientific evidence of the etiological factors is limited. The suggested pathophysiology is excessive loading during exercise or recurrent microtrauma leading to tendon damage [3]. The risk factors can be either intrinsic or extrinsic. Intrinsic factors include tendon vascularity, gastrocnemiussoleus dysfunction, age, gender, obesity, hypertension, diabetes mellitus, dyslipidemia, pes cavus and lateral ankle instability [4]. Meanwhile, extrinsic factors are changes in training pattern, poor technique, previous injuries, footwear and training on hard, slippery or slanting surfaces [2,5].

This disorder is initially treated with non-operative treatment. Patients are advised for complete or modified rest and correction of possible intrinsic or extrinsic risk factors that may contribute to pain. Adequate analgesia, local injection of sclerosing agents, physiotherapy to strengthen the triceps surae muscles and orthotic treatment like shoes change or heel lift have shown some symptomatic improvement [6]. McGarvey et al. [7] have shown that 89% of their patients improved with nonoperative treatment.

Surgical intervention is recommended for failed nonoperative treatment. The surgical principle involves removal of the inflamed bursa, thickened synovium and resection of postero-superior part of calcaneum. There are many surgical options available such as open and endoscopic method with good to excellent outcomes. A recent systematic review by Wiegerinck et al. [8] has concluded that endoscopic surgery is better compare to open intervention. This study is conducted to analyze the outcomes of endoscopic calcaneoplasty in a single operating centre within the Asian population. American Orthopaedic Foot and Ankle Society (AOFAS) hind foot scoring system, Short Form (SF 36) Health Survey and Ogilvie Harris scores were used to evaluate the patient’s outcome.

Materials and Methods

This prospective study covers 9 patients (4 men, 5 women) with mean age of 44.3 years who were operated by a single surgeon from March to November 2014. Patients are selected based on the criteria of failed conservative management for a minimum of 4 months, declared fit for operation by anesthetist and have given consent for operation. Persisting pain and difficulty in walking were the main indications for operation.

History taking and examinations were repeated to establish the diagnosis of Insertional Achilles Tendinopathy. Plain radiography and MRI were done for all the patients to confirm the diagnosis, exclude the differential diagnosis and ensure the integrity of the Achilles tendon. Written consents were obtained from all the patients for the operation. 3 patients refused surgery just before the scheduled date due to social reasons.

All the operations were done under general anesthesia.

Prophylaxis dose of Intravenous Cefuroxime 1.5g was given to the patient at the time of induction. The patients were positioned prone with feet lying at the edge of the operating table. The affected leg was raised slightly with rolled towel.

Area of interest was painted with Povidone Iodine and draped. Thigh tourniquet was inflated after exsanguination of the leg using crepe bandage. The degree of dorsiflexion of the foot is manipulated by using the surgeon’s body against plantar surface of the foot.

Endoscopic calcaneoplasty uses medial and lateral portals. Lateral portal was created by making a small vertical skin incision at the level of superior part of calcaneum lateral to Achilles tendon. Blunt trocar was used to reach the retrocalcaneal space and is replaced with 4.5-mm arthroscope shaft at the angle of 30°. Meanwhile, medial portal was created by using a spinal needle as a guide at the superior part of calacaneum medial to Achilles tendon. Stab incision was made and Kelly’s forceps were used to reach the retrocalcaneal space. Bone cutter shaver was introduced from medial portal and once placement was confirmed by using arthroscopy, the inflamed bursa and superior part of the calcaneum were removed using shaver. Sufficient amout of calcaneum was removed by manipulating ankle joint into dorsiflexion and plantarflexion position with the help of fluoroscopy. Cutter surface of shaver was always placed facing the calcaneum to protect the Achilles tendon [9].

The skin was closed with non-absorbable sutures and compression dressing was done. All the patients were discharged on the following day of operation after reviewing post-operative plain radiographs. Patients were advised for range of motion exercises and weight bearing as tolerated. Wounds were inspected on day 3 and sutures were removed at 2 weeks. All the patients were followed up at 1, 3 and 6 months following operation.

The American Orthopaedic Foot and Ankle Society (AOFAS) hind foot scoring system, Short Form (SF 36) Health Survey and Ogilvie Harris scores were calculated pre- and postoperatively. Each patient was assessed by two independent reviewers for pre and postoperative scoring and average scores were taken for each follow up. Patients also were asked whether will undergo the same operation if his or her contralateral foot is affected. Statistical Package for the Social Science (SPSS) was used to analyze the data and calculate the p value.

Results

All the patients were followed up for at least 6 months. For each visit, all the patients were re-examined and assessed for AOFAS Hind Foot Scoring, SF-36 scoring and Ogilvie Harris scoring. Pre-operative and post-operative scores at 3 months and 6 months were calculated and compared as shown in the tables below (Tables 1-3). The AOFAS Hind Foot Scoring is based pain (40 points), function (50 points) and alignment (10 points). The mean AOFAS score improved from pre-operative score of 55.5 (range, 43-72) to post-operative score of 73.0 (Range, 55- 84) at 3 months and 79.5 (range, 69-88) at 6 months. Wilcoxon signed rank analysis showed significant AOFAS scores with p values of 0.028 at 3 months and 6 months. Only one out of six patients had daily pain at 6 months follow up and could be due to scar tenderness.

The SF-36 Health Survey evaluates 8 parameters with the scores ranging from minimum of 0 to maximum of 100. Based on repeated measure ANOVA, average scores of SF-36 showed significant changes for physical functioning (p=0.04), physical role limitation (p=0.035), emotional wellbeing (p=0.005) and pain (p=0.003).

Ogilvie Harris scoring is based on clinical assessment with maximum score of 16. The results were scored as excellent (15 to 16 points), good (13 to 14 points) or unsatisfactory (<13 points). At 6 months follow up, 4 patients had excellent results, one had good result and one had unsatisfactory result. 5 out of 6 patients agreed for the same operation if contralateral foot is affected. All the wounds healed well and no incidence of infection was reported. Although all patients had improvement in all scores evaluated as compared to preoperative scores, one patient has persistent scar tenderness (Figures 1 & 2).

Discussion

Insertional Achilles Tendinopathy can be treated with or without operation and choice of treatment depends on patients. Non-active patients may choose non-operative treatment for a period of 4 to 6 months before deciding for operative treatment. Meanwhile, active patients like professional sportsman may directly opt for operation without non-operative treatment for early return to sports and work. A wide range of non-invasive and non-operative methods have been developed and modified to treat Insertional Achilles Tendinopathy. However, the success rate is inconclusive due to insufficient clinical evidence [10]. Surgical options are offered for failed non-operative treatment. Open and minimal invasive surgeries have shown excellent results but minimal invasive surgeries are gaining popularity among patients due to early work and sport resumption [11].

Non-operative treatment includes adequate rest of the Achilles tendon from excessive load and gradual muscle exercise to build the strength of the triceps surae muscles [12]. Patients are advised to avoid tight shoes and improvise their techniques in work and sporting activities [6,13]. Non-steroidal antiinflammatory drugs have only analgesic effect without any long term benefit [6,13]. Corticosteroid injections are being offered to patients by some centers but the safety of its usage in our center is outweighed by the complications. Adverse effects of using corticosteroid includes reduce strength of the tendon, thus precipitate tendon rupture [14]. None of the patients in our center was given corticosteroid injection. External shockwave therapy (ESWT) have shown high success rate when combined with eccentric exercises. Vulpiani et al. 2009 have concluded that ESWT has positive effect on the treatment of tendinopathy with long lasting improvement of pain [15].

Surgical options for Insertional Achilles Tendinopathy have changed tremendously in the past decade due to advancement of technology and increased social needs of patients. It can be divided into open and minimal invasive surgeries. Open calcaneoplasty used to be the gold standard of surgical interventions until minimal invasive surgery become available. Many literatures have reported the good outcome of open surgery. However, open surgeries are highly invasive, associated with many complications and patients need longer recovery time. Common complications associated with open surgery are surgical site infection, wound dehiscence, bad scars and rupture of Achilles tendon [16-18].

Study conducted by Chen CH et al. [17] on 19 patients (30 heels) who underwent excision of the posterior calcaneal tuberosity and bursectomy through a medial longitudinal incision with average follow up period of 6 years, 10% of the patients had persistent pain and 83% had residual pain for half to two years after operation. Meanwhile, Angermann et al. [18] reported the outcome on 40 patients (40 heels) who were managed by resection of the posterosuperior aspect of calcaneum through posterolateral approach. Results after an average of 6 years showed 50% of heels recovered, 20% were improved and 10% were worse among 37 patients who were allowed immediate weight bearing. Documented complications include one superficial heel infection, one hematoma and two cases of delay wound healing.

Advantages of endoscopic technique over open surgeries are short recovery time, rapid return to work and sports, small incision and good scar healing [19]. Van Dijk et al. [20] reported endoscopic calcaneoplasty in 2001. In this study, endoscopic calcaneoplasty was performed in 20 patients (21 heels). The average follow up was 3.9 years and one patient had fair result, 4 patients had good results and the remaining 15 patients had excellent results. Most of these cases are same day surgery and patients do not need to stay overnight. There were no surgical and post-operative complications. All the patients had short recovery time and quickly back to work and sports. Systematic review on surgical treatment of chronic retrocalcaneal bursitis has reported 12 open surgical technique trials and 3 endoscopy technique studies evaluating 547 procedures in 461 patients [21]. Patient satisfaction and complication rate favored endoscopic technique.

Studies reporting the outcome of endoscopic calcaneoplasty among Asian populations with Insertional Achilles Tendinopathy are very limited. Late presentations to hospital among Asians due to higher pain threshold and tendency to try out traditional treatment may affect the outcome of endoscopy calcaneoplasty. This study has shown a good outcome and can be used as reference for future research with larger sample size and longer follow up durations.

Conclusion

Endoscopic calcaneoplasty is a safe and effective surgery for Insertional Achilles Tendinopathy with Retrocalcaneal Bursitis providing right techniques are used and done by qualified surgeons. The significant advantages are early return to work and sports due to quick postoperative recovery with minimal rehabilitation, small incision, cosmetically acceptable scar and low morbidity.

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juniperpublishers-orthopedics · 3 years

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Wartenberg’s Syndrome: an Unusual Bilateral Case

Abstract

Wartenberg’s Syndrome is described as the entrapment of the superficial branch of the radial nerve, with only sensory manifestations and no motor deficits. Wartenberg’s syndrome may be associated with the symptoms of de Quervainâ€™s tenosynovitis. A positive Tinelâ€™s sign over the course of the nerve is the most common physical examination finding. For the surgical management there is evidence in the literature documenting the good result reported by simple neurolysis of the nerve and removing anatomical variations of the muscle brachioradialis. In this article we report an unusual bilateral case of this rare peripheral nerve compression.

Introduction

In 1932 Wartenberg as first author describe a compression of the radial sensory nerve in the third distally of the forearm, reporting five monolateral cases. He was so impressed by the similarity to the isolated involvement of the lateral cutaneous nerve of the thigh (Meralgia Paraesthetica), that he suggested the name Cheiralgia Paraesthetica [1,2].

In 1993 Lanzetta and Foucher describe 52 monolateral cases and reported 74% success rate in 23 patients who underwent surgical decompression who had failed conservative therapy [3].

From the anatomically point of view the superficial branch of the radial nerve start after the radial nerve bifurcates into the superficial radial nerve and posterior interosseous nerve, exits from under the brachioradialis at the junction of the proximal two-thirds to distal one-third of the forearm, courses distally into the forearm deep to the brachioradialis and approximately 8-9 cm proximal to the radial styloid becomes a subcutaneous structure by traveling between the brachioradialis and Extensor Carpi Radialis Longus tendons. The nerve continues to travel in the subcutaneous tissues and branches out into dorsal digital nerves responsible for afferent sensory input from the dorsum of the thumb, index, and middle fingers proximal to the proximal interphalangeal joints [4,5].

From the aetiopathogenetic point of view the superficial branch of the radial nerve, due to its anatomic location, is vulnerable to compression from trauma, masses, and constriction from the fascia connecting the brachioradialis and extensor carpi radialis longus. Specifically, in pronation, the brachioradialis and the extensor carpi radialis longus compress the nerve. Wartenberg’s syndrome is a dynamic compressive neuropathy. Trauma is a common etiology for compression,which can occur from direct pressure on the nerve (i.e. by a tight wristwatches or handcuffs) or from a stretch injury to the nerve (i.e. during a closed reduction of a forearm fracture), other etiologies have been implicated, including lipoma and bony spurs, or work-related activities demanding repetitive supination and pronation.

