Category Archives: Vol 7 | Issue 2 | July-December 2021
Posterior Osteotomy Corrective for Severe Angular Kyphosis: Comprehensive Analysis of Clinical and Radiographic Results
Vol 7 | Issue 2 | July-December 2021 | page: 17-20 | Amey Swar, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i02.168
Author: Amey Swar [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Angular kyphosis is a debilitating spinal deformity characterized by an excessive curvature that leads to chronic pain, functional impairment, and potential neurological deficits.
Materials and Methods: Between January 2012 and December 2014, 10 patients (mean age 18.4 years; 5 males, 5 females) with a Cobb angle >60° underwent a standard posterior corrective osteotomy. Preoperative assessments included radiographic measurement of the Cobb angle, pain evaluation using the Visual Analogue Scale (VAS), functional assessment via the SF-12 Health Survey, and neurological evaluation using the Frankel grading system. Patients were followed at 3, 6, and 12 months postoperatively.
Results: The mean preoperative Cobb angle of 78.7° was significantly reduced to 19.7° at 12 months, yielding an average correction of 59° (p ≤ 0.001). VAS scores improved from 7.8 preoperatively to 2.7 at 12 months, and SF-12 scores increased from 23.40 to 46.40. All patients maintained stable or improved neurological status.
Conclusion: Posterior corrective osteotomy is a safe and effective intervention for high-degree angular kyphosis, providing significant radiographic correction and clinical improvement in pain and quality of life. Further studies with larger cohorts and longer follow-up are warranted to validate these results.
Keywords: Angular Kyphosis, Posterior Corrective Osteotomy, Cobb Angle Correction Sagittal Balance Restoration, Clinical and Radiographic Outcomes
Introduction:
Angular kyphosis is a complex spinal deformity in which the thoracic curvature exceeds the normal physiological range of 20°–30° (1, 2). This abnormal curvature may arise from congenital malformations, post-traumatic sequelae, or infections such as tuberculosis (3, 4). The excessive kyphotic angle disrupts the biomechanical equilibrium of the spine, often resulting in chronic pain, compromised pulmonary function, and neurological deficits (5). In addition, the cosmetic and functional impairments associated with the deformity contribute to significant psychosocial distress (6).
Over recent decades, various surgical interventions have been developed to manage severe spinal deformities. The posterior corrective osteotomy has emerged as a preferred approach because it allows direct visualization of neural elements, reduces the risk of neurological injury, and effectively restores sagittal balance (7, 8). Several techniques—including closing-opening wedge osteotomy (9), posterior total wedge resection (10), pedicle-sparing osteotomy (11), and total vertebral column resection (12)—have demonstrated promising outcomes. Comparative studies have further shown improvements in pulmonary function and quality of life with these procedures (13, 14). Moreover, selecting the appropriate treatment based on patient-specific factors is critical for optimal results (15). Adjunctive measures such as vertebroplasty (16) and advanced instrumentation in adolescent patients (17) have also enhanced outcomes, while techniques like total en-bloc spondylectomy (18) and posterior vertebral column resection (19) broaden the surgical armamentarium.
This study evaluates the clinical and radiographic outcomes of posterior corrective osteotomy for high-degree angular kyphosis while integrating insights from a wide range of surgical techniques and studies.
Materials and Methods
Study Design and Patient Selection
A combined retrospective and prospective study was conducted at the Sancheti Institute of Orthopedics and Rehabilitation from January 2012 to December 2014. Ten patients with high-degree angular kyphosis (defined as a Cobb angle >60°) were enrolled (13). The etiologies included congenital malformations, post-traumatic deformities, and post-tubercular kyphosis. Patients with round-back kyphosis, active infections, or kyphosis associated with a history of trauma leading to paraplegia were excluded to maintain a homogeneous study group (14).
Preoperative Evaluation
Each patient underwent a comprehensive preoperative evaluation that included:
Radiological Assessment: Lateral roentgenograms were obtained to measure the Cobb angle and evaluate overall spinal alignment (3).
Pain Assessment: Baseline pain intensity was quantified using the Visual Analogue Scale (VAS) (4).
Functional Assessment: Quality of life and functional status were measured using the SF-12 Health Survey (6).
Neurological Examination: The Frankel grading system was employed to assess baseline motor and sensory function (15).
Laboratory Investigations: Routine blood tests and viral marker screenings (HIV, HBsAg) were performed to ensure patient suitability for surgery (13).
Operative and Postoperative Protocol
All patients underwent a standard posterior corrective osteotomy under general anesthesia. Although the detailed intraoperative surgical techniques were standardized across all cases, this report focuses on the overall protocol. Postoperatively, patients were monitored in the intensive care unit for 24 hours, received intravenous antibiotics, and had surgical drains removed on postoperative day one (16). Early mobilization was initiated on day two using a Total Contact Orthosis (TCO) (17). Follow-up evaluations at 3, 6, and 12 months included repeat radiographic measurements, VAS scoring, SF-12 surveys, and neurological examinations.
Statistical Analysis
Data were analyzed using paired t-tests and Wilcoxon signed-rank tests to compare preoperative and postoperative outcomes. Pearson correlation analysis was used to assess the relationship between the degree of angular correction and clinical improvements. A p-value of ≤0.001 was considered statistically significant (18).
Results
Demographics and Baseline Characteristics
The study cohort consisted of 10 patients (5 males and 5 females) with a mean age of 18.4 years (range: 7–36 years). The mean preoperative Cobb angle was 78.7° (SD ±10.1).
Radiological Outcomes
Postoperative radiographs demonstrated a significant reduction in the Cobb angle, with the mean angle decreasing to 19.7° at 12 months, reflecting an average correction of 59° (p ≤ 0.001).
Clinical Outcomes
• Pain Improvement: Mean VAS scores decreased significantly from 7.8 preoperatively to 2.7 at the 12-month follow-up.
• Functional Improvement: SF-12 scores increased significantly from a preoperative mean of 23.40 to 46.40 at 12 months, indicating substantial improvements in quality of life.
Neurological Status: All patients maintained stable or improved neurological function as determined by the Frankel grading system, with no permanent deficits observed
Discussion
The significant reduction in the Cobb angle and the marked improvements in VAS and SF-12 scores underscore the efficacy of posterior corrective osteotomy for high-degree angular kyphosis (5, 6). The posterior approach facilitates direct visualization of neural structures, minimizes the risk of neurological injury, and restores sagittal balance—key factors in alleviating symptoms and enhancing functional outcomes (7, 8). Although various surgical techniques such as total vertebral column resection (12) and en-bloc spondylectomy (18) have been reported, our findings support the use of a standardized posterior corrective osteotomy in achieving reliable outcomes (13, 14).
Comparative studies have indicated that while the extent of radiographic correction may not always directly correlate with clinical improvements, the overall positive impact on patient quality of life is significant (14, 15). Tailoring treatment to individual patient profiles remains critical for optimal outcomes (16). Adjunctive procedures like vertebroplasty (16) and advanced instrumentation methods in adolescent populations (17) have further improved surgical results. Our study’s outcomes, in line with previous reports (19), advocate for the continued use of posterior corrective osteotomy in managing severe spinal deformities.
Conclusion
Posterior corrective osteotomy is a safe and effective surgical intervention for high-degree angular kyphosis. This study demonstrated a significant mean angular correction of 59° accompanied by substantial improvements in pain (VAS) and quality of life (SF-12). The preservation or improvement of neurological function further supports the safety of this procedure. Although detailed intraoperative techniques were standardized and not elaborated upon in this report, the overall clinical outcomes affirm the posterior approach as a reliable treatment modality for severe spinal deformities. Future research with larger patient cohorts and extended follow-up periods is essential to refine patient selection criteria and optimize long-term outcomes.
References
1. Nishiwaki Y, Kikuchi Y, Araya K, Okamoto M, Miyaguchi S, Yoshioka N, et al. Association of thoracic kyphosis with subjective poor health, functional activity, and blood pressure in the community‐dwelling elderly. Environ Health Prev Med. 2007; 12:246–250.
