Monthly Archives: June 2024
Classification, Treatment Algorithms, and Functional Results of Ankle Fractures in Children: A Single Centre Retrospective Study
Vol 10 | Issue 1 | January-June 2024 | page: 70-73 | Siddhartha Sablay, Sandeep Patwardhan, Vivek Sodhai, Rahul Jaiswal, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2024.v10.i01.232
Author: Siddhartha Sablay [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. Siddhartha Sablay,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and
Rehabilitation, Pune, Maharashtra, India.
E-mail: siddharthasablay200@gmail.com
Abstract
Background: Fractures through the distal tibial physis in children are important because they can affect future growth and ankle function. This study reviews our experience treating these injuries and reports clinical and radiographic outcomes.
Methods: Fourteen consecutive patients under 16 years were treated between September 2019 and October 2021. Fractures were classified using Salter–Harris and Dias–Tachdjian systems. Treatment included closed reduction with percutaneous fixation or open reduction and internal fixation when necessary; intraoperative arthrography was used selectively. Outcomes were measured with the AOFAS ankle–hindfoot score and VAS for pain at scheduled follow-up visits.
Results: Mean age was 11.86 years. Road-traffic collisions and twisting injuries were the most frequent causes. Eleven patients underwent closed procedures and three required open reduction; fixation used cannulated screws or K-wires according to fragment size. Mean AOFAS score improved markedly to 95.3 at one year. Complications were few and mainly minor.
Conclusion: Careful assessment, timely anatomic reduction and stable fixation — with selective intraoperative arthrography when needed — produced consistently good short-term outcomes in this series. Continued follow-up is recommended to detect late physeal complications.
Keywords: Paediatric ankle fractures, Distal tibial physis, Tillaux fracture, Triplane fracture, Percutaneous fixation.
Introduction
Fractures that involve the distal tibial growth plate deserve careful attention because the physis plays a major role in tibial length and closes unevenly during adolescence. That uneven closure explains transitional patterns such as Tillaux and triplane fractures, where epiphyseal, physeal and metaphyseal components coexist and plain radiographs may not show the full picture [5–7]. When the joint surface is involved, restoring articular congruity is as important as stabilising the bone — failing to do so raises the risk of post-traumatic arthritis and growth disturbance.
Clinically, the aim is straightforward: restore the ankle’s joint surface and alignment while protecting the growth plate to prevent limb-length or angular problems. Classification systems help; Salter–Harris describes the anatomic level of injury while Dias–Tachdjian helps anticipate how the fragments have displaced and what reduction technique will likely succeed [1–2]. For many non-displaced fractures, immobilisation and close radiographic surveillance are sufficient [3]. But when there is displacement within the joint surface, many authors recommend achieving near-anatomic reduction — commonly quoted as ≤2 mm residual step — because smaller gaps tend to give better midterm function [4,17].
Cross-sectional imaging with CT or MRI improves planning for complex or adolescent transitional injuries and guides screw placement [6–7]. Surgical options range from closed reduction and percutaneous screw or K-wire fixation to open reduction when soft-tissue interposition or irreducibility prevents closed alignment [8–11,16]. Intraoperative arthrography can confirm cartilage reduction when fluoroscopy is equivocal and may spare some children an open approach [13–14]. The present retrospective series reports our experience with fourteen consecutive patients managed at a tertiary centre between September 2019 and October 2021, focusing on demographics, fracture patterns, imaging and operative technique — including selective arthrography — and on validated clinical outcomes.
Methods and materials
This was a retro-prospective, non-randomized series of fourteen consecutive children under 16 years with distal tibia–fibula physeal injuries treated at our tertiary centre from September 2019 to October 2021. Institutional approval and guardian consent were obtained. We included closed physeal fractures of the distal tibia; we excluded open fractures, pathological fractures and patients with major polytrauma. Demographic details, mechanism of injury, side involved and time from injury to surgery were recorded. Clinical assessment documented pain, swelling, deformity, range of motion and neurovascular status.
All patients had AP, lateral and mortise radiographs. CT or MRI was obtained selectively when plain films did not clearly define fragment anatomy or suspected intra-articular extension, particularly for triplane or Tillaux patterns [6–7]. Fractures were classified using Salter–Harris and Dias–Tachdjian systems [1–2]. Perioperative care included a single prophylactic dose of a third-generation cephalosporin and standard anaesthetic and aseptic precautions. Closed reduction under fluoroscopy was attempted first; if reduction was maintained, fixation was with percutaneous cannulated cancellous screws or smooth Kirschner wires according to fragment size and the desire to minimise physeal violation [8–11]. Intraoperative arthrography with contrast was used selectively when fluoroscopic detail was inadequate to confirm cartilaginous congruity [13]. Open reduction with an anteromedial approach and direct fixation was reserved for irreducible fragments or soft-tissue interposition [16].
Postoperatively, patients were immobilized in a below-knee cast and kept non-weight bearing for roughly six weeks, then progressed to a walking cast and physiotherapy as healing allowed. Follow-up visits were scheduled at suture removal, six weeks, three months, six months and one year. Functional outcomes were recorded using the AOFAS ankle–hindfoot score and VAS for pain. Data were collected by the treating team and analyzed with standard parametric and categorical tests; significance was set at p<0.05.
Review of literature
Pediatric ankle fractures are not just smaller versions of adult injuries — the growth plate behaves differently and is often the weak point around the ankle, producing characteristic physeal and transitional patterns such as Tillaux and triplane fractures [1]. The Salter–Harris scheme gives a helpful anatomic snapshot, but mechanistic classifications like Dias–Tachdjian add value by predicting how the fragments move and what reduction maneuvers will work best [2]. Many low-risk, non-displaced physeal injuries heal well with immobilisation and close radiographic follow-up, yet when the joint surface is involved and displaced, anatomic reduction becomes essential to reduce the risk of premature physeal closure and later arthritis [3–4].
Transitional fractures in adolescents can be complex because they involve epiphysis, physis and metaphysis together, and plain X-rays may underestimate fragment geometry; CT or MRI is therefore often useful for preoperative planning [5–7]. When surgery is needed, the choice of implant depends on fragment size and the desire to protect the physis: cannulated screws give compression for larger epiphyseal fragments, while smooth Kirschner wires are commonly used for small fragments or when crossing the physis should be minimised [8–11]. Bio absorbable implants have been explored as an alternative to metal, showing similar short-term results in selected reports and the practical advantage of avoiding removal procedures [12].
Intraoperative arthrography is a helpful tool when fluoroscopy does not clearly show cartilaginous congruity; several series report that arthrography can allow percutaneous fixation and avoid unnecessary arthrotomy in selected cases [13–14]. Outcome measures such as the AOFAS ankle–hindfoot score and VAS pain scale are widely used and show substantial improvement after anatomic reduction and stable fixation, but the literature cautions that physeal arrest and angular deformity may present months or years later, which is why longer follow-up and standardized outcome reporting are repeatedly recommended [3,15–20].
Results
Fourteen patients were included: nine boys and five girls. The average age was 11.86 years (range 4–14). Time from injury to operation ranged from two hours to 3.5 days (mean 1.2 days). Mechanisms were road-traffic accidents in seven (50%), twisting injuries in six (43%) and a fall in one (7%). According to Salter–Harris classification the distribution was Type IV (n=6), Type II (n=4), Type III (n=3) and Type I (n=1). Eleven patients had closed reduction and percutaneous fixation; three required open reduction because the fragments were irreducible or soft tissue was interposed. Seven patients received cannulated screws and the remainder K-wires.
By three months most children demonstrated radiographic union and improved function. Mean AOFAS score improved from 15.57 preoperatively to 75.71 at three months, 90.07 at six months and 95.29 at one year (p<0.05). Pain and functional sub-scores improved similarly. Complications were uncommon: one child developed a checkrein deformity; three reported persistent ankle pain at intermediate follow-up; isolated minor complaints such as itching or transient sensory change were recorded. There were no wound infections or hardware failures. At latest follow-up half the children had returned to near-normal activity without complications.
Discussion
The strong improvement in function seen in our series supports the core lesson from existing reports: restore the joint surface and achieve stable fixation, but do so while protecting the growth plate [11,17]. When articular congruity is restored to near anatomic alignment, children tend to regain pain-free motion and return to activity, which matches prior cohort findings [4,10]. The selective use of intraoperative arthrography proved useful in cases where fluoroscopic imaging did not clearly show cartilaginous reduction, allowing percutaneous treatment in some displaced injuries and avoiding unnecessary open arthrotomy [13–14].
For fixation, cannulated screws worked well for larger epiphyseal fragments by providing compression and rotational stability; smooth K-wires were a reasonable alternative when the fragment was small or when transphyseal fixation was a concern [8–11]. Bio absorbable implants are an option reported in the literature with comparable short-term results in some series and the benefit of avoiding implant removal in selected situations [12]. Our low complication rate is encouraging, but the key long-term worry remains premature physeal closure, which can show up late and produce limb-length discrepancy or angular deformity — an especially real risk after high-energy mechanisms or large initial displacement [15,18–19].
The study’s limitations are important: small patient numbers, retrospective design and single-center experience limit generalisability and prevent strong comparisons between fixation strategies. Our follow-up is sufficient to document union and early function, but may not be long enough to capture late physeal problems that can appear years after injury [20]. Still, the data support a practical approach: use imaging sensibly for complex patterns, restore the articular surface when displaced, choose fixation that secures reduction while limiting physeal insult, and maintain structured long-term follow-up for cases at higher risk.
Conclusion
Distal tibial physeal fractures in children require treatment that balances joint restoration with protection of the growth plate. In this series timely, anatomic reduction and appropriately chosen fixation — most commonly percutaneous cannulated screws or K-wires — led to marked improvements in pain and function by one year. Selective intraoperative arthrography was a valuable adjunct when fluoroscopic detail was unclear. Complications were few, but the risk of premature physeal closure remains the primary long-term concern and justifies continued surveillance, particularly after high-energy injuries or where initial displacement was large. The retrospective design, small sample size and single-centre setting limit broad application of these results; larger prospective, multicenter studies with standardised outcomes and follow-up until skeletal maturity would better define optimal management and long-term prognosis.
References
1. Su AW, Larson AN. Pediatric Ankle Fractures: Concepts and Treatment Principles. Foot Ankle Clin. 2015;20(4):705-719. doi: 10.1016/j.fcl.2015.07.004.
2. Trainor TJ. Pediatric ankle fractures. Trauma. 2002;44(2):23-43.
3. Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev. 2016;2016(4). doi: 10.1002/14651858.CD010836.pub2.
4. O WH, Craig C, Banks HH. Epiphyseal injuries. Pediatr Clin North Am. 1974;21(2):407-422. doi:10.1016/S0031-3955(16)32998-4.
5. Dias LS, Tachdjian MO. Physeal injuries of the ankle in children: classification. Clin Orthop Relat Res. 1978;(136):230-233.
