MEMBERS

Editorial Board Aamir Raoof Memon Mohammad Wasay

Aamna Hassan Muhammad Jamal Uddin
Abu Talib Muhammad Shahzad Shamim
Chairman Aisha Mehnaz Nilofer Safdar
Ali Yawar Alam Nosheen Zehra
Sarwar Jamil Siddiqui Anwar Siddiqui Ramsha Zaheer
Asad Pathan Rehman Siddiqui
Editor-in-Chief Asif Khaliq Rubina Naqvi
Babar Jamali Rumina Hasan
Fatema Jawad Bushra Shirazi Sadiah Ahsan
Farooq Azam Rathore Salman Adil
Associate Editor-in-Chief Fehmina Arif Shahid Shamim
Huma Qureshi Gulnaz Khalid Shahla Siddiqui
Iqbal Afridi Sharaf Ali Shah
Kaleem Thahim Sohail Akhtar
Associate Editors Khalid Zafar Hashmi Syed Mamun Mahmud
Qudsia Anjum Fasih Kiran Ejaz Uzma Fasih
Manzoor Hussain Yasmin Wajahat
Sina Aziz Masood Shaikh Zakiuddin G. Oonwala
Syed Muhammad Mubeen Mehwish Kashif Zubaida Masood
Mirza Naqi Zafar
Editor, Students' Corner
Mahnoor Amin INTERNATIONAL ADVISORS
Statistical Reviewer Ahmed Badar (KSA) Mohammad Bagher Rokni
Aamir Omair Amin Muhammad Gadit (Iran)
Nazish Masud Diaa Essam EL-Din Rizk (KSA) Mubeen Fatima Rafay (Canada)
Tayyab Raza Fraz Farhad Handjani Sanjay Kalra (India)
Mahjabeen Khan Farrokh Habibzadeh (Iran) Seerat Aziz (USA)
Managing Secretary Gerry Mugford (Canada) Shabih Zaidi (UK)
Anwar Ali Khawaja Itrat Mehdi (Oman) Sultan Ayoub Meo (KSA)
Administrative Secretary M.B. Heyman (USA) Tanveer Azher (Canada)
Ahmed Abdul Majid Mehmood I Shafi (UK) Zohra Zaidi (UK)

Articles published in JPMA do not represent the views of the Editor or Editorial Board.
Authors are solely responsible for the opinions expressed and accuracy of the data.

The Journal of Pakistan Medical Association (JPMA) is published monthly from PMA House, Aga Khan III Road, Karachi-74400, Pakistan.
All articles published represent the opinion of the authors and do not reflect official policy of the journal. All rights reserved to the Journal of
the Pakistan Medical Association. No part of the Journal may be reproduced, stored in a retrieval system, or transmitted in any form or by any
other means, electronic, mechanical photocopying, recording or otherwise, without prior permission, in writing, of the Journal of the Pakistan
Medical Association.
Price: Rs.1,500.00 (Single Issue)
Annual Subscription: Rs.17,000 in Pakistan and US$500.00 for overseas countries (including air mail postage).
Publication Office: PMA House, Aga Khan III Road, Karachi-74400, Pakistan. Telephone: 92-21-32226443.
E-mail: editor@jpma.org.pk
 CONTENTS PAGES

ACKNOWLEDGEMENT
Publication Committee — 34th International Pak OrthoCon Conference S-1

EDITORIAL
Aging Gracefully — OrthoCon 2021
Masood Umer, Haroon ur Rashid, Rizwan Haroon Rashid S-2

ORIGINAL ARTICLE
Frequency of angular malalignment after intramedullary nailing for femur shaft
fractures — A cross-sectional study
Hammad Naqi Khan, Moiz Ali, Rizwan Haroon Rashid, Yasir Mohib, Pervaiz Hashmi S-4