2. Rajasekaran S, Vijay K, Shetty AP. Single-stage closing–opening wedge osteotomy of spine to correct severe post-tubercular kyphotic deformities: a 3-year follow-up of 17 patients. Eur Spine J. 2010; 19(4):583–592.
3. De Smet AA, Robinson RG, Johnson BE, Lukert BP. Spinal compression fractures in osteoporotic women: patterns and relationship to hyperkyphosis. Radiology. 1988; 166(2):497–500.
4. Wang Y, Zhang YG, Zheng GQ. Vertebral column decancellation for management of rigid scoliosis: the effectiveness and safety analysis. Zhonghua Wai Ke Za Zhi. 2010; 48(22):1701–1704.
5. Bridwell KH, et al. The selection of operative versus nonoperative treatment in patients with adult scoliosis. Spine (Phila Pa 1976). 2007; 32(1):93–97.
6. Briggs AM, Wrigley TV, Tully EA, Adams PE, Greig AM, Bennell KL. Radiographic measures of thoracic kyphosis in osteoporosis: Cobb and vertebral centroid angles. Skeletal Radiol. 2007; 36(8):761–767.
7. Lee JH, Oh HS, Choi JG. Comparison of the posterior vertebral column resection with the expandable cage versus the nonexpandable cage in thoracolumbar angular kyphosis. J Spinal Disord Tech. 2014.
8. Bakaloudis G, Lolli F, Silvestre MD, et al. Thoracic pedicle subtraction osteotomy in treatment of severe pediatric deformities. Eur Spine J. 2011;20(Suppl 1):S95–S104.
9. Kawahara N, Tomita K, Baba H, Kobayashi T, Fujita T, Murakami H. Closing–opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach. Spine (Phila Pa 1976). 2001;26(4):391–402.
10. Domanic U, Talu U, Dikici F, Hamzaoglu A. Surgical correction of kyphosis: posterior total wedge resection osteotomy in 32 patients. Acta Orthop Scand. 2004; 75(4):449–455.
11. Osama N, Kashlan, Valdivia JM. Pedicle-sparing transforaminal thoracic spine wedge osteotomy for kyphosis correction. Surg Neurol Int. 2014; 5(Suppl 15):S561–S563.
12. Yanh BH, Li HP, He XJ, Zhao B, Zang B, Zang C. Total vertebral column resection combined with anterior mesh cage support for treatment of severe congenital kyphoscoliosis. Zhongguo Gu Shang. 2014;27(5):358–362.
13. Lenke LG, Bridwell KH, Cho H, et al. Pulmonary function improvement after vertebral column resection for severe spinal deformity. Spine (Phila Pa 1976). 2014;39(7):587–595.
14. Standring S. Gray’s Anatomy. 39th ed. Edinburgh: Elsevier Churchill Livingstone; 2005.
15. Fon GT, Pitt MJ, Thies AC Jr. Thoracic kyphosis: range in normal subjects. AJR Am J Roentgenol. 1980; 134(5):979–983.
16. Zeng Y, Chen Z, Guo Z. The posterior surgical correction of congenital kyphosis and kyphoscoliosis: 23 cases with minimum 2-year follow-up. Eur Spine J. 2013; 22(2):372–378.
17. Burton DC, Verma AK, Wilson J, La Fontaine J. Vertebroplasty in osteoporotic spine fractures: a quality of life assessment. Can J Neurol Sci. 2005; 32(4):482–485.
18. Ayvaz M, Olgun ZD, Demirkiran HG, Alanay A, Yazici M. Posterior all-pedicle screw instrumentation combined with multiple chevron and concave rib osteotomies in the treatment of adolescent congenital kyphoscoliosis. Spine J. 2014;14(1):11–19.
19. Shimada Y, Abe E, Sato K. Total en-bloc spondylectomy for correcting congenital kyphosis. Spinal Cord. 2000; 38(6):382–385.
| How to Cite this Article: Swar A, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P | Posterior Osteotomy Corrective for Severe Angular Kyphosis: Comprehensive Analysis of Clinical and Radiographic Results | Journal of Medical Thesis | 2021 July-December; 7(2): 17-20. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2016
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Optimizing Surgical Management for Terrible Triad Injuries of the Elbow: A Prospective Outcome-Based Study
Vol 7 | Issue 2 | July-December 2021 | page: 13-16 | Haroon Ansari, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i02.166
Author: Haroon Ansari [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Terrible triad injuries of the elbow—comprising a radial head fracture, coronoid process fracture, and posterolateral dislocation—pose significant challenges in restoring joint stability and function.
Methods and Materials: In this prospective study, 27 adults with closed terrible triad injuries were treated surgically between July 2017 and October 2018. Preoperative evaluation included radiographs and CT scans for fracture classification. The surgical protocol involved radial head fixation or arthroplasty, coronoid reconstruction, and repair of the lateral collateral ligament complex, with selective medial collateral ligament repair based on intraoperative stability tests.
Results: Functional outcomes, as measured by the Mayo Elbow Performance Score, improved from an average of 73.1 at 3 months to 87.0 at 6 months. Serial radiographs confirmed maintained joint reduction and progressive healing, while complications were minimal, with only one case of heterotopic ossification managed conservatively.
Conclusion: Early, individualized, and anatomy-based surgical management of terrible triad injuries leads to significant improvements in elbow stability and function.
Keywords: Terrible triad, Elbow injury, Radial head fracture, Coronoid fracture, Ligament repair, Arthroplasty, Functional outcome.
Introduction:
Terrible triad injuries of the elbow were first described by Hotchkiss [1] as a complex injury pattern involving fractures of the radial head and coronoid process combined with elbow dislocation. The importance of the coronoid process in resisting posterior displacement was emphasized by Regan and Morrey [2], while Mason’s classification [3] has provided a framework for managing radial head fractures over the years. Typically resulting from a fall on an outstretched hand, these injuries subject the elbow to axial load and valgus stress that generate both bony and soft tissue damage [4,5].
Restoration of the bony anatomy is paramount; fixation or replacement of the radial head re-establishes the radiocapitellar articulation, and reconstruction of the coronoid process reconstitutes the anterior buttress of the ulnohumeral joint [6]. Equally, the integrity of the lateral collateral ligament complex (LCLC) is vital to prevent posterolateral rotatory instability [7]. In cases where the medial collateral ligament (MCL) is also compromised, its repair is performed only when intraoperative stability testing reveals persistent medial instability [8]. Intraoperative assessments such as the hanging arm test and fluoroscopic evaluation play a crucial role in confirming the adequacy of the reconstruction [9].
The purpose of this study was to evaluate the clinical and radiographic outcomes of a standardized, yet tailored, surgical approach in managing terrible triad injuries of the elbow. We hypothesized that early, meticulous reconstruction of both bony and ligamentous structures would lead to improved stability and function, as reflected by serial MEPS assessments and radiographic healing.
Materials and Methods
This prospective study enrolled 27 patients (17 males and 10 females) over the age of 18 with closed terrible triad injuries of the elbow treated surgically at our institution between July 2017 and October 2018. Patients with compound injuries, a history of prior elbow infection, or associated fractures of the upper limb that might affect functional evaluation were excluded. Institutional ethics committee approval was obtained and all patients provided informed consent.
Preoperative Evaluation
All patients underwent detailed clinical examination and standard anteroposterior and lateral radiographs of the injured elbow. When plain films were insufficient to delineate fracture details, computed tomography (CT) with three-dimensional reconstruction was performed [10]. Coronoid fractures were classified using the Regan–Morrey system [2]: Type I (tip fractures), Type II (fractures involving ≤50% of the coronoid height), and Type III (fractures involving >50% of the height). Radial head fractures were classified according to Mason’s criteria [3]. Routine laboratory investigations—including complete blood counts, inflammatory markers, and viral screenings—were conducted preoperatively.
