Monthly Archives: December 2023
A Comparative Analysis of K wire Fixation and Dogbutton for Grade III and Higher Acromioclavicular Joint Dislocations
Vol 9 | Issue 2 | July-December 2023 | page: 5-8 | Vyankatesh Deshpande, Chetan Pradhan, Atul Patil, Chetan Puram, Ashutosh Ajri, Nilesh Kamat, Ishan Shevte, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.208
Author: Vyankatesh Deshpande [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Ashutosh Ajri [1], Nilesh Kamat [1], Ishan Shevte [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Vyankatesh Deshpande,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: paragdeshpande24@gmail.com
Abstract
Background: Acromioclavicular joint injuries are frequent in active adults; management of Rockwood grade III and higher remains debated. This study compares arthroscopic double-endobutton reconstruction with open reduction plus K-wire fixation and direct ligament repair.
Methods: Single-centre prospective and retrospective review from July 2015 to January 2017. Twenty-six adults with acute Rockwood grade III+ separations were treated: Group A (arthroscopic double-endobutton, n=8) and Group B (open K-wire fixation with ligament repair, n=18). Radiographs and stress views were recorded. A staged rehabilitation programme was applied. Ethical approval and informed consent were obtained. Primary outcomes were forward flexion, abduction and UCLA score.
Results: Both groups showed substantial improvement. At 12 months mean forward flexion reached about 175.65° and mean abduction about 177.83°. The arthroscopic group regained motion earlier, with many patients reaching near-normal range by six months. UCLA scores and patient satisfaction were high in both groups. Complications were uncommon and no major revisions were recorded.
Conclusion: Arthroscopic double-endobutton and open K-wire fixation with ligament repair both provide good one-year functional outcomes. The arthroscopic method enabled faster early recovery. Technique choice should be tailored to patient needs, implant availability and surgeon experience.
Keywords: Acromioclavicular joint, Rockwood, Double-endobutton, K-wire fixation, Ligament repair, Shoulder function.
Introduction
The acromioclavicular (AC) joint is a common site of shoulder injury, especially in young active adults who sustain direct blows to the shoulder. Clinical decision-making relies on the Rockwood classification: low-grade injuries are usually managed nonoperatively, whereas high-grade separations, particularly types IV–VI and selected symptomatic type III injuries, often require surgical treatment to restore anatomy and function [1]. Operative aims are straightforward — restore coracoclavicular spacing, re-establish AC joint congruity and provide a stable environment for ligament healing so that painless shoulder mechanics return during activity [2]. Historically, a variety of fixation methods have been employed, including K-wires, screws, hook plates and tension-band constructs, each with advantages and notable complications leading to evolving preference for anatomic reconstructions [3]. Contemporary techniques emphasize restoration of both conoid and trapezoid components of the coracoclavicular complex to recreate native kinematics and resist superior, anterior and posterior translation [4]. Minimally invasive methods such as double-button systems and arthroscopic reconstructions seek to minimize soft-tissue trauma while providing stable fixation, facilitating earlier rehabilitation and improved cosmesis [5]. However, implant-related issues such as prominence, migration or late failure remain concerns with some rigid constructs, and residual radiographic displacement can occur despite clinical improvement, underscoring the need to balance radiographic goals with patient-centred outcomes [6]. This study examines outcomes after two commonly used surgical approaches—arthroscopic double-endobutton reconstruction and open reduction with K-wire fixation plus direct ligament repair—to compare early recovery of motion, functional scores and complication profiles, using prospectively recorded data from a single tertiary centre. Postoperatively a staged rehabilitation protocol that protects repaired tissues while progressively restoring active motion is essential to achieve durable functional gains. By presenting comparative clinical and radiographic outcomes with standardized follow-up, this work aims to inform surgeon choice and patient counselling in settings where implant selection, cost and surgeon familiarity influence practice.
Review of Literature
The literature on acromioclavicular (AC) joint injuries shows a long evolution from rigid fixation toward techniques that try to restore anatomy while minimizing hardware problems. Early open reductions and fixation methods often achieved good initial alignment, but complications from prominent implants and the need for secondary procedures spurred surgeons to look for better options [7]. Classic reviews and summaries emphasized the variety of presentations and the limitations of older methods, noting that device-related irritation and implant migration were not uncommon and sometimes affected outcomes [8, 9]. Textbook descriptions reinforced the complex anatomy around the clavicle and coracoid, underscoring why reconstructions that respect the native ligamentous anatomy may perform better [10, 11].
More recent work described a shift toward anatomic reconstructions and less invasive approaches. Arthroscopic techniques and button-based fixation were introduced to reduce soft-tissue damage and permit earlier motion, with several series reporting encouraging clinical recovery and cosmetic benefits compared with bulky hardware [12]. Biomechanical and cadaveric investigations compared various reconstructive strategies and generally found that anatomic reconstructions—those that recreate both conoid and trapezoid components—restore stability more closely than non-anatomic transfers, although some residual laxity can persist in experimental setups [13]. Detailed anatomical studies clarified the landmarks and safe corridors for drilling and graft passage, information that helped refine surgical techniques and reduce iatrogenic complications [14].
Taken together, the literature supports a move toward reconstructive solutions that balance durable mechanical restoration with lower implant morbidity. However, study designs are heterogeneous and long-term comparative data remain limited; thus, treatment is often tailored to injury chronicity, patient needs and surgeon experience rather than driven by a single definitive technique.
Materials and Methods
This single-centre study combined prospective and retrospective case review at a tertiary orthopaedic institute from July 2015 to January 2017. Adult patients with acute acromioclavicular dislocation Rockwood grade III and above were enrolled after informed consent. Patients with ipsilateral clavicle or scapular fractures and chronic dislocations were excluded. Preoperative assessment included anteroposterior and Zanca radiographs, stress views with standardized weights and routine investigations to document coracoclavicular distance. Treatment choice followed clinical indication and surgeon judgement, forming two groups: arthroscopic double-endobutton fixation (Group A) and open reduction with K-wire fixation plus direct AC and CC ligament repair (Group B). The arthroscopic method involved clearance of the coracoid, guided drilling through clavicle and coracoid, passage of a continuous loop endobutton and securing a clavicular locking button to reconstruct coracoclavicular function. The open technique used a lateral clavicular incision, manual reduction, two parallel non-threaded K-wires from acromion into clavicle with bent lateral ends to prevent migration, direct repair of AC and CC ligaments with non-absorbable sutures and reattachment of the deltoid-trapezial aponeurosis. A uniform rehabilitation protocol was applied: two weeks of sling and elbow motion; weeks three and four with limited uniplanar shoulder motion; weeks five and six progressing to biplanar motion to 90°; thereafter graded strengthening toward full activity over three months. Follow-up was at one, three, six, nine and twelve months with clinical and radiographic assessment. Outcome measures included forward flexion, abduction and the UCLA shoulder score; complications and return to function were recorded and compared between groups using standard statistics. All intraoperative details and immediate postoperative radiographs were recorded on a proforma. Ethical approval and informed consent were secured. Radiographic measures included coracoclavicular distance; clinical data recorded pain, range of motion and UCLA scores at each visit. Data were entered prospectively and analyzed to compare recovery between techniques and complications.
Results
During the study 26 patients with acute AC dislocation grade III and above were followed for twelve months. Group allocation yielded eight patients in the arthroscopic double-endobutton group and eighteen in the open K-wire with ligament repair group. There were twenty right-side injuries and six left-side injuries. The cohort included thirteen patients aged forty years or younger and thirteen older than forty; twenty-one were male and five were female. Range of motion improved steadily in both groups. By twelve months mean forward flexion in the affected limb reached approximately 175.65 degrees and mean abduction averaged around 177.83 degrees. The arthroscopic group achieved full or near-full forward flexion and abduction earlier than the open group, with several endobutton patients reaching maximal motion by six months. Functional recovery measured by the UCLA shoulder score showed progressive improvement at each follow-up with high median satisfaction scores recorded at one year. Complications were infrequent and minor; no patient required major revision surgery during the follow-up period. Most patients returned to routine activities by three to six months without major functional limitations affecting final outcomes overall.
Discussion
The coracoclavicular ligaments and the surrounding soft tissues play a central role in shoulder girdle stability, and their disruption leads to functional compromise that may not be fully compensated by surrounding muscles. Restoring anatomy and joint congruity seeks to re-establish normal load transfer and reduce pain and fatigue during overhead or heavy activities. Rigid implants such as hook plates or screws often maintain radiographic reduction but can cause prominence, sub acromial irritation and often require removal, which adds morbidity to recovery [15]. Soft-tissue reconstructions and button devices reduce hardware prominence and permit earlier rehabilitation, yet have been associated in some series with loss of radiographic reduction or rare hardware failure [16]. Biomechanical evidence supports anatomic reconstruction of conoid and trapezoid components; tendon grafts and double-button constructs better replicate native restraint to superior and horizontal translation compared with older techniques, although some residual superior displacement may persist in experimental settings [17]. The management of Rockwood type III injuries remains debated; pooled analyses show that nonoperative care can yield comparable long-term objective function in many patients, while surgery may offer superior cosmetic alignment and faster return to high-demand tasks for selected individuals [18]. In our series the arthroscopic double-endobutton group showed earlier return of forward flexion and abduction with high patient satisfaction, which likely reflects reduced soft-tissue disruption and stable anatomic fixation that facilitates graded physiotherapy [19]. Surgeon experience, implant costs and availability are important determinants in real-world technique selection; these pragmatic factors may guide decisions as much as biomechanical data. Ultimately, randomized prospective trials with standardized outcome measures are needed to define which patients benefit most from operative reconstruction and which techniques provide durable, complication-free restoration of shoulder function [20]. Until such evidence emerges, individualized care that balances patient goals, surgical risk and resource considerations remains the most practical approach to management.
Conclusion
Both arthroscopic double-endobutton reconstruction and open K-wire fixation with direct ligament repair provide reliable restoration of shoulder function for acute Rockwood grade III and higher acromioclavicular injuries in this series. The arthroscopic approach permitted earlier gains in forward flexion and abduction and facilitated quicker rehabilitation while maintaining high patient satisfaction. Open fixation with ligament repair also produced good to excellent outcomes by one year, demonstrating that both techniques can achieve durable function when combined with a structured rehabilitation programme. Surgeons should individualize technique selection based on patient activity level, implant availability, cost considerations and their own experience to optimise outcomes. Further prospective, Randomised studies with longer follow-up are warranted to refine indications and compare long-term stability and complication profiles across techniques. Most patients returned to routine activities within months and serious complications were rare, supporting both methods as effective options when used with tailored rehabilitation and close follow-up, essential again.
References
1. Klemens Horst, Thomas Deinstknecht, et al. Operative treatment of acute acromioclavicular injuries graded Rockwood 3 and 4: Risks and benefits in tight rope technique vs K-wire fixation. Patient Saf Surg. 2013; 7:18.
2. Modi CS, Bezeley J, et al. Controversies relating to the management of acromioclavicular joint dislocations. Bone Joint J. 2013; 95-B: 1595-1602.
3. Choudhary D, Jain V, et al. Arthroscopic fixation for acute AC joint disruption using tight rope device. J Orthop Surg. 2015; 23(3):309-314.
4. Sugathan HK, et al. Management of type III ACJ dislocation—Comparison of long term functional results of two operative methods. ISRN Surg. 2012; 2012:580504.
5. Torkman A, Bagherifard A, et al. Double button fixation system for management of acute AC joint dislocation. Arch Bone Jt Surg. 2016; 4(1):41-46.
6. De Francisco A, et al. The use of hook plate in type III and V acromioclavicular joint dislocations—clinical and radiological midterm results and MRI evaluation in 42 patients. Injury. 2012 Feb; 43(2):147-152.
7. Struhl S, et al. Continuous loop double endobutton reconstruction for acromioclavicular joint dislocation. Techniques in Shoulder & Elbow Surg. 2007; 8(4):175-179.
8. Gladstone. Disorders of acromioclavicular joint. Curr Opin Orthop. 1999; 10.
9. Beim GM. Acromioclavicular joint injuries. J Athl Train. 2000; 35(3):261-267.
10. Gray’s Anatomy. Page 779.
11. Rockwood CA, Green’s Fractures in Adults. Vol 1; 7th ed. Chapter 39:1215-1218.
12. Bajnar L, Bartos R, et al. Arthroscopic stabilisation of acute acromioclavicular dislocation using Tight Rope device. Acta Chir Orthop Traumatol Cech. 2013; 80(6):386-390.
13. Tauber M, et al. Cohort biomechanical study comparing various surgical techniques for acromioclavicular joint reconstruction. 2009.
14. Mazzocca AD. Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligament. 2007.
15. Baker JE. A cadaveric study examining acromioclavicular joint congruity after different methods of coracoclavicular loop repair. 2003.
16. Grutter PW, Petersen SA. Anatomical acromioclavicular ligament reconstruction—A biomechanical comparison of reconstructive techniques. Am J Sports Med. 2005; 33:1723-172?
17. Gstettner C, et al. Rockwood type III acromioclavicular dislocation: Surgical versus conservative treatment. J Shoulder Elbow Surg. 2008.
18. De Carli A, et al. Acromioclavicular third degree dislocation: surgical treatment in acute cases. J Orthop Surg Res. 2015.
19. Yoon JP, et al. Comparison of results between hook plate fixation and ligament reconstruction for acute unstable acromioclavicular joint dislocation. Clin Orthop Surg. 2015 Mar; 7(1):97-103.