Case Report

A 47 year-old man, right-hand-dominant man presented with tingling, paresthesias, and pain over the dorsal aspect of his left thumb of 6 months’ duration. On physical examination, the patient had a positive Tinel’s sign over distribution of his left superficial branch of the radial nerve. A preoperative EMG was positive for radial nerve compression and a sonography not show abnormal mass or intraneural lesions.

In the operating room, an oblique incision at a right angle to the superficial branch of the radial nerve was made over the dorsoradial aspect of the forearm at the level of the musculotendinous junction of the brachioradialis. The nerve was identified in the subcutaneous tissue. The tendinous portions of the brachioradialis and extensor carpi radialis longus were identified. Continuing the dissection proximally, the musculotendinous junction of the brachioradialis was identified. At this level, the superficial branch of the radial nerve was noted to exit at the dorsal aspect of the brachioradialis tendon. Upon dissecting the nerve proximally, a fascial ring from the dorsal edge of the brachioradialis was encountered circumferentially constricting the nerve.

The fascial ring was sharply incised while protecting the nerve. Upon releasing the fascial ring, an area of compression was clearly visible on the surface of the nerve.

Discussion

Wartenberg’s Syndrome is described as the entrapment of the superficial branch of the radial nerve, with only sensory manifestations and no motor deficits. Patients typically report pain and dysesthesias on the dorsal radial forearm radiating to the thumb and index finger.

No weakness or muscular abnomalies are present, in case of presence of this symptoms a more proximal lesion (of the cervical spine, posterior cord of the brachial plexus, or radial nerve proper) or perhaps a mass in the radial tunnel large enough to affect both the PIN and SRN can posed in differential diagnosis [6]. Wartenberg’s syndrome may be associated with the symptoms of de Quervain’s tenosynovitis.

A positive Tinel’s sign over the course of the nerve is the most common physical examination finding. Spontaneous resolution of the symptoms is common, for conservative treatment removal of the external compression like inciting element such as a wristwatch is essential.

For non-surgical treatments good result are reported by splinting, tens and non steroidal anti-inflammatory drugs. For the surgical management there is evidence in the literature documenting the good result reported by simple neurolysis of the nerve and removing anatomical variations of the muscle brachioradialis? [7,8].

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Fractures of the Proximal Third Tibia Treated With Intramedullary Interlocking Nails and Blocking Screws

Abstract

Background: Internal splint age of proximal metaphyseal tibial fractures has gained acceptance as a method of early stabilization of such injuries. Intramedullary nailing is a challenging procedure .This study tries to evaluate treatment outcomes of closed reduction and intramedullary nailing with the aid of blocking screws to maintain the reduction and stabilize theses injuries.

Patients and Method: Thirty patients (23 males and 7 females) with proximal metaphyseal tibial fractures were treated and followed from June 2010 and February 2014 (44 months) with average 19 months. Age ranged between 23 to 55 years (average, 38 years). According to A.O. Classification 13 cases were Type A 2.1, 9 cases were Type A 2.1 (II), and 8 cases were Type A 3.2. Seven cases were open fractures and according to Gustilo Anderson classification 4 cases were Grade (I), 3cases were Grade (II). All cases were treated by interlocking intramedullary tibial nailing assisted by the use of blocking screws technique.

Results: The results had been evaluated through the following parameters: (pain, union, malunion, infection, range of motions, walking capacity, extension lag, knee stability and implant and technical failure. All cases had been united. Excellent alignment obtained in 27 fractures (90%). Knee and Ankle joints range of motions were equivalent to the unaffected side in 25 patients (82%). Two patients got superficial wound infection (2.7%). The final functional results were evaluated through modified Karlstrom-Olerud Score and we get: Excellent: 20 cases (66.7%), Good: 7 cases (23.3%), Satisfactory: 2 cases (6.7%) and Poor: 1 case (3.3%).

Discussion: Intramedullary nailing of proximal tibial fracture is a load sharing procedure, sparing the extraosseous blood supply, avoids additional soft-tissue dissection, thereby minimizing the risk of postoperative complications. Also, it reduces the length of hospital stay and costs, enables early mobilization and achieves satisfactory outcomes. However; it is a technically demanding procedure and may result in malalignment. Our aim is evaluating the clinical use of Pollar screws (blocking screws) as a supplement to stability fixation of these fractures with statically locked intramedullary nails.

Conclusion: Utilizing intramedullary interlocking nailing supplemented with blocking screws to aid in stabilizing proximal tibial fractures whether closed or open is a good method of treatment. The high proportions of excellent and good results in our series confirm that this technique is equal to other known methods of fracture fixation.

Keywords: Intramedullary nail; Proximal tibia fracture; Blocking screws

Introduction

Proximal tibial fractures considered a more challenging injury. The goals of treating these fractures are: achieving bony union, restoring soft tissue vitality, preventing infection and instituting early joint motion and muscle rehabilitation [1]. A wide variety of nonsurgical and surgical methods of treatment are available. They can be used in isolation or in interesting combinations involving two or more methods, depending on peculiarity of fracture, the age and health of the patient and other imperatives that might be imposed by associated injuries. Although intramedullary nailing becomes a standard biological procedure for managing diaphyseal fractures of long bones; it is still a debatable issue regarding its use in proximal tibial fractures [2].

Patients and Method

Thirty patients with proximal tibial fractures were treated and followed between June 2010 and February 2014 (44 months) with average 19 months. There were 23 males and 7 females. Age ranged between 23 to 55 years (mean, 38years) years. In 17 cases (56.7%) fracture was due to road traffic accident, 11cases (36.6%) due to work related injuries, and in 2cases (6.7%) due to sport injuries. Seven cases were open (4were Grade (I) and 3 were Grade (II) according to Gustilo-Anderson classification [3].

According to the A.O. Classification: 13 cases were Type A 2.1 (medial oblique), 9 cases were Type A 2.1 (II) (lateral oblique), and 8 cases were Type A 3.2 (fragmented wedge) (Figure 1).

Exclusion criteria involved pathological fractures, adolescent patients below 17 years old, patient with previous diaphyseal fracture, non-united fractures and fractures extending to the articular surface. Ethical clearance was obtained from the institutional ethics committee and informed consent forms from all patients were received. All cases were stabilized by intramedullary interlocking tibial nails (8-10 mm of diameter and 34 to 38 cm long).

Surgical technique

Length and width of nail was provisionally determined preoperatively. The proper nail assembled to the Distal Locking Target Device to adjust distal locking screws position. All patients had been operated-upon under general anesthesia and were placed supine on a radiolucent table. For open fracture cases; thorough irrigation was done utilizing 2-4 liters saline solution. All contaminated, devitalized soft tissues were excised. Broad spectrum antibiotic was given (3rd generation cephalosporin, 2 gm IV) just before induction and continued for 2 weeks. The knee poisoned in 90 degree flexion. A longitudinal incision about 4 cm was made from the inferior pole of the patella just medial to the patellar tendon, and extended distally. The infrapatellar fat pad was identified and its insertion into the insertion into the proximal tibia was sharply incised transversely allowing its retraction superiorly for exposure of the proximal tibial ridge.

The entry point of nail detected and opened using a curved Awl. Guide-wire passed through medullary canal down to level of the fracture site under direct vision (in cases of Open fractures) while utilizing image intensifier (in cases of closed fractures) (Figure 2). The fracture was manipulated manually or by using percutaneous clamp to achieve reduction. The guide wire then was directed toward the distal fragment and its position was checked again radiographicaly for further confirmation (Figure 3). Blocking screws were inserted percutaneously. The anteroposterior screws were inserted in the distal aspect of the proximal segment, just lateral to the central axis of the proximal tibia. The sagittal plan screws placed in the posterior half of the proximal part of the tibia from a medial to lateral direction. The chosen nail attached to insertion jig and driven over the guide wire through the medullary canal. Distal locking Target Device assembled to the jig and distal locking screws were inserted first (Figure 4), then the proximal ones (Figure 5). Wounds closed and dressed.

Post-operative regimen

Wounds dressed every other day. Patients were mobilized on first postoperative day where knee and ankle joints exercises started. Partial weight bearing was encouraged for those who had no other associated injuries prohibiting walking. Patients were allowed for touch weight bearing on first post operative day, half weight bearing for three weeks then full weight bearing when callus was seen on follow-up X-Rays. Supervised physical therapy was initiated for thigh muscles strengthening and knee range of motions exercises.

Results

All patients agreed to present our timetable of follow up until they get their fractures united and started pain free full weight bearing. The patients were followed up postoperatively at 2 and 4 weeks, 3 months, 6 months, and 1 year. The mean length of hospital stay was 6 days (range 2-19days). The results of the study had been evaluated through: union of fracture, ranges of motion of both knee and ankle joints, alignment of fracture,occurrence of infection, degree of knee pain, walking capacity, extension lag and stability of the knee joint. All cases had been united. Average union time was 15 weeks in 12 patients (40 %), from 16-20 weeks in 15 patients (50%) from 21-28 weeks in 3 patients (10 %). There were no cases of nonunion. Knee and ankle joints range of motions were measured using Goniometer. In 25 patients (83.3%) it was equivalent to the unaffected side but 3 patients (10%) got knee joint flexion restricted to about 85°, whereas 2 patients (6.7%) had 10- 15° restricted range of ankle motions. Accuracy of reduction and final alignment were evaluated via assessing the immediate postoperative and the final follow-up radiographs.

Only 3 patients (10%) had malalignment. (Two of them had 10° and 40° varus angulation respectively and one case had 10° valgus). Two patients got superficial wound infection (6.7%). One of them got wound infection in the distal screw entry sites and one patient got wound infection in the proximal nail entry sites and both responded well to antibiotics. Regarding knee pain, it was assessed after complete union of fractures. Twenty- Two patients (73.3%) denied knee pain with any activity whereas 8 (26.7%) patients had at least moderate knee pain after vigorous activity. At last follow-up 28 patients were able to walk freely without assistance (cane or crutches), while 2 patients used walking aid during free walking. Two patients had extension lag about 100 while 3 patients had less than 15o lag the rest of patients (25 patients) had no extension lag. Only one patient had moderate knee instability. In our series No case of neither implant nor technical failure developed. The overall final functional results had been evaluated using Modified Karlstrom- Olerud Score (Tables 1 & 2).

Discussion

Controversy still remains regarding the use of IMN as a definitive management of proximal third tibial fractures [4,5]. Historically, these injuries have been notoriously difficult to fix and maintain without early failure in some reported series [6]. Malunion rates have been reported to be high and several earlier series offered high rates of fracture failure, typically into an apex anterior and valgus position [7,8] (Figure 6). The natural bony anatomy and muscular attachments of the proximal tibia offers the perfect set up for a number of common deformities after fracture with subsequent malalignment during IMN placement. These are due to muscular stresses via tendinous attachments [9]. The dynamic forces of the patellar tendon pull the proximal fragment into an apex anterior angulation, whereas the attachment of the pes anserinus causes valgus stress on the same fragment (Figure 7).

These forces; in addition to the capacious medullary canal at this level, create the potential for improper reduction and suboptimal nail placement during nailing with conventional techniques for IMN of proximal third tibial fractures with the knee hyper flexed [10]. Early frustrated results disappoint surgeons from using of IMN for proximal third tibial fractures. However, with continued research and proper understanding of the specific anatomy and deforming forces surrounding the proximal tibia; several technical modifications evolved that can maintain reduction, restore native anatomy and consequently improve outcome results. The accompanied studies exhibit high rates of union and low resultant deformities which renewed the interest of IMN usage for proximal third tibial fractures [11]. Our study outlines some of technical tricks and management pearls available for treating proximal third tibial fractures via IMN, with blocking screws in order to regain the normal mechanical axis, proper length and neutral rotation [12].

In our series; the coronal plan blocking screws are inserted in the distal aspect of the proximal segment, at a point just lateral to the central axis of the proximal tibia (not the central axis of the fracture); hence the nail passes medial to the blocking screws. In the sagittal plane; blocking screws are placed in the posterior half of the proximal part of the tibia (just posterior to the central axis) from a medial to lateral direction allowing the nail to remain to the anterior cortex as it is inserted down the canal (Figure 8). The pollar screws which had been used to supplement intramedullary nailing of tibial fractures would improve stability of fixation and minimize the development of angular deformity [13].