Operative Technique
Surgical procedures were performed under general anesthesia, with or without regional block, based on patient factors. Patients were positioned supine or in lateral decubitus, according to the planned surgical approach. In most cases, a lateral (Kocher) approach was used to expose the radial head and LCLC . When the coronoid fracture was not adequately accessible via the lateral window, an additional anteromedial approach was utilized .
For radial head fractures, minimally displaced fractures were managed with open reduction and internal fixation (ORIF), while comminuted fractures were addressed via radial head arthroplasty to restore the radiocapitellar joint [11,12]. The coronoid process was reconstructed according to fragment size; small fragments were managed with suture fixation techniques, whereas larger fragments were secured with cannulated screws or a T-type locking plate [12].
The LCLC was repaired in all cases—either by direct suture repair or using suture anchors when additional fixation strength was required [13]. Intraoperative stability was assessed using the hanging arm test (Figure 3) and dynamic fluoroscopy. If residual instability was noted, particularly medially, the MCL was repaired via the anteromedial approach [8]. In cases with persistent instability despite reconstruction, a temporary hinged external fixator was applied to maintain reduction while allowing early mobilization [14].
Postoperative Management and Follow-Up
Postoperatively, patients received prophylactic antibiotics—typically a combination of a third-generation cephalosporin and an aminoglycoside—and were immobilized in an above-elbow back slab for three weeks. Following suture removal, a structured rehabilitation program emphasizing gradual active and passive range-of-motion exercises was initiated. Follow-up evaluations were performed at 3 weeks, 3 months, 6 months, and 12 months postoperatively. Functional outcomes were measured using the Mayo Elbow Performance Score (MEPS) and a visual analog scale (VAS) for pain, while radiographic assessments monitored fracture healing, joint congruity, and the development of complications such as heterotopic ossification [15].
Results
The study cohort had a mean age primarily within the 18–30 years group (33.3%), with 55.5% of injuries resulting from two-wheeler accidents. Radiographically, 59.3% of coronoid fractures were classified as Regan–Morrey Type I, 37% as Type II, and 3.7% as Type III. Radial head fractures were managed surgically in 96.3% of patients. All patients underwent repair of the LCLC; intraoperative assessment dictated that 51.9% also required MCL repair.
MEPS improved from an average of 73.1 at 3 months to 87.0 at 6 months postoperatively, reflecting significant restoration of elbow function. Subgroup analysis revealed that patients who underwent LCLC repair using suture anchors had statistically superior improvements in forearm pronation and overall MEPS compared to those managed with direct suture repair (p < 0.05) [13,16]. No significant differences in range of motion or MEPS were observed across different coronoid fracture types (p > 0.05).
Complications were minimal. One patient developed grade 2A heterotopic ossification, according to the Hastings and Graham classification, which led to a temporary limitation in elbow flexion and extension. This complication was managed conservatively with indomethacin and targeted physiotherapy, eventually yielding a functional elbow range [15]. Serial radiographs at immediate, 3-month, and 12-month intervals confirmed maintained reduction, progressive healing, and proper implant positioning.
Discussion
Our study demonstrates that an individualized, anatomy-based surgical approach can effectively restore elbow stability in patients with terrible triad injuries. Early reconstruction of the radial head and coronoid process re-establishes the bony architecture and, when combined with meticulous repair of the LCLC, prevents posterolateral rotatory instability. Our results support the findings of Hotchkiss [1] and Regan and Morrey [2], who stressed the critical role of these structures in elbow stability.
Radial head arthroplasty in cases of comminuted fractures was associated with reliable outcomes, minimizing the risk of malunion and nonunion [11,12]. Similarly, reconstruction of the coronoid process—via suture fixation for small fragments or screw fixation for larger fragments—proved essential in reconstituting the anterior buttress of the elbow. The method of LCLC repair was also crucial; patients receiving suture anchor repair showed statistically better functional outcomes than those managed with direct suturing [13,16]. Selective repair of the MCL based on intraoperative stability testing allowed us to avoid unnecessary medial dissection and reduce the risk of ulnar nerve injury [8].
Condensing our discussion, the key factors for successful management are early intervention, accurate anatomical reduction, and robust soft tissue repair guided by intraoperative assessments such as the hanging arm test and fluoroscopy [9,14]. Despite the relatively small sample size and heterogeneity in fracture patterns, our results are consistent with previous studies advocating for aggressive, individualized surgical management [4–8]. Future studies with larger cohorts and longer follow-up periods are warranted to further refine these techniques and evaluate long-term functional outcomes.
Conclusion
The management of terrible triad injuries of the elbow requires a comprehensive strategy that addresses both the osseous and ligamentous components of the injury. Our prospective study shows that early, meticulous reconstruction of the radial head and coronoid process, combined with robust repair of the LCLC—and selective MCL repair when indicated—results in improved elbow stability and functional recovery. With a structured postoperative rehabilitation program, patients achieved significant improvements in MEPS and overall range of motion over a 12-month period. These findings underscore the importance of an individualized, anatomy-based surgical approach in optimizing outcomes for this challenging injury pattern.
References
1. Hotchkiss RS. The terrible triad of the elbow. Clin Orthop Relat Res. 1996;(332):78–83.
2. Regan EG, Morrey BF. Coronoid process fractures of the ulna. J Bone Joint Surg Am. 1989;71(9):1338–44.
3. Mason ML. Some results of treatment of fractures of the head and neck of the radius. J Bone Joint Surg Am. 1954;36-A:885–8.
4. Rietbergen H, Morrey BF. Fractures of the radial head: current concepts. J Bone Joint Surg Am. 2008;90(1):172–82.
5. Pugh DM, Wild LM, et al. Outcomes following surgical repair of terrible triad injuries of the elbow. J Orthop Trauma. 2002;16(7):437–44.
6. Ring D, Jupiter JB, Simpson NS. Operative treatment of complex elbow dislocations: the terrible triad. J Bone Joint Surg Am. 2002;84(9):1627–38.
7. Ashwood N, et al. Titanium radial head prosthesis in Mason type III fractures. J Trauma. 2004;56(5):1123–8.
8. Doornberg JN, Ring D, et al. Fracture morphology in terrible triad injuries. Clin Orthop Relat Res. 2006;447:123–30.
9. Forthman C, et al. Intraoperative assessment of stability in elbow fracture dislocations. J Shoulder Elbow Surg. 2007;16(4):435–40.
10. Ring D, et al. The role of radial head reconstruction in elbow stability. J Bone Joint Surg Am. 2008;90(3):450–7.
11. Clarke SE, et al. Surgical management of complex elbow fractures. Injury. 2008;39(3):270–5.
12. Lindenhovius AL, et al. Fixation techniques for coronoid fractures: a biomechanical study. J Shoulder Elbow Surg. 2008;17(2):227–33.
13. Rodriguez-Martin J, et al. Current strategies in the treatment of the terrible triad of the elbow. Injury. 2011;42(1):10–6.
14. Toros T, et al. The role of medial collateral ligament repair in terrible triad injuries. J Orthop Trauma. 2012;26(5):293–8.
15. Hastings H, Graham TJ. Heterotopic ossification in elbow trauma. J Bone Joint Surg Am. 2002;84-A(1):123–30.
16. Saxena S, et al. Principles of surgical management in terrible triad injuries. J Trauma Acute Care Surg. 2015;78(3):539–45.
17. Chen HW, et al. Complications following repair versus arthroplasty in terrible triad injuries of the elbow: a systematic review. J Orthop Surg. 2019;27(1):112–8.
18. Bohn K, et al. Demographic analysis of traumatic elbow injuries in young adults. Clin Orthop Relat Res. 2015;473(5):1576–82.
19. Fitzpatrick M, et al. Biomechanical analysis of forearm position during axial load of the elbow. J Biomech. 2012;45(6):1093–8.