20. Vrgoc G, Japjec M, et al. Operative treatment of acute acromioclavicular dislocations Rockwood III and V—comparative study between K-wires combined with Fiber-Tape vs Tight Rope System. Injury. 2015; 46S:S107-112.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2017
| How to Cite this Article: Deshpande V, Pradhan C, Patil A, Puram C, Ajri A, Kamat N, Shevte I, Sonawane D, Shyam A, Sancheti P. A Comparative Analysis of K wire Fixation and Dogbutton for Grade III and Higher Acromioclavicular Joint Dislocations. Journal of Medical Thesis. July-December 2023; 9(2):5-8. |
Full Text HTML | Full Text PDF
Optimizing Thoracolumbar Fracture Management: Hypothesis – Superiority of Long-Segment Posterior Pedicle Screw Fixation for Long-Term Stability
Vol 9 | Issue 2 | July-December 2023 | page: 26-30 | Sangmeshwar Siddheshwar, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.218
Author: Sangmeshwar Siddheshwar [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Sangmeshwar Siddheshwar,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: dr.sangamms@gmail.com
Abstract
Background: Multilevel degenerative lumbar spinal stenosis commonly causes progressive leg pain, numbness and reduced walking capacity that interfere with daily activities and independence. This prospective study reports the one-year clinical and functional outcomes of 99 consecutive patients treated surgically between October 2016 and October 2017 after failing conservative management. Surgical approaches were tailored to each patient and included decompression alone, decompression with stabilization, or decompression combined with instrumented fusion when instability was present.
Hypothesis: We hypothesised that individualized decompression, with selective addition of stabilization or fusion when indicated by symptoms or imaging, would produce consistent and durable improvements in pain, disability and health-related quality of life across patients with stenosis at two or more lumbar levels.
Clinical importance: By one year most patients recorded meaningful gains. Most patients returned to routine activities within months. Mean disability scores fell from levels indicating marked functional limitation to scores compatible with mild residual disability, and median pain scores declined substantially. Broad improvements were evident in physical functioning, role limitation, bodily pain and social participation. Complication rates were acceptable; intraoperative dural tears were the most frequent event and were managed without lasting neurological deficit in the majority. A small number of patients developed adjacent segment problems or required further intervention, but these did not negate the overall functional gains achieved.
Future research: Larger prospective studies and randomized trials should examine which clinical and radiological features best identify patients who benefit from fusion in addition to decompression, evaluate long-term durability beyond one year, and assess cost-effectiveness and patient-centred outcomes such as return-to-work and persistent analgesic use. Registries and standardized outcome reporting will strengthen evidence and guide clearer decision-making.
Keywords: Multilevel lumbar stenosis, Decompression, Instrumented fusion, Oswestry Disability Index, Quality of life, Dural tear.
Background
Degenerative narrowing of the lumbar spinal canal is a leading cause of walking difficulty, leg pain and lost independence in older adults. Over decades the spinal motion segments lose disc height, facet joints hypertrophy and the ligamentum flavum thickens and buckles; these changes reduce space for the nerve roots and the dural sac and create the classic picture of lumbar spinal stenosis. Symptoms usually include leg pain, numbness or weakness that worsen with standing and walking and improve with sitting or forward flexion of the spine — a pattern that distinguishes it from vascular claudication. Accurate diagnosis depends on combining the clinical story with imaging, since many people have degenerative changes on MRI without troubling symptoms. Verbiest and later clinical reviews set out the classic descriptions still used today. [1–3]
Multilevel involvement — where two or more levels show compressive change — becomes more common with age and often produces a mixture of axial low back discomfort and diffuse leg symptoms. That mixture can make it hard to localize a single symptomatic level on exam, and it makes imaging and functional assessment central to surgical planning. MRI is the preferred modality for showing soft-tissue causes of compression such as ligamentum flavum hypertrophy and facet overgrowth, while standing radiographs and dynamic films help reveal instability or slippage (spondylolisthesis) that may change the operation required. Grading systems and morphological descriptions on axial MRI help surgeons weigh where and how much decompression is needed. [2–4]
Conservative care is the first line for most patients: patient education, analgesics, structured physiotherapy, walking programs and selective epidural injections frequently yield meaningful improvement and delay or avoid surgery. Surgery is considered when symptoms — most importantly, walking limitation and leg pain — remain disabling despite adequate conservative management. Surgical options span from focused microsurgical decompression (unilateral or bilateral laminotomy, over-the-top decompression) to more extensive multilevel laminectomy. When instability is present or anticipated because decompression would remove stabilizing structures, instrumented fusion is added to restore or preserve alignment. Minimally invasive methods try to free nerves while preserving posterior elements and Para spinal muscles, with the goal of faster recovery and less postoperative back pain. [5–8]
A key practical question for surgeons is when to add fusion to decompression. Fusion stabilizes the segment, prevents progression of deformity and increases the chance of durable mechanical integrity when instability is present; however, it also increases operative time, blood loss, cost and the potential for implant-related complications. Several comparative studies show that fusion improves radiographic stability, but consistent clinical advantage for routine fusion in stable stenosis is not firmly established. Thus, careful patient selection and individualized planning are essential; fusion is generally reserved for clear instability, high-grade spondylolisthesis or cases where decompression would itself destabilize the spine. [9–12]
Patient-reported measures such as the Oswestry Disability Index (ODI), the Visual Analog Scale (VAS) for pain and general quality-of-life instruments are standard tools to judge surgical benefit. Most contemporary series report meaningful improvement in leg symptoms and walking tolerance after surgical decompression, whether fusion is performed or not, provided the operation and selection are appropriate. Common perioperative problems include dural tears, infection, wound healing problems, and in the long term, adjacent-segment degeneration. Careful surgical technique, perioperative optimization and rehabilitation reduce these risks and improve outcomes. The current thesis offers a prospective dataset of consecutive patients treated for multilevel stenosis, with standardized preoperative assessment and 6- and 12-month follow-up to evaluate these issues. [13–25]
Hypothesis.
Primary hypothesis
When patients with multilevel lumbar spinal stenosis are selected for surgery based on clear clinical-radiologic correlation, and the operative approach is tailored to the presence or absence of instability (decompression alone for stable segments versus decompression plus instrumented fusion when instability or deformity exists), most patients will experience substantial and clinically meaningful improvement in pain, function and quality of life at one year.
Why this matters
The clinical problem is practical and common: many older patients have multilevel degenerative changes, but not all of them are disabled by those changes. Surgery that is too limited may leave persistent compression; surgery that is too aggressive may create instability or needlessly expose patients to the extra risks of fusion. The surgeon’s task is to match the invasiveness of the operation to the mechanical and symptomatic needs of the patient. Existing literature suggests clear benefit from fusion when there is demonstrable instability, and good relief from decompression alone when the spine is stable; however, the evidence is mixed for borderline cases. A prospective cohort where selection criteria and outcomes are systematically recorded helps clarify real-world results. [9–12, 25]
Specific aims
1. To measure change in disability (ODI) from baseline to one year as the primary outcome. Secondary outcomes include changes in VAS pain scores and SF-36 quality-of-life domains, perioperative complications, reoperation rates and radiographic fusion status where fusion was performed.
2. To compare clinical outcomes and complication profiles among three operative strategies used in the cohort: decompression alone; decompression plus posterolateral stabilization; and decompression plus instrumented interbody fusion.
3. To examine whether the number of levels treated (two, three, or four and above) or the MRI severity of stenosis influences functional outcome or complication risk.
4. To identify perioperative predictors of less favorable outcomes (older age, greater comorbidity, larger blood loss, dural tear, and extent of decompression) to support shared decision-making.
Operational testable statements
• H1: Mean ODI and VAS will improve significantly at six months and be maintained at one year after appropriate surgery.
• H2: In patients with radiographic instability, adding fusion will yield comparable or better functional outcomes but with higher intraoperative resource use (longer operating time, more blood loss).
• H3: Higher-grade morphological stenosis on MRI predicts larger absolute symptomatic benefit from decompression, while the number of levels treated will not independently predict worse functional outcomes when operations are appropriately chosen.
• H4: Advanced age and increased comorbidity raise complication risk but do not necessarily prevent meaningful clinical gains in those who recover without severe complications.
Study approach and measures
A prospective cohort design of consecutive patients with two or more levels operated for symptomatic stenosis, with standardized collection of ODI, VAS and SF-36 at baseline, six months and one year, together with detailed perioperative data and radiographs/MRI, provides the necessary structure to test these hypotheses and to develop risk-stratified guidance for practice. [25]
Discussion
What the outcomes usually show
When surgery is chosen for patients with disabling symptoms and concordant imaging, decompression reliably reduces leg pain and improves walking capacity. In most cohorts, including the present thesis cohort, patients report large early gains in leg pain and functional ability by six months that tend to persist at one year. The magnitude of benefit commonly relates to how closely symptoms and imaging match — patients with clear neurogenic claudication and compressive lesions on MRI gain the most. [13–15]
Fusion: when it helps and when it does not
Instrumented fusion restores stability and alignment when clear instability exists, and it reduces the chance of postoperative mechanical failure where wide decompression would otherwise destabilize the spine. That mechanical benefit is evident radiographically and in some series leads to better long-term outcomes for selected patients. At the same time, fusion increases operative time, blood loss and implant-related complexity, and in otherwise stable stenosis it does not consistently produce better patient-reported outcomes than decompression alone. Therefore, fusion is best reserved for cases with objective instability, high-grade spondylolisthesis or deformity that needs correction; routine fusion for all multilevel disease is not supported by the balance of evidence. [9–12, 16–18]
Surgical technique and tissue preservation
Wherever possible, techniques that decompress the neural elements while preserving midline structures and paraspinal musculature reduce early postoperative back pain and may hasten recovery, especially in older or frail patients. Muscle-sparing and minimally invasive decompression approaches can achieve adequate neural decompression in many cases, leaving fusion for those with instability or unavoidable destabilizing resections. Proper selection minimizes the overall physiological burden without compromising decompression. [5–8, 19–21]
Complications and mitigation
Dural breaches during decompression are a common intraoperative event; careful microsurgical technique and prompt repair keep long-term consequences uncommon. Infection, thromboembolism and wound problems are important perioperative concerns and are reduced by standard prophylactic measures (antibiotics, early mobilization, and DVT prophylaxis as appropriate) and by optimizing medical comorbidities before surgery. Fusion adds risk of implant-related issues and potential future adjacent-segment degeneration; this underlines the need for precise indications and for long-term follow-up in registries and trials. [22–25]
Limitations and remaining questions
Most single-center cohorts have relatively short follow-up, making it hard to judge long-term adjacent-segment problems and fusion durability over many years. Randomized trials directly comparing decompression alone and decompression plus fusion in multilevel stenosis with borderline instability are limited. Future research should focus on longer follow-up, standardized imaging metrics, and pragmatic comparative designs that reflect real-world patient selection. These efforts would help surgeons and patients choose the operation that best balances relief of symptoms and procedural risk. [12, 24, 25]
Clinical importance
Multilevel lumbar spinal stenosis causes real and reversible disability for many older adults. When symptoms and imaging agree and conservative measures have failed, carefully planned surgery can restore walking capacity and reduce pain in most patients. The key to good results is matching the technical plan to the mechanical needs of the spine: perform muscle-sparing decompression when the spine is stable, and reserve fusion for segments with true instability or deformity. Using standardized outcome measures supports honest, evidence-based counseling about expected benefits and risks, and thorough perioperative optimization reduces complications. Personalized decision-making preserves function while avoiding unnecessary surgical burden.
Future directions
1. Set up large, long-term patient registries that follow people for five to ten years after surgery so we can see how often fusion holds up, how often adjacent segments fail, and which patients need repeat operations.
2. Run practical, real-world clinical trials that focus on patients with borderline or uncertain instability to find out when adding a fusion truly improves pain, function and quality of life.
3. Build simple, usable risk scores that combine the MRI picture, dynamic X-rays and basic patient factors (age, health, activity level) so surgeons and patients can make clearer, personalized choices before operating.
4. Study muscle-sparing and less invasive decompression methods in older and medically frail patients to see whether they speed recovery, reduce early pain and lower the need for further surgery — and include cost and rehab outcomes so hospitals can plan better.
References
1. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br. 1954; 36-B (2):230–237.
2. Postacchini F. Management of lumbar spinal stenosis. J Bone Joint Surg Br. 1996; 78(1):154–164.
3. Arbit E, Pannullo S. Lumbar stenosis: a clinical review. Clin Orthop Relat Res. 2001; 384:137–143.
4. Möller H, Hedlund R. Surgery versus conservative management in adult isthmic spondylolisthesis — a prospective randomized study: part 1. Spine. 2000; 25(17):1711–1716.
5. Tsai RY, Yang RS, Bray RS Jr. Microscopic laminotomies for degenerative lumbar spinal stenosis. J Spinal Disord. 1998; 11(5):389–394.
6. Young S, Veerapen R. Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy. Neurosurgery. 1988; 23(5):628–633.
7. Steven Young et al. Multilevel fenestration technique. Neurosurgery. 1988; 23(5):628–633.
8. Herron LD, Mangelsdorf C. Lumbar spinal stenosis: results of surgical treatment. J Spinal Disord. 1991; 4(3):263–273.
9. Roy-Camille R, Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res. 1986; 203:7–17.
10. Krag MH, Beynnon BD, Pope MH, et al. An internal fixator for posterior application to short segments of the thoracic, lumbar, or lumbosacral spine: design and testing. Clin Orthop Relat Res. 1986; 203:75–98.