From mechanical point of view; Pollar screws function through the principle of 3-point fixation. By this it would abolish all forces exerted by muscles and ligaments on the proximal tibial fragment. Also, it lessen the path via the metaphysic [7,13]. We revised some studies utilizing same technique of fixation [10,11,13-15]. The prolonged period of follow-up which was not issued by some studies gave us a chance to predict even minor complications and those shortcomings that require very long period of follow-up [15]. The average age of patients was 34.4 years. This age group needed to return back to work as soon as possible, so early mobilization is mandatory. Union could be detected clinically when the patient is walking without pain on the operated leg with full weight bearing and on radiological examination bridging bone callus on at least three of the four cortices in the Antero-posterior and lateral views is visible.

No cases of non-union developed in our series and these results are more or less coincident with the results of other studies [14,16,17]. Malunion was analyzed at the time of union as the axis deviation between the proximal and distal fragment at the level of the previous fracture, on the anteroposterior and lateral x- rays. It was measured on long x-ray films and in some cases CT scanogram was utilized. Avoidance of this complication prohibits the development of joint pain and degenerative joint disease [18]. It was reported in 3 cases (10%); two of them were due to technical defects and the third case showed sever comminution and at the same time the patient bear weight early without protection as recommended by many authors [5]. Although Seven patients (23.3%) in this study have open fractures, there is a concern that performing an extended incision (which requisite arthrotomy) may lead to pyarthrosis.

Despite this concern, just one patient with open injury developed superficial infection. There was no cases of deep infection and this may be attributed to proper management of open fractures and preservation of soft tissue envelop around the fracture ends in addition to adequate antibiotic coverage [19,20]. Range of motions of knee and ankle joints as a key for evaluating efficiency of the technique was evaluated after complete union of fracture. There were 25 cases (83.3%) regained full range of motions for both knee and ankle joints and this attributed to the early rehabilitation of the patient’s joints In 5 cases (16.7%) the range of motions of knee and ankle joints were affected. All of them related to open fractures (3 Grade (I) and 2 Grade (II) which explains that the more the soft tissues damage the more the delay of patient recovery which in turn affecting the nearby joints range of motions [21].

The overall functional results were evaluated utilizing Modified Functional Evaluation System by Karlstrom-Olerud Score [22]. They were as follows: Excellent: 20 cases (66.7%), Good: 7 cases (23.3%), Satisfactory: 2 cases (6.7%) and Poor: One case (3.3%) (Table 3). Giving details of surgical technique as regard point of nail insertion, semi extended position during nailing, polar screws to avoid deforming forces acting on the proximal and distal fragments all are technical challenge to attain perfect reduction and finally good results [11,23]. In contrast to open reduction and internal fixation, intramedullary nailing can be performed initially on the first or second day of admission (Figure 9) presenting a female patient 25 years with open fracture proximal right tibia (A), after using the mentioned technique; the fracture fully united by 8 months (B), patient has full knee extension (C) and can put full weight bearing (D).

Conclusion

The results of the study share the idea that tibial nailing of proximal metaphyseal fractures aided by blocking screws being a suitable procedure. The advantages include being a familiar technique for fixing tibial shaft fractures; allows osteosynthesis under biological aspects; no need to open the fracture site; soft tissue dissection is not necessary; and the blood supply is spared. It enables symmetric, dynamic and load-sharing fracture stabilization without the need to restrict joint motion.

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Repair and Rehabilitation of Zone Five Tendon Injuries of the Wrist

Abstract

Background: Volar cut wrist injuries represent a challenge for most hand surgeons as the anatomical complexity of the hand mirrors its functional efficiency. A specialized management approach is often necessary to treat such injuries which are variables and multidisciplinary team can decrease the morbidity rate.

Purpose: To evaluate the clinical outcome of early repair and rehabilitation of zone 5 tendon injuries of the wrist and return to work after trauma.

Patients and Methods: This study included thirteen patients with volar cut wrist injuries. Ten patients were males and three patients were females. the age ranged from 18 to 46 years (average 30 years). All injuries were single sharp cut wound in flexor zone five. Injury was accidental in all patients without skeletal involvement. Neurovascular examinations were done, the sensory and motor components of the nerve tested clinically while assessment of the hand and fingers vascularity carried out by clinical study and hand held Doppler. The surgeries were done by a team of surgeons consists of orthopedic surgeon and neurosurgeon. All patients were subjected to an intensive rehabilitation program under supervision of a specialist in physiotherapy medicine. All cases were followed up for vascularity, sensation and functions of the hand, the average follow up was 8 months (range from 6 - 12).

Results: For thirteen patients over the period of clinical follow up, there was marked reduction in morbidity with satisfactory significant hand functions and no ischemia, neuroma or tendon ruptures were observed during the follow-up period.

Conclusion: Early and technically proper evaluation, exploration and repair of volar cut wrist injuries with programmed intensive rehabilitation protocol result in good functional outcome.

Keywords: Wrist injuries; Flexor tendons; Median nerve; Ulnar nerve; Functional disability

Abbreviations: PL: Palmaris Longus; FCR: Flexor Carpi radialis; FCU: Flexor Carpi ulnaris; FPL: Flexor Pollicis Longus; FDS Flexor Digitorum Superficialis; FDP: Flexor Digitorum Profundus; RT: Right; LT: Left; ED: Emergency department

Introduction

Hand injuries are common and account for 5-10% of emergency department (ED) injuries and 4.7% of all trauma patients [1]. Various mechanisms of injury can lead to volar wrist injuries, and the most common are; machine injuries, glass lacerations, knife wounds, and suicide attempts [2]. Flexor Zone five extends from distal wrist crease to the flexor musculotendinous junction as described by Verdan in 1959 [3].This is the most exposed and so the most vulnerable zone for injuries. Extensive injuries to flexor tendons and surrounding structures are sometimes referred to as spaghetti wrist [4]. The functional importance of the closely packed structures, blood vessels, nerves and flexor tendons, makes the injuries in this zone very hazardous and the carful management of paramount importance [5,6]. The aim of this study was to determine the clinical outcome for early repair and programmed rehabilitation of acute cut injuries in Flexor Zone five. Also to evaluate of the efficacy of multidisciplinary team in evaluation and management of acute volar wrist injuries.

Patients and Methods

The study includes thirteen patients with average age 30 years (range from 18 to 46). All patients with single sharp cut wound in Flexor Zone five (eight patients with knife cut and five patients with glass cut) presented within 12 hours from injury to emergency department (Figure 1). Patients with all other kind of injuries and patients with associated skeletal injuries were excluded from the study. Informed written consent was taken from all patients.

After resuscitation, pain management and tetanus prophylaxis, complete examination of the limb was done including proximal and distal neurovascular evaluation and musculoskeletal examination as thoroughly as could be done without causing pain and discomfort to patient. Rest of examination was with held till the patient was anaesthetized .

Investigations included baseline blood tests mainly complete blood count and radiological studies. The four most commonly involved structures included flexor carpi ulnaris, ulnar artery, ulnar nerve and flexor digitorum superficialis. Ulnar aspect of the wrist had more propensity for involvement followed by central cuts of wrist. Ulnar artery alone was involved in six cases, radial artery alone in three cases while both ulnar and radial arteries were involved in two cases and no vascular injury in two cases. Ulnar nerve alone was involved in three cases, median nerve alone in five cases while both median and ulnar nerves were involved in five cases. Superficial and deep flexor tendons of fingers were involved in all cases with a total of 65 tendons injured. Flexor carpi ulnaris was involved in eight cases and Flexor pollicis longus was involved in four cases. Flexor carpi radialis was involved in nine cases while palmaris longus was involved in ten cases (Table 1). The surgeries were done by a team of surgeons consists of orthopedic surgeon and neurosurgeon. All patients were operated under general anesthesia, tourniquet control and loupe magnification. In all cases, tendons were repaired first followed by nerves and finally vessels except in two cases where both ulnar and radial arteries were severed, hand needed revascularization and time since injury was approaching 6 hours, in which case ulnar artery was repaired first followed by the above sequence. All flexor tendons were repaired by modified Kessler repair with 4 core sutures with prolene 4/0 with knots in the centre followed by paratenon running suture circumferentially with prolene 6/0. Median and ulnar nerves were repaired with prolene 7/0. Ulnar and radial arteries were repaired with prolene 8/0. Postoperatively, hand was kept in a splint and elevated.

Postoperative physiotherapy rehabilitation program was started after 24 hours under supervision of specialist in physical medicine rheumatology and rehabilitation removing the splint during physiotherapy, initially with active extension and controlled passive flexion and passive range of motion exercises. After two weeks activity was progressed to placing objects but not holding and after 4 weeks holding objects but not exerting force. After 6 weeks holding and lifting light weights was allowed with progressively increasing resistance to flexion. After 6 weeks splint was worn only at night for another 2 weeks (Figures 4 & 5). Progressively increased activity was allowed from 8 weeks onwards. Patients were followed-up with evaluation of:

Patency of arterial repair

Nerve repair results (sensory and motor)

Active range of motion for fingers and wrist joint,

Grip strength was evaluated. Functional recovery was also evaluated by the duration of return to work.

Results

Thirteen cases with sharp cut wounds in Zone five of Flexor Tendons fulfilled the inclusion criteria during the study period. The average follow up period was eight months (range from 6 - 12).

A: Patency of arterial repair

The patients followed for patency of arterial repair by hand held Doppler. None of the patients required re-exploration for ischemia of distal limb. Doppler showed nine out of the eleven vascular anastomoses remained patent over follow-up period. One showed loss of anastomotic patency on the first postoperative day while another on second post-operative day, both in cases of isolated radial artery injury. Vascularity of hand was not found to be compromised in either case so reexploration was not carried out.

B: Nerve repair results (sensory and motor)

Nerve repair results were evaluated serially by advancing Tinnel’s sign, electrophysiological studies (nerve conduction study and electromyography) and sensory perception scored from (S0 to S4) compared to normal opposite upper limb. Seven cases out of eight repaired ulnar nerves showed sensory perception score (S4) level sensory return and one case had (S3). On the other hand, seven cases out of ten median nerves repaired showed sensory perception score (S4) level of sensory return, two cases showed (S3) level of sensory return and one case had (S2) level of sensory return. Power of intrinsic muscles of the hand was evaluated from (Grade 0 to Grade 5). Three Opponens pollicis had (Grade 5), six cases showed (Grade 4) while one case showed (Grade 3), out of 10 cases of median nerve repair. The other intrinsic muscles of the hand showed (Grade 5) in five cases, (Grade 4) in two cases and (Grade 3) in one case of ulnar nerve repair. Nerve conduction studies showed regenerative changes in all repaired nerves but the results of these studies did not always correlate exactly with clinical findings.

C: Active range of motion for fingers and wrist joint

The average wrist flexion was 77 degrees (range from 60 - 85) and average wrist extension was 75 degrees (range from 65 - 85). Active range of motion for fingers was evaluated by Strickland’s Adjusted Formula [(DIP + PIP) flexion - extension deficit x 100/175 degrees = % normal] with excellent from (75 - 100%), good from (50 - 74%), fair from (25 - 49%) and poor less than (25%). There were eight cases had excellent results, three cases had good results and two cases had fair results. Poor excursion was not found in any of the repaired flexor pollicis longus.

D: Grip strength

The power of grip strength was evaluated by using of Jamar dynamometer compared to normal side. The average grip strength was 75% of normal side (range from 60% to 90%). All patients returned to their previous work and recreational activities without disability. The patients returned to work in average 12 weeks (range from 10 - 16). One patient had superficial infection treated with oral antibiotics and daily dressing. Mild occasional wrist pain was recorded in two patients. The pain did not affect work status or daily activities and no need for medical treatment. Neuroma, tendon rupture or tendon adhesions did not recorded in any one of our patients but one patient had painful hypertrophic volar wrist scar treated with local corticosteroids injection and Silicone sheets for 12 weeks, the hypertrophic scar gradually regress.