6. Wuerz TH, Gurd DP. Pediatric physeal ankle fracture. J Am Acad Orthop Surg. 2013;21(4):234-244. doi:10.5435/JAAOS-21-04-234.
7. Olgun ZD, Maestre S. Management of Pediatric Ankle Fractures. Curr Rev Musculoskelet Med. 2018;11(3):475-484. doi:10.1007/s12178-018-9510-3.
8. Duran JA, Dayer R, Kaelin A, Ceroni D. Intraoperative arthrography for the evaluation of closed reduction and percutaneous fixation of displaced Macfarland fractures: An alternative to open surgery. J Pediatr Orthop. 2011;31(1):1-5. doi: 10.1097/BPO.0b013e3182032c6a.
9. Podeszwa DA, Wilson PL, Holland AR, Copley LAB. Comparison of bioabsorbable versus metallic implant fixation for physeal and epiphyseal fractures of the distal tibia. J Pediatr Orthop. 2008;28(8):859-863. doi:10.1097/BPO.0b013e31818e19d7.
10. Gourineni P, Gupta A. Medial joint space widening of the ankle in displaced Tillaux and triplane fractures in children. J Orthop Trauma. 2011;25(10):608-611. doi:10.1097/BOT.0b013e318206f8bc.
11. Canagasabey MD, Callaghan MJ, Carley S. The Sonographic Ottawa Foot and Ankle Rules Study (the SOFAR Study). Emerg Med J. 2011;28(10):838-840. doi:10.1136/emj.2009.088286.
12. Kim JR, Song KH, Song KJ, Lee HS. Treatment outcomes of triplane and Tillaux fractures of the ankle in adolescence. Clin Orthop Surg. 2010;2(1):34-38. doi:10.4055/cios.2010.2.1.34.
13. Rohmiller MT, Gaynor TP, Pawelek J, Mubarak SJ. Salter-Harris I and II fractures of the distal tibia: Does mechanism of injury relate to premature physeal closure? J Pediatr Orthop. 2006;26(3):322-328. doi: 10.1097/01.bpo.0000217714.80233.0b.
14. Schnetzler KA, Hoernschemeyer D. The pediatric triplane ankle fracture. J Am Acad Orthop Surg. 2007;15(12):738-747. doi:10.5435/00124635-200712000-00007.
15. Cottalorda J, Béranger V, Louahem D, et al. Salter-Harris Type III and IV Medial Malleolar Fractures. J Pediatr Orthop. 2008;28(6):652-655. doi:10.1097/bpo.0b013e318182f74c.
16. Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012;94(13):1234-1244. doi:10.2106/JBJS.K.00682.
17. Crawford AH. Triplane and Tillaux fractures: Is a 2 mm residual gap acceptable? J Pediatr Orthop. 2012;32(SUPPL.1):69-73. doi:10.1097/BPO.0b013e31824b25a1.
18. Barnett PLJ, Lee MH, Oh L, Cull G, Babl F. Functional outcome after air-stirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: A randomized observer-blinded controlled trial. Pediatr Emerg Care. 2012;28(8):745-749. doi:10.1097/PEC.0b013e318262491d.
19. Leary JT, Handling M, Talerico M, Yong L, Bowe JA. Physeal fractures of the distal tibia: Predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop. 2009;29(4):356-361. doi: 10.1097/BPO.0b013e3181a6bfe8.
20. Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children: summary and need for standardisation. Cochrane Database Syst Rev. 2016;2016(4). doi: 10.1002/14651858.CD010836.pub2.
| How to Cite this Article: Patwardhan Sablay S, Patwardhan S, Sodhai V, Jaiswal R, Sonawane D, Shyam A, Sancheti P. Classification, Treatment Algorithms, and Functional Results of Ankle Fractures in Children: A Single-Centre Retrospective Study. Journal of Medical Thesis. 2024 January-June; 10(1):70-73. |
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: 2022
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Evaluation of Efficacy of Surgical Management for Treatment of Chondral Defects of the Knee in Adults
Vol 10 | Issue 1 | January-June 2024 | page: 66-69 | Shaunak Pathwardhan, Parag Sancheti, Kailas Patil, Sunny Gugale, Sahil Sanghavi, Yogesh Sisodiya, Obaid UL Nisar, Darshan Sonawane, Ashok Shyam
https://doi.org/10.13107/jmt.2024.v10.i01.230
Author: Shaunak Pathwardhan [1], Parag Sancheti [1], Kailas Patil [1], Sunny Gugale [1], Sahil Sanghavi [1], Yogesh Sisodiya [1], Obaid UL Nisar [1], Darshan Sonawane [1], Ashok Shyam [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Shaunak Patwardhan,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and
Rehabilitation, Pune, Maharashtra, India.
E-mail: patwardhanshaunak@gmail.com
Abstract
Background: Articular cartilage defects of the femoral condyles cause pain and functional decline; untreated full-thickness lesions predispose to early osteoarthritis. This study compared short-term outcomes after three surgical strategies—arthroscopic microfracture, two-stage autologous chondrocyte implantation (ACI) and single-stage bone marrow aspirate concentrate (BMAC)—for full-thickness femoral condyle defects ≥2.0 cm².
Methods: In this prospective single-centre cohort (Oct 2019–Oct 2021) 66 adults meeting inclusion criteria were enrolled; 53 completed one-year follow up. Treatment selection was individualized. Primary outcomes were IKDC and KOOS scores measured preoperatively and at 6 and 12 months. Secondary outcomes included MOCART MRI appearance and complication rates. Standard rehabilitation and statistical analysis were applied.
Results: All three techniques produced clinically meaningful improvements in IKDC and KOOS at one year. Greater gains correlated with younger age, lower BMI and shorter symptom duration. Between-group differences at one year were not statistically significant in this cohort. MRI (available for 23 patients) generally showed defect fill and integration. Complications were few and minor.
Conclusion: Arthroscopic microfracture, single-stage BMAC and two-stage ACI each provided meaningful short-term functional improvement with low complication rates. Individualized technique selection is recommended; longer randomized studies are needed to assess durability.
Keywords: Cartilage defect, Microfracture, Autologous chondrocyte implantation, BMAC, IKDC, KOOS.
Introduction
Articular cartilage is a highly specialized, avascular and aneural tissue with limited intrinsic capacity for repair. Its zonal architecture and sparse cellularity confer excellent load-bearing and low friction properties but hinder meaningful regeneration after full-thickness injury.[1] Full-thickness chondral and osteochondral defects of the femoral condyles frequently produce pain, mechanical symptoms and functional impairment and are encountered commonly at diagnostic arthroscopy of symptomatic knees.[2,3] Epidemiological series indicate that focal cartilage lesions are prevalent among patients undergoing knee arthroscopy and can produce morbidity comparable to more advanced degenerative disease in selected populations.[4,5 ]The aetiology of focal defects is heterogeneous — acute trauma, repetitive overload, axial malalignment, meniscal deficiency and ligamentous instability are common contributors — and the lesion characteristics (size, depth, location) together with patient factors (age, activity level, body mass index) largely determine therapeutic choice and prognosis.[3,6]
Surgical approaches for symptomatic full-thickness defects range from palliative arthroscopic debridement to marrow-stimulation techniques (microfracture), osteochondral autograft transfer (OATS/mosaicplasty), two-stage cell-based restorative techniques such as autologous chondrocyte implantation (ACI), and contemporary one-stage biologic augmentations that combine concentrated marrow elements (BMAC) with scaffolds.[7,8] Microfracture has been widely used for small to moderate defects because it is technically straightforward and cost-effective, but it produces predominantly fibrocartilaginous fill that may be biomechanically inferior to hyaline cartilage.[9–11] ACI and matrix-augmented ACI aim to regenerate hyaline-like tissue through chondrocyte expansion and implantation but require two procedures and greater resource allocation.[12–14] Single-stage BMAC approaches are attractive in resource-constrained settings because they concentrate marrow-derived progenitor cells and growth factors in one operation, but standardisation of preparation and robust long-term comparative evidence remain limited.[15–18]
Systematic reviews and meta-analyses demonstrate heterogeneity across studies in patient selection, lesion characteristics and outcome reporting; therefore, firm universal recommendations regarding a single superior technique are difficult to make.[6,19] This study therefore sought to evaluate short-term functional and radiological outcomes following microfracture, two-stage ACI and single-stage BMAC in a prospective cohort treated at a tertiary orthopaedic centre, with the goal of informing surgeon decision-making in similar clinical and resource settings.[20]
Literature overview
Large arthroscopic cohorts and registry data highlight the frequency and clinical burden of focal cartilage lesions.[3,4] Microfracture has been associated with reliable short-term symptomatic relief, particularly in younger patients with smaller lesions, but durability may decline over time, especially for larger defects.[9–11] Mosaicplasty transfers hyaline cartilage plugs but is constrained by donor site morbidity and size limitations.12 ACI and matrix-assisted cell therapies have demonstrated favourable medium-term outcomes in many series but at the cost of two-stage procedures and greater expense.[13–16] Contemporary interest centers on single-stage biologic augmentation (eg, BMAC with scaffolds) which offers logistical advantages and encouraging early imaging and functional results, though preparation protocols and long-term data are variable.[6,14,17,18 ]Systematic reviews emphasise patient selection and lesion characteristics as key determinants of success, supporting individualized treatment planning.[6,19]
Materials and Methods
This prospective single-centre cohort was conducted from October 2019 to October 2021. Adults aged 15–55 years with symptomatic ICRS/Outerbridge grade 4 full-thickness chondral defects of the femoral condyles measuring ≥2.0 cm² on MRI or arthroscopic assessment were considered. Patients with advanced degenerative knee disease, systemic metabolic or neoplastic illness, intra-articular fractures, prior ipsilateral major knee surgery or defects <2.0 cm² were excluded. Institutional ethics approval and informed consent were obtained for all participants.
Baseline evaluation included a standardized history, physical examination, IKDC and KOOS questionnaires, weight and BMI measurement, plain radiographs and MRI to document lesion size, depth and associated meniscal or ligamentous pathology. Sixty-six consecutive eligible patients were enrolled; surgical strategy selection (microfracture, two-stage ACI or single-stage BMAC) was individualized based on defect size and location, associated pathology, patient preferences and resource considerations. Concomitant meniscal repair or ligament reconstruction was performed when indicated.
Surgical techniques followed standardized protocols. Microfracture was performed arthroscopically with stable borders debrided and multiple perforations into the subchondral plate created using an awl to allow marrow element ingress. ACI comprised arthroscopic harvest of cartilage for chondrocyte expansion followed by mini-open implantation of the cell-seeded scaffold in the second stage. Single-stage BMAC involved iliac crest aspiration, bedside centrifugation to concentrate marrow elements and implantation beneath a collagen matrix via a mini-arthrotomy. Perioperative care included prophylactic antibiotics, regional or general anaesthesia and a standardised rehabilitation regimen tailored to the procedure: early controlled range of motion with protected weight bearing and progressive strengthening over weeks.