11. France JC, Yaszemski MJ, Lauerman WC, et al. A randomized prospective study of posterolateral lumbar fusion: outcomes with and without pedicle screw instrumentation. Spine. 1999; 24(5):553–560.
12. Fritzell P, Hägg O, Wessberg P, Nordwall A. Lumbar fusion versus nonsurgical treatment for chronic low back pain: Swedish Lumbar Spine Study. Spine. 2001; 26(23):2521–2534.
13. Park DK, an HS, Lurie JD, et al. Does multilevel lumbar stenosis lead to poorer outcomes? Subanalysis of the SPORT trial. Spine (Phila Pa 1976). 2010; 35(10):439–444.
14. Whitecloud TS 3rd, Roesch WW, Ricciardi JE. Transforaminal interbody fusion versus anteroposterior interbody fusion of the lumbar spine: a financial analysis. J Spinal Disord. 2001; 14(2):100–103.
15. Mummaneni PV, Kaiser MG. Cervical spine surgery in patients older than 65 years: outcomes and complications. Neurosurg Clin N Am. 2008; 19(4):581–592.
16. Postacchini F, Cinotti G. Bone regrowth after surgical decompression for lumbar spinal stenosis. J Bone Joint Surg Br. 1992; 74-B (1):86–92.
17. Solini A, Paschero B, Ruggieri N, Paladini Molgora A. Lumbar stenosis surgery: “recalibrage” according to Senegas. Chir Organi Mov. 1992; 77(1):55–59.
18. Murthy H, Reddy TVS. VAS score assessment for outcome of posterior lumbar interbody fusion in cases of lumbar canal stenosis. Int J Res Orthop. 2016; 2(3):164–169.
19. Hur JW, Kim SH, Lee JW, Lee HK. Clinical analysis of postoperative outcome in elderly patients with lumbar spinal stenosis. J Korean Neurosurg Soc. 2007; 41(3):157–160.
20. Herron LD. Surgical considerations in lumbar stenosis: techniques and outcomes. Spine J. 2002; 2(6):123–129.
21. Getty R. Degenerative lumbar pathology — clinical overview. J Bone Joint Surg Br. 1980; 62(4):481–?
22. Aryanpur J, Ducker T. Multilevel laminotomies — an alternative to laminectomy in the treatment of lumbar stenosis. Spine. 1990; 15(3):429–433.
23. Roy-Camille R. Spine instrumentation: evolution and current concepts. Clin Orthop Relat Res. 1990; 257:15–28.
24. Herron LD, Mangelsdorf C. Outcome predictors after lumbar decompression. J Spinal Disord Tech. 1998; 11(4):300–307.
25. To study functional outcome of surgical treatment of multilevel lumbar spinal stenosis.
_
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2019
| How to Cite this Article: Siddheshwar S, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P. Optimizing Thoracolumbar Fracture Management: Hypothesis - Superiority of Long-Segment Posterior Pedicle Screw Fixation for Long-Term Stability. Journal of Medical Thesis. July-December 2023; 9(2):26-30. |
Full Text HTML | Full Text PDF
Hypothesis-Driven Patient Selection in Perthes Shelf Acetabuloplasty: Slip-In Index Threshold as a Prognostic Tool
Vol 9 | Issue 2 | July-December 2023 | page: 21-25 | Udit Vinayak, Sandeep Patwardhan, Vivek Sodhai, Rahul Jaiswal, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.216
Author: Udit Vinayak [1], Sandeep Patwardhan [1], Vivek Sodhai [1], Rahul Jaiswal [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Udit Vinayak,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: uditvinayak@gmail.com
Abstract
Background: Legg–Calvé–Perthes disease is a childhood disorder in which blood flow to the femoral head is temporarily interrupted, causing bone death that is followed by a slow phase of collapse and repair. When the weakened femoral head is not well supported by the hip socket during healing, it can flatten and lose its round shape, which impairs motion and raises the risk of early arthritis. Children who are older at the time of onset or who present late in the disease course have less ability to remodel the head back to a spherical shape, so surgeons often consider procedures that improve containment of the femoral head while healing occurs.
Hypothesis: In older children whose femoral head is extruded but still reducible into the socket, lateral shelf acetabuloplasty — a surgery that builds out the outer rim of the acetabulum with bone graft — will increase lateral coverage and reduce lateral migration of the head. By creating better support during the reparative phase, the procedure should encourage a more spherical healed femoral head, preserve pain-free range of motion, and produce improved functional outcomes at medium-term follow-up when compared with the expected natural history for similar late-presenting hips.
Clinical importance: Shelf acetabuloplasty protects a vulnerable femoral head without changing femoral anatomy. By improving how the socket covers and supports the head, the operation can reduce pain, maintain hip motion and increase the chance of near-normal remodeling. This approach is particularly useful when altering the femur (for example, with a varus osteotomy) carries unwanted consequences such as limb-length or alignment changes. Careful preoperative assessment of reducibility and realistic counselling about the remodeling process are essential.
Future research: Prospective multi-centre studies that compare shelf acetabuloplasty with femoral and other pelvic containment procedures are needed, with long-term follow-up into adulthood. Incorporating three-dimensional imaging, objective gait and biomechanical measures, and standardized patient-reported outcomes will help identify which patients benefit most. Such studies will guide clearer, evidence-based decisions and improve long-term hip health for affected children globally.
Keywords: Legg–Calvé–Perthes disease, Shelf acetabuloplasty, Containment, Femoral head sphericity, Pediatric hip, Late presentation.
Background
Legg–Calvé–Perthes disease (LCPD) is a childhood disorder in which blood supply to the femoral capital epiphysis is disrupted, producing necrosis followed by a prolonged phase of resorption and new bone formation. The final shape of the femoral head after this healing process largely determines future pain, motion and risk of early osteoarthritis. Early pathological descriptions and later clinical series make clear that age at onset and the extent of epiphyseal involvement are the main predictors of outcome: younger children with limited involvement usually remodel well, whereas older children and those with extensive necrosis face a much higher chance of permanent deformity. [1][2]
Microscopically and biomechanically, the weakened femoral head succumbs to body weight and muscular forces during revascularisation; collapse or subchondral fracture leads to flattening and loss of sphericity if the head is not adequately supported. This mechanical vulnerability provides the rationale for treatments that protect and contain the head while remodelling proceeds. [3][4]
Initial management ranges from simple observation, activity modification and physiotherapy to bracing; these conservative measures remain appropriate for many young children with limited disease. But when the femoral head is extruded, subluxated or the child is older at onset, spontaneous remodelling is less reliable and surgical containment is commonly considered to limit progressive deformity. [5][6]
Surgical containment falls into two broad strategies: femoral procedures and pelvic/acetabular procedures. Femoral varus or valgus osteotomies work by repositioning the femoral head under the native acetabular roof, which can be effective in certain age groups but permanently alters proximal femoral geometry and can cause leg-length or gait issues in some cases. [7][8] Pelvic procedures — including Salter innominate osteotomy, triple osteotomy and shelf acetabuloplasty — instead change the acetabular support. These options aim to improve lateral coverage without disturbing the femur itself, an advantage in older children where femoral geometry should ideally be preserved. [9][10]
Shelf acetabuloplasty has a straightforward mechanical logic: by extending the lateral acetabular rim with a graft, a larger lateral roof is created to keep an extruded or partially subluxated head contained while biology does its work. Increasing contact area and moving load away from a weakened lateral epiphysis reduce the tendency to collapse and flatten, thereby promoting a more spherical remodeling pattern. Early and medium-term clinical series have reported improved radiographic coverage indices and favourable morphological results in many patients treated with shelf procedures, particularly when the head remains reducible and the procedure is performed before irreversible deformity is established. [11][12]
Compared with some pelvic osteotomies, the shelf is often technically simpler and avoids an osteotomy through the innominate bone, while still increasing lateral support. That practical simplicity has made shelf acetabuloplasty a popular option for older children and late presenters with Perthes disease — cases where femoral osteotomy may be less desirable. Nonetheless, outcomes depend heavily on careful selection: a reducible head, adequate joint motion, and an acetabular shape that can accept an augmentation without producing impingement are prerequisites for success. [13][14]
Because LCPD evolves over years, meaningful assessment of any containment strategy requires medium- to long-term follow-up. Radiographic endpoints (coverage measures, migration indices) and final morphologic grading (such as Stulberg classification) are commonly used to judge success, along with clinical measures of pain and function. The thesis under review reports a consecutive series of older children treated with lateral shelf acetabuloplasty and examines radiographic coverage, morphological outcome and clinical function — adding a focused dataset to the ongoing debate about containment choice in older, late-presenting hips. [15][16]
Hypothesis
Primary hypothesis
In older children and late presenters with Legg–Calvé–Perthes disease who have an extruded but reducible femoral head, lateral shelf acetabuloplasty will (1) produce a measurable increase in lateral acetabular coverage and reduce lateral migration, and (2) lead to improved morphological outcomes and clinical function at medium- to long-term follow-up when compared with the expected natural history for similar age/stage cohorts.
Why this hypothesis is reasonable
Perthes disease presents a period in which the femoral head is biologically active but mechanically weak. Changing the mechanical environment during this window can alter remodeling forces and ultimately the healed shape of the head. Augmenting the lateral acetabular rim with a shelf graft increases coverage and spreads contact forces across a larger area, diminishing focal stress on vulnerable lateral subchondral bone and lowering the chance of progressive collapse. Prior series and reviews have documented radiographic gains in coverage and satisfactory Stulberg outcomes after shelf procedures in appropriately chosen patients, supporting the mechanistic rationale behind this hypothesis. [17][18]
Why target older children and transitional hips?
Older children (commonly defined as those >8 years at onset) have less intrinsic capacity for spontaneous remodeling and a higher likelihood of poor natural history outcomes. Femoral varus osteotomy remains an option but may introduce permanent femoral alignment changes and limb-length effects that are undesirable in older children where remodelling potential is limited. A shelf procedure offers lateral containment without altering femoral anatomy, making it a particularly attractive option in this subgroup. [19][20]
Specific, measurable predictions (endpoints)
1. Radiographic: A statistically significant postoperative increase in standard lateral coverage measures (for example, center-edge angle or migration index equivalents used in the thesis) and a reduction in lateral displacement compared with preoperative baselines. These changes will be evident on serial radiographs taken from immediate postoperative to latest follow-up. [21]
2. Morphologic: At medium-term follow-up or skeletal maturity, the majority of hips will achieve favourable Stulberg-type grades (I–III) rather than poor grades (IV–V), shifting the distribution towards better sphericity than expected from natural history for similar late-presenting cohorts. [22]
3. Clinical: Patients will report reduced pain, improved or preserved hip range of motion (notably abduction and internal rotation), and acceptable functional scores consistent with activities of daily living and school/play participation. [23]
4. Safety: The procedure will have low rates of major complications (no frequent need for reoperation, acceptable graft incorporation with minimal clinically relevant migration and no significant limb-length discrepancy attributable to the surgery). [24]
Selection and timing rationale
The shelf assumes a reducible head that will sit under the augmented rim; therefore, preoperative dynamic assessment (arthrography or careful radiographic/dynamic examination) matters. Earlier containment, when the head is still salvageable, tends to produce better morphological outcomes than late salvage, so timing—balanced with realistic assessment of reducibility—is central to testing this hypothesis. [25]
Discussion
What the thesis series demonstrates
This single-centre consecutive series reports consistent improvements in acetabular coverage indices after lateral shelf acetabuloplasty, a reduction in lateral migration and generally favourable morphological outcomes at follow-up. Many hips reached acceptable Stulberg-type grades and most patients experienced pain relief and preserved motion at their latest assessments.
Compared with femoral varus osteotomy, shelf procedures avoid changing femoral anatomy and thus spare issues such as limb-length discrepancy or altered gait mechanics — advantages particularly relevant in older children where remodeling is limited and femoral geometry should be preserved. [3][4]
Strengths and methodological caveats
Strengths of the study include a clearly described operative technique, consistent follow-up with serial radiographs, and a consecutive cohort that reduces selection bias. However, as with many surgical retrospective series, the absence of a randomized or matched control group limits causal claims. Two-dimensional radiographs were the primary imaging modality, which constrains full volumetric assessment of femoral head sphericity and acetabular congruence compared with three-dimensional imaging. Single-surgeon experience improves technical consistency but may reduce generalisability. These limitations should temper the interpretation of favorable outcomes. [5][6]
Mechanistic considerations and practical application
Biomechanically, increased lateral support from a shelf graft redistributes load and reduces focal collapse risk, allowing the biologic reparative phase to produce a more regular ossification pattern. Clinically, this mechanism is reflected in better containment on radiographs, improved abduction and internal rotation, and less pain during follow-up visits. Graft resorption or partial remodeling of the shelf is common but often clinically acceptable if net coverage and joint mechanics remain improved. [7][8]
Where shelf is most useful — and its limits
The shelf is most helpful when the head is extruded but reducible and when preserving femoral anatomy is desirable. It is less effective for grossly deformed, non-reducible heads or hips with irreversible collapse; in those situations, reconstructive or salvage options (including later arthroplasty in adults) might be the only effective solutions. Thus, careful preoperative evaluation to establish reducibility and residual joint motion is crucial to avoid futile operations. [9][10]
Implications for surgeons and patients
For surgeons treating late-presenting Perthes hips, the shelf represents a practical containment procedure that can shift the balance toward better morphological and functional outcomes without the morbidity associated with femoral geometry alteration. Patient selection, realistic counselling about expected remodeling and the need for multi-year follow-up remain central to achieving good results. [11][12]
Clinical importance
Shelf acetabuloplasty is a useful surgical option for older children and late presenters with Perthes disease when the femoral head is extruded but reducible. By increasing lateral acetabular coverage, it reduces eccentric loading on a weakened head, preserves hip motion, and frequently results in improved head sphericity at follow-up — outcomes associated with better function and potentially delayed degenerative change. Because the operation does not alter proximal femoral anatomy, it avoids limb-length and alignment consequences that sometimes follow femoral osteotomies. Careful selection, thorough preoperative assessment of reducibility, and long-term follow-up are essential to secure durable benefits.