Discussion

Injuries to the volar wrist surface have the potential to be severely debilitating, mainly due to the superficial location and high density of tendons, nerves and arteries in that area [1]. Extensive injuries to flexor tendons and surrounding structures are sometimes referred to as spaghetti wrist [4- 6]. The tendons have pretty less inherent tendency of healing. The functional integrity of hand requires intact neurovascular units and a stable platform in the form of a normal wrist joint [7]. Per-operatively, close proximity of structures poses a great challenge in identification of structures. Repair of structures is highly demanding especially in combined neural and tendon injuries [8]. Postoperatively, inter-structural adhesions are a major problem. Prolonged rest postoperatively increases the propensity for adhesions while early mobility impairs healing of nerves [8]. It was found that Zone five Flexor tendon injury is much more common in younger and manually working people. Tuncali et al. [2] studied a total of 228 patients with various types of upper extremity structures injuries. They concluded that tendon and nerve repair are far superior in the younger age group people [2].

This further supports the findings of Yrjana et al. [9] who studied the tendon repair in pediatric age group in 28 patients with 45 injured structures in upper extremity. Accidental injuries are far more common than suicidal and homicidal cases. So most of these patients are co-operative and motivated and have a high intent of recovery and return to work [10,11]. This further stresses on the need for early repair in these patients. This study shows that primary repair of flexor tendons has superior results as far as postoperative functional recovery is concerned compared to results of studies with delayed repairs. Chan et al. [10] came to same conclusion in their study of 31 zone 2 flexor tendon injuries. Strickland also agreed on an early primary repair of flexor tendons [11]. Primary repair of nerves also has a superior outcome [12]. In the present study the results of primary repair of ulnar and median nerves are comparable. This is shown by the improvement in sensation, which is comparable in patients post-ulnar and median nerve repairs.

Motor return in both groups of nerve repairs, shown by recovery of Opponens pollicis and adductors, is also comparable. This is in accordance with the Karaberg et al. [13] comparison of Ulnar and Median nerve repairs, in which they studied 55 patients post-ulnar and/or median nerve repair. This study also concludes that electrophysiological studies do not always co relate accurately with clinical assessment and so they should only be considered in conjunction with clinical evaluation rather than alone as a diagnostic tool as shown by Dutelli et al. [14] in their study as well. This study also implies that the increasing number of core sutures is directly proportional to the strength of repair and it does not hamper the healing or gliding of tendons. It did not have an impact on the adhesion formation as well which is in accord with a number of other studies.

An additional advantage of multiple core sutures, four in case of this study is that early mobilization and physiotherapy can be carried out which has beneficial effects in both promotion of healing and prevention of adhesion formation, as stated by Morya et al. [15] in their study of various suture techniques for flexor tendon repair. There has always been a debate on early versus late mobilization post-tendon repair. Some believe in commencement of early physiotherapy while others believe in prolonged rest post-tendon repair. In this study it was seen that with proper technique of repair, early mobilization and therapy is safe and indeed beneficial. It has been proposed as the stress theory that controlled early stress promotes the healing process of tendons. Prolonged rest post-tendon repair may be responsible for adhesion formation which is an important limiting factor in the final recovery and return of function after tendon repair. This was also shown in an elaborate study by Hung et al. [16]. Some of these studies were characterized by the variation of settings in which the injuries occurred including domestic neat blade cuts to industrial machine injuries with grossly contaminated wounds. Also some patients were more motivated in rehabilitation therapy than others. It is beyond the scope of this study to achieve all these standardizations.

Conclusion

Care of patients with acute hand injury begins with a focused history and physical examination. In most clinical scenarios, a diagnosis is achieved clinically. While most patients require straight forward treatment, the emergency clinician must rapidly identify limb-threatening injuries and obtain critical clinical information. From all results reported in the present study, it can be said that, multidisciplinary team can evaluate and manage acute volar wrist injuries saving time and decreasing post-operative functional disability with short time to return to patient’s daily activity due to accurate repair of injured structures, early movement and appropriate rehabilitation program which need patient co-operation.

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Osteoporosis and Osteopenia in Patients with Osteoarthritis

Abstract

Both osteoporosis and osteoarthritis are recognized as age related skeletal disorders, but it is commonly held that these diagnoses do not often occur together in the same patient. Recent studies of bone mineral density scores in subjects with osteoarthritis indicate that osteoporosis occurs worldwide in 21-32% of patients with advanced osteoarthritis. Advanced age and low body-mass-index are major discriminating factors for osteoporosis in osteoarthritis. Because of clinical implications of osteoporosis in patients being managed for osteoarthritis, it is important to identify and refer for osteoporosis evaluation those patients at risk.

Osteoarthritis

Osteoarthritis (OA) most frequently involves the hands, knees, hips, and spine; it is diagnosed on the basis of joint pain and radiographic evidence of non-uniform narrowing of a joint space, osteophytes, and subchondral osteosclerosis and cysts [1,2]. There are three etiological classifications; Type I is genetic, Type II is estrogen-dependent, and Type III is aging-related [3] (Table 1). The generalized pillars of aging that affect other tissues also pertain to cartilage [4]. These include inflammation, oxidative stress, molecular damage, proteostasis, autophagy, and stem cell depletion. Recent data indicate that factors produced by excessive adipose tissue, such as leptin, may play direct roles in pathogenesis and/or progression of OA [5].

The pathophysiology of OA may involve both articular cartilage and subchondral bone. Articular cartilage is avascular, alymphatic, and aneural, with a single cell type, the chondrocyte, capable of both anabolic and catabolic activities [6,7]. Articular cartilage is 70% water and 30% collagen, other noncollagenous proteins, and glycosaminoglycans. Its ultrastructure is critical to its function. The collagen is Type 2, and the collagen fibrils are located in a parallel array at the surface (lamina splendens) and ultrastructural studies reveal that the subsurface collagen fibrils form arcades (arcades of Benninghoff) between the lamina splendens and the subchondral bone. The negatively-charged glycosaminoglycans imbibe water to give an ideal cushion to absorb load. The chondrocytes are arrayed throughout the matrix and receive nutrients that percolate from the synovium through the matrix. This requires a certain pressure on the articular surface, roughly 20-25 kg/cm2. Insufficient load to the cartilage will prevent the nutrients from entering the matrix. Once the upper limit of load is exceeded, the cartilage begins to break down. The chondrocytes attempt to repair, but cannot overcome the disintegration of matrix architecture. The classical understanding of OA is as a problem of wear-and-tear, but this is likely an oversimplification [2,4,5].

There is growing evidence that the subchondral bone may intitiate OA [8]. Radin and Rose proposed that subchondral bone stiffening in OA may result from healing of trabecular microfractures due to joint overloading or misalignment; such an alteration in the biomechanical environment could produce damage in the overlying cartilage [9]. Subchondral thickening and confluence of trabeculae are exceedingly focal, occurring in regions with the thinnest overlying cartilage [10]. Formation of osteophytes, subchondral osteosclerosis, and evidence of increased uptake of radioactive strontium [11] suggest increased bone formation in OA. Studies comparing subchondral bone specimens from OA and control, non-OA subjects showed abnormalities in OA osteoblasts, including decreased responses to PTH and PGE2 and increased urokinase plasminogen activator, alkaline phosphatase activity, osteocalcin, and IGF-I release [12]. A detailed microCT and histological study of subchondral bone from women requiring knee arthroplasty revealed two patient subtypes; subchondral trabecular bone volume doubled under regions with complete loss of cartilage in the majority of specimens [13]. Five of 20, however, were non-sclerotic even with extreme loss of cartilage. The non-sclerotic group showed greater vascular penetration and a greater osteoclastto- osteoblast ratio. These histopathological differences in subchondral bone suggest important metabolic differences that need to be better understood, given the possibility of different therapeutic approaches.

Osteoporosis and Osteopenia

OP is called “a silent disease” because it may not be recognized until a fracture occurs upon minimal trauma, such as a fall from a standing height. OP fractures are also termed fragility or low-energy fractures. A useful distinction was made between Type I (post-menopausal) and Type II (senile) OP, the former being associated with fractures in women within 20 years after menopause and the later occurring in men and women 70 years of age or older [14]. Type I OP is characterized by fractures at sites rich in cancellous bone, such as vertebrae (crush type fractures), wrist, and ankle. Type II OP entails hip and wedge-type vertebral fractures, although fractures of the proximal humerus, proximal tibia, and pelvis are common.

Bone mass decreases with menopause and age due to an excess of bone resorption relative to formation. There have been many ways to monitor bone loss, including radiographic indices, photon absorptiometry, and computed tomography. There is a reproducible association of fracture risk with dualenergy x-ray absorptiometry (DXA) measurement of bone mineral density (BMD), such that fracture risk doubled for each standard deviation (SD) decrease in BMD. This led the World Health Organization (WHO) to establish a scale for diagnosis of osteoporosis and osteopenia [15]. Osteopenia is defined as a value for BMD that lies between 1 and 2.5 SD below the young adult mean value. Osteoporosis is defined as a value for BMD that is more than 2.5 SD below the young adult mean value. Severe or established osteoporosis is defined as a value for BMD more than 2.5 SD below the young adult value in the presence of one or more fragility fractures. Reference young adult mean values are specific for men and women, for different countries, and for different racial and ethnic groups. These diagnostic criteria remain the guides for treatment decisions. An advance that takes other patient factors into account (age, family history, previous fracture, glucocorticoid use, smoking, alcohol use) are seen in the nation- and race-specific FRAX calculator:

[http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9], a tool that estimates the 10-year probability of fracture for an individual.

Age is a major risk factor for osteoporosis (Table 1). Agerelated changes in bone tissue contribute to its loss of mechanical properties [16]. The mechanical properties of samples of cortical bone decrease by 7-12% per decade in fracture toughness [17]. There are age-related changes in collagen that generate advanced glycation end products (AGE) associated with mechanical deterioration [18]. Further, bone and blood from osteoporotic fracture patients have a higher content of AGEs than do samples from controls. There are also age-related changes in the mineral component of bone that result in accumulation of larger, dense crystals that make bone more brittle with decreased fracture toughness [19]. Micro architectural changes with age contribute to bone quality and fracture risk; these include loss of trabecular connectivity and thickness, increases in cortical porosity, and accumulation of micro cracks.

Bone-active hormones play multiple pathophysiological roles in osteoporosis. Women and men undergo multiple aspects of endocrinologic aging that have impacts on bone metabolism (Figure 1). To different degrees, both men and women experience menopause, andropause, and adrenopause, and their effects upon the skeleton [20]. The abrupt post-menopausal loss of bone mass is primarily due to increased resorption unfettered by estrogen, and the slower age-dependent phase results mainly from impaired bone formation due to loss of osteoanabolic activities. Estrogen suppression of osteoclastic bone resorption entails reduction of pro-resorptive factors including Interleukin-6. Age-associated declines in circulating estrogens, androgens, and adrenal dehydroepiandrosteronesulfate contribute to decreases in bone formation that are mediated locally through IGF-I.

Origin of the Inverse Hypothesis

Both OA and OP are recognized as age-related skeletal disorders, but it is commonly held that these diagnoses do not often occur together in the same patient. In 1972, Foss & Byers [21] noticed the absence of radiographic osteoarthritic changes in hips of osteoporotic patients with hip fractures [21]. That study was not well-matched for age or gender, but was taken as evidence for an inverse relationship between the two diseases, OA and OP. It remains widely held that “osteoarthritis protects against hip fracture” [22]. The hypothesis was appealing because of the observations that patients with a high body mass index (BMI) are at risk for OA and those with low BMI are at risk for OP.

The most recent systematic literature review of the relationships between hip fracture and OA at various joints was limited in drawing any conclusions because of the small numbers of eligible articles, different case definitions, only moderate agreement among reviewers, and heterogeneity in numerous covariates [23]. Those authors indicated the need for studies with evaluation of joints by magnetic resonance imaging (MRI) and evaluation of bone by BMD.

To be sure, BMD measured at the femoral neck of OA hips was significantly greater than for age-matched non-OA subjects [24], but this does not address the question of systemic OP. A detailed twin study found increased BMD only at the OA-affected site and not at other sites [25].

Coexistence of Osteoarthritis and Osteoporosis

Surgeons use radiographic indices of bone quality for arthroplasty treatment planning, knowing that poor bone quality is a determinant of intraoperative fracture risk and poor prosthesis longevity. The Dorr classification of femoral geometry distinguishes three types of bone (A, B, C) and a measurement of cortical thickness to characterize the quality of the implantation site [26]. There are strong correlations between bone types and cortical thickness that were validated by histomorphometric indices of bone microarchitecture. It is notable that 63% of the osteoarthritic men and women studied had radiologic and histomorphometric evidence of osteopenia. More recently, we found strong correlations between BMD T-scores and Dorr radiographic parameters in a cohort of OA women [27].