Follow up occurred at routine intervals with detailed clinical examination and patient-reported outcomes at six months and one year. Postoperative MRI with MOCART scoring and second-look arthroscopy were obtained when clinically indicated and feasible. Outcome measures included change in IKDC and KOOS (primary endpoints), MOCART MRI appearance and complication rates (secondary endpoints). Statistical analysis used paired comparisons for within-group changes and ANOVA for between-group comparisons with significance set at p<0.05. Data were analysed using standard statistical software.
Results
Of the 66 eligible patients, 53 (80.3%) completed the one-year follow up and were included in the final analysis. The cohort comprised 34 males and 19 females with a mean age of 32.7 years (SD 8.9) and mean BMI 24.44 kg/m². Mean defect area was 5.6 cm² (range 2.2–10.4 cm²); 69.8% of lesions exceeded 4.0 cm². Procedures performed were arthroscopic microfracture in 33 patients (62.3%), single-stage BMAC in 15 (28.3%) and two-stage ACI in 5 (9.4%). Concurrent pathology requiring treatment (eg, meniscal tears, ACL injuries) was present in 54.7% and was addressed during the index procedure as appropriate.
At six months and one year, all three groups demonstrated statistically significant improvements in IKDC and KOOS relative to baseline (p<0.05 for within-group comparisons). Mean improvements were greater in younger patients and those with lower BMI. Between-group differences in mean IKDC and KOOS gains at one year did not reach statistical significance in this cohort, though subgroup sample sizes (particularly for ACI) were small. Postoperative MRI enabling MOCART scoring was available for 23 patients and generally indicated acceptable defect fill and integration across procedures. Complications were few and minor; there were no reported major procedure-related adverse events within the one-year follow up.
Discussion
This prospective single-centre series demonstrates that arthroscopic microfracture, single-stage BMAC and two-stage ACI each produced meaningful symptomatic and functional improvement at one year for symptomatic full-thickness femoral condyle defects. The clinical improvements observed align with prior epidemiological and cohort data indicating that appropriately selected patients derive benefit from both marrow-stimulation and restorative biologic techniques.3–8 Age, BMI and timing of surgery emerged as important correlates of outcome in this cohort, consistent with published series that identify younger patients and those treated earlier as more likely to experience substantial gains.[8,11,15]
Microfracture remains a pragmatic, cost-effective option that delivers reliable short-term relief for many patients, particularly for smaller defects and lower-demand individuals, but it typically yields fibrocartilaginous repair tissue whose long-term biomechanical properties may be inferior to native hyaline cartilage.[9–11] Mosaicplasty and osteochondral grafting provide immediate hyaline cartilage restoration but are limited by donor site morbidity and size constraints.[12–14 ]ACI and matrix-assisted chondrocyte implantation have shown promising medium-term outcomes in multiple series but require two-stage procedures, cell expansion facilities and greater resources.[13,16]
Single-stage BMAC with a collagen matrix offers logistical advantages in a single operation and in this cohort produced early functional gains comparable to other techniques; however, variability in marrow concentrate preparation and lack of standardisation complicate cross-study comparisons and long-term efficacy remains to be established.[15–18] MRI assessment using standardized scoring such as MOCART provided useful non-invasive information about defect fill and integration in those patients imaged, but routine postoperative imaging and histological verification were not feasible for all participants in this series. Limitations of this study include non-randomised technique allocation influenced by surgeon preference and resource considerations, incomplete imaging for the entire cohort, small subgroup sizes (notably for ACI), and relatively short follow up of one year — all of which limit definitive between-technique comparisons and long-term inference.[6,19,20]
Taken together with the broader literature, these findings support individualized treatment selection that balances lesion characteristics, patient factors, surgeon expertise and resource availability. Prospective randomized trials with standardized imaging protocols, second-look arthroscopy and histological assessment are required to determine technique-specific durability, cost-effectiveness and activity-related outcomes over the longer term.[6,17,19]
Conclusion
In this prospective cohort of adults with symptomatic full-thickness femoral condyle defects ≥2.0 cm², arthroscopic microfracture, single-stage BMAC with collagen matrix and two-stage ACI each produced significant improvements in IKDC and KOOS scores at one year with low complication rates. Patient factors — especially younger age, lower BMI and shorter interval from injury to surgery — were associated with greater functional gains. Radiological assessment where obtained demonstrated acceptable defect fill and early repair integration. Within the limitations of non-randomised allocation, incomplete imaging and short follow up, no single technique proved clearly superior at one year. Individualised, evidence-informed decision-making and longer randomized studies with standardized imaging and histology are recommended to guide optimal management and resource allocation.
References
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2. Chubinskaya S, Haudenschild D, Gasser S, Stannard J, Krettek C, Borrelli J. Articular Cartilage Injury and Potential Remedies. J Orthop Trauma. 2015; 29(Suppl):S47–S52.
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6. Migliorini F, Eschweiler J, Schenker H, Baroncini A, Tingart M, Maffulli N. Surgical management of focal chondral defects of the knee: a Bayesian network meta-analysis. J Orthop Surg Res. 2021; 16:543. Doi: 10.1186/s13018-021-02684-z.
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9. Heir S, Nerhus TK, Røtterud JH, Løken S, Ekeland A, Engebretsen L, et al. Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: knee injury and osteoarthritis outcome score in patients scheduled for knee surgery. Am J Sports Med. 2010 Feb; 38(2):231–7. Doi: 10.1177/0363546509352157.
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12. Willers C, Wood DJ, Zheng MH. A current review on the biology and treatment of articular cartilage defects (Part I & II). J Musculoskelet Res. 2003; 7:157–81. Doi: 10.1142/S0218957703001125.
13. da Cunha Cavalcanti FMM, Doca D, Cohen M, Ferretti M. Updating on diagnosis and treatment of chondral lesion of the knee. Rev Bras Ortop. 2012 Jan; 47(1):12–20. Doi: 10.1016/S2255-4971(15)30339-6.
14. Camp CL, Stuart MJ, Krych AJ. Current concepts of articular cartilage restoration techniques in the knee. Sports Health. 2014 May; 6(3):265–73. Doi: 10.1177/1941738113508917.
15. Moyad TF. Cartilage Injuries in the Adult Knee: Evaluation and Management. Cartilage. 2011 Jul;2(3):226–36. Doi: 10.1177/1947603510383973.
16. Bedi A, Feeley BT, Williams RJ 3rd. Management of articular cartilage defects of the knee. J Bone Joint Surg Am. 2010 Apr; 92(4):994–1009. doi:10.2106/JBJS.I.00895.
17. Robinson PG, Williamson T, Murray IR, Al-Hourani K, White TO. Sporting participation following the operative management of chondral defects of the knee at mid-term follow up: a systematic review and meta-analysis. J Exp Orthop. 2020 Oct 6; 7(1):76. Doi: 10.1186/s40634-020-00295-x.
18. Chalmers PN, Vigneswaran H, Harris JD, Cole BJ. Activity-related outcomes of articular cartilage surgery: a systematic review. Cartilage. 2013 Jul; 4(3):193–203. Doi: 10.1177/1947603513481603.
19. Litchfield RB, Kirkley A, Brimingham T, Giffin R, Willits K, Feagan B, et al. A randomized trial comparing arthroscopic surgery to non-surgical care for knee osteoarthritis. Arthroscopy. 2009.
20. Steadman JR, Rodkey WG, Briggs KK. Microfracture to treat full-thickness chondral defects: surgical technique, rehabilitation, and outcomes. J Knee Surg. 2002; 15(3):170–6.
| How to Cite this Article: Patwardhan S, Sancheti P, Patil K, Gugale S, Sanghavi S, Sisodia Y, Nisar OU, Sonawane D, Shyam A. Evaluation of Efficacy of Surgical Management for Treatment of Chondral Defects of the Knee in Adults. Journal of Medical Thesis. 2024 January-June; 10(1):66-69. |
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: 2022
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Functional and Radiological outcomes after Surgical Management of Crouch Gait in Spastic Diplegic Cerebral Palsy: A Prospective Cohort Study
Vol 10 | Issue 1 | January-June 2024 | page: 62-65 | Rohit Gupta, Sandeep Patwardhan, Vivek Sodhai, Rahul Jaiswal, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2024.v10.i01.228
Author: Rohit Gupta [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. Rohit Gupta,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji
Nagar, Pune, Maharashtra, India.
Email : coolgupta73@yahoo.com
Abstract
Background: Crouch gait—walking with excessive knee bend during stance—is a common, disabling pattern in children with spastic diplegic cerebral palsy. It raises the effort of walking, causes knee pain, and limits participation. Restoring a more extended knee during stance often requires both bony correction and improvement of the extensor mechanism.
Methods and materials: We treated ambulatory children with severe crouch using a tailored combination of distal femoral extension osteotomy (DFEO) and patellar tendon advancement (PTA), adding selective soft-tissue releases when needed. Preoperative assessment included clinical measures (popliteal angle, extensor lag), functional scoring, and knee radiographs to measure patellar height. Surgery used growth-respecting fixation in immature patients and standardized postoperative immobilization and rehabilitation.
Results: Patients showed improved knee extension on exam, lower patellar-height indices on radiographs, better short-distance walking scores, and less anterior knee pain. Osteotomies healed without major complications and patients progressed through rehabilitation to better function.
Conclusion: When crouch is caused by fixed knee flexion and extensor mechanism insufficiency, combining DFEO with PTA—and following it with disciplined physiotherapy and orthotic support—produced reliable short-term gains in alignment, pain, and walking ability in this series.
Keywords: crouch gait; cerebral palsy; distal femoral extension osteotomy; patellar tendon advancement; Functional Mobility Scale
Introduction
Cerebral palsy is a lifelong disorder of movement and posture originating from early brain injury and frequently leads to secondary musculoskeletal problems. [1] Clinicians use the Gross Motor Function Classification System (GMFCS) to describe a child’s mobility and to help plan treatment. [2] Among the gait patterns seen in diplegic cerebral palsy, crouch gait—marked by persistently increased knee flexion during stance—stands out for its negative impact on energy cost, pain, and independence. [3]
Crouch usually develops or worsens during growth spurts, when weak antigravity muscles and evolving soft-tissue tightness fail to maintain an upright gait pattern. [4] The causes are multiple and often act together: shortened or spastic hamstrings, weak quadriceps with patella alta and extensor lag, torsional femoral abnormalities, fixed knee flexion contractures, and foot deformities. Each element must be assessed carefully before planning surgery. [5] While instrumented gait analysis offers precise data, many centers rely on clinical measures—popliteal angle, extensor lag, and patellar-height ratios—together with validated function scales to guide treatment. [6]
The modern approach favors single-event multilevel surgery (SEMLS) when multiple deformities contribute to poor gait, because tackling relevant problems at once can reduce repeated operations and speed rehabilitation. [7] For older children and adolescents with a fixed crouch and clear extensor-mechanism dysfunction, combining distal femoral extension osteotomy (DFEO) to correct bony alignment with patellar tendon advancement (PTA) to restore quadriceps mechanics addresses the two main pathologies that maintain crouch. This study describes our experience with that combined strategy and its short-term outcomes.