Future directions
Future research should prioritize prospective, multi-centre comparative studies that match patients by age and disease stage to determine which hips benefit most from shelf versus femoral or other pelvic osteotomies. Long-term follow-up into adulthood is necessary to confirm whether improved intermediate sphericity after shelf indeed reduces osteoarthritis and the need for hip replacement. Incorporating three-dimensional imaging (MRI/CT), quantitative cartilage assessment, and objective gait/biomechanical analysis will refine selection criteria and provide clearer measures of true joint congruence beyond plain radiographs. Finally, harmonizing outcome measures across studies will let meta-analyses guide evidence-based choices for containment strategies in late-presenting Perthes disease.
References
1. Koob TJ, Pringle D, Gedbaw E, Meredith J, Berrios R, Kim HKW. Biomechanical properties of bone and cartilage in growing femoral head following ischemic osteonecrosis. J Orthop Res. 2007; 25(6):750-757. doi:10.1002/jor.20350
2. Catterall A. Legg-Calve-Perthes syndrome. Clin Orthop Relat Res. 1981; NO.158:41-52.
3. Atsumi T, Yamano K, Muraki M, Yoshihara S, Kajihara T. The blood supply of the lateral epiphyseal arteries in Perthes’ disease. J Bone Jt Surg Br. 2000; 82(3):392-398. doi:10.1302/0301-620X.82B3.10193
4. Joseph B, Varghese G, Mulpuri K, Rao KLN, Sreekumaran Nair N. Natural evolution of Perthes disease: A study of 610 children under 12 years of age at disease onset. J Pediatr Orthop. 2003; 23(5):590-600. doi:10.1097/01241398-200309000-00005
5. Legg AT. An obscure affection of the hip joint. 1910. Clin Orthop Relat Res. 2006; 451:11-13. doi:10.1097/01.BLO.0000238798.05338.13
6. Calvé J. On a particular form of pseudo-coxalgia associated with a characteristic deformity of the upper end of the femur. 1910. Clin Orthop Relat Res. 2006; 451:14-16. doi:10.1097/01.blo.0000238799.05338.5a
7. Perthes GC. Concerning arthritis deformans juvenilis. 1910. Clin Orthop Relat Res. 2006; 451:17-20. doi:10.1097/01.blo.0000238800.12962.b2
8. Guille JT, Lipton GE, Szöke G, Bowen JR, Harcke HT, Glutting JJ. Legg-Calve-Perthes disease in girls. A comparison of the results with those seen in boys. J Bone Jt Surg Am. 1998; 80(9):1256-1263. doi:10.2106/00004623-199809000-00002
9. Kim HKW. Legg-Calve-Perthes disease: Etiology, pathogenesis, and biology. In: Journal of Pediatric Orthopaedics. Vol 31. J Pediatr Orthop; 2011. doi:10.1097/BPO.0b013e318223b4bd
10. Moens P, Defoort K, Vancampenhout A, Peerlinck K, Fabry G. Thrombophilia and Legg-Calvé-Perthes disease: Is it a causative factor and does it affect the severity of the disease? Acta Orthop Belg. 2007; 73(5):612-617.
11. Vosmaer A, Rodrigues Pereira R, Koenderman JS, Rosendaal FR, Cannegieter SC. Coagulation abnormalities in Legg-Calvé-Perthes disease. J Bone Jt Surg Am. 2010; 92(1):121-128. doi:10.2106/JBJS.I.00157
12. Bahmanyar S, Montgomery SM, Weiss RJ, Ekbom A. Maternal smoking during pregnancy, other prenatal and perinatal factors, and the risk of Legg-Calvé-Perthes disease. Pediatrics. 2008; 122(2). doi:10.1542/peds.2008-0307
13. Wynne-Davies R, Gormley J. The aetiology of Perthes’ disease: genetic, epidemiological and growth factors in 310 Edinburgh and Glasgow patients. J Bone Jt Surg Br. 1978; 60B (1):6-14. doi:10.1302/0301-620x.60b1.564352
14. Kamegaya M. Nonsurgical treatment of Legg-Calvé-Perthes disease. In: Journal of Pediatric Orthopaedics. Vol 31. J Pediatr Orthop; 2011. doi:10.1097/BPO.0b013e318223b4a6
15. Thompson GH. Salter osteotomy in Legg-Calvé-Perthes disease. In: Journal of Pediatric Orthopaedics. Vol 31. J Pediatr Orthop; 2011. doi:10.1097/BPO.0b013e318223b59d
16. Copeliovitch L. Femoral varus osteotomy in Legg-Calve-Perthes disease. In: Journal of Pediatric Orthopaedics. Vol 31. J Pediatr Orthop; 2011. doi:10.1097/BPO.0b013e318223b55c
17. Sergio KS, Alvin CH. Comparison between Salter’s innominate osteotomy and Augmented Acetabuloplasty in the treatment of patients with severe Legg-Calve-Perthes disease. J Pediatr Orthop. 2002; 11(1).
18. Kruse RW, Guille JT, Bowen JR. Shelf arthroplasty in patients who have Legg-Calvé-Perthes disease. J Bone Jt Surg Am. 1991; 73(9):1338-1347. doi:10.2106/00004623-199173090-00008
19. Reinker KA. Shelf and/or Reduction and Containment Surgery. Orthop Clin North Am. 2011; 42(3):355-359. doi:10.1016/j.ocl.2011.03.003
20. Li WC, Xu RJ. Lateral shelf acetabuloplasty for severe Legg-Calvé-Perthes disease in patients older than 8 years: A mean eleven-year follow-up. Med (United States). 2016; 95(45). doi:10.1097/MD.0000000000005272
21. Herring JA. Tachdjian’s Pediatric Orthopaedics. Philadelphia: Saunders/Elsevier; 2014.
22. Salter RB. Legg-Perthes disease: The scientific basis for the methods of treatment and their indications. Clin Orthop Relat Res. 1980; NO.150:8-11. doi:10.1097/00003086-198007000-00004
23. Nathan AJ, Scobell A. How China sees America. Foreign Aff. 2012; 91(5).
24. Willett K, Hudson I, Catterall A. Lateral shelf acetabuloplasty: An operation for older children with Perthes’ disease. J Pediatr Orthop. 1992; 12(5):563-568. doi:10.1097/01241398-199209000-00001
25. Staheli LT, Chew DE. Slotted acetabular augmentation in Childhood and adolescence. J Pediatr Orthop. 1992; 12(5):569-580. doi:10.1097/01241398-199209000-00002
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2021
| How to Cite this Article: Vinayak U, Patwardhan S, Sodhai V, Jaiswal R, Sonawane D, Shyam A, Sancheti P. Hypothesis- Driven Patient Selection in Perthes Shelf Acetabuloplasty: Slip-In Index Threshold as a Prognostic Tool. Journal of Medical Thesis. July-December 2023; 9(2):21-25. |
Full Text HTML | Full Text PDF
Calcium Sulphate-Based Local Antibiotic Delivery in Chronic Osteomyelitis: Hypothesis of Biodegradability and Clinical Efficacy”
Vol 9 | Issue 2 | July-December 2023 | page: 17-20 | Sai Krishna, Sandeep Patwardhan, Vivek Sodhai, Rahul Jaiswal, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.214
Author: Sai Krishna [1], Sandeep Patwardhan [1], Vivek Sodhai [1], Rahul Jaiswal [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sanc heti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Sai Krishna,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: saikrishna207@gmail.com
Abstract
Background: Chronic osteomyelitis is a persistent bone infection that often follows trauma or surgery and is difficult to cure because bacteria can hide in dead bone and biofilms. Successful treatment requires thorough removal of infected tissue, control of dead space, and effective antibiotic delivery to the local site. Biodegradable carriers such as calcium sulphate that are mixed with antibiotics offer the promise of high local drug levels, resorption without a second operation, and potential support for bone healing.
Hypothesis: We tested the idea that single-stage radical debridement combined with vancomycin-loaded calcium sulphate granules would achieve a high rate of infection control while avoiding a planned second surgery to remove carrier material. In a cohort treated with this approach, we measured clinical signs, CRP trends, radiographic pellet resorption and defect filling, and implant-related complications to judge effectiveness and safety.
Clinical importance: This single-stage approach concentrates antibiotics where they are most needed, reduces the need for repeat surgery, and simplifies care for patients and health services. When combined with meticulous debridement and good soft-tissue management, vancomycin-impregnated calcium sulphate granules are a practical, cost-sensitive adjunct for many cases of chronic osteomyelitis.
Future research: Larger, multicentre trials comparing calcium sulphate with composite substitutes, studies to optimize antibiotic dosing and elution, and standardized postoperative pathways using biomarkers and imaging will help refine patient selection and improve long-term outcomes.
Keywords: Chronic osteomyelitis, Calcium sulphate, Vancomycin, Local antibiotic delivery, Single-stage debridement.
Background
Osteomyelitis remains one of orthopedics’ most persistent and challenging problems. It commonly follows open fractures, post-operative contamination or hematogenous seeding and is difficult to eradicate because bacteria can survive within necrotic bone and form biofilms that shield them from systemic antibiotics [1–3]. Clinically, chronic osteomyelitis presents with pain, variable swelling, sinus formation and occasional systemic signs; blood markers such as ESR and CRP help monitor disease activity while radiographs and MRI define extent and sequestra [4–6]. Successful treatment rests on four complementary principles: meticulous surgical debridement to remove devitalized bone and soft tissue, stability of the affected limb when required, effective dead-space management, and delivery of antibiotics at effective concentrations to the infected site [3, 7].
Traditional local antibiotic delivery used polymethylmethacrylate (PMMA) beads, which release high local antibiotic concentrations but are non-resorbable and typically require later removal — an accepted but inconvenient second procedure [8–10]. The limitations of PMMA spurred development of biodegradable carriers that could deliver antibiotics locally and then resorb, thereby avoiding planned re-entry and reducing foreign-body burden [9, 11]. Calcium sulphate (CaSO₄) emerged as a widely used biodegradable carrier because of its predictable resorption, osteoconductive qualities and strong initial antibiotic elution profile when mixed with suitable agents such as vancomycin or tobramycin [11–14].
Clinical series of antibiotic-loaded calcium sulphate report encouraging infection-control rates, often exceeding 80–90% in carefully selected cohorts, and they highlight practical benefits: single-stage dead-space management, elimination of a routine removal operation, and high local antibiotic concentrations that exceed systemic achievable levels [11, 15–17]. The most commonly reported adverse event is transient serous wound drainage in a subset of patients; this is generally self-limited but sometimes demands prolonged wound care [12, 16]. Radiographic bone filling after pellet resorption is variable across reports: contained, small defects in well-vascularized hosts often show meaningful in-fill, while larger or poorly vascularized defects may demonstrate only partial radiographic filling and can require additional grafting or staged reconstruction [13, 18–20].
Comparative work between PMMA and calcium sulphate suggests trade-offs: PMMA’s slower sustained elution and structural persistence can be advantageous for prolonged local suppression in certain circumstances but come at the cost of a second operation and potential tissue damage on removal; calcium sulphate’s faster elution and resorption shifts the emphasis to the quality of the initial surgical debridement and the host’s biological ability to form new bone [8, 15, 21]. Host factors (Cierny–Mader stage), microbial virulence and soft-tissue status remain key determinants of outcome across series [7, 22]. Recent large series using antibiotic-loaded CaSO₄ in single-stage procedures report high cure rates when debridement and soft-tissue management are adequate, strengthening the case for its broader use especially where staged surgery carries high cost or logistical burden [11,17,23–25].
The present work assesses vancomycin-impregnated calcium sulphate granules implanted after radical debridement. Outcomes of interest are clinical eradication of infection, trends in inflammatory markers, degree of radiographic defect filling after pellet resorption, and implant-related complications — outcomes that align with published literature and allow direct comparison with other series using biodegradable carriers [11, 15, 17, 19, 24].
Hypothesis
Primary hypothesis
when combined with thorough surgical debridement and appropriate soft-tissue management, local delivery of vancomycin via resorbable calcium sulphate granules will produce a high rate of infection eradication in chronic osteomyelitis without the need for a planned second procedure to remove carrier material. Specifically, single-stage debridement plus vancomycin-loaded CaSO₄ will achieve clinical control and a sustained fall in CRP in the majority of patients at medium-term follow-up, mirroring outcomes reported in contemporary series of antibiotic-loaded biodegradable carriers [11, 15, and 17].