BMD studies of OA subjects provide consistent evidence of the coexistence of OA and OP [2]. We initiated a study to characterize women presenting for hip arthroplasty for OP hip fracture, compared with OA subjects scheduled for hip arthroplasty as a non-fracture control group [28]. An unexpected finding was that 25% of OA subjects met the WHO criterion for OP (having BMD T-score of less than -2.5). They also had elevated markers of bone turnover, statistically equivalent to those with OP fracture [29]. These findings clearly reject the hypothesis that all OA women are protected against bone loss and OP risk. Vitamin D-deficiency was common in both groups of OA women with and without occult OP. OP was found even in the early post-menopausal period, but there was a significant effect of years-since-menopause on T-scores and bone turnover markers. In addition, OA subjects with lower weight or lower BMI had poorer quality of bone by both radiographic and DXA measures.

Subsequent BMD studies of subjects with advanced OA revealed OP in 21-32% of women and men. A Finnish study reported 28% of OA women had OP and 45% had osteopenia (BMD T-score between -1 and -2.5) [30]. A German study revealed OP in 29% of women and 20% of men with OA, with age as a significant risk factor [31]. In that study, 37% and 43% of the male and female patients, respectively, had osteopenia. A British BMD study reported that 23% of patients with endstage OA had evidence of OP at one or more sites and a further 43% of patients had osteopenia at one or more of the sites measured [32]. A Brazilian study reported that 21% of OA men and women awaiting hip arthroplasty had osteoporosis and 38% had osteopenia [33]. A Slovakian study detected 32% of hip arthropathy subjects with osteoporosis and 21% with osteopenia; lower BMI was found to be associated with osteoporosis [34]. A number of generalizations can be drawn from our and others’ studies with OA subjects awaiting arthroplasty. Most groups reported a high incidence of vitamin D-deficiency in their cohorts, but not significantly greater in the OP groups. Advanced age and low BMI are major discriminating factors for OP in OA subjects.

There is limited information about rates of bone loss in OA and non-OA subjects. A large longitudinal cohort of communitydwelling subjects between the ages of 50 and 80 years was used for analysis of changes in hip BMD over 2.6 years and correlation of those changes with baseline hip and knee OA [35]. Non-OA and OA subjects had equivalent baseline hip BMD scores. Subjects with radiographic hip or knee OA had significantly greater total hip bone loss, as much as 3.6-fold. The authors considered it unlikely that differences in mobility accounted for the findings because there were equivalent changes in pain scores and in numbers of steps taken per day (by pedometer).

A different approach by investigators in Norway entailed analysis of OA in patients with a hip fracture, compared with patients hospitalized for hip contusion, the fracture being considered by the authors as an indication of greater bone fragility [36]. Finding similar prevalences of radiographic OA in those two groups led the authors to reject the hypothesis that OA protects against sustaining a hip fracture.

Some information is available from subjects with shoulder OA [37]. Based upon BMD T-scores at the femoral neck, 12% of 230 women and men were osteoporotic and 46% were osteopenic. Several predefined risk factors were associated with low hip BMD in subjects with shoulder OA: female sex, advanced age, sedentary lifestyle, prior fracture, family history of fractures, thyroid replacement therapy, and inflammatory joint disease. Hounsfield unit (HU) measurements from shoulder CT scans were found to be significantly correlated with femoral neck BMD. The investigators urged surgeons to use humerus HU and patient characteristics to identify and refer patients at risk for osteoporosis.

A large longitudinal cohort of Australian men and women was used to examine the effect of BMD on the association with self-reported OA and with fracture incidence during the follow-up period of 0.1 to 22 years [38]. Consistent with many previous findings, prevalence of OA increased with each higher BMI and femoral neck BMD category. Fractures were identified by radiological evaluations and were found to be significantly greater for women, but not men, who had self-reported OA. Both OA women and men had greater reported falls than did the non-OA women and men, and falls may have some part in the observed OA-fracture relationship for women. The associations were stronger for vertebral and limb fracture than for hip fracture. Additional inexplicable findings were that fracture incidence was not elevated in women with osteoporotic BMD scores and that OA-hip fracture relationship disappeared upon adjustment for age, BMI, and hip BMD. It appears that the OA women were older than the non-OA group and that OA was not in advanced stages. More details are needed about OA diagnosis, joints involved, duration of OA, and nature of the falls in order to interpret those findings. A smaller survey of Canadian women and men scheduled for hip or knee arthroplasty indicated OP in 26%, as defined by reporting a physician’s diagnosis, history of a fracture occurring as a result of a fall from standing height or less, or current treatment for OP with bisphosphonates [39].

Clinical Implications of Osteoporosis in Osteoarthritic Patients

It is critical for surgeons to recognize the quality of bone in patients undergoing surgery for advanced OA. There are great implications brought about by OP in OA both in consideration of joint replacement and complications following joint replacements. A major consideration of initial fixation of uncemented implants in OP bone is that any micromotion would decrease construct stability and thus interfer with ingrowth at the implant/bone interface. There is risk of periprosthetic fracture due to the unfavorable combination of osteoporosis, stress shielding, and the differences between the modulus of the implant and the bone. The Dorr classifications are useful for surgical planning in cases of Dorr type C (osteoporotic) bone where use of cement may be indicated. Methylmethacrylate cement has a modulus between cortical and cancellous bone and can mollify the differences between sclerotic and OP or osteopenic bone.

OP can produce specific complications in an obese female with varus osteoarthritis of the knee. The patient may have general osteoporosis and sclerosis on the medial side. If there is significant core obesity and a long moment of increased load, the patient may be better served if the tibial component has a longer stem to prevent collapse of the tibial surface.

Studies that included bilateral hip BMD for subjects with unilateral hip OA raise warnings about BMD screening for OP in the general population [28,30,40,41]. In all studies, femoral neck BMD or BMC measurements were significantly higher in the OA hip than contralateral, non-OA hips for both women and men. Because measurements of BMD are commonly done in only one hip (usually the non-dominant), bilateral differences in subjects with occult hip OA may result in differences in osteoporosis classification and treatment decisions. In fact, the calculated probabilities for total or hip fracture according to the FRAX calculator were confounded by the presence of OA [42]. Thus, clinicians who perform bone density testing should assess the possibility of OA in 1 hip and measure the BMD on the contralateral hip.

Conclusion

A subset of OA patients with advanced age and low BMI may have low bone density at non-OA sites and if left untreated may be at risk of fragility fracture.

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Clinical Review about the Role of Platelet Rich Plasma for the Treatment of Traumatic and Degenerative Musculoskeletal Disorders

Abstract

The use of orthobiologics compounds is rapidly expanding in the field of orthopedics and sports medicine. Platelet rich plasma (PRP) represents the second generation of ortobiologics that has numerous advantages as an autologous blood derivate for the treatment of traumatic and degenerative musculoskeletal diseases. Platelet is naturally involved in haemostasis and tissue healing processes due to their content in growth factor and other bioactive molecules. Basic science and preclinical evidence supports the use of platelet derived growth factors as well as of PRP for enhancing reparatory processes in musculoskeletal tissues. Clinical results about the use of PRP for bone, tendon, cartilage or muscle healing are encouraging and continue to accumulate in the recent years. Proteomic profiling and biomarker based PRP characterization have the potential of advancing the field of PRP application. High quality studies are awaited in order to enable clear cut therapeutic indications

Keywords: Platelet rich plasma; Orthopedics; Tendon; Osteoarthritis; Bone; Muscle

Abbreviations: PRP: Platelet Rich Plasma; BMP: Bone Morphogenetic Protein; HA: Hyaluronic Acid; WBC: White Blood Cells; RBCs: Red Blood Cells; ADP: Adenosine Diphosphate; ATP: Adenosine Triphosphate; TGF: Transphorming Growth Factors; PDGF: Platelet Derived Growth Factor; ECM: Cell-Extracellular Matrix; FGF: Fibroblast Growth Factors; IL-1: Interleukin -1; MSCs: Mesenchymal Stem Cells; TNF-α: Tumor Necrosis Factor α; NFκβ: Nuclear Factor Kappa-Beta; 3D: Three Dimensional; ADSC: Adipose Derived Stem Cells; ACT: Autologus Chondrocyte Implantation Techniques; GF: Growth Factors; PRF: Platelet Rich Fibrin Products; OA: OsteoArthritis; KL: Kellgren-Lawrence; IA: IntraArticular; IKDC: International Knee Documentation Committee; KOOS: Knee Injury and Osteoarthritis Outcome Score; MRI: Magnetic Resonance Imaging; HHS: Harris Hip Score; VAS: Visual Pain Analogue Score; OCL: OsteoChondral Lesions; PCL-TCP: PolyCaproLactone-20% TriCalcium Phosphate; TLIF: Trans-foraminal Lumbar Inter-foraminal Fusion; VEGF: Vascular Endothelial Growth Factor; HGF: Hepatocyte Growth Factor; RCT: Rotator Cuff Tear; ACL: Anterior Cruciate Ligament Reconstruction; DASH: Disabilities of the Arm; Shoulder and Hand; CRAT: Chronic Recalcitrant Achilles Tendinopathies; MRSA: Methicillin-Resistive Staphylococcus Aureus

Introduction

The use of orthobiologics is expanding at a rapid pace in the field of bone and joint surgery, tendon and wound healing [1]. While a precise definition has not been elaborated, orthobiologics are considered to be the naturally occurring elements that are used in order to initiate, augment or modulate healing of bone, joints, tendons, ligaments, muscles and/or cutaneous defects. Among the biological compounds currently considered as orthobiologics are included the bone grafts of various origins, autologous blood and conditioned serum, platelet rich plasma (PRP), growth factors and stem cells. Some of these factors such as bone grafts or autologous blood have a long history of use in orthopaedic and/or rheumatologic settings. The use of platelet rich plasma (PRP) or stem cells has been initiated with the beginning of the third millennium and is currently in different stages of penetrating clinical practice. Taking advantage of cutting edge research and using advanced technologies, orthobiologics are processed or engineered to respond to a certain clinical need.

The era of orthobiologics is considered to originate in the pioneering discovery of bone morphogenetic protein (BMP), the first growth factor to be described. Marshal Urist [2] an orthopedic surgeon, isolated BMP from demineralized bone matrix demonstrating its role in bone healing of fractures and nonunion. The modern use of orthobiologics has been stratified by some authors in three stages of increasing complexity as referring to the intrinsic mechanism of action. The first generation is represented by viscosupplementation with hyaluronic acid (HA), the second stage involves the use of PRP while the third and most advanced stage consists in cell based therapies and the use of growth factors [3,4]. In the following we will introduce basic science motivating the use of PRP further presenting the current status of the use of PRP in orthopaedic practice in the field of cartilage, tendon and bone healing.

Platelet rich plasma for musculoskeletal healing

PRP is a plasma suspension derived from whole blood containing variable amounts of platelets [5] Depending on the preparation process PRP might contain as well white blood cells (WBC) and red blood cells (RBCs). Platelet content ranges from 2 to 6 fold above baseline, making PRP a valuable source of concentrated autologous platelets. PRP is usually prepared from autologous blood using extracorporeal blood processing methods such as cell savers/separators, centrifugation or filtration [6]. The large variability of blood processing methods result in plasma samples with variable composition and platelet content that inevitable influences the biological effect [7].

PRP was used for the first time in 1987 as a blood substitute during open heart surgery [8]. In 1990 an autologous fibrin sealant (fibrin glue) obtained by polymerization of fibrinogen with thrombin or calcium chloride [9] was introduced as a topical hemostatic while the first preparation of an autologous PRP product from a small quantity of blood was described in 1999 [10]. Initially used in dental and oral and maxillofacial surgery, PRP use has spread in various fields from sports medicine to cosmetics, orthopedic surgery and ophthalmology. The relatively low cost, easiness in use as well as massive commercial involvement has facilitated PRP rapid expansion in medical practice. As with every relatively new method, the use of PRP has opponents and advocates. There is a strong basic science motivation for the use of platelet concentrate as a healing promoter and/or enhancer, however, evidence from welldesigned clinical trials to support specific clinical indications are only beginning to accumulate.