Materials and Methods
We reviewed consecutive ambulatory patients under 18 years with spastic diplegic cerebral palsy and clinical crouch treated between October 2019 and October 2021. Inclusion required functional ambulation with GMFCS II–IV and clinical evidence of fixed knee flexion and/or patella alta with extensor lag. Patients who were non-ambulant (GMFCS V) or medically unfit for surgery were excluded. Institutional approval and informed guardian consent were obtained. [8]
Before surgery every child had a focused history and standardized exam: measurement of popliteal angle, passive knee range of motion, extensor lag, hamstring and gastrocnemius tightness, and spasticity grading (Modified Ashworth, Tardieu). Functional mobility was recorded using the Functional Mobility Scale (5, 50, 500 m) and GMFCS to establish baseline capacity. Plain AP and lateral knee radiographs were used to measure patellar height (Koshino and Insall–Salvati indices) and to plan the need for PTA. [9] [10]
Surgical planning was individualized. DFEO was performed through a lateral approach using a wedge or V-shaped osteotomy fixed with pediatric condylar locking plates; care was taken to protect the distal femoral physis in skeletally immature patients. PTA was achieved by advancing the patellar tendon with either a periosteal flap or bone-block technique depending on skeletal maturity. Additional soft-tissue procedures—hamstring fractional lengthening, gastrocnemius recession, patellar plication, or rectus femoris procedures—were added selectively when clinical assessment indicated their benefit. [4]
Postoperatively patients had an above-knee cast or long knee brace for about six weeks, radiographs at follow-up intervals, staged weight bearing after immobilization, orthoses as needed, and a structured physiotherapy program emphasizing knee-extension control, quadriceps strengthening, and gait re-training. Data were recorded prospectively when possible; paired comparisons assessed pre- and postoperative changes with significance set at p < 0.05. [11][12]
Results
The study group comprised 16 patients (14 boys, 2 girls) with a mean age of 11.6 ± 3.5 years (range 5–17), most classified as GMFCS III (14 patients) and ambulant with assistance (15 of 16). All patients underwent distal femoral extension osteotomy combined with patellar tendon advancement, with selective soft-tissue procedures added as needed (hamstring release in 11 patients, gastrocnemius/gastro soleus release in 2, patellar plication in 9; bilateral supracondylar extension osteotomy in 14, bilateral varus-derotation osteotomy in 2). Fixed knee-flexion deformity improved from a preoperative mean of ≈36° (right 37.5° ± 3.1, left 35.9° ± 3.7) to about 1° (right 1.56° ± 2.3, left 0.63° ± 1.7). The popliteal angle fell markedly (overall from roughly 61° to 28.4°), and lateral radiographs showed correction of patella alta with Koshino index improving from 1.45 ± 0.06 to 1.27 ± 0.05 and Insall–Salvati ratio from 1.36 ± 0.06 to 1.05 ± 0.03. Functional Mobility Scale scores rose at short distances—5 m from 3.0 to 4.0, and 50 m from 2.06 to 3.06—while 500 m remained unchanged at 2.0. At a minimum follow-up of 12 months (radiographs at 1 month, 6 months, and 1 year), most families reported less anterior knee pain and easier transfers; there were no major intraoperative complications, all osteotomies united uneventfully, hardware remained stable, and only minor transient postoperative issues were seen that resolved with conservative care and rehabilitation.
Discussion
Our experience supports the idea that fixing crouch often requires correcting more than one problem at the same time. DFEO straightens a fixed knee-flexion deformity, while PTA brings the patella and tendon into a better mechanical position so the quadriceps can work more efficiently. When both issues coexist, treating only one may leave a residual gait problem. [11][13]
Stable fixation that protects growth plates is crucial in children; locking plates offer secure correction and allow the team to start rehabilitation sooner. [15] Adding selective soft-tissue releases—hamstring or gastrocnemius lengthening, patellar plication, or muscle transfers—depends on the child’s specific contractures and motor control, and tailoring these choices improves outcomes. [16][17][18] Non-surgical adjuncts such as orthoses, functional electrical stimulation, or targeted botulinum toxin injections can also help before or after surgery, depending on the underlying deficits. [12][9]
This study’s limitations include the small cohort size, single-center design, and lack of instrumented gait laboratory data to quantify kinematic change precisely. These caveats mean that while early clinical and radiographic improvements are encouraging, long-term follow-up with objective gait analysis would better define durability and any secondary changes at the hip or pelvis. [14][20] Nonetheless, the consistent improvements seen here align with other series that report good short-term gains when DFEO and PTA are combined in appropriate patients. [13][15]
Clinical implications
When a child with diplegic cerebral palsy walks in crouch because of a fixed knee-flexion deformity combined with patella alta and quadriceps inefficiency, a planned combined operation that corrects the bone alignment and the extensor mechanism—followed by disciplined rehabilitation and orthotic support—can produce meaningful improvements in pain and function. Preoperative planning should use simple, reliable clinical measures and patellar-height indices to decide which components require correction. Respecting growth plates, ensuring stable fixation, and engaging a multidisciplinary team are essential to turn anatomic correction into better every day walking.
Conclusion
In this series, combining distal femoral extension osteotomy with patellar tendon advancement in selected ambulatory children and adolescents with spastic diplegic cerebral palsy and severe crouch gait produced reliable short-term improvements in knee alignment, patellar height, pain, and walking ability. The operation is safe when surgical technique protects the growth plate and when a coordinated postoperative program of immobilization, orthotic support, and physiotherapy is followed. Larger studies with gait laboratory follow-up are needed to confirm how long these benefits last and to refine which adjunct procedures give the best long-term results.
References
1. Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007; 109:8-14.
2. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997; 39(4):214-223. doi:10.1111/j.1469-8749.1997.tb07414.x
3. Shore BJ, White N, Kerr Graham H. Surgical correction of equinus deformity in children with cerebral palsy: a systematic review. J Child Orthop. 2010; 4(4):277-290. doi:10.1007/s11832-010-0268-4
4. Das S, Pradhan S, Ganesh S, Sahu P, Mohanty R, Das S. Supracondylar femoral extension osteotomy and patellar tendon advancement in the management of persistent crouch gait in cerebral palsy. Indian J Orthop. 2012; 46(2):221-228. doi:10.4103/0019-5413.93677
5. Rodda JM, Graham HK, Nattrass GR, Galea MP, Baker R, Wolfe R. Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery. J Bone Joint Surg Am. 2006; 88(12):2653-2664. doi:10.2106/JBJS.E.00993
6. Schutte LM, Hayden SW, Gage JR. Lengths of hamstrings and psoas muscles during crouch gait: Effects of femoral anteversion. J Orthop Res. 1997; 15(4):615-621. doi:10.1002/JOR.1100150419
7. Kedem P, Scher DM. Evaluation and management of crouch gait. Curr Opin Pediatr. 2016; 28(1):55-59. doi:10.1097/MOP.0000000000000316
8. Rosenberg M, Steele KM. Simulated impacts of ankle foot orthoses on muscle demand and recruitment in typically developing children and children with cerebral palsy and crouch gait. PLoS One. 2017; 12(7):0-1. doi:10.1371/journal.pone.0180219
9. Hastings-Ison T, Sangeux M, Thomason P, Rawicki B, Fahey M, Graham HK. Onabotulinum toxin-A (Botox) for spastic equinus in cerebral palsy: a prospective kinematic study. J Child Orthop. 2018; 12(4):390-397. doi:10.1302/1863-2548.12.180044
10. Abou Al-Shaar H, Imtiaz MT, Alhalabi H, Alsubaie SM, Sabbagh AJ. Selective dorsal rhizotomy: A multidisciplinary approach to treating spastic diplegia. Asian J Neurosurg. 2017; 12(3):454-465. doi:10.4103/1793-5482.175625
11. Morais Filho MC, Neves DL, Abreu FP, Juliano Y, Guimarães L. Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy. J Child Orthop. 2008; 2(1):37-43. doi:10.1007/s11832-007-0073-x
12. Khamis S, Martikaro R, Wientroub S, Hemo Y, Hayek S. A functional electrical stimulation system improves knee control in crouch gait. J Child Orthop. 2015; 9(2):137-143. doi:10.1007/s11832-015-0651-2
13. de Morais Filho MC, Neves DL, Abreu FP, Juliano Y, Guimarães L. Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy. J Child Orthop. 2008; 2(1):37-43. doi:10.1007/s11832-007-0073-x
14. Nordmark E, Josenby AL, Lagergren J, Andersson G, Strömblad L-G, Westbom L. Long-term outcomes five years after selective dorsal rhizotomy. BMC Pediatr. 2008; 8:54. doi:10.1186/1471-2431-8-54
15. Das S, Pradhan S, Ganesh S, Sahu P, Mohanty R, Das S. Supracondylar femoral extension osteotomy and patellar tendon advancement in the management of persistent crouch gait in cerebral palsy. Indian J Orthop. 2012; 46(2):221-228. doi:10.4103/0019-5413.93677
16. Mallet C, Simon AL, Ilharreborde B, Presedo A, Mazda K, Penneçot GF. Intramuscular psoas lengthening during single-event multi-level surgery fails to improve hip dynamics in children with spastic diplegia. Orthop Traumatol Surg Res. 2016; 102(4):501-506. doi:10.1016/J.OTSR.2016.01.022
17. Thawrani D, Haumont T, Church C, Holmes LJ, Dabney KW, Miller F. Rectus femoris transfer improves stiff knee gait in children with spastic cerebral palsy. Clin Orthop Relat Res. 2012; 470(5):1303-1311. doi:10.1007/s11999-011-2215-1
18. de Morais MC, Blumetti FC, Kawamura CM, Lopes JAF, Neves DL, Cardoso M de O. Does rectus femoris transfer increase knee flexion during stance phase in cerebral palsy? Acta Ortop Bras. 2016; 24(1):27-31. doi:10.1590/1413-785220162401145765
19. Aroojis A, Sarathy K, Doshi C. Clinical Examination of Children with Cerebral Palsy. 2019. doi:10.4103/ortho.IJOrtho_409_17
20. Park H, Park BK, Park KB, et al. Distal Femoral Shortening Osteotomy for Severe Knee Flexion Contracture and Crouch Gait in Cerebral Palsy. J Clin Med. 2019;8(9). doi:10.3390/JCM8091354
| How to Cite this Article: Gupta R, Patwardhan S, Sodhai V, Jaiswal R, Sonawane D, Shyam A, Sancheti P. Functional and Radiological outcomes after Surgical Management of Crouch Gait in Spastic Diplegic Cerebral Palsy: A Prospective Cohort Study. Journal Medical Thesis. 2024 January-June; 10(1):62-65. |
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: 2022
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PAPhAR-Guided Algorithms Improve Early Detection and Intervention of Growth Disturbances
Vol 10 | Issue 1 | January-June 2024 | page: 58-61 | Siddhartha Sablay, Sandeep Patwardhan, Vivek Sodhai, Rahul Jaiswal, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2024.v10.i01.226
Author: Siddhartha Sablay [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. Siddhartha Sablay,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and
Rehabilitation, Pune, Maharashtra, India.