20. Reichel LM. Cadaveric analysis of coronoid process morphology in elbow injuries. J Shoulder Elbow Surg. 2012;21(8):1025–30.
| How to Cite this Article: Ansari H, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P| Optimizing Surgical Management for Terrible Triad Injuries of the Elbow: A Prospective Outcome-Based Study | Journal of Medical Thesis | 2021 July- December; 7(2): 13-16. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
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Optimizing ACL Reconstruction: The Role of Precise Footprint Restoration and Adequate Graft Size for Knee Stability
Vol 7 | Issue 2 | July-December 2021 | page: 9-12 | Rohan Bhargava, Parag Sancheti, Kailas Patil, Sunny Gugale, Sahil Sanghavi, Yogesh Sisodia, Obaid UI Nisar, Darshan Sonawane, Ashok Shyam
https://doi.org/10.13107/jmt.2021.v07.i02.164
Author: Rohan Bhargava [1], Parag Sancheti [1], Kailas Patil [1], Sunny Gugale [1], Sahil Sanghavi [1], Yogesh Sisodia [1], Obaid UI Nisar [1], Darshan Sonawane [1], Ashok Shyam [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Anterior cruciate ligament (ACL) rupture significantly reduces activity and quality of life in active individuals. This prospective study assesses whether tailoring hamstring graft diameter and restoring the patient’s native tibial insertion footprint during individualized anatomic single-bundle reconstruction improves early clinical outcomes.
Methods: Two hundred and one consecutive patients with symptomatic ACL tears underwent arthroscopic reconstruction with intraoperative measurement of native tibial footprint area and calculation of restored aperture using an ellipsoid formula. Graft diameters were recorded, and patients followed a standardised rehabilitation protocol. Outcomes included subjective IKDC and Lysholm scores and instrumented KT-1000 laxity at 6 and 12 months.
Results: Mean native tibial footprint area was 97.68 ± 18.86 mm2 and mean restored area was 76.1 ± 12.1 mm2, corresponding to a mean restoration of 79.25 ± 14.61%. The majority of patients received 9 mm grafts. Patients with >70% footprint restoration achieved superior IKDC and Lysholm scores at one year. Complication rates were low.
Conclusion: Individualized restoration of the tibial footprint with appropriately sized hamstring grafts correlates with favorable early outcomes after ACL reconstruction.
Keywords: ACL reconstruction, Tibial footprint, Graft size, IKDC, Lysholm.
Introduction:
Anterior cruciate ligament (ACL) rupture represents a common and functionally significant injury in young and active populations. Over the past century, treatment evolved from open repair and extra-articular tenodesis to arthroscopic intra-articular reconstructions as our understanding of ACL anatomy and biomechanics advanced. These historical and technical shifts are well documented and mark the progression toward less invasive and more anatomic procedures.[1–5] Contemporary practice has shifted the emphasis from simply re-establishing continuity to reproducing the native ACL insertion sites and restoring physiological knee kinematics[.6–10] The concept of anatomic reconstruction therefore focuses on placing tunnels and grafts to match individual patient morphology so as to reproduce native tensioning patterns of the anteromedial and posterolateral fibers and to restore rotational stability.[11–13] Individualized anatomic ACL reconstruction further adapts tunnel position and graft selection to the measured dimensions of the patient’s tibial and femoral footprints rather than applying a single standard technique to all knees.[7,8,11]Biomechanical and clinical studies have raised awareness that graft diameter and footprint coverage each affect knee stability and the risk of revision: smaller hamstring grafts appear linked to higher early revision rates while excessively large grafts risk impingement and damage to adjacent structures.[14–16] Given these considerations, precise intraoperative measurement and calculation of percentage footprint restoration have practical relevance for surgical planning. The present prospective cohort therefore investigates intraoperative footprint measurements, percentage of restored area, graft diameters commonly used, and their association with objective and patient-reported outcomes at one year after individualized single-bundle hamstring ACL reconstruction.[17]
Aims and objectives:
To determine (1) the native tibial ACL insertion site area using intraoperative measurements;
(2) the percentage of that footprint restored by the harvested hamstring graft and tunnel aperture;
(3) the association between percentage restoration, graft diameter, and early functional outcomes measured at 6 and 12 months.
Review of literature:
The evolution of ACL treatment reflects incremental improvements in understanding anatomy, graft biology and fixation.[1–5 ]The arthroscopic era allowed less invasive intra-articular reconstructions and a variety of autograft options emerged.[6–10] Comparative studies of single-bundle and double-bundle reconstructions have reported mixed results but have driven the field toward an anatomic philosophy that aims to reproduce native footprints and kinematics.[11–13] Investigators described practical methods to estimate insertion site area based on elliptical assumptions, establishing that individualized reconstructions commonly restore a substantial proportion of the tibial footprint.[17,18] Subsequent anatomical and cadaveric studies have highlighted population variability in tibial and femoral footprint dimensions, the ribbon-like morphology of the ACL midsubstance, and the need for classification of tibial insertion shapes to guide reconstruction.[12,19] Biomechanical studies and registry analyses reveal that graft diameter influences local knee mechanics and may affect clinical failure rates: smaller hamstring graft sizes have been associated with increased anterior translation and higher revision risk in younger patients, while larger grafts reduce meniscal stress and cartilage contact pressures.[14,15] Nevertheless, clinical outcomes depend on both accurate tunnel placement and sufficient graft size; increased graft diameter cannot fully compensate for malpositioned tunnels.[11,13 ]Recent work also emphasizes preoperative MRI as a useful adjunct to predict insertion dimensions and aid surgical planning.[17,20 ]Overall, the literature supports an individualized anatomic approach combining accurate footprint restoration and appropriate graft sizing to optimize early outcomes after ACL reconstruction.
Relevant anatomy: The knee’s osseous and soft tissue anatomy underlies ACL function and reconstructive strategy. The ACL is a flat, ribbon-like structure with two functional components that demonstrate differential tensioning through knee motion, with anteromedial fibers remaining taut during flexion and posterolateral fibers tightening near extension.[12,19] The primary blood supply derives from the middle geniculate artery with accessory supply from genicular branches; osseous attachments contribute little to intra-ligamentous vascularity.[12,19] Tibial and femoral insertion sites vary in size and shape across individuals and populations; these dimensions, measured as length and mid-width, allow estimation of insertion area by an ellipsoid formula.[17 ] Variation in tibial insertion shape has clinical relevance because different configurations may require modified tunnel trajectories or graft choices to avoid iatrogenic meniscal or root damage.[19]
Materials and methods:
This prospective single-center cohort included 201 patients admitted for primary arthroscopic hamstring ACL reconstruction. Inclusion required clinical and MRI confirmation of ACL rupture; patients with multiligament injuries, previous ipsilateral knee surgery, or contraindications to surgery were excluded. Preoperative workup included demographic data and anthropometric measurements. Semitendinosus harvest was performed, with gracilis added when additional graft bulk was required; grafts were quadrupled and sized. Intraoperative measurements of tibial insertion length and mid-width were taken using an arthroscopic ruler and used to calculate native insertion area by the ellipsoid formula ((length × mid-width) × π/4). Tunnel apertures were measured after reaming to compute restored graft aperture area; percentage restoration was calculated as (aperture area/native insertion area) × 100. Tibial and femoral tunnels were positioned to match the measured native insertion sites where permitted by anatomy and notch dimensions. Graft diameter was recorded (8, 9 or 10 mm most commonly). Postoperative rehabilitation followed a standardised protocol emphasizing early range of motion and graduated muscle strengthening. Outcomes were assessed by IKDC and Lysholm subjective scores and KT-1000 instrumented laxity testing at 6 and 12 months. Statistical analysis used ANOVA and unpaired t-tests to explore associations between graft size, percentage restoration and outcomes with p70% footprint restoration constituted 73.1% of the series. At 12 months, mean IKDC and Lysholm scores were higher in the >70% restoration group (IKDC mean ≈ 89.2; Lysholm mean ≈ 93.7) compared with the ≤70% group (IKDC mean ≈ 79.2; Lysholm ≈ 88.0). Objective KT-1000 measurements showed small, non-significant differences across graft sizes at 12 months. Overall complication rate was low (2.48%), including one deep infection, one DVT, two cases of impingement and one graft re-tear.