Basic science- platelets and their role in hemostasis and tissue healing

Platelets are the smallest cellular components of blood. With a diameter ranging from 2-6 μm, platelets are a-nucleated but do have, however, cellular organelles such as mitochondria, a contractile cytoskeleton and intracellular vesicles. Platelets are formed in the bone marrow representing fragmented parts of cytoplasm from megakaryocytes differentiated from a myeloid precursor. Platelets contain among intracellular vesicles dense and alpha granules. Dense granules content consists in calcium, serotonin as well as Adenosine diphosphate (ADP) and Adenosine triphosphate (ATP) molecules. Alpha (α) granules are formed during megakaryocyte stage; contain clotting factors as well as more than 30 types of growth factors, cytokines and other proteins [11]. Platelet membrane is folded and contains an interconnected network of canaliculi. In normal resting state, platelets have a round shape and are not thrombogenic. Upon activation platelets spread their membrane forming pseudopodia, aggregate and release their granular content through canaliculi system exerting their role in haemostasis and wound healing.

Haemostasis involves the balanced action of local vasculature, plasma factors as well as platelets. After an injury, blood vessel walls contracts, the exposed sub endothelial collagen binds the plasmatic Von Willebrand factor facilitating platelet adhesion and activation. Other two mechanisms are the Thromboxane A2 from arachidonic acid within the phospholipidic layer of cellular membrane and thrombin activation. Upon activation platelets release their granular content resulting in the formation of initial clot plug. The second haemostasis stage involves the formation of fibrin from blood fibrinogen by activation of the coagulation factors cascade. Fibrin network stabilizes the platelet plug consolidating the clot. The third haemostasis step involves the activation of WBCs that release fibrinolytic cytokines that will produce clot lysis and blood vessel re-permeabilization after healing [12].

Wound healing is a complex event that involves intercellular, cell-extracellular matrix (ECM) interaction as well as growth factors and cytokines. The type of healing response and efficiency depends on the extent of injury and wound type. In this process, platelets and platelet released growth factors such as platelet derived growth factor (PDGF) have a significant role. Basically wound healing begins with blood clotting process and local haemostasis. Further on, in the following 2-3 days, inflammation is produced by migration of blood neutrofils and subsequently of tissue resident macrophages. Activated macrophages release growth factors such as members of transphorming growth factors (TGF) family, fibroblast growth factors (FGF), PDGF, interleukin -1(IL-1). After third day, local angiogenetic processes as well as fibroblast proliferation begins, followed by ECM collagen deposition after day 5. Wound epithelization in the case of skin injuries and tissue remodelling concludes the healing process that can last 10-14 days depedingly on anatomic location and host dependent parameters [13]. Platelet derived growth factors are therefore involved in multiple stages of wound healing starting with degranulation process and inflamation, to matrix deposition, colagen production and reepitelization. It is important to note that an important part of the growth factors contained by the α granules have receptors on various musculoskeletal tissues justifying their use for enhancing healing of these structures.

In the process of fracture repair and calus formation (bone healing) platelet derived growth factors exert a stimulatory action on bone cells. Bone growth, turnover and repair after fracture or in surgically induced fusion processes represents an interplay between the activity of cellular elements and numerous biochemical and biomechanical factors. Cells (osteoblasts, osteoclasts, osteocytes, osteoprogenitor cells, and the hematopoietic component in the bone marrow) cooperate in matrix deposition, resorbtion and remodeling [14]. Similar with the wound healing process, fracture repair and calus formation incorporates an innitial stage of clot formation, followed by inflamation, proliferation and remodelling. At fracture sites, platelet degranulation release PDGF, members of TGF-β family, EGF, that are present as well in bone and cartilage. Chondrocytes and osteocytes are enriched in TGFβ1 receptors [15] while a combination of PGF, TGF- , FGF, and EGF has been found to stimulate osteoblast differentiation to mature osteocytes [16]. Platelet derived growth factors are involved in bone healing in by three mechanisms: during osteogenesis induce the presence and proliferation of osteoprogenitor cells within the fracture area, participate to osteoinductive process by stimulating progenitor differentiation to mature osteocytes being involved as well in osteoconduction. Osteoconduction requires the presence of a natural or synthetic scaffold acting as a ECM (a natural autologus or allogeneic bone graft of a syntethic cone substitute). Platelet derived growth factors, especially PDGF was shown to be involved in chemotaxis of stem cells, mitogenesis and differentiation, contributing to graft population and de novo bone formation [17]. This supports the use of PRP for enhancing bone repair in fractures, in combination with bone grafts in non or delayed unions and bone fusion procedures.

Cartilage repair and regeneration Cartilage lesions, traumatic or degenerative, are challenging to treat due to the inherent tissue structure with a poor cellularity and lack of vascularity that does not allow for innitiation of classical wound healing processes [18]. In vitro and in vivo studies on the effect of different PRP formulation or platelet derived growth factors are available (for a systematic review of basic science of cartilage repair using PRP [19]. PRP was found to increase chondrocyte and mesenchymal stem cell (MSCs) proliferation [20] and to increase cartilage ECM compound synthesys (proteoglycan, glycosaminoglycan, and type II collagen deposition) [21]. In inflmatory conditions, in the presence of IL-1β, tumor necrosis factor α (TNF-α) or nuclear factor kappa-beta (NFκβ), PRP partially decreased the inhibitory effect of inflamation on collagen II and aggregan gene expression [22] with strong restoration of type II collagen and proteoglycan from the inhibition of IL-1β+TNF-α in a three dimensional (3D) model in the presence of collagen matrix [23].

Evidence from animal studies using PRP formulation as adjunct therapy in focal cartilage repair procedures reported histological improvment of repair tissue [24] while others reported worsening gross apearance and histological scores compared to untreated group [25]. ECM matrix deposition proteoglycan [26] or collagen II content of repair tissue [27] increased in the PRP treated groups compared to control. PRP was found to increase gross and histologic appearance of focal defects treated with PRP conditioned adipose derived stem cells (ADSC) pointing toward a method for enhancing chondrogenesis [28]. In vivo studies using PRP for treating osteoarthritis or inflamatory arthritis reported the increase of proteoglycan mRNA levels, cartilage macroscopic and histologic appearance as well as attenutation of synovial and cartilage inflamation. The pro inflamatory environment of arthritic joints could be modulated by platelet growth factor release and PRP administration [29]. It has been proposed that PRP application could improve cartilage repair after bone marrow stimulation techniques by improving subchondral plate derived MSCs chondrogenesis [30]. PRP could be used as well in combination with scaffolds when repairing chondral or osteochondral defects or in combination with autologus chondrocyte implantation (ACT) techniques [31].

Clinical results regarding PRP application

The main rationale for using PRP in clinical practice is to deliver a concentrate of platelet derived proteins including growth factors (GF) that assist and enhance the reparative processes. The ease of preparation of an autologus blood derivative at the time of surgery or application is appealing. In an appropriate laboratory, operating theatre or even in an appropriate room of an outpatient clinic facility, PRP can be prepared in the extent of couple of minutes using commercially available equipments from blood collected by venous puncture using an anticoagulant. Non coagulated blood is used mostly for preparation of fibrin and/or platelet rich fibrin products (PRF) [32]. PRP can be delivered via open or arthroscopic surgery during various orthopedic procedures as a step of a ligament, meniscal, tendon or muscle repair. PRP can be mixed with bone or ligament grafts, and is usually activated in order to form a gelatinous mass that is easier to handle during open surgery. Minimally intervention procedures in the form of injection therapy using fluid PRP can be performed by a sports medicine, rheumatologist, physical therapist or orthopedist. Injectional therapy is preferably performed under ultrasound guidance to maximize results [6,33]. PRP prepared from blood collected on anticoagulant can be activated at the preparation time. For activation, calcium chloride, autologus prepared thrombin or soluble collagen type I are preffered to bovine thrombin products due to risck of inducing coagulopathy [34]. Collagen activation might be prefferable for preserving growth factor avaialbility than thrombin [35]. Other oppinions advocate the use of inactivated PRP since platelets can be activated by the contact with the tissue to be treated. From platelet granules 95% of growth factors are relased during the first hour post preparation. In the following 5-7 days platellets secrete and release additional growth factors. Different types of PRP preparation exist and a working classification based on platellet and fibrin content is currently accepted and validated [36,37] (Table 1).

Clinical application of PRP in joint healing

Joint environment requires a delicate balance of catabolic and anabolic factors that promote development, turnover and repair. The currently definition and treatment orientation focused mainly on cartilage pathology is giving way to a more integrative approach conssidering joint as a complex organ componed of subchondral bone, synovial tissue, fatty sinovium, subcutaneous fat as well as cartilage, intraarticular tendon and menisci and periarticular ligaments [38]. The intraarticular use of PRP products could act simoultaneously in a concerted manner to restore protein synthesis to rebalance metabolic pathways that are disturbed in post traumatic, degenerative or inflamatory joints. It has been used to treat cartilage lesions, to prevent posttraumatic arthritis and to retard progression in osteoarthritis and rheumatoid or psoriasic arthritis. In a systematicc review including 59 papers of which 22 clinical studies, Filardo et al. [39] concluded that the existent clinical evidence denotes overall good outcomes and no adverse effects. Instalation of results as well as the reported clinical benefits are more likelly be the result less of cartilage restauration but more of overall joint metabolic balancing. Thus, tissue regeneration in itself might not be the predominat mechanism of PRP action thac could rather induce reduction of inflamatory mechanisms. Reduced inflamatory cell chemotaxis toward symovium and periarticular tissue has as result decreased pain and increased mobility [39]. In a case series of 50 active patients with knee osteoarthritis (OA) grade 1-3 Kellgren-Lawrence (KL) were treated with 2 intraarticular (IA) injections at 1 month interval of autologous PRP were followed up to 1 year using International Knee Documentation Committee (IKDC) subjective and objective score, Knee injury and Osteoarthritis Outcome Score (KOOS) and magnetic resonance imaging (MRI).

All patients significantly improved in terms of pain and reported quality of life [34]. In a prospective, randomized, comparative clinical trial enrolling 104 patients with unilateral hip OA followed up over 12 months, autologous PRP was delivered in three doses over two weeks interval under ultrasound guidance. Harris hip score (HHS) and visual pain analogue score (VAS). Compared to the use of hyaluronic acid (HA), PRP was proved to be as safe and efficacious as HA at 12-month follow-up in terms of functional improvement and pain reduction [33]. A non-randomized, prospective study on 312 patients with knee OA and Outerbridge I-IV chondropathy were treated with three IA PRP doses at 2 weeks interval. Significant improvement in pain and functional parameters were recorded at 6 months post last injection [40,41]. A prospective study compared the use of PRP versus high and low molecular weight HA in 150 patients with knee OA. At 2 months interval, similar improvements in terms of pain and function was recorded in PRP and high molecular weight HA groups, however PRP group showed significant improvement at same parameters at 6 months follow up [42]. It has been argued that to date the power as well as quality of the studies being limited the role of PRP injections in the treatment of OA is still unclear [43,44]. However, high level evidence studies are beginning to accumulate supporting the use of PRP formulations for OA treatment. In a FDA sanctioned, double blind, placebo controlled randomized study, PRP administration improved WOMAC scores by78% from the baseline score versus only 7% for the placebo control group after 1 year with no adverse effect. Study concluded PRP is safe and benefits patients with knee OA [45].

The presence or absence of leucocyte fraction within the PRP preparation is a factor that influences results. A metaa-analysis including 6 randomized controlled trials and 3 prospective comparative studies compared clinical outcomes and rates of adverse reactions between LP-PRP and LR-PRP for the treatment of knee OA. The study concluded that there is sufficient evidence to state LP-PRP improves functional outcome scores compared with HA and placebo, both LR-PRP and LP-PRP being safe [46]. PRP has been used as well for the treatment of cartilage defects. A randomized controlled trial evaluated the safety and efficacy of IA injections of PRP compared to HA for the treatment of osteochondral lesions of the talus (OCL). Pain reduction and functional improvement at short time follow up (6 months) was significant higher for the PRP group, recommending the procedure for the treatment of OCL with this location [47].