RESEARCH ARTICLES
Frequency of osteoarthritis and functional outcome of operated tibial plateau
fractures: A minimum of 5 years follow up
Mohammad Tahir, Sandeep Kumar, Saeed Ahmed Shaikh, Allah Rakhio Jamali S-8
Functional and radiological outcomes of atypical femur fractures among
elderly in Karachi, Pakistan
Rizwan Haroon Rashid, Marij Zahid, Usama Khan, Yasir Mohib, Pervaiz Hashmi S-13
Comparison of physiotherapy with and without intra-articular corticosteroid injection
for treatment of frozen shoulder: A comparative study
Rana Dawood Ahmad Khan, Khawar Shahzad, Shahzad Khan, Mahwish Israr, Faisal Maqbool Zahid S-17
Unilateral versus simultaneous bilateral total knee arthroplasty: A comparative study
Obaid-ur-Rahman, Sohail Hafeez, Muhammad Suhail Amin, Jahanzeb Ameen, Rana Adnan S-21
The timing of closed unstable ankle fracture fixation and major wound
complications — an observation from a UK major trauma centre
Conrad Lee, Efthymios Iliopoulos, Sohail Yousaf S-26
An experience with soft transforaminal lumbar interbody fusion in postoperative
discitis not responding to conservative treatment
Irfan Anwar, Waseem Afzal, Muhammad Talha, Muhammad Mahmood Ahmad, Shahzad Ahmed Qasmi, Muhammad Asad Qureshi S-32
Complex tibial plateau fractures: Clinical and radiological outcome
following plate osteosynthesis
Hisham Khan Gandapur, Suhail Amin S-35
Empty Bursa SIGN: Significance in arthroscopic sub acromial decompression —
an audit of consecutive patients 2003 to 2020
Nikhil Arvind Khaddabadi, Kishen Parekh, Danial Shah, Usama Bin Saeed, Munawar Shah S-41
An experiment of Mega-prosthesis in bone tumours: A retrospective cross-sectional
study in a tertiary care hospital
Masood Umer, Eraj Khurshid Khan, Javeria Saeed S-45
 CONTENTS PAGES

Inter-observer variation of the Schatzker and Khan classification of

Tibial plateau fractures: Cohort study
Mansoor Ali Khan, Sateesh Pal, Syed Kamran Ahmed, Muhammad Amin Chinoy S-51
Ilizarov fixator pin site infection: A comparison between transverse wires and half pins
Asadullah Makhdoom, Raheel Akbar Baloch, Muhammad Faraz Jokhio, Syed Muhammad Ali, Zameer Hussain Tunio, Jehanzaib, Tahir Ahmed S-55
Osetosynthesis of Fractures neck femur with cannulated screws: Evaluation of
risk factors for post-operative complications
Saeed Ahmed Shaikh, Sajid Hussain, Muhammad Qasim Ali Samejo, Nadeem Ahmed, Allah Rakhio Jamali S-59
Outcome of minimally invasive plate osteosynthesis using locking compression
plate in long bone fractures
Muhammad Ali, Arif Mustafa Khan, Muhammad Hamza Azhar, Muhammad Tahir Javed, Muhammad Saleem, Zahid Hafeez S-64

AUDIT
Outcome of percutaneous screw fixation of posterior pelvic ring injuries
Hussain Wahab, Pervaiz Hashmi, Haroon Kasi, Naveed Baloch, Tasfheen Ahmad, Haroon Rashid, Masood Umer S-70
Treatment and outcomes of soft tissue sarcoma of groin, hip and thigh: a
retrospective review from a tertiary care hospital
Masood Umer, Javeria Saeed, Zaid Shamsi, Muhammad Usman Tariq S-75
Prevention of falls in hospital: Audit report from a Tertiary care hospital of Pakistan
Anum Sadruddin Pidani, Tashfeen Ahmad, Nasreen Panjwani, Shahryar Noordin S-79
Our experience of treating adult bone lymphoma, A retrospective cross-sectional
study in a tertiary care center, Aga Khan University Hospital, Karachi
Masood Umer, Muhammad Younus Khan Durrani, Javeria Saeed, Nasir Uddin S-83
Functional outcomes and complications of total hip arthroplasty with dual mobility cup: an audit
Muhammad Younus Khan Durrani, Javeria Saeed, Masood Umer, Pervaiz Hashmi S-87