Secondary and mechanistic expectations
1. Pellet resorption and bone in-fill: calcium sulphate will resorb progressively over weeks to months, and in contained defects with good host biology it will permit osteoconduction and partial to complete radiographic filling. Prior series show variable but frequently favorable defect-filling in such circumstances. [13,18,20]
2. Reduced systemic surgical burden: by avoiding routine bead removal, the biodegradable carrier will lower the number of planned re-operations compared with PMMA-based protocols, with consequent savings in theatre time and morbidity associated with repeat surgery. [8,21]
3. Safety profile: the commonest implant-related issue will be transient serous wound drainage, with serious systemic toxicity or frequent mechanical failures being uncommon. The literature shows drainage as the most reported complication, usually manageable with conservative measures. [12,16]
4. Predictors of failure: higher Cierny–Mader stages, compromised host physiology (Type-B hosts), large segmental defects and aggressive or resistant organisms will correlate with higher recurrence risk, emphasizing that the implant supplements but does not replace meticulous debridement and host optimization. [7,22,24]
Operational hypothesis (measurable outcomes)
In a prospective cohort receiving radical debridement and vancomycin-impregnated CaSO₄ granules we expect: (a) clinical eradication in the high-80s to low-90s percent range at minimum 6–12 months; (b) progressive pellet resorption in most patients with variable radiographic defect filling by 3–6 months; (c) low rates of major complications and rare requirement for implant removal, consistent with prior reports. These outcomes will be tracked with serial clinical reviews, CRP monitoring and standard radiographs to compare with published benchmarks. [11, 15, 17, 19]
Discussion
The present cohort’s results fall in line with an expanding body of evidence that antibiotic-loaded calcium sulphate is an effective adjunct in single-stage management of chronic osteomyelitis. Reported eradication rates in contemporary series commonly lie in the mid-80s to mid-90s percent range, and this study’s cure rate is consistent with those figures when debridement and soft-tissue reconstruction are adequate [11,15,17]. The practical advantage of avoiding a planned secondary operation is substantial for patients and health systems alike, particularly where resource constraints or patient comorbidity make repeat theatre attendance undesirable [8, 21].
Radiographic outcomes vary: contained defects and defects in healthier hosts often show appreciable bone in-fill as pellets resorb, whereas segmental or poorly vascularized cavities may heal with limited radiographic filling and occasionally require secondary interventions for structural restoration [13, 18, and 20]. This variability highlights a central truth: the implant is a facilitator of local antibiotic delivery and dead-space management, not a stand-alone bone graft substitute in large defects. In practice, surgeons should anticipate the need for adjunctive grafting or staged reconstruction in major segmental defects and counsel patients accordingly [19, 23].
Complications are usually manageable. Serous drainage after implantation is reported in multiple series; it often resolves without surgical intervention but may prolong wound care and outpatient follow-up [12, 16]. Rare mechanical events — such as fracture at the site of aggressive debridement — are preventable with careful technique and consideration of temporary stabilization when bone integrity is compromised. Culture results and microbial susceptibility remain vital guides for which antibiotic to incorporate into the carrier; vancomycin is a reasonable choice for gram-positive coverage, particularly for MRSA or culture-proven staphylococcal infections common in post-traumatic cases [11, 17, and 24].
Comparative considerations versus PMMA and composites are pragmatic: PMMA provides a long-lasting spacer and prolonged antibiotic elution but commits the patient to a later removal procedure; calcium sulphate relieves that burden but relies more heavily on initial surgical clearance and host biology for long-term success [8, 15, and 21]. Emerging composites — blends of CaSO₄ with calcium phosphate or bioactive glass — show promise for improved scaffold function and slower resorption, potentially improving radiographic filling in larger defects, but cost and availability vary and more comparative randomized data are needed [14,25].
Finally, patient selection and surgical discipline determine outcomes more than choice of carrier alone. High-quality debridement, robust soft-tissue coverage, culture-guided antibiotic selection and close follow-up with CRP and radiography remain the cornerstones. When these elements are in place, vancomycin-loaded calcium sulphate granules offer a reproducible, patient-friendly option for many cases of chronic osteomyelitis. [3, 7, 11, 17]
Clinical importance
Using vancomycin-impregnated calcium sulphate as a single-stage adjunct after radical debridement concentrates antibiotics at the infected site, manages dead space with a resorbable material and eliminates the routine need for a second surgery to remove beads. For patients this can mean fewer operations, shorter disruption to life and potentially faster functional recovery; for health systems, it offers a cost-sensitive approach that reduces repeat theatre use. Nevertheless, success depends on sound surgical technique, host optimization and tailored microbiological therapy — the implant augments but does not replace these fundamentals.
Future directions
1. Prospective randomized trials comparing CaSO₄ alone with composite carriers (CaSO₄/CaPO₄, bioactive glass) for defect filling, infection control and cost-effectiveness.
2. Pharmacokinetic optimization studies to refine antibiotic selection and dose within pellets to balance initial burst with sustained therapeutic levels.
3. Biomarker-guided postoperative antibiotic pathways (e.g., CRP dynamics) and standardized radiographic reporting would reduce practice variability and clarify when systemic antibiotics can be safely shortened. Multicentre registries collecting uniform outcomes will strengthen evidence for guideline development.
References
1. Romer AS. Paleopathology. An Introduction to the Study of Ancient Evidences of Disease. Roy L Moodie. J Geol. 1924; 32:262–3.
2. Conterno LO, Turchi MD. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database Syst Rev. 2013 Sep 6 ;( 9):CD004439.
3. Petty W. Diagnosis and Management of Bone Infections. In: Jauregui LE, editor. Marcel Dekker; 1995.
4. McNally M, Nagarajah K. Osteomyelitis. Orthop Trauma. 2010 Dec; 24(6):416–29.
5. Kocher MS, Lee B, Dolan M, Weinberg J, Shulman ST. Pediatric orthopedic infections: early detection and treatment. Pediatr Ann. 2006 Feb; 35(2):112–22.
6. Holtom PD, Warren CA, Greene NW, et al. Relation of surface area to in vitro elution characteristics of vancomycin-impregnated polymethylmethacrylate spacers. Am J Orthop. 1998 Mar; 27(3):207–10.
7. Cierny G, DiPasquale D. Treatment of Chronic Infection. J Am Acad Orthop Surg. 2006; 14(S):S105–10.
8. Buchholz HW, Elson RA, Heinert K. Antibiotic-loaded Acrylic Cement. Clin Orthop Relat Res. 1984:96–108.
9. Klemm K. Gentamicin-PMMA beads in treating bone and soft tissue infections. Zentralbl Chir. 1979; 104(14):934–42.
10. Marks KE, Nelson CL, Lautenschlager EP. Antibiotic-impregnated acrylic bone cement. J Bone Joint Surg. 1976; 58:358–64.
11. Ferguson JY, Dudareva M, Riley ND, Stubbs D, Atkins BL, McNally MA. Use of biodegradable antibiotic-loaded calcium sulphate containing tobramycin for chronic osteomyelitis: a series of 195 cases. Bone Joint J. 2014; 96-B (6):829–36.
12. Beuerlein RL, et al. Calcium sulphate: uses, side effects and pitfalls. Clin Orthop Relat Res. (cited in thesis).
13. McKee MD, et al. Tobramycin-impregnated bioabsorbable bone graft substitute for infected bony defects. J Orthop Trauma. 2002.
14. El-Husseiny M, Patel S, MacFarlane RJ, Haddad FS. Biodegradable antibiotic delivery systems. J Bone Joint Surg Br. 2011 Feb; 93(2):151–7.
15. McConoughey SJ, Howlin RP, Wiseman J, Stoodley P, Calhoun JH. Comparing PMMA and calcium sulphate as carriers for local antibiotic delivery. J Biomed Mater Res B Appl Biomater. 2015; 103(4):870–7.
16. Humm G, Noor S, Bridgeman P, et al. Adjuvant treatment of chronic tibial osteomyelitis using OSTEOSET-T: a review of 21 patients. Strategies Trauma Limb Reconstr. 2014; 9(3):157–61.
17. Tsai Y-H, Hsu R-W. Treatment of infected tibial nonunion with tobramycin-impregnated calcium sulphate: case reports. Chang Gung Med J. 2004; 27(7):542–7.
18. Chang W, Colangeli M, et al. Adult osteomyelitis: debridement versus debridement plus Osteoset T pellets. Acta Orthop Belg. 2007; 73(2):238–43.
19. Patzakis MJ, et al. Septopal beads and autogenous bone grafting for bone defects in chronic osteomyelitis. Clin Orthop Relat Res. 1993; 112–118.
20. Gitelis S, et al. Biodegradable antibiotic implant for chronic osteomyelitis. 2002.
21. McConoughey SJ, Howlin RP, Wiseman J, Stoodley P, Calhoun JH. Carrier comparisons and clinical considerations. J Biomed Mater Res B Appl Biomater. 2015.
22. Cierny G, Mader JT, Penninck JJ. A Clinical Staging System for Adult Osteomyelitis. Clin Orthop Relat Res. 2003; 414:7–24.
23. Tang H-J, et al. Treatment of osteomyelitis by liposomal gentamicin-impregnated calcium sulphate. Arch Orthop Trauma Surg. 2009; 129(10):1301–8.
24. Kumar CY, Menon J, Patro DK, et al. Calcium sulphate as bone graft substitute — prospective study. J Clin Diagn Res. 2013 Dec; 7(12):2926–8.
25. Beuerlein et al. Specific calcium sulphate review. Clin Orthop Relat Res.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2021
| How to Cite this Article: Krishna S, Patwardhan S, Sodhai V, Jaiswal R, Sonawane D, Shyam A, Sancheti P. Calcium Sulphate-Based Local Antibiotic Delivery in Chronic Osteomyelitis: Hypothesis of Biodegradability and Clinical Efficacy. Journal of Medical Thesis. July-December 2023; 9(2):17-20. |
Full Text HTML | Full Text PDF
Chaput Fragment Percutaneous Plating and Ankle-Spanning External Fixation in Pilon Fractures: Hypothesis for Superior Early Outcomes
Vol 9 | Issue 2 | July-December 2023 | page: 13-16 | Nayan Shrivastav, Rajeev Joshi, Sahil Sanghavi, Mahavir Dugad, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.212
Author: Nayan Shrivastav [1], Rajeev Joshi [1], Sahil Sanghavi [1], Mahavir Dugad [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sanc heti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Nayan Shrivastav,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: nayanshri93@gmail.com
Abstract
Background: Distal tibial intra-articular (pilon) fractures are serious injuries that commonly follow high-energy axial impacts or lower-energy twisting events. They often cause joint fragmentation, metaphyseal collapse and damage to the surrounding soft tissues. Because the ankle is the primary weight-bearing joint, imperfect reduction or fixation can lead to persistent pain, loss of motion and early post-traumatic arthritis that interfere with daily activities and the ability to return to work. These injuries therefore frequently require staged surgical strategies that balance accurate articular reconstruction with protection of fragile soft tissues.
Hypothesis: We hypothesis that selecting the operative technique according to fracture morphology and the condition of the soft tissues—using staged external fixation when soft tissues are unsuitable for immediate open exposure and performing open reduction and internal fixation (ORIF) when local conditions permit—will produce comparable mid-term functional outcomes across approaches, provided that articular congruity, limb alignment and stable fixation are achieved.
Clinical importance: This study compares commonly used treatment pathways using validated patient-reported outcome instruments and clinician-rated scores, objective ankle range of motion, complication and reoperation rates, and length of hospital stay. By clarifying which injury patterns and patient characteristics predict better recovery or higher risk of wound problems, clinicians can make more individualized treatment choices, counsel patients about realistic recovery timelines, tailor rehabilitation plans and reduce avoidable complications, readmissions and the longer-term socioeconomic burden for patients and families. Clearer evidence will also help surgeon’s priorities soft-tissue management without sacrificing joint reconstruction.
Future research: Larger, prospective multicenter trials with longer follow-up are needed to confirm comparative effectiveness and refine indications for each technique. Future work should evaluate targeted measures to prevent soft-tissue complications and early arthritis, and incorporate imaging biomarkers, gait and biomechanical analysis and registry data to improve prognostication and personalize care.
Keywords: Pilon fracture, Distal tibia, Intra-articular, Open reduction and internal fixation, External fixation, Functional outcome, Soft-tissue management.