E-mail: siddharthasablay200@gmail.com
Abstract
Background: Children’s ankles differ from adults’ — the growth plate (physis) is mechanically and biologically weaker than surrounding bone and ligaments, so twisting or sports injuries that would sprain an adult often produce physeal fractures in a child. Distal tibial physeal closure is asymmetric and creates a window in adolescence when transitional patterns (Tillaux, triplane) commonly occur and involve the joint surface. Accurate classification (Salter–Harris, Dias–Tachdjian), careful imaging (mortise views, CT, arthrography or MRI when needed) and prompt, anatomy-respecting treatment are essential because intra-articular step-off or physeal damage can lead to pain, malalignment, growth arrest and early arthritis. This abstract summarizes findings and conclusions drawn from the attached thesis on pediatric ankle fractures.
Hypothesis: When pediatric ankle fractures are evaluated with the proper imaging, classified correctly, and managed according to fracture type — non-operative immobilization for stable, non-displaced injuries and anatomic reduction with growth-respecting fixation for displaced or intra-articular injuries — most children will achieve good-to-excellent functional recovery at one year. Transitional and intra-articular physeal fractures that are reduced to near-anatomic alignment (residual articular step-off ≤2–2.5 mm) and stabilized appropriately will have functional outcomes comparable to simpler physeal fractures; greater residual displacement or delayed/inadequate reduction predicts worse pain, function or physeal complications.
Clinical importance: For clinicians: obtain adequate imaging when suspicion is high, aim for anatomic restoration of the joint surface (surgery if residual step-off exceeds ~2 mm), and choose fixation that minimizes additional physeal injury. Early, accurate treatment and planned follow-up reduce the risk of leg-length discrepancy, angular deformity and early osteoarthritis.
Future research: larger prospective, multicentre cohorts with standardized outcomes and longer follow-up to skeletal maturity are needed to define exact displacement thresholds for surgery, compare immobilization strategies, and quantify late physeal arrest and arthritic changes.
Keywords: Pediatric ankle fracture, Salter–Harris, Tillaux, Triplane, Physeal preservation, Anatomic reduction.
Background
Children’s ankles are not just “small adult” ankles — their bones, cartilage and growth plates behave differently under stress. The physis (growth plate) at the distal tibia is relatively weaker than the surrounding ligaments and often bears the brunt of rotational or axial forces. As a result, injuries that would produce ligament sprains in adults commonly produce physeal fractures in children. This basic anatomic truth underlies the distinct fracture patterns and treatment priorities in the pediatric population. [1][2]
The distal tibial physis closes in a predictable, asymmetric fashion during adolescence, which gives rise to transitional fracture patterns such as Tillaux and triplane fractures near skeletal maturity. These transitional patterns cross the physis and involve the joint surface, so they demand careful imaging and precise reduction to avoid long-term joint dysfunction. [3][4] Mechanistic classifications — for example the Dias–Tachdjian system — help relate foot position and force direction to the fracture pattern and therefore guide the treating surgeon toward an appropriate strategy. [5]
Epidemiologically, ankle fractures are a frequent subset of physeal injuries in children and are commonly linked to sports and playground injuries; high-energy mechanisms such as road traffic collisions account for more complex patterns and a greater risk of complications. [6][7] Clinically, affected children present with pain, swelling, and inability to bear weight; however, physeal or cartilage injuries can be subtle on routine radiographs, so a low threshold for additional views and advanced imaging is recommended when clinical suspicion remains high. Mortise views, CT scans for intra-articular detail, and arthrography or MRI for cartilage and physeal assessment are tools that frequently change management decisions. [8][9]
Classification carries prognostic weight. The Salter–Harris scheme remains the foundation for describing physeal injuries because higher-grade injuries (types III and IV) more often involve the joint surface and carry a higher risk of growth disturbance. [10] Complementary classifications that describe injury mechanism furnish practical guidance for reduction and fixation. In transitional injuries, the articular involvement is the dominant concern: even small steps or gaps in the joint surface predispose to early arthritis and functional problems later in life. [11][12]
Treatment principles for pediatric ankle fractures balance three goals: restore joint congruity, maintain mechanical alignment, and preserve the physis. For minimally displaced and stable patterns, immobilization in a cast or functional brace is reliable. Indications for operative fixation include irreducible or significantly displaced fractures, intra-articular step-off beyond accepted limits, and specific patterns — for example displaced medial malleolar fragments or transitional fractures with articular incongruity. [13][14] When operating, implant choice and technique must minimize additional physeal insult: smooth K-wires or percutaneous techniques are preferred when crossing an open physis is unavoidable, whereas cannulated compression screws are chosen when physeal crossing is acceptable (often in transitional injuries or near-mature physes). Intraoperative imaging (fluoroscopy, arthrography) and preoperative CT are commonly used to confirm reduction and plan fixation. [15][16]
Despite decades of experience, robust randomized trials comparing specific treatments are sparse; much practice rests on cohort studies, systematic reviews and expert consensus. This relative paucity of high-level evidence makes careful case-by-case decision-making essential and reinforces the importance of accurate imaging, anatomic reduction and growth-respecting fixation techniques. [17][18]
Finally, the clinical focus must extend beyond early bone healing. Growth arrest, angular deformity and leg-length discrepancy may not become apparent until months or years after the injury, so both the initial management and planned follow-up must anticipate and detect these late complications. [19][20]
Hypothesis
This study rests on two complementary hypotheses intended to link fracture morphology and management strategy to outcomes.
Primary hypothesis: When pediatric ankle fractures are assessed with the appropriate imaging, classified accurately, and managed with a treatment plan that prioritizes anatomic articular reduction and growth-plate preservation, the majority of children will reach good-to-excellent functional outcomes at one-year follow-up. The aim is to show that classification-guided care — using closed reduction and immobilization for stable, nondisplaced injuries and operative reduction ± fixation for displaced or intra-articular injuries — leads to predictable functional recovery. [21]
Secondary hypothesis: Transitional and intra-articular physeal fractures (Tillaux, triplane, Salter–Harris III/IV) that are reduced to near-anatomic alignment (residual articular step-off ≤2–2.5 mm) and stabilized appropriately will achieve functional outcomes similar to less complex physeal fractures. Conversely, fractures with greater residual displacement or delayed/inadequate reduction will show higher rates of persistent pain, reduced function and possible physeal complications. [22][23]
Rationale: The distal tibial physis contributes substantially to tibial length and alignment. Disruption to the physis or residual articular incongruity can therefore produce clinically meaningful consequences, from gait disturbance to early degenerative changes. By quantifying functional outcomes (for example, using AOFAS and VAS scores) and documenting complications (including evidence of growth arrest on follow-up radiographs), the study evaluates whether careful imaging and technique can mitigate these risks. [24]
Operational definitions and thresholds are important. The literature commonly cites an intra-articular residual of approximately 2 mm as the cutoff beyond which operative fixation should be considered to reduce the risk of poor joint outcomes. The study tests whether this threshold correlates with functional results in the patient cohort. Imaging modalities such as CT scans and intraoperative arthrography are used to detect occult displacement and confirm reductions that fluoroscopy alone might miss. Technique selection — closed reduction and percutaneous fixation when possible, open reduction for irreducible or soft-tissue–interposed fractures — is explicitly tied to the fracture classification and patient skeletal maturity. [11][12][25]
In short, the study hypothesizes that a disciplined, classification-informed approach — diligent imaging, anatomic reduction, and physeal-conscious fixation — will deliver reliable short-term function while minimizing the risk of complications that threaten future growth and joint health.
Discussion
The cohort examined in the thesis reflects the typical pediatric ankle fracture population: older children approaching skeletal maturity predominate, and transitional injury patterns (Tillaux, triplane) are well represented. Mechanisms are predominantly sports-related or low- to moderate-energy twists, although higher-energy events appear in the more complex fracture patterns. These demographic and mechanism profiles align with larger published series. [1][2][6]
Key management themes emerge from the data. First, imaging matters. Plain radiographs are the starting point, but the addition of mortise views, CT for suspected intra-articular extension and intraoperative arthrography for cartilage/physeal assessment frequently altered operative plans. CT in particular clarifies three-dimensional displacement in transitional fractures and is a valuable planning tool when anatomic reduction is the goal. [8][11][23]
Second, anatomic articular reduction predicts outcome. The dataset supports the commonly accepted threshold that residual intra-articular displacement beyond approximately 2 mm correlates with worse functional outcomes and should prompt fixation. In the series, operations aimed at restoring joint congruity — often using percutaneous cannulated screws or smooth pins depending on the physis status — achieved excellent short-term AOFAS and VAS improvements. These functional gains mirror results reported in other observational studies. [12][16][22]
Third, respect the physis. When growth remains, implants and techniques are chosen to limit additional physeal harm: smooth pins instead of transphyseal threaded screws when feasible, minimal soft-tissue dissection, and percutaneous approaches where possible. Transitional injuries, however, create a practical tension: the physis is partially closed and transphyseal fixation may be acceptable to secure the epiphyseal fragment. The clinical judgment here depends on skeletal age, fracture geometry and the need for rigid fixation to maintain joint congruity. [13][15][25]
Complications in the cohort were relatively infrequent and tended to be minor — superficial wound issues, temporary sensory changes, or transient stiffness. Growth arrest and angular deformity are the complications clinicians fear most, but they often require longer follow-up than the one-year window to become clinically obvious. For that reason, the thesis rightly highlights the need for continued surveillance to skeletal maturity in those at risk. [19][20]
Limitations merit emphasis. The small sample size limits statistical power and generalizability. The single-centre design reflects local practice patterns that may differ elsewhere. Most importantly, follow-up duration in many pediatric series is inadequate to fully capture physeal arrest or late degenerative changes, so short-term functional success cannot be equated with absence of late sequelae. These limitations underscore the need for larger, prospective multicenter studies with standardized outcomes and longer-term follow-up. [17][24]
In practice, this work supports a pragmatic algorithm: obtain precise imaging for suspected intra-articular or transitional fractures; pursue anatomic reduction when the articular surface is involved; choose implants and approaches that minimize additional physeal damage; and maintain vigilance for late growth-related complications. When applied consistently, this approach yields reliable short-term functional recovery while reducing the immediate risk of joint incongruity.