CASE SERIES
Radiological outcome of acute subtrochanteric fractures fixed with recon
intramedullary nailing, a retrospective case series
Shah Fahad, Ahmed Abdul Habib, Ashmal Sami, Haroon ur Rashid S-90
Clinical and functional outcomes following platelet rich plasma in the management
of knee osteoarthritis: A case series in a tertiary care hospital
Rahat Zahoor Moton, Zohaib Nawaz, Muhammad Latif, Muhammad Azeem Akhund, Zohaib Khan S-94
Long-term functional outcomes after total scapulectomy with dual suspension
reconstruction in children — A case series
Akbar Jaleel Zubairi, Mohammad Mustafa, Javeria Saeed, Masood Umer S-99
Role of platelet rich plasma in fracture non-union of scaphoid — Case series
Muhammad Zeeshan Aslam, Josephine Ip, Syed Kamran Ahmed, Boris Fung S-103
S-1 34th International Pak OrthoCon Conference 2021

ACKNOWLEDGEMENT

I
t gives us immense pleasure to share this JPMA special supplement with our readers, published as an
adjunct to the 34th International Pak OrthoCon Conference. The themes of the conference are: Ageing
Gracefully, Frugal Innovations & Orthopaedic Complications.
We are grateful for the enormous response from both national and international contributors and a total of 72
manuscripts were received. We adopted JPMA's strict criteria for publication and each submission was first
evaluated for plagiarism through specialized computer software. No manuscript was rejected at this level. This
was followed by coding of each submission to insure that the peer-review process remains blinded and
transparent. Each submission was then assigned to two independent reviewers, who were subject specialists
belonging to the same specialty, again based on standard JPMA policy. In case of discrepancy, a statistical
review or a third editorial review was also done. Complete confidentiality of the reviewers was ensured. All
reviews were carried out on standard JPMA review forms. Only articles that were judged by both reviewers to
be publishable in their present form; or with minor changes only, were selected. Articles requiring major
revisions were not considered for publication.
A total of 24 articles were thus accepted for publication. This final list of articles was forwarded to JPMA for
final editorial review, along with the comments of the reviewers. At this point we must mention that some of
the rejected articles were actually of reasonable quality, but could not be published, on the basis that they
were not related to the theme or required major revisions in either format or language, which given the short
time-line, was not possible for this particular supplement.
We would also like to take this opportunity to thank our Conference Chair: Dr. Masood Umer | Scientific Chair:
Dr. Haroon ur Rashid |JPMA Publication Committee Chair: Dr. Rizwan Haroon and other team members of our
publication committee: Drs. Tashfeen Ahmad, Yasir Mohib, Akbar Jaleel Zuberi, Naveed Juman Baloch and our
administrative staffs, Syed Saad (Administrator, POA) and Shariff Charania (Associate, Department of Surgery,
AKU) who worked tirelessly day and night and made this herculean task possible. We hope you will appreciate
the quality of papers in this supplement.
We look forward to welcoming you all and we hope you will take an active participation in the 34th
International Pak OrthoCon Conference to be held on November 11-14, 2021.