Background
Pilon fractures, involving the distal tibial plafond, produce a unique clinical challenge because they damage both joint cartilage and the surrounding soft tissues. Although they represent a relatively small proportion of tibial injuries, their impact on an individual’s gait and quality of life is disproportionately large. Mechanisms range from low-energy torsional injuries that cause limited comminution, to high-energy axial loading — commonly seen in road traffic collisions or falls from height — that shatters the plafond and frequently compromises soft tissues. Recognizing this spectrum is essential; fracture morphology and skin condition together determine technical strategy and prognosis. [1]
Early in the modern era these injuries were often managed nonoperatively, with disappointing results: malunion, persistent pain, stiffness and progressive arthritis were common. That experience drove the move toward operative reconstruction of the articular surface to restore joint mechanics. However, early enthusiasm for immediate ORIF revealed a serious downside: when surgery is performed through swollen or blanched skin the risk of wound dehiscence and deep infection is high. This led to the now-familiar staged approach — immediate provisional external fixation to restore length and alignment while soft tissues recover, followed by definitive reconstruction — which seeks to capture the advantages of anatomical reduction without provoking soft-tissue complications. [2–5]
Fracture classifications such as Rüedi–Allgöwer and AO/OTA help stratify injury severity and guide expectations; high-grade injuries tend to have greater comminution, worse soft-tissue trauma and poorer outcomes. CT imaging is widely used because it reveals the fragment patterns that largely determine surgical approach: principal fragments such as Chaput, Volkmann and posterolateral fragments are best identified and addressed when they are mapped on axial and reconstructed CT images. This fragment mapping informs incision choice, fixation sequence and the feasibility of minimally invasive techniques. [3, 4]
Surgical options include primary ORIF with buttress or locking plates, minimally invasive percutaneous plating, limited open fixation combined with external stabilization, and circular external fixation. Each has trade-offs. Primary ORIF offers the best opportunity for precise anatomic reconstruction and the application of stable constructs that permit early controlled motion — when the soft tissues tolerate the exposure. Minimally invasive plating reduces additional soft-tissue insult but can be limited by fragment complexity. External fixation techniques preserve the skin and soft-tissue bed but may accept some residual articular incongruity unless combined with limited internal fixation. Thus technique choice is not about which implant is best in abstraction, but about matching the implant and approach to the biology and anatomy of the individual case. [5–11]
Patient comorbidities also shape decisions and outcomes. Diabetes, peripheral vascular disease, smoking and obesity increase the risk of wound complications and infection and thus lower the threshold for staged, soft-tissue–respecting strategies. Timing of surgery is critical: operating before swelling has subsided or while blisters are tense is a recognized risk for wound failure; delaying definitive internal fixation until local biology improves reduces that risk and often preserves options for later reconstruction. [6, 9, 11, 12]
Beyond the operation itself, postoperative care — early controlled range of motion, edema control and graded weight bearing tied to fixation stability — is essential to translate radiographic success into meaningful function. Systems-level coordination, including timely CT imaging, access to soft-tissue/plastic surgery expertise where needed and structured physiotherapy, improves outcomes and is why results may differ between centres. The contemporary management goal, then, is to restore joint congruity where safely possible while always prioritizing soft-tissue health — a balance that aims to minimize complication risk while maximizing the chance of a pain-limited, functional ankle. [7–13]
Hypothesis
Primary hypothesis:
• A soft-tissue–guided treatment pathway optimizes patient outcomes in pilon fractures: when the soft tissues are favorable, primary ORIF targeting anatomic articular restoration yields superior early functional recovery; when soft tissues are hostile, staged provisional external fixation followed by delayed definitive reconstruction reduces wound complications while permitting satisfactory intermediate functional outcomes.
Rationale:
Restoring the articular surface and mechanical alignment is the biomechanical imperative for a weight-bearing joint. Anatomic reduction reduces focal cartilage overload and thereby lowers the risk of symptomatic post-traumatic arthritis; ORIF performed through healthy soft tissues provides the most reliable means to achieve this reduction and to apply stable constructs that enable early, supervised rehabilitation. However, this mechanical goal must be tempered by biological reality. Performing extensile exposures in the presence of swelling or compromised skin dramatically increases wound complications, which can require repeated surgery, hardware removal or even compromise limb salvage. The staged approach reconciles these competing demands: provisional external fixation restores alignment and length while allowing soft tissues to settle, and definitive ORIF is performed later under safer conditions when indicated. [14–16]
Supporting propositions:
1. CT-guided fragment mapping drives approach selection. Axial and 3D CT reconstructions identify principal fragments and the approaches most likely to reduce them effectively. Using CT mapping to plan incisions and fixation sequences reduces unnecessary soft-tissue dissection and improves the chance of anatomical reduction. [4,17]
2. Technique must match pattern and biology. Minimally invasive plating is appropriate when fragment patterns permit and when it reduces exposure-related soft-tissue insult; more extensile exposures are reserved for cases where CT shows fragments not reconstructable by less invasive means. Where reconstruction is not practical, external fixation with limited internal fixation or a circular frame supports alignment and soft-tissue healing without the risk of a wound catastrophe. [16–19]
3. Postoperative rehabilitation is a co-determinant. Stable fixation that allows early controlled range of motion and progressive weight bearing is associated with better ankle motion and higher patient-reported functional scores. Therefore, optimal outcome depends on both surgical technique and a planned, staged rehabilitation pathway. [17–20]
4. Patient optimization matters. Active management of diabetes, smoking cessation where possible and vascular assessment in at-risk patients reduces the risk of wound complications and helps determine which patients are safe candidates for early ORIF versus staged management. [15,16]
These hypotheses can be tested in prospective cohorts stratified by AO/Rüedi–Allgöwer grade and soft-tissue status, using standardized CT descriptors and validated outcome measures (AOFAS, FADI, and SF-36). The overarching aim is not merely to compare implants but to define context-specific strategies that align anatomical possibility with biological safety. [14–20]
Discussion
The practical management of pilon fractures is guided by a single surgical truth: biology determines timing and extent. When the soft tissues are healthy and swelling minimal, primary ORIF gives the best pathway to anatomic restoration and earlier functional recovery. But when soft tissues are compromised, forcing definitive open exposure risks wound dehiscence and deep infection — complications that often produce worse long-term outcomes than a temporary, conservative approach. The staged pathway — external fixator to restore length and alignment followed by delayed ORIF — is a biologically respectful compromise that preserves reconstructive options while minimizing early wound morbidity. [21]
External fixation with limited internal fixation, and circular frame techniques, have an essential place for highly comminuted fractures or when soft tissues cannot tolerate further insult. These approaches emphasize limb preservation and soft-tissue healing; clinicians must accept that they may not always restore perfect articular congruity, but they reduce the immediate risk of soft-tissue catastrophe and often allow acceptable, pain-limited function. That trade-off must be communicated to patients clearly during shared decision making. [22, 23]
Operational refinements that consistently improve outcomes include CT-based planning to map fragments and guide approach selection; avoiding incision placement that undermines vascularized skin bridges; selective use of minimally invasive plate osteosynthesis where feasible; and temporary fragment fixation to sequence reduction before plate application. Postoperative care — edema control, early supervised motion as fixation allows, and staged weight bearing — is critical to convert a technically successful reconstruction into usable function. [4, 17–20]
Limitations in the evidence base reflect case heterogeneity, variable rehabilitation protocols and the predominance of single-center series. Randomized trials are difficult in this heterogeneous field, but multicenter prospective registries with standardized CT descriptors and rehabilitation protocols would permit more robust subgroup analysis, clarify long-term incidence and impact of post-traumatic arthritis, and refine indications for immediate versus staged strategies. Patient-level factors such as diabetes and smoking must be actively managed to improve outcomes across strategies. [24]
In sum, while anatomic articular restoration remains the biomechanical ideal, it must not be pursued at the cost of the soft tissues. A strategy that integrates CT-driven planning, biology-led timing, and coordinated rehabilitation offers the best chance to return patients to functional, pain-limited activities. [21–24]
Clinical importance
For practicing surgeons: prioritize the soft tissues. When skin and swelling permit, pursue primary ORIF to optimize early restoration of joint congruity and function. When soft tissues are hostile, use provisional external fixation and delay definitive internal fixation to lower wound complications while preserving the option for later reconstruction. Reserve combined external/internal fixation or circular frames for unreconstructible patterns or cases with severe soft-tissue compromise. CT-guided fragment mapping, careful incision planning, and structured, early rehabilitation are central to converting anatomical repair into a functional ankle. Clear preoperative counselling about staged care and realistic recovery timelines improves patient expectations and satisfaction.
Future directions
Priorities are multicenter prospective registries using standardized CT fragment descriptors, uniform rehabilitation protocols and minimum two-year follow-up to capture post-traumatic arthritis and functional trajectories. Comparative effectiveness work stratified by fracture grade and soft-tissue status, together with objective gait analysis and patient-reported outcome mapping, will translate radiographic success into patient-centered metrics and help refine subgroup-specific recommendations.
References
1. Jacob N, Amin A, Giotakis N, Narayan B, Nayagam S, Trompeter AJ. Management of high-energy tibial Pilon fractures. Strategies Trauma Limb Reconstr. 2015 Nov; 10(3):137–47.
2. Fialka C, Vécsei V. Anatomical and Radiological Classification of Pilon Tibial Fractures. Fractures of the Tibial Pilon. 2002. p. 13–8.
3. Stephen D. Fractures of the Distal Tibial Metaphysis Involving the Ankle Joint: The Pilon Fracture. The Rationale of Operative Fracture Care. p. 523–50.
4. Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The Pilon Map. J Orthop Trauma. 2013; 27:e152–6.
5. Conroy J, Agarwal M, Giannoudis PV, Matthews SJE. Early internal fixation and soft tissue cover of severe open tibial pilon fractures. Int Orthop. 2003; 27:343–7.
6. I R, Allgöwer M, Matter P. Intra-articular fractures of the distal tibia. J Trauma. 1969; 9:640.
7. Johnson A. Distal Tibial Fractures. Atlas of Orthopedic Surgical Procedures of lower limb. p. 198–9.
8. Bonnin JG. Injuries to the ankle. William Heinemann (Medical Books) Ltd. 1950. (British Journal of Surgery review).
9. McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma. 1992; 6(2):195–200.
10. Rogge D. External Articular Transfixation for Joint Injuries with Severe Soft Tissue Damage. Fractures with Soft Tissue Injuries. 1984. p. 103–17.
11. Rüedi T, Allgöwer M. The operative treatment of intraarticular fractures of the lower end of the tibia. Orthopedic Trauma Directions. 2011; 9:23–5.
12. Michelson J, Moskovitz P, Labropoulos P. The Nomenclature for Intra-articular Vertical Impact Fractures of the Tibial Plafond: Pilon versus Pylon. Foot Ankle Int. 2004; 25:149–50.
13. Rockwood CA Jr., Green DP, Bucholz RW, Heckman JD, editors. Fractures in Adults. 4th ed. Lippincott-Raven; 1996.
14. Pilon Fracture. Encyclopedia of Trauma Care. 2015:1252.
15. Helfet DL, Koval K, Pappas J, Sanders RW, Dipasquale T. Intraarticular Pilon Fracture of the Tibia. Clin Orthop Relat Res. 1994; 221–228.
16. Tarkin IS, Clare MP, Marcantonio A, and Pape HC. An update on the management of high-energy pilon fractures. Injury. 2008 Feb; 39(2):142–54.
17. Collinge C, Kuper M, Larson K, Protzman R. Minimally invasive plating of high-energy metaphyseal distal tibia fractures. J Orthop Trauma. 2007 Jul; 21(6):355–61.
18. Zhao Y, Wu J, Wei S, Xu F, Kong C, Zhi X, et al. Surgical approach strategies for open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans. J Orthop Surg Res. 2020 Jul 27; 15(1):283.
19. Collinge CA, Sanders RW. Percutaneous plating in the lower extremity. J Am Acad Orthop Surg. 2000 Jul; 8(4):211–6.
20. Grose A, Gardner MJ, Hettrich C, Fishman F, Lorich DG, Asprinio DE, et al. Open reduction and internal fixation of tibial pilon fractures using a lateral approach. J Orthop Trauma. 2007 Sep; 21(8):530–7.
21. Calori GM, Tagliabue L, Mazza E, de Bellis U, Pierannunzii L, Marelli BM, et al. Tibial pilon fractures: Which method of treatment? Injury. 2010; 41:1183–90.
22. Amorosa LF, Brown GD, Greisberg J. A Surgical Approach to Posterior Pilon Fractures. J Orthop Trauma. 2010; 24:188–93.
23. Korkmaz A, Çiftdemir M, Özcan M, Çopuroğlu C, Sarıdoğan K. The analysis of the variables, affecting outcome in surgically treated tibia pilon fractured patients. Injury. 2013; 44:1270–4.
24. Assal M, Ray A, Stern R. The Extensile Approach for the Operative Treatment of High-Energy Pilon Fractures: Surgical Technique and Soft-Tissue Healing. J Orthop Trauma. 2007; 21:198–206.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2021
| How to Cite this Article: Shrivastav N, Joshi R, Sanghavi S, Dugad M, Sonawane D, Shyam A, Sancheti P. Chaput Fragment Percutaneous Plating and Ankle-Spanning External Fixation in Pilon Fractures: Hypothesis for Superior Early Outcomes. Journal of Medical Thesis. July-December 2023; 9(2):13-16. |
Full Text HTML | Full Text PDF
Integrating Patient-Specific Lifestyle Demands into Post-Arthroplasty Care: Hypothesis – Enhancement of HRQoL in Indian Patients
Vol 9 | Issue 2 | July-December 2023 | page: 9-12 | Peeyush Belsare, Rajeev Joshi, Sahil Sanghavi, Mahavir Dugad, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.210
Author: Peeyush Belsare [1], Rajeev Joshi [1], Sahil Sanghavi [1], Mahavir Dugad [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sanc heti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Peeyush Belsare,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: peeyushbelsare.03@gmail.com
Abstract
Background: Arthritis of the hip and knee causes persistent pain, stiffness and loss of function that limit everyday activities and reduce quality of life. Total hip and knee replacement are effective treatments that relieve pain and restore mobility for most patients, but the size and timing of benefit vary with a patient’s preoperative health, body weight, social support and access to rehabilitation. Studying how patient-reported outcomes change after surgery helps clinicians decide when to operate, how to prepare patients beforehand, and which supports speed recovery.
Hypothesis: We expected that most patients would experience large, clinically meaningful improvements in pain, joint-specific function and overall health-related quality of life within the first year after surgery, with the largest gains in the first three to six months. We also proposed that baseline function and modifiable factors — notably body mass index, comorbidities and psychosocial support — would influence both the amount of improvement and the final level of function at one year.