Clinical importance
Pediatric ankle fractures have the potential for lasting harm if joint congruity or physeal integrity is compromised. The practical takeaways are: (1) obtain appropriate imaging (including CT or arthrography where indicated) to detect articular involvement and plan treatment; (2) aim for anatomic reduction of intra-articular fractures — residual steps >2 mm usually justify fixation; and (3) select fixation techniques that respect remaining growth, using smooth pins or percutaneous techniques when crossing an open physis would otherwise risk arrest. Applying these principles minimizes the chance of long-term pain, deformity, leg-length discrepancy and early arthritis.
Future directions
Priority areas include prospective multicentre studies with longer follow-up to quantify physeal arrest and late arthritis rates, randomized trials comparing immobilization strategies for low-risk fractures, and research into biologic or regenerative methods to repair damaged physis. Standardized outcome sets and imaging protocols would also improve comparability across studies.
References
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2. Trainor TJ. Pediatric ankle fractures. Trauma. 2002; 44(2):23-43. doi:10.1016/j.fcl.2015.07.004
3. Yeung DE, Jia X, Miller CA, Barker SL. Interventions for treating ankle fractures in children. Cochrane Database Syst Rev. 2016; 2016(4). doi:10.1002/14651858.CD010836.pub2
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5. Dias LS, Tachdjian MO. Physeal injuries of the ankle in children: classification. Clin Orthop Relat Res. 1978 ;( 136):230-233.
6. Wuerz TH, Gurd DP. Pediatric physeal ankle fracture. J Am Acad Orthop Surg. 2013; 21(4):234-244. doi:10.5435/JAAOS-21-04-234
7. Olgun ZD, Maestre S. Management of Pediatric Ankle Fractures. Curr Rev Musculoskelet Med. 2018; 11(3):475-484. doi:10.1007/s12178-018-9510-3
8. Denning JR. Complications of Pediatric Foot and Ankle Fractures. Orthop Clin North Am. 2017; 48(1):59-70. doi:10.1016/j.ocl.2016.08.010
9. Boutis K, Komar L, Jaramillo D, et al. Sensitivity of a clinical examination to predict need for radiography in children with ankle injuries: A prospective study. Lancet. 2001; 358(9299):2118-2121. doi:10.1016/S0140-6736(01)07218-X
10. Rohmiller MT, Gaynor TP, Pawelek J, Mubarak SJ. Salter-Harris I and II fractures of the distal tibia: Does mechanism of injury relate to premature physeal closure? J Pediatr Orthop. 2006; 26(3):322-328. doi:10.1097/01.bpo.0000217714.80233.0b
11. Schnetzler KA, Hoernschemeyer D. The pediatric triplane ankle fracture. J Am Acad Orthop Surg. 2007; 15(12):738-747. doi:10.5435/00124635-200712000-00007
12. Cottalorda J, Béranger V, Louahem D, et al. Salter-Harris Type III and IV Medial Malleolar Fractures. J Pediatr Orthop. 2008; 28(6):652-655. doi:10.1097/bpo.0b013e318182f74c
13. Podeszwa DA, Wilson PL, Holland AR, Copley LAB. Comparison of bioabsorbable versus metallic implant fixation for physeal and epiphyseal fractures of the distal tibia. J Pediatr Orthop. 2008; 28(8):859-863. doi:10.1097/BPO.0b013e31818e19d7
14. Kim JR, Song KH, Song KJ, Lee HS. Treatment outcomes of triplane and tillaux fractures of the ankle in adolescence. Clin Orthop Surg. 2010; 2(1):34-38. doi:10.4055/cios.2010.2.1.34
15. Duran JA, Dayer R, Kaelin A, Ceroni D. Intraoperative arthrography for the evaluation of closed reduction and percutaneous fixation of displaced Macfarland fractures: An alternative to open surgery. J Pediatr Orthop. 2011; 31(1):1-5. doi:10.1097/BPO.0b013e3182032c6a
16. Gourineni P, Gupta A. Medial joint space widening of the ankle in displaced tillaux and triplane fractures in children. J Orthop Trauma. 2011; 25(10):608-611. doi:10.1097/BOT.0b013e318206f8bc
17. Canagasabey MD, Callaghan MJ, Carley S. The Sonographic Ottawa Foot and Ankle Rules Study (the SOFAR Study). Emerg Med J. 2011; 28(10):838-840. doi:10.1136/emj.2009.088286
18. Crawford AH. Triplane and tillaux fractures: Is a 2 mm residual gap acceptable? J Pediatr Orthop. 2012; 32(SUPPL. 1):69-73. doi:10.1097/BPO.0b013e31824b25a1
19. Blackburn EW, Aronsson DD, Rubright JH, Lisle JW. Ankle fractures in children. J Bone Joint Surg Am. 2012; 94(13):1234-1244. doi:10.2106/JBJS.K.00682
20. Barnett PLJ, Lee MH, Oh L, Cull G, Babl F. Functional outcome after air-stirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: A randomized observer-blinded controlled trial. Pediatr Emerg Care. 2012; 28(8):745-749. doi:10.1097/PEC.0b013e318262491d
21. Parrino A, Lee MC. Ankle fractures in children. Curr Orthop Pract. 2013; 24(6):617-624. doi:10.1097/BCO.0000000000000033
22. Choudhry IK, Wall EJ, Eismann EA, Crawford AH, Wilson L. Functional outcome analysis of triplane and tillaux fractures after closed reduction and percutaneous fixation. J Pediatr Orthop. 2014; 34(2):139-143. doi:10.1097/BPO.0000000000000085
23. Eismann EA, Stephan ZA, Mehlman CT, et al. Pediatric Triplane Ankle Fractures: Impact of Radiographs and Computed Tomography on Fracture Classification and Treatment Planning. J Bone Joint Surg Am. 2015; 97(12):995-1002. doi:10.2106/JBJS.N.01208
24. Rammelt S, Godoy-Santos AL, Schneiders W, Fitze G, Zwipp H. Foot and ankle fractures during childhood: review of the literature and scientific evidence for appropriate treatment. Rev Bras Ortop (English Ed.). 2016; 51(6):630-639. doi:10.1016/j.rboe.2016.09.001
25. Leary JT, Handling M, Talerico M, Yong L, Bowe JA. Physeal fractures of the distal tibia: Predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop. 2009; 29(4):356-361. doi:10.1097/BPO.0b013e3181a6bfe8
| How to Cite this Article: Sablay S, Patwardhan S, Sodhai V, Jaiswal R, Sonawane D, Shyam A, Sancheti P. PAPhAR-Guided Algorithms Improve Early Detection and Intervention of Growth Disturbances. Journal Medical Thesis 2024 January-June ; 10(1):58-61. |
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: 2022
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Single-Stage BMAC in a Collagen Scaffold Achieves Hyaline-Like Regeneration Superior to Micro fracture and Equivalent to ACI in Medium/Large Knee Defects”
Vol 10 | Issue 1 | January-June 2024 | page: 54-57 | Shaunak Pathwardhan, Parag Sancheti, Kailas Patil, Sunny Gugale, Sahil Sanghavi, Yogesh Sisodiya, Obaid UL Nisar, Darshan Sonawane, Ashok Shyam
https://doi.org/10.13107/jmt.2024.v10.i01.224
Author: Shaunak Pathwardhan [1], Parag Sancheti [1], Kailas Patil [1], Sunny Gugale [1], Sahil Sanghavi [1], Yogesh Sisodiya [1], Obaid UL Nisar [1], Darshan Sonawane [1], Ashok Shyam [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Shaunak Patwardhan,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and
Rehabilitation, Pune, Maharashtra, India.
E-mail: patwardhanshaunak@gmail.com
Abstract
Background: Focal full-thickness chondral defects of the femoral condyles cause persistent knee pain, swelling and reduced function in adults. Articular cartilage has limited healing potential, so symptomatic lesions frequently become chronic and may contribute to early osteoarthritis. Surgeons manage these defects with techniques such as microfracture, osteochondral graft transfer, autologous chondrocyte implantation and single-stage biologic augmentation using bone marrow aspirate concentrate. Selecting the optimal approach depends on lesion size, location, patient age, activity goals and coexisting knee pathology.
Hypothesis: Surgical intervention for symptomatic full-thickness femoral condylar defects will produce meaningful improvements in pain and function at one year across commonly used techniques when the procedure is matched to lesion and patient characteristics. Younger age, lower body mass index and shorter symptom duration are expected to be associated with larger gains in validated patient-reported outcomes. Regenerative procedures may demonstrate superior structural repair on imaging, but early clinical improvements are predicted to be similar across appropriate techniques.
Clinical importance: This study offers practical guidance: individualized surgical care can reduce symptoms and restore knee function within a year, usually with low complication rates when standard perioperative pathways and rehabilitation are followed. Focusing on modifiable factors such as weight management and timely referral can improve outcomes. Where resources or logistics limit options, single-stage techniques provide a pragmatic route, while cell-based restoration remains valuable for larger defects when long-term tissue quality is a priority.
Future research: Randomized, longer term trials with standardized rehabilitation, routine MRI assessment and, where feasible, tissue evaluation are needed to compare durability between marrow-stimulation and regenerative strategies. Economic analyses and return-to-activity metrics should be incorporated to guide value-based care. Including patient-reported quality of life measures and stratified subgroup analyses will improve applicability across diverse patient populations.
Keywords: Chondral defect, Femoral condyle, Cartilage repair, Microfracture, Autologous chondrocyte implantation, Bone marrow aspirate concentrate
Background
Articular cartilage is the smooth, slippery tissue that allows our knee joints to glide and bear weight. When a focal full thickness chondral or osteochondral defect develops on the femoral condyles, patients typically experience pain, swelling, and reduced ability to walk, run or return to sports. Because cartilage has very limited capacity to heal on its own, these defects can persist and sometimes lead to early joint degeneration if not treated appropriately [1, 2]. Painful cartilage lesions are common findings at knee arthroscopy, reinforcing the need to choose effective, patient centred treatment options [3, 4].
Over the years, surgeons have developed three broad strategies to manage symptomatic focal cartilage defects: palliative procedures (for example, arthroscopic debridement), reparative methods (most commonly microfracture), and restorative or regenerative techniques (such as osteochondral grafts and cell based therapies) [5–7]. Each approach has pros and cons. Microfracture is simple and inexpensive and often helps small to medium defects—especially in younger patients—but the repair tissue tends to be fibrocartilage rather than true hyaline cartilage and may wear out sooner in larger or high demand lesions [8–10]. Osteochondral autograft transfer (mosaicplasty) replaces the damaged area with native hyaline cartilage from a non weight bearing site and works well for small defects, but it is limited by donor site issues and the practical size of the grafts [11,12]. Fresh osteochondral allografts can treat larger defects without donor site morbidity but bring logistical and availability hurdles [13].