Publication Committee
34th International Pak OrthoCon Conference

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-2

EDITORIAL
Aging Gracefully — OrthoCon 2021
Masood Umer, Haroon ur Rashid, Rizwan Haroon Rashid
It is an old saying that wisdom comes with age. established. All these programmes involve a
Increasing age has its untoward effect on one's health. multidisciplinary team approach and aim at preventing
Population ageing is one of the greatest triumphs of fragility fractures. They also aim at improving bone
human race and is linked to advancement in the field of health, screening high risk individuals, prompt, and
medicine, public health, and socioeconomic timely pharmacological interventions so that fracture
development over diseases. As per the department of related morbidity and mortality and overall health care
Economic and Social Affairs United Nation worldwide a expenditure can be reduced.4,5
person aged 65 years would be expected to live an
additional 17 years. By 2045-2050 this figure will have Primary prevention of disease is one of the most
increased to 19 years.1 important aspect in geriatric populations which results in
disability prevention. There are certain diseases like
Like all other health care specialties, major influx in degenerative joint diseases which are unpreventable due
orthopaedics surgical care is the aging patient, requiring to its idiopathic etiology. Here the emphasis should be
not only treatment of acute conditions but also on early detection, lifestyle modification,
management of parallel chronic illnesses. Radosavljevic pharmacological intervention so that the progression of
N et al in 2014 published a study which showed that out the disease can be slowed down and hence disability
of the 6.8 million operations done on patients aged 65 or could be prevented. But once established total joint
above about 27% were related to the musculoskeletal arthroplasty was found to have a significant impact in
system with Total hip replacement being the most reducing disability and maintain the musculoskeletal
common one.2 function. In the last decade total joint replacement has
Geriatric population is at considerable risk of revolutionized the treatment of arthritis in elderly still
developing musculoskeletal disorders and the multimodal team approach and individual patients need
incidence is directly proportional to increasing age. should be considered before treatment.
Pain, stiffness, fatigue and muscle weakness directly Surgical Intervention in geriatric patients requires a team
affects the quality of life in these patients. Fragility of experts who can optimize patient for early operative
fractures which are caused by changes in both bone care by avoiding unnecessary test and consults that can
and soft tissue architecture can not only cause lead to increase cost and delay in surgery. Time to
significant morbidity and mortality but also have surgery particularly in geriatric hip fractures has shown
significant social, psychological, and financial impact to affect outcomes of surgery. Outcome of surgery is
on them. While orthopaedics surgery has a wide highly dependant on preoperative, perioperative, and
subspecialty practice like spine, hand and wrist, sports postoperative care and rehabilitation.6,7
medicine, foot and ankle surgery, paediatrics but
geriatric orthopaedics is still having a generalized Treating geriatric patients pose a unique challenge to the
practice. With ever increasing "baby boomers" time has orthopaedic surgeon. It is not only the disease which
come to make geriatric orthopaedics a well-recognized needs treatment but also the psychosocial and financial
multidisciplinary sub-specialty with fellowship needs which need consideration. All efforts should be
programmes exclusively designed to cater the needs of made to limit disability and if this occurs a multimodal
the aging population.3 cost-effective treatment strategy should be designed to
treat it. Way forward would be a structured and well-
With increasing age of population fragility fractures have
designed Geriatric orthopaedic fellowship covering all
also increased. As the famous saying goes "Prevention is
the health care challenges posed by ageing population.
better than Cure" various models and programmes like
We aim to highlight all these issues in the forthcoming
"Own the Bone" and "Fracture Liaison Service" have been
OrthoCon 2021.

Aga Khan University Hospital, Karachi, Pakistan. References

Correspondence: Masood Umer. Email: 1. Dixon A. The United Nations Decade of Healthy Ageing requires

J Pak Med Assoc (Suppl. 5)

S-3 34th International Pak OrthoCon Conference 2021

concerted global action. Nat Aging. 2021; 1:2- https://doi.org/ Joint Surg Am. 2016; 98:e109.
10.1038/s43587-020-00011-5. 5. Noordin S, Allana S, Masri BA. Establishing a hospital based
2. Radosavljevic N, Nikolic D, Lazovic M, Jeremic A. Hip fractures in fracture liaison service to prevent secondary insufficiency
a geriatric population - rehabilitation based on patients needs. fractures. Int J Surg. 2018;54(Pt B):328-32.
Aging Dis. 2014;5:177-82. 6. Accelerated surgery versus standard care in hip fracture (HIP
3. Quatman CE, Switzer JA. Geriatric Orthopaedics: a New Paradigm ATTACK): an international, randomised, controlled trial. Lancet.
for Management of Older Patients. Curr. Geriatr. Rep. 2017;6:15-9. 2020;395:698-708.
4. Bunta AD, Edwards BJ, Macaulay WB, Jr., Jeray KJ, Tosi LL, Jones 7. Shah AA, Kumar S, Shakoor A, Haroon R, Noordin S. Do delays in
CB, et al. Own the Bone, a System-Based Intervention, surgery affect outcomes in patients with inter-trochanteric
Improves Osteoporosis Care After Fragility Fractures. J Bone fractures? J Pak Med Assoc. 2015;65(11 Suppl 3):S21-4.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-4