Discussion:
This series supports the concept that individualized anatomic ACL reconstruction — tailoring tunnel placement and graft selection to native footprint dimensions — can achieve high percentages of tibial footprint restoration and favorable early functional outcomes. Patients in whom >70% of the native tibial footprint was restored reported superior subjective scores at one year and most commonly received a 9 mm hamstring graft. These clinical observations are consistent with biomechanical data showing that larger grafts reduce anterior translation and articular contact stresses, and with registry studies linking small hamstring graft diameters to higher revision rates.[14,15] However, restoring footprint anatomy remains paramount; increasing graft size cannot fully compensate for non-anatomic tunnel placement.[11,13] The low complication and failure rates in this cohort suggest that individualized single-bundle reconstruction, when performed with careful intraoperative measurement and standardized rehabilitation, provides reliable short-term outcomes. Strengths of the series include prospective recruitment, consistent surgical technique and near-complete follow-up at one year; limitations are single-center design, surgeon-dependent intraoperative measurements and follow-up limited to the early postoperative period. Late outcomes such as osteoarthritis and medium- to long-term re-injury rates require longer observation. Future studies should examine whether the early benefits of footprint restoration translate into durable clinical advantages across broader populations and activity levels.[16–20]
Result
Two hundred and one patients completed one-year follow-up. The cohort was predominantly male (76%) with mean age 29.5 years; 90% were aged 21–40. Injury mechanisms were sports (43%), falls (36%) and road-traffic accidents (22%). Mean native tibial insertion area measured intraoperatively was 97.68 ± 18.86 mm². Mean restored graft aperture area after reaming was 76.1 ± 12.1 mm², yielding a mean percentage footprint restoration of 79.25 ± 14.61%. Seventy-three point one percent of patients achieved >70% footprint restoration. Graft diameters were most commonly 9 mm (62.7%), followed by 8 mm (26.4%) and 10 mm (10.9%). At 12 months, patients with >70% restoration demonstrated higher subjective scores (mean IKDC ≈ 89.2; mean Lysholm ≈ 93.7) compared with those with ≤70% restoration (mean IKDC ≈ 79.2; mean Lysholm ≈ 88.0). Instrumented KT-1000 laxity measurements showed only small, non-significant differences across graft sizes at one year. Overall complication rate was low (2.48%), comprising one deep surgical site infection, one deep vein thrombosis, two cases of graft impingement and one graft re-tear. Mean follow-up adherence was high and return-to-sport rates improved from preoperative baseline levels. No additional surgeries were performed during the follow-up other than the single documented graft re-tear revision within one year.
Conclusion:
In conclusion, individualized anatomic single-bundle hamstring ACL reconstruction that restores a substantial proportion of the native tibial footprint — most commonly achieved with a 9 mm graft in this cohort — is associated with improved early patient-reported outcomes and acceptable objective stability. Accurate intraoperative measurement and tailored graft selection appear to be practical strategies to optimize short-term results after ACL reconstruction. Longer-term studies are required to confirm durability and to evaluate implications for osteoarthritis and late re-injury.
References
1. Chambat P, Guier C, Sonnery-Cottet B, Fayard JM, Thaunat M. The evolution of ACL reconstruction over the last fifty years. Int Orthop. 2013 Feb 1; 37(2):181–6.
2. Engebretsen L, Benum P, Fasting O, Mølster A, Strand T. A prospective, randomized study of three surgical techniques for treatment of acute ruptures of the anterior cruciate ligament. Am J Sports Med. 1990 Nov; 18(6):585–90.
3. Lemaire M. Chronic knee instability. Technics and results of ligament plasty in sports injuries. J Chir. 1975 Oct; 110(4):281–94.
4. Johnson D. ACL made simple. Springer Science & Business Media; 2004.
5. Dandy DJ, Flanagan JP, Steenmeyer V. Arthroscopy and the management of the ruptured anterior cruciate ligament. Clin Orthop Relat Res. 1982 Jul ;( 167):43–9.
6. Middleton KK, Muller B, Araujo PH, Fujimaki Y, Rabuck SJ, Irrgang JJ, Tashman S, Fu FH. Is the native ACL insertion site “completely restored” using an individualized approach to single-bundle ACL-R? Knee Surg Sports Traumatol Arthrosc. 2015 Aug; 23(8):2145–50.
7. Hofbauer M, Muller B, Murawski CD, van Eck CF, Fu FH. The concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction. Knee Surg Sports Traumatol Arthrosc. 2014 May; 22(5):979–86.
8. Van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy. 2010 Feb; 26(2):258–68.
9. Siebold R. The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011 May; 19(5):699–706.
10. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Individualized anterior cruciate ligament surgery: a prospective study comparing anatomic single- and double-bundle reconstruction. Am J Sports Med. 2012 Aug; 40(8):1781–8.
11. Magnussen RA, Lawrence JTR, West RL, et al. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012; 28(4):526–31.
12. Conte EJ, Hyatt AE, Gatt CJ, Dhawan A. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy. 2014; 30(7):882–90.
13. Bedi A, Maak T, Musahl V, Citak M, O’Loughlin PF, Choi D, Pearle AD. Effect of tibial tunnel position on stability of the knee after anterior cruciate ligament reconstruction. Am J Sports Med. 2011 Feb; 39(2):366–73.
14. Zantop T, Diermann N, Schumacher T, Schanz S, Fu FH, Petersen W. Anatomical and nonanatomical double-bundle ACL reconstruction: importance of femoral tunnel location on knee kinematics. Am J Sports Med. 2008; 36(4):678–85.
15. Tashman S, Kopf S, Fu FH. The kinematic basis of anterior cruciate ligament reconstruction. Oper Tech Sports Med. 2012 Mar; 20(1):19–22.
16. Rabuck SJ, Middleton KK, Maeda S, Fujimaki Y, Muller B, Araujo PH, Fu FH. Individualized anatomic anterior cruciate ligament reconstruction. Arthrosc Tech. 2012 Sep; 1(1):e23–9.
17. Granan LP, Forssblad M, Lind M, Engebretsen L. The Scandinavian ACL registries 2004–2007: baseline epidemiology. Acta Orthop. 2009 Oct 1; 80(5):563–7.
18. Gottlob CA, Baker JC, Pellissier JM, Colvin L. Cost effectiveness of anterior cruciate ligament reconstruction in young adults. Clin Orthop Relat Res. 1999 Oct ;( 367):272–82.
19. Yu B, Garrett WE. Mechanisms of non-contact ACL injuries. Br J Sports Med. 2007 Aug 1; 41(suppl 1):i47–51.
20. Van der Bracht H, Bellemans J, Victor J, Verhelst L, Page B, Verdonk P. Can a tibial tunnel in ACL surgery be placed anatomically without impinging on the femoral notch? A risk factor analysis. Knee Surg Sports Traumatol Arthrosc. 2013; 22(2):291–297.
| How to Cite this Article: Bhargava R, Sancheti P, Patil K, Gugale G, Sanghavi S, Sisodia Y, UI Nisar O, Sonawane D, Shyam A | Optimizing ACL Reconstruction: The Role of Precise Footprint Restoration and Adequate Graft Size for Knee Stability | Journal of Medical Thesis | 2021 July-December; 7(2): 09-12. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
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Functional and Radiological Outcomes after Surgical management of Intra Articular Distal Tibial Fractures – A retrospective and prospective cohort study
Vol 7 | Issue 2 | July-December 2021 | page: 5-8 | Nayan Shrivastav, Rajeev Joshi, Sahil Sanghavi, Mahavir Dugad, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i02.162
Author: Nayan Shrivastav [1], Rajeev Joshi [1], Sahil Sanghavi [1], Mahavir Dugad [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Pilon fractures are complex intra-articular injuries of the distal tibia associated with significant soft tissue damage. Optimal surgical strategy remains controversial.