Cell based restoration, such as autologous chondrocyte implantation (ACI) and matrix assisted ACI, aims to restore a surface that more closely resembles native cartilage; these techniques have shown durable benefits in selected patients, particularly those who are younger and more active [14–16]. In recent years, one stage biologic approaches using bone marrow aspirate concentrate (BMAC) or platelet rich products on scaffolds have become popular because they try to combine regenerative potential with the convenience and lower cost of a single operation; early reports suggest promising clinical and MRI results, although long term data are still limited [17–19].
Picking the right treatment comes down to matching the patient and the lesion. Important considerations include the size and location of the defect, the patient’s age and activity goals, body weight, limb alignment, and whether other knee problems (meniscal tears, ligament injuries) need addressing at the same time [20–22]. The scientific literature includes many case series and some comparative studies, but randomized trials remain few and the results are mixed, which means surgeons often make decisions based on a combination of evidence, experience and patient preference [23, 24].
This synopsis draws on a prospective single centre cohort that compared three commonly used strategies—microfracture, two stage ACI and single stage BMAC—for symptomatic full thickness femoral condylar defects larger than 2 cm². Outcomes were tracked using validated patient reported tools (IKDC and KOOS) at baseline, 6 months and 12 months, and MRI (MOCART) where available. The aim was practical: to describe short term improvements patients can expect, and to identify which patient factors most strongly influence those results.
Hypothesis
The central idea guiding this study was straightforward: surgical treatment for symptomatic full thickness femoral condylar defects will lead to meaningful improvement in pain and function by one year, but the size of that improvement depends more on patient factors—age, body mass index (BMI), and how long the problem has been present—than on the specific technique used when each procedure is chosen appropriately.
More specifically:
• We expected that microfracture, ACI and BMAC would each produce measurable and clinically important gains in IKDC and KOOS scores at 6 and 12 months compared with where patients started before surgery. While ACI and BMAC target regeneration and might show better tissue repair on imaging, short term functional gains in real world practice may be similar across techniques when surgeons select patients to match the strengths of each approach [8, 14, 17].
• Younger patients, those with lower BMI and those who have surgery soon after symptoms begin were expected to do better regardless of surgical choice. These factors make biological sense: younger tissue heals more readily, lower body weight reduces mechanical stress, and treating the problem earlier may prevent chronic changes that blunt repair [20–22].
• Imaging—MRI MOCART scores and, where available, second look inspection—was expected to show superior structural fill with regenerative approaches (ACI, BMAC) compared with microfracture. However, we believed that better MRI appearance would not always translate into vastly superior patient reported function within the first postoperative year, because tissue maturation and adaptation take time [16, 18].
• From a safety and practicality perspective, single stage procedures (microfracture, BMAC) should be more convenient and less costly, while ACI would be more resource intensive but potentially more suitable for larger defects.
These hypotheses shaped the analyses: we compared score changes over time between groups and used multivariable models to test which patient factors independently predicted better outcomes.
Discussion
In this cohort, patients treated for full thickness femoral condylar defects showed meaningful improvements in function and symptoms at 6 and 12 months after surgery. Across the three techniques—microfracture, ACI and BMAC—patients generally improved and differences between groups at one year were small. This suggests that when surgeons pick the right patient for each procedure, different surgical strategies can all lead to worthwhile short term benefit [8, 16, and 17].
Two patient characteristics stood out as predictors of better recovery: younger age and lower BMI. Patients who had surgery sooner after symptom onset also tended to do better. These findings reflect common clinical sense and prior reports: biological healing potential, lower mechanical loading, and avoiding chronicity help drive recovery [20–22].
MRI evaluation tended to favour regenerative approaches (ACI, BMAC) in terms of defect fill and surface congruity. Still, better imaging did not always equate to better patient reported outcomes at one year. This mismatch between image and symptoms is well recognized—patients feel better for many reasons beyond the tissue seen on MRI, and repair tissue continues to remodel after the first year [16, 18]. Complications were infrequent and mostly minor in this series.
The study has limitations worth noting. It was not randomized and reflects single centre experience, so selection and surgeon biases influence which patients received which treatment. The sample size was modest and follow up limited to one year, which is too short to comment on long term durability or the potential to prevent osteoarthritis. Also, we lacked histologic confirmation of repair tissue in most cases, which limits conclusions about the exact quality of the new cartilage.
Despite these limitations, the practical message is clear: surgical repair for symptomatic focal full thickness chondral defects can produce meaningful short term improvements, and clinicians should consider patient factors (age, BMI, timing) when choosing among effective options. In settings where resources or logistics constrain choices, single stage options like microfracture or BMAC can be reasonable, while ACI remains an option for larger defects where restoring hyaline like tissue is a priority.
Clinical Importance
Painful chondral defects of the femoral condyle limit activity and reduce quality of life. This study shows that, with appropriate case selection, microfracture, ACI and BMAC each can substantially reduce symptoms and improve knee function within a year of surgery, with low rates of complications. Younger patients, those with lower BMI, and those treated earlier after symptom onset are more likely to experience better outcomes. Discussing these factors openly with patients helps set realistic expectations and tailor treatment to individual goals.
Future Directions
Longer follow up studies, ideally randomized, are needed to compare durability between marrow stimulation and regenerative strategies. Research should combine patient outcomes with standard MRI scoring and, where possible, tissue sampling to link repair quality with long term function. Economic analyses and return to activity measures will also help clinicians choose cost effective treatments for different patient groups.
References
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2. Flanigan DC, Harris JD, Trinh TQ, Siston RA, Brophy RH. Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc. 2010; 42(10):1795–801.
3. Widuchowski W, Widuchowski J, Trzaska T. Articular cartilage defects: study of 25,124 knee arthroscopies. Knee. 2007; 14:177–82.
4. Migliorini F, Eschweiler J, Schenker H, Baroncini A, Tingart M, Maffulli N. Surgical management of focal chondral defects of the knee: a Bayesian network meta-analysis. J Orthop Surg Res. 2021; 16(1):543.
5. Seo SS, Kim CW, Jung ADW. Management of focal chondral lesion in the knee joint. Knee Surg Relat Res. 2011; 23(4):185–96.
6. Bedi A, Feeley BT, Williams RJ 3rd. Management of articular cartilage defects of the knee. J Bone Joint Surg Am. 2010; 92(4):994–1009.
7. Chubinskaya S, Haudenschild D, Gasser S, et al. Articular cartilage injury and potential remedies. J Orthop Trauma. 2015; 29(Suppl):S47–52.
8. Steadman JR, Rodkey WG, Briggs KK. Microfracture technique and outcomes. J Knee Surg. 2002; 15(3):170–6.
9. Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of microfracture: evidence-based analysis. Am J Sports Med. 2009; 37(10):2053–63.
10. Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG. Outcomes of microfracture: average 11-year follow-up. Arthroscopy. 2003; 19(5):477–84.
11. Hangody L, Feczko P, Bartha L, et al. Mosaicplasty for the treatment of articular cartilage defects: long-term results and a new one-step technique. Orthopedics. 2001; 24(9):821–7.
12. Marcacci M, Zaffagnini S, Iacono F, et al. Autologous osteochondral transplantation for chondral defects of the knee. Knee Surg Sports Traumatol Arthrosc. 2005; 13(8):673–7.
13. Bugbee WD. Fresh osteochondral allografts. J Knee Surg. 2002; 15(3):191–5.
14. Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Johnson E, Lindahl A. Two- to 9-year outcome after autologous chondrocyte transplantation of the knee. Clin Orthop Relat Res. 2000 ;( 374):212–34.
15. Kon E, Filardo G, Delcogliano M, et al. Long-term outcomes after autologous chondrocyte implantation. Am J Sports Med. 2011; 39(6):1234–43.
16. Kon E, Condello V, Delcogliano M, Filardo G. Biologic approaches for cartilage repair. Knee Surg Sports Traumatol Arthrosc. 2012; 20(6):1227–39.
17. Gobbi A, Whyte GP, Diaz-Rodriguez S. BMAC and scaffold techniques for cartilage repair: clinical results. Cartilage. 2015; 6(1):29–41.
18. Soler R, Lavernia C, Galache F, et al. MRI evaluation after cartilage repair: correlation with clinical outcomes. Eur Radiol. 2013; 23(1):71–9.
19. Steinwachs MR, Kreuz PC, Erggelet C. Overview of biological approaches in cartilage repair: BMAC and platelet concentrates. Sports Med Arthrosc Rev. 2012; 20(4):206–12.
20. Niemeyer P, Pestka JM, Kreuz PC, and et al. Autologous chondrocyte implantation for cartilage defects of the knee: factors influencing outcome. Am J Sports Med. 2012; 40(7):1598–605.
21. Harris JD, Siston RA, Pan X, Flanigan DC, Brophy RH. Predictors of outcome after cartilage repair. Arthroscopy. 2013; 29(1):55–71.
22. Løken S, Heir S, Holme I, Engebretsen L, Årøen A. The effect of timing on cartilage repair outcomes. Knee Surg Sports Traumatol Arthrosc. 2013; 21(11):2579–86.
23. Robbennolt FK, Patel RN. Rehabilitation strategies following cartilage procedures: evidence and protocols. J Orthop Sports Phys Ther. 2014; 44(8):598–615.
24. Gomoll AH, Madanat R, Bugbee WD. Current and future strategies in cartilage repair. J Bone Joint Surg Am. 2014; 96(2):126–39.
25. Filardo G, Kon E, Di Martino A, et al. Marrow stimulation augmented with biological scaffolds: comparative outcomes and indications. Knee. 2016; 23(6):1026–35.
| How to Cite this Article: Patwardhan S, Sancheti P, Patil K, Gugale S, Sanghavi S, Sisodia Y, Nisar OU, Sonawane D, Shyam A. Single-Stage BMAC in a Collagen Scaffold Achieves Hyaline-Like Regeneration Superior to Micro fracture and Equivalent to ACI in Medium/Large Knee Defects. Journal Medical Thesis 2024 January-June ; 10(1):54-57. |
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: 2022
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Dual-Column Locking Plate Fixation for AO/OTA 33C3 Distal Femur Fractures: A Hypothesis on Enhanced Mechanical Stability and Healing
Vol 10 | Issue 1 | January-June 2024 | page: 50-53 | Raunak Satia, Rajeev Joshi, Sahil Sanghavi, Mahavir Dugad, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2024.v10.i01.222
Author: Raunak Satia [1], Rajeev Joshi [1], Sahil Sanghavi [1], Mahavir Dugad [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. Raunak Satia,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: raunaksatia670@yahoo.com
Abstract
Background: Distal femur fractures that involve severe metaphyseal and articular comminution (AO 33-C3) remain a major therapeutic challenge. The distal fragment’s short bone stock, frequent osteoporotic bone in older patients, and the complexity of intra-articular fracture patterns increase the risk of loss of reduction, varus collapse and nonunion when fixation is inadequate. Lateral locked plating is widely used and often effective, but in fractures with medial column deficiency or large medial condylar (Hoffa) fragments the lateral construct may behave as a cantilever and be prone to mechanical failure. Contemporary biomechanical and clinical series suggest that adding a medial locking plate restores a two-column support, increases construct stiffness and may reduce mechanical complications in selected, high-risk fractures.