Clinical importance: Measuring outcomes from the patient’s perspective highlights simple, practical ways to improve results: operate before severe functional decline when appropriate, optimize modifiable risks such as high body weight and uncontrolled medical conditions, screen for and address mental-health or expectation-related issues, and provide structured postoperative physiotherapy and education. These steps increase the chances that patients regain meaningful day-to-day abilities and are satisfied with their surgery, especially where rehabilitation resources are limited.
Future research: Longer follow-up will link early improvements to implant longevity and late complications. Trials of prehabilitation (weight loss, exercise, psychological support) would clarify whether improving modifiable risks before surgery leads to better long-term outcomes. Studies that adapt outcome measures and rehabilitation to cultural activities (for example squatting) will make recommendations more relevant to local patients.
Keywords: Total hip arthroplasty, Total knee arthroplasty, Quality of life, Patient-reported outcomes, Preoperative optimization, Rehabilitation.
Background
Arthritis of the hip and knee is a common and often disabling problem. Pain, stiffness and reduced mobility make everyday tasks — walking, climbing stairs, sitting and squatting — difficult, and they take a real toll on quality of life. Over the years the goals of treatment have moved beyond simply keeping implants in place: we now measure success by how patients feel and function after surgery. Preoperative function strongly predicts what patients experience after joint replacement; those who are less disabled before surgery generally reach a higher final level of function, while those with worse baseline scores often show larger absolute improvements but may still lag behind in absolute terms. (1) Long-term follow-up studies show meaningful gains in patient-reported health for many years after arthroplasty, confirming durable benefit for appropriately selected patients. (2)
Most published series find that the greatest relief from pain and the biggest functional gains happen early — within the first three to six months — with further smaller improvements or stabilization up to a year and beyond. (3) Age affects outcomes in complex ways: older patients may carry more comorbidity but can still enjoy large relative improvements, while younger patients often have different expectations tied to higher activity levels. (4) Appropriateness of surgery matters too; selecting patients who are likely to benefit improves both resource use and outcomes. (5) Alongside patient selection, implant survival and complication rates remain important, but these technical metrics alone do not capture how much better a patient’s life has become after surgery. (6)
Total knee and hip replacement have evolved over decades, and improvements in implant design, surgical technique and perioperative care have broadened the pool of patients who can safely undergo these operations. (7) Contemporary practice increasingly emphasizes a multidisciplinary approach — coordinated perioperative care, better pain control, early mobilization, physiotherapy and clear patient education — to speed recovery and improve longer-term outcomes. (8) Shared decision-making, where patients understand realistic goals and risks, is now central to planning arthroplasty and is linked to higher satisfaction after surgery. (9)
Despite a strong international evidence base, differences in lifestyle, cultural expectations and activity demands mean that outcomes observed elsewhere may not map perfectly to every population. In countries where activities like squatting and sitting cross-legged remain important, the functional priorities after surgery differ from those emphasized in many western studies. This reality underscores the importance of studying health-related quality of life (HRQoL) in local patient groups, using validated patient-reported outcome measures that capture pain, stiffness, function and broader health domains. The thesis on which this synopsis is based addresses these questions by prospectively following patients undergoing primary total hip and knee arthroplasty and measuring changes in PROMs over the first postoperative year. The aim is practical: to describe the magnitude and timing of improvement, and to identify the patient and treatment factors that most strongly influence recovery in our setting. (1–9)
Hypothesis
This study grew out of three practical hypotheses that reflect what surgeons and patients commonly observe and what previous research suggests.
First, elective primary hip and knee arthroplasty produce large, clinically meaningful improvements in pain, joint-specific function and overall quality of life within a year after surgery, with most gains appearing early (by three to six months) and then stabilizing. This expectation is supported by multiple reports showing early, marked improvement in PROMs followed by sustained benefit at medium-term follow up. (10–12) Measuring patients at baseline and again at 3, 6 and 12 months allows us to capture both the speed and size of recovery and to confirm whether the same pattern holds in our patient population.
Second, preoperative clinical status influences both the amount of improvement and the final functional level. Patients who present with worse pain and poorer function often achieve large absolute improvements, but they may not reach the same final level as those who started with better function. This has implications for timing: operating earlier, before severe decline, may increase the chance that a patient returns to desired activities. (13–16) The study therefore examines how baseline WOMAC, SF-36 and joint-specific scores correlate with one-year outcomes, and whether practical thresholds exist that should inform when to recommend surgery.
Third, characteristics such as body mass index, presence of other medical problems, psychosocial status and expectations act as modifiers of outcome and are, in several cases, at least partly modifiable. Obesity is frequently associated with more complications and less favourable functional recovery after joint replacement, and psychological factors such as depression or unrealistic expectations can dampen perceived benefit even when objective measures improve. (16–17) Socioeconomic context and access to rehabilitation resources similarly shape recovery. (14–17) By testing the relationships between these variables and outcomes, the study aims to identify targets for preoperative optimization (for example weight management or treating depression) and perioperative interventions (structured rehabilitation, education) that can improve both objective recovery and patient satisfaction.
Taken together, these hypotheses address a straightforward clinical question: who benefits most from arthroplasty, when is the best time to operate to maximize improvement, and which modifiable factors should clinicians address before and after surgery to improve results? The thesis tests these ideas using standard statistical approaches — paired comparisons to evaluate within-subject change over time, regression analyses to find independent predictors of outcomes, and subgroup comparisons between hip and knee patients — while using a mix of disease-specific and general health instruments to give a rounded, patient-centred view of recovery. (10–17)
Discussion
The findings from this study fit comfortably with what many earlier, patient-focused reports have shown: people tend to feel markedly better after hip or knee replacement, especially in the early months after surgery. Pain relief and improvements in daily function are often the most noticeable changes patients describe, a pattern reported in large cohorts of arthroplasty patients. (18, 19)
How patients start—how much pain and disability they have before surgery—still matters a great deal. Those who come to surgery with better function generally end up with higher function at follow-up, while those who are more disabled can show large absolute gains but may not reach the same final level. That pattern highlights a practical dilemma: waiting longer often means the chance to regain full function is smaller. (20)
Social and practical supports clearly shape recovery. Patients with stronger social networks, stable finances and easy access to physiotherapy tend to recover more quickly and report higher satisfaction in the early months after surgery. Where rehabilitation is limited or follow-up is inconsistent, recovery can lag even when the operation itself is technically successful. (21, 22)
Body weight emerged as an important, and at times modifiable, factor. Higher body mass index was associated with slower functional recovery and a higher risk of complications in this cohort. That finding supports programs that help patients reduce weight and optimize fitness before surgery, not as reasons to deny care but to improve the chance of a smoother recovery. (23)
When we look specifically at hip replacement, many patients report durable improvements in quality of life across physical and social domains. These gains translate into better mobility and fewer restrictions in daily activities for a large proportion of patients. Still, there is variation between individuals—how much people return to specific cultural or lifestyle activities (for example deep squatting or sitting on the floor) can differ, and standard outcome tools may not capture those nuances completely. (24)
Finally, prospective follow-up—measuring patient-reported outcomes at set intervals—proved invaluable. Tracking patients at baseline, three, six and twelve months gives a clear picture of the speed and scale of recovery, reveals who needs additional support, and helps clinicians and patients set realistic expectations. Short- and mid-term follow-up studies like this one are useful for guiding immediate care decisions and for designing targeted interventions to improve recovery. (25)
There are limitations to keep in mind. This was a single-center, observational study with one-year follow-up: it tells us a lot about early and intermediate recovery but not about long-term implant survival or very late complications. Cultural differences in daily activities mean some standard questionnaires may under- or over-estimate the functional limitations that matter most to patients here. Despite these limits, the results point toward clear, actionable steps clinicians can take to improve outcomes.
Clinical importance
Joint replacement for the hip or knee reliably eases pain and restores everyday function for most people — often within the first few months after surgery. Using patient-reported measures to assess pain and function before surgery helps decide the right timing: operating before a person’s abilities fall too far often leads to a better final result. Simple, practical steps make a big difference: help patients optimize weight and control medical problems, screen and support mental health, give clear education about what to expect, and ensure access to basic physiotherapy and follow-up. In settings with limited resources, prioritizing patients who are likely to gain the most and making sure they receive focused rehab and support offers the best value for both patients and the health system.
Future directions
Future work should follow patients beyond one year to link early HRQoL improvements with implant longevity and late revisions. Randomized or controlled studies of prehabilitation, weight-reduction programs and focused psychosocial interventions would clarify whether improving modifiable risks before surgery translates into better long-term outcomes. Comparative studies of implant choices and fixation strategies that account for cultural activity demands (deep flexion, squatting) will help tailor surgery to local needs. Finally, qualitative research that explores patient expectations and day-to-day functional priorities can inform adaptation of PROMs and preoperative counseling so that measures and messages match what patients value most.
References
1. Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999; 42(8):1722–8.
2. Nilsdotter A-K, Isaksson F. Patient relevant outcome 7 years after total hip replacement for OA - a prospective study. BMC Musculoskelet Disord. 2010; 11:47.
3. Neuprez A, Neuprez AH, Kaux J-F, Kurth W, Daniel C, Thirion T, et al. Early clinically relevant improvement in quality of life and clinical outcomes 1 year postsurgery in patients with knee and hip joint arthroplasties. Cartilage. 2018;9(2):127–39.
4. Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med. 2001; 161(3):454–60.
5. Quintana JM, Escobar A, Arostegui I, Bilbao A, Azkarate J, Goenaga JI, Arenaza JC. Health-related quality of life and appropriateness of knee or hip joint replacement. Arch Intern Med. 2006; 166(2):220–6.
6. Berry DJ, Scott Harmsen W, Cabanela ME, Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements. J Bone Joint Surg Am. 2002; 84:171–7.
7. Patel NG, Waterson HB, Phillips JRA, Toms AD. 50 years of total knee arthroplasty. Bone Jt 360. 2019; 8:3–7.
8. Feng JE, Novikov D, Anoushiravani AA, Schwarzkopf R. Total knee arthroplasty: improving outcomes with a multidisciplinary approach. J Multidiscip Healthc. 2018; 11:63–73.
9. Slover J, Alvarado C, Nelson C. Shared decision making in total joint replacement. JBJS Rev. 2014; 2(3).
10. Barlow T, Griffin D, Barlow D, Realpe A. Patients’ decision making in total knee arthroplasty: a systematic review of qualitative research. Bone Joint Res. 2015;4(10).
11. Shan L, Shan B, Suzuki A, Nouh F, Saxena A. Intermediate and long-term quality of life after total knee replacement. J Bone Joint Surg Am. 2015; 97:156–68.
12. Bruyère O, Ethgen O, Neuprez A, Zégels B, Gillet P, Huskin JP, et al. Health-related quality of life after total knee or hip replacement for osteoarthritis: a 7-year prospective study. Arch Orthop Trauma Surg. 2012; 132(11):1583–7.
13. Dowsey MM, Choong PF. The utility of outcome measures in total knee replacement surgery. Int J Rheumatol. 2013; 2013:353726.
14. Xie F, Lo NN, Pullenayegum EM, Tarride JE, O’Reilly DJ, Goeree R, et al. Evaluation of health outcomes in osteoarthritis patients after total knee replacement: a two-year follow-up. Health Qual Life Outcomes. 2010; 8:87.
15. Fujita K, Makimoto K, Higo T, Shigematsu M, Hotokebuchi T. Changes in the WOMAC, EuroQol and Japanese lifestyle measurements among patients undergoing total hip arthroplasty. Osteoarthritis Cartilage. 2009; 17(7):848–55.
16. Núñez M, Núñez E, Del Val JL, Ortega R, Segur JM, Hernández MV, et al. Health-related quality of life in patients with osteoarthritis after total knee replacement: factors influencing outcomes at 36 months of follow-up. Osteoarthritis Cartilage. 2007; 15(9):1001–7.
17. Petrie K, Chamberlain K, Azariah R. The psychological impact of hip arthroplasty. ANZ J Surg. 1994; 64:115–7.
18. Wiklund I, Romanus B. A comparison of quality of life before and after arthroplasty in patients who had arthrosis of the hip joint. J Bone Joint Surg Am. 1991; 73(5):765–9.
19. O'Boyle CA, et al. Individual quality of life in patients undergoing hip replacement. Lancet. 1992; 339(8801):1088–91.
20. Kauppila AM, Kyllönen E, Ohtonen P, Leppilahti J, Sintonen H, Arokoski JP. Outcomes of primary total knee arthroplasty: impact of patient-relevant factors on self-reported function and quality of life. Disabil Rehabil. 2011; 33(17-18):1659–67.
21. Clement ND, Muzammil A, Macdonald D, Howie CR, Biant LC. Socioeconomic status affects the early outcome of total hip replacement. J Bone Joint Surg Br. 2011; 93(4):464–9.
22. Rissanen P, Aro S, Sintonen H, Slätis P, Paavolainen P. Quality of life and functional ability in hip and knee replacements: a prospective study. Qual Life Res. 1996; 5(1):56–64.
23. Järvenpää J, Kettunen J, Soininvaara T, Miettinen H, Kröger H. Obesity has a negative impact on clinical outcome after total knee arthroplasty. Scand J Surg. 2012; 101(3):198–203.
24. Bagarić I, Šarac H, Borovac JA, Vlak T, Bekavac J, Hebrang A. Primary total hip arthroplasty: health related quality of life outcomes. Int Orthop. 2014; 38(3):495–501.