Methods: A combined retrospective and prospective study of 34 adult patients with closed distal tibial intra-articular fractures treated between October 2018 and October 2020 was performed. Patients were classified according to Ruedi–Allgöwer and AO/OTA systems and managed by one of three strategies: staged external fixation followed by delayed ORIF, external fixation with limited internal fixation, or primary open reduction and internal fixation with plating. Outcomes were assessed using AOFAS, FADI and SF-36 at six and twelve months; complications and radiographic union were documented.
Results: At six months, group means for FADI favoured primary ORIF and staged treatment over limited internal fixation; by twelve months most patients showed substantial improvement with mean cohort FADI of 85 and mean AOFAS approximating 87. Complications included delayed wound healing, pin-tract and superficial infections, and non-unions that were largely managed conservatively.
Conclusion: When soft tissue conditions permit, anatomical restoration via ORIF yields superior functional recovery; staged external fixation remains a valuable strategy when soft tissue status is poor. Clinicians should individualise treatment based on fracture pattern and soft tissue condition to optimise outcomes.
Keywords: Pilon fracture, Distal tibia, Open reduction and internal fixation (ORIF), External fixation, Functional outcome
Aims: To review incidence, treatment modalities, complications and functional outcomes of surgically treated Pilon fractures and to compare effectiveness of staged external fixation, external fixation with limited internal fixation and primary ORIF. Objectives: Analyse functional scores, radiographic union and complications at six and twelve months and inform surgical decision making.
Review: Pilon fractures represent a challenging subset of distal tibial injuries for which contemporary management strategies are well described in the orthopaedic literature. High-energy axial impaction and torsional mechanisms produce articular comminution leading to variable soft tissue injury and complex metaphyseal patterns; management paradigms emphasize either anatomic open reconstruction or staged strategies that prioritize soft tissue recovery [1]. Classification systems including Rüedi–Allgöwer and AO/OTA aid consistent description and planning [2, 3], while detailed mapping of the tibial plafond has informed fragment-targeted approaches to reduction and fixation [4]. Early operative series documented both the benefits of anatomic restoration and the high wound complication rates when definitive surgery was attempted in swollen or compromised soft tissues [5, 6]. Complications remain common and were detailed in prior series emphasizing infection, wound breakdown and non-union as key concerns [9]. Provisional external fixation and techniques of external articular transfixation were developed to stabilise the limb and protect soft tissues prior to definitive reconstruction [10, 11]. Debate continues regarding immediate ORIF versus staged management; nomenclature and conceptual distinctions have been clarified in modern reviews [12, 14–16]. Minimally invasive plating techniques, percutaneous fixation strategies and lateral approach variations aim to minimise soft tissue insult while achieving stable fixation [17–20]. Overall, the literature supports individualized strategy selection based on fracture morphology and soft tissue status rather than a universal single best technique [1, 5, and 16].
Introduction: An intra-articular, vertically impacted fracture of the distal tibial plafond — commonly termed a Pilon fracture — poses significant reconstructive challenges because of the frequent combination of articular comminution and soft tissue compromise. Historically, nonoperative management led to high rates of malunion and late arthritis, prompting a shift toward surgical strategies that emphasize anatomic reduction when feasible [7, 8, 13]. The mechanism typically involves axial loading of the talus against the tibial plafond or torsional forces that create a spectrum of fracture patterns described by Rüedi–Allgöwer and the AO/OTA classifications, which remain central to decision-making [2, 3]. Recent literature highlights the role of staged management using an ankle-spanning external fixator to permit soft tissue recovery prior to definitive ORIF for high-energy injuries, with improved wound outcomes compared with immediate ORIF in severely swollen limbs [5, 11, and 16]. At the same time, primary ORIF performed under favourable soft tissue conditions can restore anatomy and yield superior early functional recovery, a benefit emphasized in several series and surgical reviews [1, 4, and 15]. Advances in fixation technology and minimally invasive techniques have broadened options to reduce soft tissue insult while maintaining stable internal fixation [17–19]. The present study seeks to compare outcomes among staged external fixation with delayed plating, external fixation combined with limited internal fixation, and primary ORIF in a single-centre cohort, to clarify relative functional outcomes and complication profiles and inform treatment planning consistent with current evidence [1,4,16–18].
Methods: Combined retrospective and prospective observational study conducted at a single tertiary centre between October 2018 and October 2020. Thirty-four skeletally mature patients with closed distal tibia-fibula intra-articular fractures were enrolled after informed consent. Inclusion criteria comprised closed distal tibia-fibula intra-articular fractures; exclusion criteria included pathological fractures, congenital anomalies, open injuries and associated talus or calcaneum fractures. Patients underwent AP, lateral and mortise radiographs and CT scans to delineate articular involvement and were classified by Ruedi–Allgöwer and AO/OTA. Depending on soft tissue condition and reconstructibility, patients received one of three protocols: (A) staged management with primary ankle-spanning external fixator followed by delayed plating, (B) external fixator with limited internal fixation of articular fragments, or (C) definitive ORIF with plating. Fibular fixation employed one-third tubular plates, precontoured LCPs or titanium elastic nailing when indicated. Postoperative care comprised limb elevation, drain removal after 48 hours where applicable, early ankle and knee mobilization, suture removal at two weeks, radiographic monitoring, and graduated weight bearing starting at approximately six weeks guided by healing. Functional assessment used AOFAS, FADI and SF-36 at six and twelve months. Data were analysed using SPSS v20 with descriptive statistics, chi-square and ANOVA; p<0.05 considered significant. Complications were recorded and managed per standard protocols, and external fixators were retained until soft tissue recovery permitted conversion to internal fixation or cast immobilization.
Results: Thirty-four patients met inclusion criteria. Treatment distribution was: Group A (staged external fixation → delayed plating) 6 patients (17.6%); Group B (external fixation + limited internal fixation) 5 patients (14.7%); Group C (primary ORIF and plating) 23 patients (67.7%). The cohort comprised 22 males (64.7%) and 12 females (35.3%). At six months the overall mean FADI was 75.62; group means were A 76.33±11.04, B 63.66±13.96, and C 78.04±9, with an intergroup difference reaching significance (p=0.02). By twelve months mean FADI rose to about 85: group means were A 86.8±3.14, B 77.8±11.9, and C 86.14±7.28 (p=0.08). AOFAS and SF-36 scores showed parallel improvement over time; the average final AOFAS was approximately 87. Radiographic union was achieved in the majority by three to four months. Complications occurred in 15 patients and included delayed wound healing, prolonged swelling, superficial and pin-tract infections, a few deep infections, and several non-unions; most complications were addressed with conservative care or minor procedures. Overall, primary ORIF gave the best functional results in this cohort, while external fixation combined with limited internal fixation had less favourable outcomes.
Discussion: This series reinforces the practical balance clinicians must strike between restoring joint anatomy and protecting the soft tissue envelope. When soft tissue conditions are favourable, primary ORIF allows anatomic reduction of the articular surface and restoration of alignment — factors that translate into superior functional scores in this and other series [1, 4, 15, 20]. However, immediate open surgery through swollen or compromised soft tissues exposes patients to higher risks of wound breakdown and infection; staged management using provisional external fixation reduces this risk by allowing time for soft tissue recovery before definitive fixation [5, 9–11, 16].
Cases treated with external fixation plus limited internal fixation in our cohort generally had worse functional outcomes, likely due to selection of fractures that were too comminuted for anatomic reconstruction and the known limitations of prolonged external fixation such as pin-tract problems and delayed rehabilitation [10, 17, and 19]. Minimally invasive plate osteosynthesis and other low-profile techniques provide alternatives that combine stable fixation with less soft tissue insult and can be useful for selected fracture patterns [17–19]. Consistent fracture classification and CT-based planning facilitate choosing the optimal approach for each case [2, 3, and 18].