Hypothesis: For skeletally mature patients with AO 33-C3 distal femur fractures and/or clear medial column deficiency, supplementing lateral locked plating with a medial distal femoral locking plate will improve mechanical stability, increase the likelihood of timely radiographic union and reduce rates of varus collapse or implant failure, without an unacceptable rise in wound or soft-tissue complications. When combined with meticulous surgical technique and structured rehabilitation, dual-column fixation should permit safer early joint motion and improved patient-centred functional recovery.
Clinical importance: Identifying fractures that truly lack medial support and applying targeted medial augmentation can meaningfully change outcomes — converting a fragile single-sided construct into a balanced dual-column fixation. For surgeons, the practical benefits are fewer mechanical revisions, more reliable maintenance of alignment, and a better platform for early mobilization. These advantages must be weighed against longer operative time, added implant cost and the need for careful soft-tissue handling to limit wound problems.
Future research: Larger matched-cohort or randomized studies are needed to define precise thresholds of medial bone loss or fragment size that justify medial plating, to compare dual plating with other augmentation strategies, and to analyze cost-effectiveness and standardized rehabilitation protocols.
Keywords: Distal femur fracture, AO 33-C3, Medial plate, Lateral locking plate, Dual plating, Nonunion, Hoffa fragment.
Background
Fractures of the distal femur present a difficult problem for trauma surgeons because they combine an anatomically complex articular surface with often poor bone quality and limited distal bone stock. The injury shows a bimodal distribution — high-energy fractures in younger adults and low-energy osteoporotic fractures in older patients — and accounts for a small proportion of overall fractures but a disproportionate burden of disability when healing or alignment fails. [1–4]
Treatment goals are consistent: restore articular congruity, correct alignment and rotation, preserve limb length, and enable early knee motion. Historically, treatment ranged from conservative management to a variety of internal fixation solutions including blade plates and intramedullary devices; modern locked plating technology gave surgeons a fixed-angle option that improved fixation in osteoporotic bone and allowed percutaneous (biologic) techniques in many cases. [5–7] Despite this progress, complex intra-articular injuries with metaphyseal comminution (AO 33-C3) and fractures with medial column deficiency remain at risk for mechanical failure after lateral locking plate fixation alone. Problems such as varus collapse, screw toggle, plate breakage and nonunion have been reported when medial support is absent. [8–11]
Biomechanical studies show that constructs which provide a medial buttress — either by adding a medial plate or combining a lateral plate with an intramedullary device — markedly increase axial stiffness and reduce displacement under cyclic loading compared with a lone lateral plate in comminuted models. [12–14] Clinically, several retrospective series and single-centre reports describe improved union rates and fewer revisions when a medial plate is added for clearly indicated fractures, although the level of evidence remains limited. [11, 15, 16]
Surgeons weigh the mechanical advantage of a second plate against concerns about increased soft-tissue dissection, operative time, cost and theoretical risks to fragment vascularity. Anatomical and cadaveric work suggest that a medial approach can be performed safely when respecting anatomic safe zones and using minimally invasive techniques where appropriate; vascular compromise does not appear to be a frequent clinical problem when medial fixation is applied judiciously. [17–19]
Practical indications emerging from the literature include: large medial condylar (Hoffa) fragments, medial supracondylar bone loss, peri-prosthetic distal femur fractures, nonunion after failed lateral fixation, severe metaphyseal comminution (AO 33-C3) and poor bone quality. In these situations medial augmentation functions as a buttress that offloads the lateral plate and converts a cantilever construct into a dual-column support, which improves survivorship under physiologic loading. [15, 20–22]
The present single-centre retro-prospective study reviewed 20 skeletally mature patients with AO 33-C3 distal femoral fractures treated with combined lateral locked plate and medial distal femoral locking plate between October 2019 and October 2021. Outcomes recorded through one year included radiographic union, knee range of motion, HSS knee score, SF-36, time to weight-bearing and complications. Results in this cohort (high union rate, no plate failure, manageable wound issues and a majority achieving good knee ROM and HSS/SF-36 scores) mirror the positive signals seen in other dual-plating series and reinforce the rationale for selective medial augmentation in complex distal femur injuries. [1, 11, 16, 23]
Hypothesis and rationale
Primary hypothesis: In skeletally mature patients with AO 33-C3 distal femur fractures and/or medial column deficiency, supplemental medial locking-plate fixation added to a lateral locked plate produces improved mechanical stability that translates into higher union rates, fewer mechanical failures (varus collapse, plate/screw breakage), and at least equivalent — if not superior — functional outcomes compared with expectations from lateral plating alone.
Why this should be true
1. Mechanics. With an absent medial buttress a lateral plate functions as an unsupported cantilever and concentrates bending load on the lateral implant and its distal screws. A medial plate restores the second column and shares axial and bending loads: biomechanical work consistently demonstrates increased axial stiffness and less displacement for dual-plate constructs in comminuted models. [12–14]
2. Biology and function. Rigid anatomic fixation that resists collapse permits early controlled knee motion and protects articular reduction. Where lateral fixation alone risks progressive varus or fragment subsidence, medial augmentation allows safe rehabilitation, which is a key determinant of long-term knee mobility and patient-centred outcomes. [22,24]
3. Targeted, not routine, use. Dual plating is not proposed as the default for all distal femur fractures. Its benefit is greatest where medial stability is clearly compromised: medial Hoffa fragments, peri-prosthetic fractures, nonunion after failed lateral fixation, wide metaphyseal bone loss, or severe osteoporotic comminution (AO 33-C3). Carefully selecting cases maximizes gain and minimizes extra soft-tissue exposure. [15,16,21]
Operational hypotheses for the cohort
• Radiographic union by 12–24 weeks in the majority, with overall union rates comparable to or better than published series of similarly comminuted fractures treated without medial augmentation.
• Low mechanical failure rate (expectation: plate/screw breakage or varus collapse will be uncommon).
• Functional recovery (knee ROM, HSS and SF-36) will be satisfactory in most patients when coupled with structured rehabilitation.
• Complications (wound discharge, superficial infection, and stiffness) will occur but remain manageable without routine implant removal. [1,11,16,23]
Endpoints and thresholds
• Primary: clinical and radiographic union at 52 weeks without mechanical failure.
• Secondary: knee ROM at serial intervals, HSS knee score and SF-36 at one year, time to full weight-bearing, and rates of complications requiring reoperation or prolonged wound care. These endpoints combine mechanical success with outcomes that matter to patients. [1,23]
Discussion
The cohort of 20 patients treated with medial plus lateral locking plates demonstrated encouraging outcomes: the large majority achieved radiographic union within expected timeframes, knee ROM of ≥100° in most patients at one year, favorable HSS and SF-36 scores for the cohort, no implant breakage and a modest rate of wound-related complications and stiffness. These findings are consistent with prior clinical reports that reserve medial augmentation for severely comminuted or medial-deficient fractures. [16, 23, 24]
Why might dual plating work clinically? Mechanically it reduces bending stresses on the lateral plate and distributes load across both columns; biologically it allows more reproducible maintenance of articular reduction and alignment, enabling earlier controlled motion that reduces stiffness. Biomechanical and cadaver studies support these mechanics, and accumulated clinical series suggest fewer catastrophic failures in appropriately selected patients. [12–14, 20]
However, limitations require emphasis. The present study is a small, non-randomized, retro-prospective series without a matched lateral-only comparator; thus selection bias is inherent — surgeons tended to choose medial augmentation for fractures judged most unstable. This limits causal inference about superiority. Also, sample size restricts precise estimation of complication rates. Published literature is similarly dominated by retrospective series and biomechanical work; randomized data are scarce. [9, 20]
Practical lessons for surgeons follow:
• Select patients carefully. Reserve medial augmentation for AO 33-C3 fractures with clear medial column deficiency, large medial condylar (Hoffa) fragments, peri-prosthetic fractures, nonunion after failed lateral plating, and severe osteoporotic metaphyseal comminution. Routine dual plating where not indicated adds exposure without clear benefit. [15,16,21]
• Respect soft tissues. A single longitudinal medial incision or minimally invasive medial plate insertion reduces soft-tissue morbidity compared with extensive dissection. Anatomical studies define safe zones; strict surgical technique and gentle handling of soft tissues reduce wound complications. [17,18]
• Stage rehabilitation. Encourage early controlled knee motion but delay unprotected full weight-bearing until radiographic consolidation (bridging on at least three cortices). Individualize protocols for elderly/osteoporotic patients. Structured physiotherapy mitigates long-term stiffness. [22,24]
• Plan for cost and time. Dual plating increases implant use and OR time; however, if it reduces the need for costly revisions, it may be cost-effective for high-risk fractures — a question for formal health-economic study. [20,25]
From a research standpoint, the field needs larger comparative cohorts or randomized trials to determine thresholds of medial bone loss or fragment size where medial augmentation meaningfully changes outcomes. Biomechanical refinements (optimal plate placement and screw strategies in osteoporotic bone) and standardization of postoperative protocols would also enhance evidence-based practice. [12, 25]
Clinical importance
For practising orthopaedic surgeons: medial plate augmentation is a practical option when the medial column is compromised. It restores a mechanical buttress, decreases bending load on the lateral implant, and can reduce the risk of varus collapse and nonunion in AO 33-C3 and other high-risk patterns. Appropriate case selection, careful soft-tissue technique (or minimally invasive medial insertion), and a rehabilitation plan that encourages early controlled motion but delays full weight-bearing until radiographic healing produce the best outcomes. The technique should be seen as a targeted adjunct in a surgeon’s toolkit rather than as routine for all distal femur fractures. [15, 17, 22]
Future directions
Priority research includes multicentre, matched-cohort or randomized comparisons of lateral-only versus lateral+medial fixation for comparable AO 33-C3 fractures, cost-effectiveness analyses, and biomechanical work to optimize plate placement and screw patterns for osteoporotic bone. Registry data for peri-prosthetic fractures and standardized rehabilitation trials would also clarify best practice and help develop evidence-based algorithms for when to add medial fixation. [20, 25]
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| How to Cite this Article: Satia R, Joshi R, Sanghavi S, Dugad M, Sonawane D, Shyam A, Sancheti P. Dual-Column Locking Plate Fixation for AO/OTA 33C3 Distal Femur Fractures: A Hypothesis on Enhanced Mechanical Stability and Healing. Journal Medical Thesis 2024 January-June ; 10(1):50-53. |
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: 2022
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