When used as an adjunct therapy, in combination with microfractures for the treatment of OCL, PRP resulted in resulted in improved functional score status in the follow up time (medium 16, 5 months) The study concluded that further investigations will be required to determine the long-term efficacy of this approach [48]. In a randomized prospective controlled study the effect of PRP versus HA as adjunct therapy for microfracture in OCL was investigated with a medium 15,3 months follow up. Both PRP and HA injections improved the clinical outcomes and can be used as adjunct therapies to treating OCL with microfracture. Because a single dose of PRP provided better results, PRP was recommended as the primary adjunct treatment option in the talar OCL in the postoperative period [49] (Table 2).

PRP in bone regeneration

PRP is used predominantly in maxillofacial surgery as an additive to autologus or synthetic bone grafting. For the orthopaedic practice, its use remains limited mainly due to the current lack of well documented evidence based medicine as well as of clinical treatment algorithms. PRP has been used as a co-adjuvant method for enhancing union of long bones (acute fractures, pseudoarthrosis) and in bone defect grafting. Results from animal studies are controversial. One study investigating the healing 8 mm femoral non unions in rats using polycaprolactone-20% tricalcium phosphate (PCL-TCP) composite scaffolds, mixed with PRP reported accelerated early vascular ingrowth and improved longer-term functional graft integration compared to PCL-PCT only [50]. Other studies are reporting no beneficial efects when using PRP combined with collagen sponge for the healing of calvarial defects in rats [51] or limited regenerative potential when mixed with xenogeic bone grafts for treating mandibular defects in dogs [52].

Two randomized prospective clinical trials with a total of 148 cases, published before December 2011 were evaluated. One of the studies compared recombinant human BMP-7 (rh- BMP-7) versus PRP for the treatment of pseudoarthrosis, the other compared the union of valgising tibial osteotomies in three conditions (PRP, PRP plus mesenchymal stem cells and no adjuvant therapy). The evaluation concluded that the studies had low power and moderate to high risk of bias not being able to support the use of PRP as an adjuvant therapy for these indications [53].

A prospective review of 23 patients who underwent transforaminal lumbar inter-foraminal fusion (TLIF) with PRP with a minimum 2-year follow-up concluded non-significant differences between PRP treated group compared to historical non-treated lot, however, faster healing and bony fusion could be reported in the PRP group [54]. A study using PRP as adjuvant modality to prevent syndesmosis non-union during total ankle reconstruction using DePuy Agility system, reported statistically significant improvement in the 8- and 12-week fusion rates as well as significant reduction in delayed unions and non-union in the PRP group [55]. PRP has been investigated as a method for percutaneous treatment of enhancing long bone healing for clinical applications. It is proposed to be an efficient method to address delayed union, however only limited results can be obtained for nonunion and only in selected cases [56]. The essential factor is reported to be the average time from the initial surgery to PRP injection for non-union, less than 11 months seems to be critical for good outcomes. A prospective study investigating the role of fluoroscopic guided percutaneous injection of PRP for selected cases of delayed unions or nonunions of long bones (femur or tibia) concluded that sufficient union could not be induced by PRP administration in the case of non unions. However, in selected patients with delayed unions of long bones PRP can be reccomended to augment the preexistent fracture fixation methods (intramedular nail or plate fixation) [57,58].

In a prospective randomized study the efficacy of PRP was compared to the use of rhBMP-7 in combination with autologus bone graft in 120 patients with tibial, femoral, humeral radial and ulnar non unions with a maximum 9 months follow up. The study concluded that the application of rhBMP-7 as a bone-stimulating agent is superior compared to that of PRP with regard to their clinical and radiological efficacy. Evidence accumulated in the recent years point toward a necessary effort to standardize PRP procurement protocols, therapeutic formulations, dosage, and timing of application as well as modalities of reporting clinical outcomes. This will derive in accumulation of high quality clinical evidence required for establishing if there is a role for PRP use as bone healing stimulator in orthopedic applications (Table 3).

PRP for tendon healing

PRP treatment for tendon and ligament injuries and degeneration was one of its earliest use for musculoskeletal applications. In vitro studies support the mitogenic activity of PRP on tenocytes, the stimulatory effect on their ECM protein production. Moreover, PRP promotes expression of angiogenetic factors such as vascular endothelial growth factor (VEGF) or hepatocyte growth factor (HGF) by tenocytes contributing to healing process [6]. Growth factors in PRP cocktail were proven to exert anabolic effects, increased chemotaxis of bone marrow cells, improved histologic organization, and increased force at failure in vitro as well as in animal models [59,60]. The anticatabolic effect of TGF-β known to inhibit expression of potent catabolic factors such as IL-1β and TNF-α as well as of matrix degradative enzymes might have a role in protecting tendons from degradative processes.

Several clinical studies report about the use of different PRP formulations as injection therapy or as tendon repair augmentation procedure. Revising the results from 2 randomized and 3 non-randomized with comparative control studies investigating the role of PRP as augmentation procedure for complete rotator cuff tear (RCT), Cahhal et al. [61] concluded that PRP does not have an effect on overall re-tear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair [61]. A meta-analysis including sevens studies on 379 patients undergoing arthroscopic RCT procedures with and without PRP application found no benefits on the overall clinical outcomes and re-tear rate. There was, however, a decrease rate of re-tears among patients treated with PRP for small- and medium-sized rotator cuff tears but not for large- and massive-sized tears [62].

In a multicenter retrospective review on 180 cases investigated the role of ultrasound guided injections in treating tendinopathies (most common sites lateral epicondyle, Achilles, and patellar tendons). Majority of the patients reported moderate pain improvement, 95% of patients having no pain at rest 68% reported no pain during activities, and 85% of patients were satisfied with the procedure [63]. Another study investigated the effect of PRP application at the site of patellar tendon harvest for anterior cruciate ligament reconstruction (ACL). PRP was reported to increase healing of patellar tendon harvest site as assessed by MRI after 6 months and reduced pain in the immediate postoperative period. However, isokinetic testing results were not different between the PRP treated and non-treated groups at 6 months [64]. In a systematic review, the role of PRP in treating tendon injuries and tendinopathies was investigated. PRP was used for patellar (2 studies) and elbow tendinosis, (3 studies) Achilles tendon injuries (3 studies) rotator cuff repair (2 studies) and for augmenting ACL reconstruction procedures (3 studies).

The type of the studies investigated were 3 prospective, randomized, double-blind, 3 were prospective cohort studies and 7 were case reports or case-control studies. Eight of the studies investigated reported favorable outcomes after the use of PRP as augmentation in rotator cuff surgery, injection in elbow tendinosis, patella tendinosis, and Achilles tendon injuries (repair after acute tear and revision surgery), one prospective randomized controlled study showed no significant improvment in PRP application as injection therapy in Achiles tendonopathy.

A large variability in the modality of obtaining PRP, the volume of blood collected, the activation methods as well as modalities of application (injection, gel, fibrin membrane scaffold) making the results difficult to compare. The meta– analysis concluded that PRP application has advantages such as faster recovery, possible reduction of recurence and no adverse effects, however, more randomized controlled comparative studies are needed in order to ascertain the clinical efficiency in tendon healing. The optimal dosage, number and interval in the case of injection therapy needs to be further clarified. Special investigation are requiered in order to compare the use of liquid PRP to gel or scaffold/matrix basedd formulation relative to their potential additive effect [65].

Whenever the use of PRP for chronic overuse tendinopaties is more efficient than other existent treatment methods and whenever a certain anatomic location is more prone to be responsive, is still a question of investigation. To date, results from clinical studies report a moderate to medium effects in the treatment of elbow or Achiles tendinopathies. A multicentric randomized controlled trial compared the use of PRP and needling under local anesthesia compared to needling only for lateral epicondilitis in 230 patients (in 12 centers over 5 years). Even thought no significant differences could be detected at 12 weeks , at 24 weeks, clinically meaningful improvements regarding pain were reported for the PRP group [66]. A randomized controlled trial compared the use of PRP versus corticosteroids in 100 patients with elbow epicondilitis. Pain and functionality as assesed by Disabilities of the Arm, Shoulder and Hand (DASH) was found to be significantly improved in the PRP group exceeding the cortocosteroid effect even at 2 years interval. The authors concluded that in order to establish a clinical therapeutic algorythm, further investigation and follow up of the study are needed [67]. In a randomized controled trial comparing the efect of PRP to whole blood injection in 76 patients with lateral epicondilitis for maximum 12 months follow up concluded that no significant evidence could be detected between groups regarding pain and functionality [68].

In a retrospective study, intra-tendon administration of a single PRP injection was found to have significant role in improving pain and function in mid-portion Chronic Recalcitrant Achilles Tendinopathies (CRAT) over a median 50 months follow up with no adverse effects and significant lower tear rate [69]. In another retrospective study on 26 patients with Achilles tendinopathy that have undergone surgery with PRP administration or injection PRP treatment alone, showed significant degrees of improvement in pre-MRI and post-MRI imaging studies with no significant differences between the groups [70].

A systematic review included all clinical evidences on the use of PRP as a method for biological augmentation of ACL repair, Andriolo et al. [71] included 15 clinical trials, 1 randomized controlled, 3 prospective comparative studies, and 1 retrospective comparative trial. In the studies investigated PRP was used either to improve healing of patellar tendon (in bone patellar bone BPB procedures), to coat the intraarticular portion of the graft or administered within the bonny tunnels in hamstring procedures to enhance bone tendon healing. No adverse effects and even reduced surgical morbidity in two of the studies, better healing response of patellar tendon with BTB procedures as assessed radiologically or functionally. PRP might enhance graft maturation with no significant evidence on osteoligamentous healing or prevention of tunnel enlargement [71] (Table 4).

A preclinical study reports on PRP delivered in gelatin hydrogen efficient in improving avascular zone meniscal tears healling in rabbits [72]. Currently no study has been published on clinical results using PRP for meniscal repair while one registered clinical trial has been wihtdrawn prior to enrollment [73].

Antimicrobial activity of PRP

PRP posses antimicrobial activity due to WBC content, to intrinsic microbiostatic and microbiocidal effect of platelet α granules, as well as of complement or other heat-sensitive components within plasmatic fraction [5]. An in vitro study tested the antimicrobial activity of pooled PRP samples finding antimicrobial activity against Methicillin-resistive Staphylococcus aureus (MRSA) and E Coli [74]. Preclinical evidence suggest that use of PRP might be efficient in addressing surgical wound or even MRSA infections. In a rabbit model of MRSA osteomielitis, local application of PRP gel exterted antimicrobial activity even though not comparable with the Vancomycin control group [75]. Clinical application of PRP in treating high energy trauma soft tissue infected wounds was reported to induce healing [76]. Local application of autologous PRP in pressure ulcers in spinal injured patients reduced Staphylococcus aureus colonization [77]. To date there is no clinical evidence supporting the use of PRP as antimicrobial agents in orthopedic related infections as therapeutic agent or adjuvant therapy.

Role of PRP after muscle injury

The use of PRP in order to enhance recovery time and return to activity after muscle injury has become a relativelly common practice in sports medicine. Several preclinical studies demonstrate that PRP can increase skeletal muscle healing after acute injury. Local PRP administration increased expression of several myogenic factors at mRNA level acting on modlating the inflamatory response and myogenesis in the early stages after acute injury in rats [78]. A significant increase of the quantity of colagen was found in the PRP treated group compared to control at 7 days in a rat model of gastrocnemius injury, however morphological aspects of the msucle at 21 days was similar in the two groups [79]. A systematic review on articles reporting on preclinical and clinical results with the use of PRP until December 2012 for acute muscle injuries retrieved three in vivo animal studies and one human pilot study.

Pre clinical studies reported significant histological and accelerate muscle healing while in the clinical study athletes treated with repeated PRP injection were found to significantly faster than a retrospective control [80]. Higher level of evidence studies are beginning to accumulate in the recent years. A randomized controled trial on 75 patiens reported on effects of autologous PRP injections on time to return to play and recurrence rate after acute muscle injuries in recreational and competitive athletes. A single PRP injection significantly decreased the time of return to sports as well as pain severity score with no significant reduction of re-injury rates at 2 years follow up [81]. Current evidence supports PRP administration for accelerating muscle healing after sport related trauma while little is known about the effect on improving soft tissue healing in other traumatic contexts.