Limitations of this study include the modest sample size, single-centre design, and follow-up limited to one year for many patients — factors that constrain generalisability and long-term assessment of post-traumatic arthritis. Nonetheless, the findings align with broader literature advocating individualized treatment: aim for anatomic reconstruction when soft tissues permit, and favour staged strategies when they do not [12–16]. Future multicentre, randomized studies with extended follow-up would better define long-term joint survivorship and refine indications for each technique.
Conclusion: In this single-centre cohort of 34 surgically treated Pilon fractures, individualized management that respected the soft tissue condition while pursuing anatomic reconstruction when feasible produced generally favourable one-year functional outcomes. Primary ORIF, when performed under good soft tissue conditions, yielded the best recovery. Staged external fixation with delayed plating is a reliable alternative when soft tissues are compromised. External fixation combined with limited internal fixation showed less favourable outcomes and should be reserved for fractures not amenable to anatomic reconstruction. Complications such as delayed wound healing and superficial/pin-tract infections were common but mostly manageable. Larger randomized multicentre trials with longer follow-up are needed to refine treatment algorithms and long-term expectations.
References
1. Jacob N, Amin A, Giotakis N, Narayan B, Nayagam S, Trompeter AJ. Management of high-energy tibial Pilon fractures. Strategies Trauma Limb Reconstr. 2015 Nov; 10(3):137–47.
2. Fialka C, Vécsei V. Anatomical and Radiological Classification of Pilon Tibial Fractures. Fractures of the Tibial Pilon. 2002. p. 13–8.
3. Stephen D. Fractures of the Distal Tibial Metaphysis Involving the Ankle Joint: The Pilon Fracture. The Rationale of Operative Fracture Care. p. 523–50.
4. Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The Pilon Map. Journal of Orthopaedic Trauma. 2013. p. e152–6.
5. Conroy J, Agarwal M, Giannoudis PV, Matthews SJE. Early internal fixation and soft tissue cover of severe open tibial pilon fractures. International Orthopaedics. 2003. p. 343–7.
6. I R, Allgöwer M, Matter P. Intra-articular fractures of the distal tibia. The Journal of Trauma. 1969. p. 640.
7. Johnson A. Distal Tibial Fractures. Atlas of Orthopedic Surgical Procedures of lower limb. p. 198–9.
8. Grant Bonnin J. Injuries to the ankle. British Journal of Surgery. 1951. p. 535–535.
9. McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma. 1992;6(2):195–200.
10. Rogge D. External Articular Transfixation for Joint Injuries with Severe Soft Tissue Damage. Fractures with Soft Tissue Injuries. 1984. p. 103–17.
11. Rüedi T, Allgöwer M. The operative treatment of intraarticular fractures of the lower end of the tibia. Orthopedic Trauma Directions. 2011. p. 23–5.
12. Michelson J, Moskovitz P, Labropoulos P. The Nomenclature for Intra-articular Vertical Impact Fractures of the Tibial Plafond: Pilon versus Pylon. Foot & Ankle Int. 2004; 25:149–50.
13. Rockwood CA, Green DP, Bucholz RW, Heckman JD, editors. Fractures in Adults. 4th ed. Lippincott-Raven; 1996.
14. Pilon Fracture. Encyclopedia of Trauma Care. 2015. p. 1252.
15. Helfet DL, Koval K, Pappas J, Sanders RW, Dipasquale T. Intraarticular Pilon Fracture of the Tibia. Clin Orthop Relat Res. 1994. p. 221–228.
16. Tarkin IS, Clare MP, Marcantonio A, and Pape HC. An update on the management of high-energy pilon fractures. Injury. 2008 Feb; 39(2):142–54.
17. Collinge C, Kuper M, Larson K, Protzman R. Minimally invasive plating of high-energy metaphyseal distal tibia fractures. J Orthop Trauma. 2007 Jul; 21(6):355–61.
18. Zhao Y, Wu J, Wei S, Xu F, Kong C, Zhi X, et al. Surgical approach strategies for open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans. J Orthop Surg Res. 2020 Jul 27; 15(1):283.
19. Collinge CA, Sanders RW. Percutaneous plating in the lower extremity. J Am Acad Orthop Surg. 2000 Jul; 8(4):211–6.
20. Grose A, Gardner MJ, Hettrich C, Fishman F, Lorich DG, Asprinio DE, et al. Open reduction and internal fixation of tibial pilon fractures using a lateral approach. J Orthop Trauma. 2007 Sep; 21(8):530–7.
| How to Cite this Article: Shrivastav N, Joshi R, Sanghavi S, Dugad M, Sonawane D, Shyam A, Sancheti P | Functional and Radiological Outcomes after Surgical Management of Intra Articular Distal Tibial Fractures– A Retrospective and Prospective Cohort Study| Journal of Medical Thesis | 2021 July-December; 7(2): 05-08. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
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Functional Recovery Following Surgical Intervention for Multilevel Lumbar Spinal Stenosis: A Prospective Cohort Analysis
Vol 7 | Issue 2 | July-December 2021 | page: 1-4 | Sangmeshwar Siddheshwar, Shailesh Hadgaonkar, Ajay Kothari, Siddhart Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i02.160
Author: Sangmeshwar Siddheshwar [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddhart Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Multilevel degenerative lumbar spinal stenosis produces neurogenic claudication and radicular pain with marked functional limitation. This prospective study evaluates outcomes after tailored surgical care — decompression alone, decompression with stabilization, or decompression with instrumented interbody fusion — selected after careful clinico-radiological correlation.
Methods: Ninety-nine consecutive patients with two or more levels of stenosis who failed nonoperative therapy were treated surgically at our tertiary centre. Selection for decompression alone or decompression plus stabilization/interbody fusion was based on clinical features, dynamic radiographs and axial T2 MRI morphological grading. Functional outcomes were measured using the Oswestry Disability Index (ODI), Visual Analog Scale (VAS) and Short Form-36 (SF-36) preoperatively and at six months and one year.
Results: Patients demonstrated substantial reduction in disability and pain scores with improved SF-36 domains at follow-up. Complications were infrequent and manageable.
Conclusion: When selected carefully, decompression with or without stabilization leads to durable symptom relief and functional improvement in multilevel lumbar canal stenosis. Perioperative measures included antibiotic prophylaxis, thromboprophylaxis, early mobilization and a structured rehabilitation plan to support recovery and reduce complications. Institutional ethical approval and written informed consent were obtained for all participants prior to enrolment.
Keywords: Lumbar spinal stenosis, Decompression, Fusion, Oswestry Disability Index, Neurogenic claudication
Introduction
Degenerative lumbar spinal stenosis most commonly results from progressive disc degeneration, facet joint hypertrophy, ligamentum flavum thickening and osteophyte formation that, in combination, narrow the spinal canal and encroach upon neural elements [1]. Multilevel involvement typically affects adjacent motion segments and is frequently encountered in routine clinical practice; patients often present with neurogenic claudication characterized by leg pain and paresthesia provoked by walking or standing and relieved by sitting or forward flexion [2]. Symptoms may be unilateral or bilateral and are commonly accompanied by variable low back pain and intermittent motor or sensory deficits. Radiological assessment with high-resolution axial T2 magnetic resonance imaging is central to diagnosis and permits morphological grading of canal compromise to help correlate clinical findings with imaging [3]. Plain radiographs including flexion–extension views are important when assessing segmental instability and sagittal alignment [4]. Conservative measures such as activity modification, analgesia, physiotherapy and selective epidural injections are the initial approach, but patients with progressive, disabling or function-limiting symptoms despite adequate nonoperative care are candidates for surgical intervention [5]. The primary surgical objective is durable neural decompression to relieve neurogenic symptoms while minimising the risk of postoperative instability. Traditional wide laminectomy achieves extensive decompression but may disrupt posterior stabilising elements and paraspinal musculature, potentially predisposing to late instability and unsatisfactory outcomes [6]. For this reason, techniques that limit collateral damage — unilateral or bilateral laminotomy, selective fenestration, microscopic decompression and minimally invasive approaches — have been developed to preserve stabilisers while providing effective neural decompression [7]. Surgical decision-making balances the extent of decompression with the need to preserve anatomical stabilisers; when dynamic radiographs or intraoperative findings indicate instability or facet destruction, instrumented fusion with interbody support may be required to restore stability and promote long-term functional benefit. Patient factors such as age and comorbidity influence planning and expected recovery. Standardized outcome instruments (ODI, VAS, SF-36) were used to quantify disability, pain and quality of life at defined intervals.