ORIGINAL ARTICLE
Frequency of angular malalignment after intramedullary nailing for femur shaft
fractures — A cross-sectional study
Hammad Naqi Khan, Moiz Ali, Rizwan Haroon Rashid, Yasir Mohib, Pervaiz Hashmi

Abstract
Objective: To determine the frequency of angular malalignment of femur in patients undergoing Intra Medullary
nailing for femur shaft fracture by measuring axis on immediate postoperative plain radiographs.
Methods: A cross-sectional study was conducted at the Section of Orthopaedics, Department of Surgery, Aga Khan
University Hospital, Karachi from 1st January 2019 till 30th June 2019. All patients between the ages of 15 to 80 years
who underwent IM nailing for femur shaft fractures were included. Angulation was measured on immediate post-
operative X-ray films and an angle of ≥5° on AP and/or lateral views was defined as malalignment.
Results: A total of 65 patients were enrolled in the study with a mean age of 39.9 ± 16.5 years. Majority of the
patients,49 (75.4) were males and road traffic accidents were found to be the most common mechanism of injury.
Malalignment after surgery was encountered in 6(9.2%) patients. Proximal femur fractures were noted to be
significantly associated with malalignment with a p-value of 0.014.
Conclusion: This shows that frequency rate of malalignment after IM nail for femoral shaft fractures in a developing
country like Pakistan is comparable to internationally reported literature and proximal femur fracture is a risk factor
for malalignment.
Keywords: Angular malalignment, Femur, fracture, Intramedullar Nailing. (JPMA 71: S-4 [Suppl. 5]; 2021)

Introduction is one of the complications reported in literature which

can lead to non-union and may result in a need for re-do
Femur bone has always been a source of fascination for
surgery with reconstruction.6
orthopaedic surgeons and femoral shaft fractures are one
of the most commonly encountered fractures in Hence the objective of this study was to determine the
orthopaedic surgery.1 In healthy individuals, femur frequency of angular malalignment of femur in patients
fracture usually occurs as a result of high velocity trauma undergoing IM nailing for femur shaft fracture by
and is often associated with multiple complex injuries measuring axis on immediate postoperative plain
resulting in a life threatening injury pattern.1 radiographs.
As femur is an important load bearing bone, its Methods
fractures can lead to significant disability and
A cross-sectional study was conducted at the Section of
morbidity, unless appropriate treatment is received in
Orthopaedics, Department of Surgery, Aga Khan
time.2,3 Some of the factors influencing the choice of
University Hospital, Karachi, from 1st January 2019 till
treatment include age of the patient, location and type
30th June 2019. All patients between the ages of 15 to 80
of fracture, degree of comminution and socio-economic
years who underwent IM nailing for femur shaft fractures
status of the patient.2
were included in the study. Patients with any known
Although multiple implants are available for metabolic bone diseases, who underwent IM nailing for
management of femoral shaft fractures, interlocking deformities other than femur shaft fracture, or who were
intramedullary (IM) nail is currently considered the gold treated with flexible nails were excluded. Approval was
standard for treatment.1,4 Few of the major advantages of obtained from the ethical review committee of the
IM nail include high union rates and early mobilization of institution.
the limb.5 Though complication rates after IM nailing of Informed consent was taken from all included patients
femur are low, there are still certain pitfalls. Malalignment and baseline characteristics were recorded including
demographic details (age and gender), name, mechanism
Department of Orthopedic Surgery, Aga Khan University Hospital, Karachi, of injury, fracture site and side, type of nailing technique
Pakistan. (antegrade/retrograde) and degree of angulation.
Correspondence: Hammad Naqi Khan. Email: drhammadnaqikhan@gmail.com Angulation was measured through a standardized