Conclusion

Increasing knowledge is accumulating about the intimate molecular mecanisms involved in tissue homeostasis, healing and functional recovery. The use of PRP as an autologus source of naturally occuring growth factors for accelerating reparatory processes is an appealing therapeutic strategy. As a versatile product of autologus origin that can be relativelly easy to obtain and to administrate intraoperatively or in outpatient settings, PRP used has spread consistently during recent years. Its use has proven to be safe with minimum complications for a large spectrum of applications in orthopedics and sports medicine. However, to this date, there are still a sum of scientific questions to be answered. Little is known about the exact GF content that can be obtained from a PRP sample. The particular modality of processing the blood sample , platellet enrichment and recovery, PRP storage or manipulation are likely to influence GF biodispoibility for a given therapeutic dose.

Moreover, a large individual variability can be expected to occur not only in the number of platellets that can be extracted but as well in the quantity and quality of GF that could have as result different proteomic profile of the samples. The development of cost efficient methods to assess PRP content and eventually the establishment of a biomarker based product characteristic requiered for every and each application will be likely to revolutionize the use of PRP in any field, includingly for musculoskeletal applications.

Current laboratory and preclinical studies are deepening knowledge about the mechanism and timing of GF involvmnet in specific patways during healing antiinflamatory processes. Setting up a cost efficient methodology of extracting a panel of growth factors from the PRP mixture has the potential to target a specific biological process more accurately. To date, the variability of administration (timing, preparation, doses) and large variations in assessing outcome results has made difficult to interpret the results from available clinical studies. High level evidence studies will be needed in order to enable the establishment of clear therapeutic indications eventually which product type would be more suitable for a given clinical situation.

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juniperpublishers-orthopedics · 3 years

Text

Effectiveness of French Physiotherapy in Treating Congenital Clubfoot Deformity

Abstract

Clubfoot is the most common congenital structural deformity that leads to physical impairments in children in many developing countries. Neglected clubfoot has been found to be a common cause of physical disability globally among children and young growing adults. The purpose of this study was to investigate the effectiveness of French physiotherapy in treating congenital clubfoot deformity. This cross sectional study was conducted among 102 parents and data were collected by face to face interview with semi-structured questionnaire. Statistical Package for Social Science (SPSS) was used to analyze the data. The mean age of the participants was 405 days. Unilateral limbs were more affected than bilateral limbs. Results shows that out of 30(100%) children with clubfoot deformity, 17(56.7%) were completed cured under French Physiotherapy while 8(26.7%) were completed cured under Ponseti method, almost equal number of children were in both group improved to moderate cured. There was significance difference found between two groups after intervention (p<0.05). French physiotherapy was more effective method for the treatment of clubfoot over the Ponseti method

Keywords: French Physiotherapy; Congenital Clubfoot

Introduction

Disability has emerged as a major public health problem worldwide. Childhood disability is one of them and it remains hidden in developing country like Bangladesh [1]. Importance of conservative treatment in congenital clubfoot has been known since the Hippocrates era (approximately 400 B.C) [2]. Continuous passive movement treatment method of French authors has also been added to manipulation, bandage, cast and device applications [3]. There is not a clear opinion in the literature on how to treat overcorrection. In the long-term follow-up studies, weakness in muscle groups around the ankle, joint stiffness was found [4,5]. Laaveg & Ponseti [6] obtained 89% success rate by using the conservative treatment method and minimal invasive surgery if required. Prevalence of congenital clubfoot in Bangladesh is high and most of the cases remain untreated or poorly treated [7]. According to French physiotherapy method (93-96%) so congenital clubfoot is manageable if the treatment can be started before child’s 1st birth day. It is important to identify the effectiveness of French physiotherapy in treating congenital clubfoot deformity than other conservative method like Ponseti Method. In French method the complication should be minimize. As there no study was done in this topic before in our country, I was very much interested to do research on this topic.

Material and Methods

Study design: Randomized clinical trial

Study population: Children with congenital clubfoot deformity who are attending the selective clinics.

Inclusion criteria:

Willingly participating patients

Age below 3 years

Before tenotomy patients

Exclusion criteria:

Benign feet

Severe clubfoot deformity

Before treated patient

Sampling technique

Treatment allocation: Treatment procedure was allocated randomly in two groups by tossing. The heads were taken in odd serial i.e. group -1 while the tails were placed in even serial i.e. group 2.

Group-1: This group was treated by Ponseti method [8-15].

Group-2: This group was treated by French physiotherapy methods. This treatment will carry out by a team with large experience in managing clubfoot with such a method [16,17]. In this study the sample size was taken as 30 for both group i.e Ponseti Method and French Physiotherapy Method.

Study place: The study was carried out at

BCCW, Dhaka

NGO- TLMB (Gaibandha), SEID Trust.

Study period and duration: From 14th January 2013 to 13th January 2014.

Data collection tool and instrument:

Face to face interview of mother using pre-tested structure questionnaire

Data collection method

Data were gathered by pre verified semi structured questionnaires and in face to face interview. Information about pregnancy related question, family history & other characteristics was also obtained. The field work was conducted from March to September 2013 at Comilla & Dhaka district. The respondents were selected consecutively who will meet the inclusion and exclusion criteria. Two interviewers were trained for four days by the author. The training was consisted of lectures on how to fill up the questionnaires and mock interviews between participants.

Data analysis: Computer technology (SPSS 20.0) version was used for classification, presentation and analysis of data.

The Pirani score is a simple. The components are scored as follows:

Each component may score 0, 0.5 or 1

Hind foot contracture score (HCFS): Mid foot contracture score (MFCS):

Posterior crease Medial crease

Empty heel Curvature of lateral border

Rigid equinus Position of head of talus (Table 1).

The mean age of the participants was 405 days, n=17 (28%) participants in between 0-90 days of age, n=8 (13%) in between 91-180 days of age and n=1 (2%) in between 181-270 days. n=4 (7%) participants in between 271-360 days of age, n=10 (17%) in between 361-450 days of age and n=6 (10%) in between 451- 540 days. n=3 (5%) participants in between 541-630 days of age, n=5 (8%) in between 631-720 days of age and n=6 (10%) in between 721-810 days. Result shows that 0-90 days are more common age those who had taken French physiotherapy & ponseti method. In control group the participants 21 out of 30(70%) were male and 9 out of 30 (30%) were female. Result shows that male was more affected than female. In intervention group the participants 21 out of 30(70%) were male and 9 out of 30 (30%) were female. Result shows that the male was more affected than female (Table 2).

In terms of father occupation in ponseti group, out of 30(100%), 5(16.7%) were service holder while the equal number of service holders in French physiotherapy method group, 13(43.3%) were business holders in ponseti group while the equal proportion of respondents were business holders in French physiotherapy method group. Only 13% were farmers in ponseti group whereas the double proportion of fathers were farmers in France physiotherapy method group. Of the fathers in ponsity group 23% were day labor while the half of proportion were day labor in French group. In terms of father education almost equal proportion of fathers was same education level in both groups. Mother occupation indicates that almost all were house makers in both groups. Educational status was also same in both groups (Figure 1).

The above figure shows that almost equal proportion of father were same occupation in ponseti and French group. The majority were involved in business (Table 3).

Results

Result shows that among all the participants in Group A, unilateral n=47(78%) among them n=23(38%) were right limb affected & n=24(40%) were left limb affected and bilateral n=13(22%) were involvement of the affected limb of the participants. Result shows that unilateral limbs were more affected than bilateral limbs (Table 4).

Result shows that among all the participants approximately 5% (3 of 60) had past family history of clubfoot and 95% (57 of 60) had no past family history of club foot. Of them 2(6.7%) were in ponseti group and 1(3.3%) were in French Physiotherapy group (Table 5).

In both group 10% baby was preterm while 86% was born in time in ponseti group and 83.3% was in French group, the rest 3.3% in ponseti group and 5% was in France group was born in post term. Of the children with clubfoot deformity 60% had normal mode of delivery in ponseti group while 66.7% had in French group. Cesarean delivery had 40% in ponseti group and 33.3% had in French group. Problem during pregnancy occurred 0% in poseti group and 3.3% in French group. Place of delivery was home, hospital and clinic, the majority of the children’s place in delivery was home in both groups. It was about fifty percent. Only 13.3% had clinic in ponseti group and 16.7% in French group. Only 3.3% mothers had suffered problems during delivery while the rest had not suffered any problems during delivery. Of the mothers almost fifty percent had health workers during delivery, others had no health workers. Out of 30(100%) children, only 3.3% had other disability and it was in ponseti group (Table 6).

Results shows that out of 60(100%) children with clubfoot deformity equal numbers of them were in both group with severe and moderate deformity. There was no significance difference between two groups before intervention (p>0.05) (Table 7).

Results shows that out of 30(100%) children with clubfoot deformity, 17(56.7%) were completed cured under French Physiotherapy while 8(26.7%) were completed cured under Ponseti method, almost equal number of children were in both group improved to moderate cured. There was significance difference found between two groups after intervention (p<0.05). France physiotherapy was more effective method for the treatment of clubfoot over the Ponseti method (Table 8).

The above table shows that there was significance difference found between two methods in terms of clubfoot treatment (t=2.9, p=0.005). The calculated mean score was 1.1 and .53 in Ponseti and French physiotherapy method respectively. French Physiotherapy was more effective treatment for clubfoot deformity.

Discussion

The present study showed French physiotherapy was more effective method for the treatment of clubfoot over the Ponseti method. A study reporting early results of the Ponseti treatment, 95% of the deformities were corrected without need for extensive surgery [18]. This recovery rate is consistent with the results, reported by Herzenberg et al. [19], whose study included similar population and follow-up. Though it was not a new treatment method, Ponseti method had not been adopted by many and surgical treatment methods had been used as standard treatment until recent years. Initially, extensive surgical methods aimed physical improvement but owing to long term follow-up studies the importance of functional outcomes and maintenance of movement were recognized [20,21]. Muscular weakness and biomechanical changes [22-23], observed in patients who were considered as corrected initially, increased the popularity of conservative treatment methods again. Cooper & Dietz [24], found functionally and clinically perfect and good outcomes in 78% of deformities in patients, who were treated by Ponseti, in their average 30 years, follow-up study. This success rate was 85% in control group, consisting of the patients without congenital foot deformity. In their magnetic resonance imaging study, Pirani et al. [25] detected improvement in both the relation of tarsal bones and the forms of osteochondral outlines of the bones in patients, treated by Ponseti method. These findings support the Ponseti’s hypothesis, which asserts that with a proper treatment method that considers the functional anatomy of foot and uses biological potential in the tissues of a newborn, an appropriate improvement can be obtained in most of the deformities which is contradictory with the present study. The present study shows that there was significance difference found between two methods in terms of clubfoot treatment (t=2.9, p=0.005). Different conservative treatment methods have been suggested in the literature. One of the popular methods in Europe is the method of Dimeglio et al. [26] consisting of daily physiotherapy and continuous passive motion machine.

With this method, only 28% of the cases required surgical treatment. However, difficulties in long term physiotherapy, and its high cost makes adoption of this method problematic in many countries, including our country. In many countries, especially in the USA, Kite’s method has been used widely for a long time [27]. Kite, who tried to correct the components of the deformity separately and patiently, obtained improvement within 36 weeks. Ponseti attributes such a delay in improvement to the effort for correction of forefoot by counter pressure from calcaneocuboidal joint, which was Kite’s error according to Ponseti. Because kinematics of the foot does not allow evertion of calcaneus before abduction (outward rotation) of it, correction of varus became time consuming for Kite [28]. In a careful study, by Tümer et al. [29] where Kite’s and Ponseti’s manipulation methods were used concomitantly, it was reported that 33% of the cases were treated by only using plaster cast. This success rate reached at 41% with addition of the patients who underwent posterior release surgery. Bursalı [30] reported that they obtained correction in all of the untreated cases and in 75% of the cases, treated previously elsewhere, by using Ponseti’s method strictly.

Limitation

100% accuracy was not possible in any research so that some limitation may exist. Regarding this study, there were some limitations or barrier to consider the result of the study. The first limitation of this study was sample size. It was taken only 30 samples in each group. A very few researches have been done on a few of research among the effectiveness of French physiotherapy in management of clubfoot patients. So there was little evidence to support the result of this project study in the context of Bangladesh.

Conclusion

This study demonstrates that French physiotherapy method is an effective and reproducible method for correction of idiopathic Congenital Clubfoot deformities. Furthermore, it may be used in our country widely. For successful outcomes, this technique should be applied carefully and the patients should use the foot abduction orthosis with full compliance. For patient compliance, besides parent training, producing proper and comfortable shoes is required.

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