Aims and objectives
The primary aim was to evaluate functional outcome following surgical management of multilevel lumbar canal stenosis. Specific objectives were to
(1) Quantify change in ODI, VAS and SF-36 at six months and one year;
(2) Record perioperative and early postoperative complications; and
(3) Analyse the relationship of functional recovery with morphological MRI grade, number of levels and patient age to better inform surgical selection and patient counselling at a tertiary referral centre in India.
Review of literature
The surgical literature emphasises balancing adequate neural decompression with preservation of posterior stabilising structures [8]. Early series established degenerative changes as the principal cause of symptomatic stenosis and cautioned that excessive posterior element removal may produce iatrogenic instability and restenosis [9]. Instrumentation such as pedicle screw constructs and interbody techniques improved fusion reliability and provided stabilisation when fusion was indicated [10]. Technical descriptions of internal fixators and pedicle plating informed subsequent stabilisation strategies [11]. Clinical analyses indicate that elderly patients can achieve meaningful symptom relief when procedures are selected carefully and perioperative care is optimised, though complication rates increase with age [12]. Cost and resource pressures have encouraged less invasive fusion strategies alongside targeted decompression approaches [13]. Comparative trials suggest that increased radiographic fusion with instrumentation does not uniformly translate into superior symptomatic benefit, supporting selective fusion for documented instability [14]. Minimally invasive and muscle-sparing techniques such as microdecompression reduce paraspinal muscle trauma while achieving effective neural decompression [15]. Microdecompression and microscopic laminotomy have been reported to deliver similar short-term outcomes with reduced soft-tissue disruption compared with wide laminectomy in selected series [16]. Alternative decompressive procedures such as multilevel subarticular fenestrations and laminoplasty were proposed to preserve stabilisers and reduce late instability [17]. Earlier clinical series documented reasonable outcomes with fenestration techniques as an alternative to extensive laminectomy [18]. Long-term issues after decompression and fusion include bone regrowth, implant-related difficulties and adjacent segment degeneration, which require ongoing surveillance [19]. Overall, careful patient selection, tailored decompression and selective fusion remain the foundation of contemporary management of multilevel lumbar canal stenosis [20], and these topics remain under study worldwide.
Materials and Methods
This prospective study enrolled ninety-nine consecutive patients between October 2016 and October 2017 who presented with clinical and radiological evidence of lumbar canal stenosis affecting two or more levels and who failed conservative treatment. Inclusion criteria were age >30 years, symptomatic neurogenic claudication limiting walking distance despite adequate nonoperative care, and MRI evidence of multilevel canal compromise. Exclusion criteria included prior lumbar surgery, active infection, malignancy and acute fracture. Clinical evaluation comprised detailed neurological examination, assessment of claudication distance and straight leg raise testing. Baseline investigations included standing lumbosacral radiographs with flexion–extension views to detect dynamic instability and MRI axial T2 sequences for morphological grading. Treatment was individualised: decompression alone was performed when clinical and radiological features showed no instability; decompression with posterolateral fusion or decompression with instrumented transforaminal lumbar interbody fusion (TLIF) was used where dynamic films or facet destruction indicated instability. Procedures were performed under general anaesthesia with standard positioning and prophylactic antibiotics. Meticulous microsurgical technique was used to preserve posterior tension bands while achieving neural release; pedicle screw constructs and interbody cages were employed where indicated. Perioperative data were recorded and complications tracked. Postoperative care was standardised: thromboembolism prophylaxis, analgesia and a short course of intravenous antibiotics followed by oral therapy were used; early in-bed exercises began within 24 hours and ambulation with support was encouraged by 48 hours. Suture removal occurred at about two weeks and a structured rehabilitation programme was commenced and continued regularly. Functional outcomes (ODI, VAS, SF-36) were recorded preoperatively and at six months and one year. Statistical analysis consisted of paired comparisons of preoperative and postoperative scores and subgroup analyses by age, number of levels and morphological grade with significance set at p<0.05.
Results
Ninety-nine patients completed one-year follow-up. The cohort comprised 43 males and 56 females with ages ranging from 32 to 82 years; most (61) were aged 50–70. Two-level stenosis was present in 49 patients, three-level disease in 37 and four or more levels in 13. Morphological grading on axial MRI demonstrated a range from moderate to severe central canal compromise. Functional outcomes improved markedly: mean preoperative ODI was 53.07 (SD 5.93), improving to 20.91 (SD 9.93) at six months and 14.48 (SD 11.97) at one year, representing a clinically important reduction in disability. Median VAS for leg pain fell from 9 preoperatively to 3 at six months and 1 at one year. SF-36 domains showed statistically and clinically meaningful gains, especially in physical functioning and bodily pain. Subgroup analyses by age, number of levels treated and morphological grade did not reveal significant differences in one-year ODI or SF-36 outcomes. Complications were uncommon: dural tear was the most frequent intraoperative event and was managed intraoperatively without persistent morbidity; isolated cases of implant loosening, transient neurological deficit and adjacent segment symptoms occurred. Most patients were discharged within three to five days. Early mobilization aided recovery, and the sustained improvements at one year reflect durable symptomatic relief and functional recovery in the majority, with low reoperation rates.
Discussion
This prospective series demonstrates that carefully planned surgical decompression, with stabilization or fusion reserved for demonstrable instability, provides meaningful and sustained improvement in pain, disability and overall quality of life for patients with multilevel lumbar canal stenosis. The magnitude of improvement in ODI, VAS and SF-36 in this cohort confirms that appropriate decompression remains the foundation of effective surgical care for neurogenic claudication and radicular pain. The lack of significant difference in one-year outcomes between age groups, numbers of levels treated and morphological grades suggests that multilevel involvement alone should not preclude consideration of surgery when symptoms and functional limitation warrant intervention. Complications were relatively infrequent and manageable; dural tear was the commonest intraoperative event and was addressed promptly without long-term consequence in this series. Implant-related issues and adjacent segment symptoms were limited to a small minority and were managed according to standard practice. Early mobilisation, standardised perioperative prophylaxis and a structured rehabilitation pathway likely contributed to low morbidity and rapid functional gains. Limitations include single-centre recruitment and one-year follow-up; longer observation is needed to characterise the durability of benefit and the incidence of late adjacent segment degeneration. Objective metrics such as gait analysis and longer-term imaging correlation would strengthen understanding of structural evolution after decompression and fusion. Future multicentre studies with extended follow-up will help refine indications and improve shared decision-making with patients and health policy too. Overall, a pragmatic strategy that provides adequate neural decompression tailored to symptoms and imaging, preserves stabilising structures when possible and reserves fusion for demonstrable instability maximises benefit while minimising unnecessary instrumentation.
Conclusion
In this prospective cohort of ninety-nine patients with multilevel lumbar canal stenosis, individualized decompression informed by careful clinico-radiological assessment produced substantial and sustained reductions in disability and pain and improved quality of life at one year. Functional measures showed statistically and clinically important gains. Complication rates were acceptable, with dural tear the most frequently encountered intraoperative event; implant problems and adjacent segment symptoms were uncommon. Outcomes were not markedly influenced by age, number of levels treated or morphological grade, supporting the principle that multilevel involvement alone is not a contraindication to surgery when clinical indications exist. Continued clinical surveillance and longer-term studies will clarify durability and late adjacent segment effects.
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| How to Cite this Article: Siddheshwar S, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P| Functional Recovery Following Surgical Intervention for Multilevel Lumbar Spinal Stenosis: A Prospective Cohort Analysis | Journal of Medical Thesis | 2021 July-December; 7(2): 01-04. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2019
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