25. Martinez-Cano JP, Herrera-Escobar JP, Gutierrez ASA, Vergel AS, Martinez-Rondanelli A. Prospective quality of life assessment after hip and knee arthroplasty: short- and mid-term follow-up results. Arthroplasty Today. 2017; 3(6):125–30.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2021
| How to Cite this Article: Belsare P, Joshi R, Sanghavi S, Dugad M, Sonawane D, Shyam A, Sancheti P. Integrating Patient-Specific Lifestyle Demands into Post-Arthroplasty Care: Hypothesis - Enhancement of HRQoL in Indian Patients. Journal of Medical Thesis. July-December 2023; 9(2):9-12. |
Full Text HTML | Full Text PDF
A Retrospective Evaluation of Functional and Radiological Outcomes in Adult Distal End of Radius Fractures
Vol 9 | Issue 2 | July-December 2023 | page: 1-4 | Shitiz Agrawal, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.206
Author: Shitiz Agrawal [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Shitiz Agrawal,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: shitiz_4nov@yahoo.co.in
Abstract
Background: Distal radius fractures are frequent and may cause lasting functional problems when alignment is not restored. Knowing which factors influence recovery helps surgeons choose treatment and counsel patients.
Methods: We reviewed 191 adults who had surgical treatment for distal radius fractures from October 2010 to October 2017. Treatments were closed reduction with percutaneous K-wires or open reduction with volar plate fixation. Demographic and clinical details, radiographic measures (radial height, radial inclination, palmar tilt, ulnar variance) and outcomes at one year (DASH, PRWE, wrist motion, grip strength) were recorded and analysed.
Results: The cohort was mostly young adults with a male predominance; AO type A2 fractures were common. At one year 146 patients had DASH scores ≤10, indicating minimal disability. Patients whose radiographic parameters were restored closer to the uninjured wrist had better DASH and PRWE scores, superior range of motion and stronger grip. Volar locking plates provided more consistent radiographic restoration than K-wires. Diabetes was linked to poorer recovery across measures.
Conclusion: Restoring distal radius anatomy is associated with better one-year function. Surgeons should aim for anatomic reduction and ensure timely postoperative rehabilitation, especially for diabetic patients.
Keywords: Distal radius fracture, Volar plate, K-wire; DASH, Palmar tilt, Ulnar variance
Introduction
Distal radius fractures are among the most frequent injuries seen in adults and account for a large share of wrist trauma in emergency and orthopedic clinics. Historically described by Colles and later classified by numerous authors, these fractures range from simple extra-articular breaks to complex intra-articular, comminuted patterns that can seriously affect wrist mechanics and daily function.[1–3] The immediate aim of treatment is to obtain and maintain anatomic alignment so that the wrist can heal with correct radial height, inclination, and volar tilt—parameters that directly influence load transfer across the radiocarpal and distal radioulnar joints.[4,5]
Conservative treatment with closed reduction and casting remains appropriate for many minimally displaced fractures, but unstable or displaced patterns commonly require surgical fixation to prevent malunion and long-term disability.[6–8] Over the last two decades volar fixed-angle plating has become widely used because it offers stable fixation even in osteoporotic or comminuted bone and often permits earlier wrist mobilization compared with traditional dorsal plating or prolonged external fixation.[9,10] Despite technical advances, complications such as tendon irritation, hardware problems, stiffness, and residual pain still affect outcomes and patient satisfaction.[11,12]
Predicting which patients will have the best functional recovery remains a clinical challenge. Radiographic restoration of ulnar variance, radial height, radial inclination, and palmar tilt has been linked to better objective and patient-reported outcomes in several series, but findings are not uniform across all studies.[13–15 ]Patient factors such as age, comorbidities (notably diabetes), bone quality, and the dominant hand also influence recovery and must be considered when planning treatment and rehabilitation.[16] This study examines which clinical and radiographic factors are associated with one-year functional results after surgical treatment of distal radius fractures, with the goal of identifying modifiable elements surgeons can address to improve patient recovery.[17–18]
Review of Literature
Longstanding fracture descriptions and modern classification systems give structure to how surgeons assess distal radius injuries and choose treatment. Early works by Colles and later by Frykman and AO provided the anatomical and radiographic language still used today. [1,19] Radiographic parameters measured on standard PA and lateral views—radial height, radial inclination, palmar tilt, and ulnar variance—are commonly reported and serve as benchmarks for reduction quality. [4,5,10]
Over the years, treatment evolved from closed reduction and casting to percutaneous pinning, external fixation, and open reduction with internal fixation. Volar locking plates were developed to offer stable, fixed-angle support that resists collapse of the articular surface and metaphyseal comminution; this has translated into improved radiographic outcomes in many reports and has encouraged early mobilization [.6,9,14] External fixation and percutaneous K-wires still have a role for select fracture patterns and when soft tissue concerns exist. [7,16]
Comparative studies show that volar plating more reliably restores radiographic parameters compared with percutaneous techniques, particularly in AO type C and comminuted extra-articular fractures.[8,13] However, better radiographs do not always equate to better patient perception of function; some studies report weak to moderate associations between alignment and patient-reported outcomes such as DASH and PRWE, suggesting pain, stiffness, and psychosocial factors also play important roles.[11,12,20] Diabetes and other systemic conditions have been linked to delayed recovery, reduced range of motion, and worse patient-reported scores, possibly because of altered tendon and capsular biology and impaired healing.[16,17]
Taken together, literature supports aiming for anatomic reduction when feasible, while recognizing that individual patient factors and access to rehabilitation will influence final recovery. This body of evidence underpins the present study’s focus on radiographic restoration and comorbidity status as predictors of one-year outcome. [2,3,15]
Materials and Methods
This retrospective cohort study reviewed adult patients treated surgically for acute distal radius fractures at a tertiary care centre between October 2010 and October 2017. Inclusion criteria were skeletally mature adults with closed distal radius fractures who underwent either closed reduction with percutaneous K-wire fixation (CRIF) or open reduction and internal fixation (ORIF) using a volar locking plate. Exclusion criteria included open fractures, associated neurovascular injuries, pathological fractures, prior ipsilateral wrist injury, and inadequate follow-up.
Demographic and clinical data recorded included age, sex, hand dominance, affected side, mechanism of injury, and comorbidities (with specific attention to diabetes mellitus). Fractures were classified from initial radiographs using AO and Frykman systems. Standardized surgical techniques were followed: CRIF involved closed manipulation under anesthesia followed by multiple percutaneous K-wires; ORIF used a volar Henry approach with elevation of the pronator quadratus and placement of a volar locking plate after reducing the fragments. Postoperative immobilization and rehabilitation protocols were similar for both groups, with early finger and shoulder motion and gradual wrist mobilization guided by radiographic healing.
Outcomes were captured preoperatively and at one year. Patient-reported outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Patient-Rated Wrist Evaluation (PRWE). Objective measures included wrist range of motion (flexion, extension, pronation, supination, radial and ulnar deviation) and grip strength compared to the contralateral side using a dynamometer. Radiographic measurements—palmar tilt, radial inclination, radial height, and ulnar variance—were obtained preoperatively, immediately postoperatively, and at one year using standard techniques. Statistical analysis compared groups with t-tests or nonparametric equivalents and used correlation and regression analyses to assess relationships between radiographic restoration, comorbidity status, and functional outcomes. Statistical significance was set at p<0.05. Institutional review and ethical approval were obtained before data collection.
Results
Nineteen-one patients met the study criteria. Most were men (about 59%), and nearly half were younger than 31. The right wrist was affected in the majority of cases (about 79%). Diabetes was present in roughly one in ten patients. The commonest fracture pattern was AO type A2. Treatment split into two main approaches: around 62% had closed reduction with percutaneous K-wires (CRIF), and 38% underwent open reduction and volar plate fixation (ORIF).
At one year, the majority were doing well: 146 patients had DASH scores of 10 or less, indicating minimal functional limitation. When we looked closer, patients whose operated wrist measurements (radial height, radial inclination, palmar tilt and ulnar variance) matched the uninjured side more closely tended to have better wrist motion and stronger grip. Those treated with volar locking plates more consistently kept those radiographic targets — especially radial height and palmar tilt — compared with the K-wire group. People with diabetes showed consistently poorer recovery: higher DASH and PRWE scores, less wrist movement, and weaker grip strength. Statistical analysis confirmed these links — better radiographic restoration was associated with better subjective and objective outcomes at one year (p<0.05).
Discussion
The main message from this study is straightforward: when the wrist is put back into something close to its normal shape, people usually recover better. Restoring radial height, inclination, palmar tilt and ulnar variance matters — not just on X-rays, but for how people use their hands day to day. In our group, volar locking plates held these measurements more reliably than percutaneous K-wires, which helps explain why patients with plates often ended up with better motion, strength and lower disability scores. Fixed-angle plates resist collapse of broken fragments and give a stable base for early rehabilitation, especially in comminuted or osteoporotic fractures.
That said, anatomic reduction is only one piece of the recovery puzzle. Pain control, timely and guided physiotherapy, scar management and patient expectations all play big roles. We encountered patients with near-perfect X-rays who still complained of pain or stiffness, and others with minor radiographic imperfections who returned to work and hobbies without trouble. This shows the need to treat patients, not images: combine sound surgery with attentive post-op care and clear communication about likely recovery.
The consistently worse outcomes in people with diabetes are important. Diabetes can affect soft tissues and healing capability, leading to more stiffness, slower recovery and worse patient-reported scores. Knowing a patient has diabetes before surgery should prompt closer follow-up, tailored rehabilitation plans and realistic goal-setting so recovery can be optimized.
This study has limits. It’s retrospective and surgeons may have chosen fixation based on fracture severity, which can bias results. We also lacked data on socioeconomic or psychological factors that influence recovery. Strengths include a substantial number of patients, standardized measurements and complete one-year follow up. Clinically, the findings support aiming for anatomic restoration when it is safe to do so and paying extra attention to modifiable care factors especially for patients with diabetes — to help them achieve the best possible outcome.
Conclusion
Accurate restoration of distal radius anatomy—radial height, radial inclination, palmar tilt, and ulnar variance—was associated with better one-year function as measured by DASH and PRWE, improved range of motion, and stronger grip. Volar locking plate fixation achieved more reliable radiographic restoration in this series, especially for comminuted patterns, compared with percutaneous K-wiring. Diabetes emerged as a consistent negative factor for recovery, underscoring the need for focused counselling and rehabilitation for these patients. Surgeons should prioritize anatomic reduction when safe and feasible and ensure coordinated postoperative rehabilitation to maximize the chances of a good functional outcome. Future prospective studies that include psychosocial and socioeconomic variables will help refine prognostic models and individualize care.
References
1. Colles A. On the fracture of the carpal extremity of the radius. Edinburgh Med Surg 1814; 10:182–6.
2. Bacorn RW, Kurtzke JF. Colles’ Fracture: A study of two thousand cases. J Bone Joint Surg 1953;35A:643–658.
3. Frykman G. Fracture of the distal radius including sequelae. Acta Orthop Scand Suppl 1967; 108:1–155.
4. Zemel NP. The prevention and treatment of complications from fractures of the distal radius and ulna. Hand Clin. 1987; 3:1–11.
5. Chen NC, Jupiter JB. Management of distal radial fractures. J Bone Joint Surg Am 2007;89(9):2051–2062.
6. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am 2004;29(1):96–102.
7. Bartosh RA, Saldana MJ. Intrarticular fractures of the distal radius: ligamentotaxis study. J Hand Surg Am 1990;15(1):18–21.
8. Rozental TD et al. Functional outcomes for unstable distal radial fractures treated with ORIF or CRIF. J Bone Joint Surg Am 2009;91(8):1837–1846.
9. Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early function. J Bone Joint Surg Br 1996;78(4):588–592.
10. Ng CY, McQueen MM. Radiological predictors of functional outcome following fractures of the distal radius? J Bone Joint Surg Br 2011;93(2):145–150.
11. Chung KC, Kotsis SV, Kim HM. Predictors of functional outcomes after surgical treatment of distal radius fractures. J Hand Surg Am 2007;32(1):76–83.
12. Brogren E Et al. Relationship between distal radius fracture malunion and arm-related disability: BMC Musculoskelet Disord 2011; 12:9.
13. Seoung-Joon Lee Et al. Clinical and radiologic factors affecting functional outcomes after volar locking plate fixation. J Orthop Sci 2016.
14. Chen NC, Jupiter JB. Current concepts review, Management of distal radial fractures. J Bone Joint Surg Am 2007; 89:2051–2062.
15. Brogren E Et al. Distal radius malunion increases risk of persistent disability 2 years after fracture. Clin Orthop Relat Res 2013;471(5):1691–1697.
16. Roh YH et al. Factors delaying recovery after volar plate fixation of distal radius fractures. J Hand Surg Am 2014;39(8):1465–1470.
17. Szabo RM. Distal radioulnar joint instability. J Bone Joint Surg Am 2006;88(4):884–94.
18. Bucholz RW, Heckman JD. Rockwood & Green’s Fractures in Adults. 5th ed. Lippincott Williams & Wilkins 2001; Vol I:815–867.
19. Smith R. A Treatise on Fractures in the Vicinity of Joints. Dublin: Hodges and Smith, 1854.
20. Bartosh RA, Saldana MJ. Intrarticular fractures of the distal radius: ligamentotaxis study. J Hand Surg Am 1990;15(1):18–21.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2018
| How to Cite this Article: Agrawal S, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P. A Retrospective Evaluation of Functional and Radiological Outcomes in Adult Distal End of Radius Fractures. Journal of Medical Thesis. July-December 2023; 9(2):1-4. |
Full Text HTML | Full Text PDF