J Pak Med Assoc (Suppl. 5)

S-5 34th International Pak OrthoCon Conference 2021

computer software on immediate post-operative X-ray Table-2: Association of patient characteristics with malalignment.
films using antero-posterior and lateral views. The angle
measured was at the point of intersection of two lines Patient Mal-alignment P-value
Characteristics Present (%) Absent (%)
drawn from anatomical axis of proximal and distal
segments of femur respectively. Malalignment was Gender 0.54
defined as presence of greater than 5° varus/valgus Male 5 (10.2) 44 (89.8)
angulation on antero-posterior radiograph and/or Female 1 (6.2) 15 (93.8)
presence of greater than 5° flexion/extension on lateral Mechanism of Injury 0.1
radiograph.7 All surgeries were performed by experienced Road Traffic Accident 5 (11.6) 38 (88.4)
orthopaedic surgeons with at least 5 years of experience Fall NIL (0.0) 18 (100)
and same type of prosthesis was used for all procedures. Gunshot NIL (0.0) 2 (100)
Sample size was calculated by using WHO Sample size Others 1 (50.0) 1 (50.0)
Fracture Location 0.014
calculator.8 Confidence level (1-a %) was taken as 95%,
Proximal 5 (25.0) 15 (75.0)
with precision (d) of 0.07 and taking the frequency of mal- Middle 1 (2.5) 39 (97.5)
alignment from literature as 9%. Considering the Distal NIL (0.0) 5 (100)
frequency of femur fracture presented to our institute, the Type of Nail 0.61
largest sample size that was calculated for the frequency Anterograde 6 (10.0) 54 (90.0)
of malalignment was 65. Retrograde NIL (0.0) 5 (100)

Data was analysed using SPSS version 21. All quantitative

the patients were males and road traffic accidents were
variables are represented as mean ± standard deviation
found to be the most common mechanism of injury as
while all qualitative variables are expressed in terms of
shown in Table-1. Fracture of mid shaft of femur was
percentages. Data was checked for normality using
noted to be more common than proximal and distal
Shapiro-Wilk test. Chi-square and Independent sample T-
femur fractures. Majority of the patients 60(92.3%)
tests were used where appropriate and p-value of <0.05
underwent anterograde nailing while 5(7.7%) underwent
was taken as significant.
retrograde nailing of the femur.
Results In terms of evaluation of malalignment of femur, 6
A total of 65 patients were enrolled in the study with the (9.2%) patients were noted to have malalignment after
mean age being 39.9 ± 16.5 years. Majority, 49 (75.4) of surgery while 59 (90.8%) patients had no malalignment.
The mean age of patients with malalignment was noted
Table-1: Baseline Characteristics of study population. to be 35.8 ± 2.2 years compared to 40.4 ± 17.3 years for
those who had no malalignment, however the
Patient Characteristics Frequency (%) / difference was not found to be statistically significant
Mean ± Standard deviation (p= 0.07). Association of multiple patient characteristics
with presence or absence of malalignment is shown in
Mean Age (years) 39.9 ± 16.5 Table-2. Proximal femur fractures were noted to be
Gender significantly associated with malalignment with a p-
Male 49 (75.4)
value of 0.014.
Female 16 (24.6)
Mechanism of Injury Discussion
Road Traffic Accident 43 (66.2)
Fall 18 (27.7) The incidence of femoral shaft fractures is reported to
Gunshot 2 (3.1) vary between 10-21 per 100,000 persons/year and
Others 2 (3.1) therefore is of great significance in orthopaedic practice.9
Laterality Timely management of this fracture is necessary to avoid
Right 38 (58.5) considerable morbidity and disability, hence multiple
Left 27 (41.5)
treatment modalities have been used for internal fixation
Fracture Location
Proximal 20 (30.8) of femur fractures.2,3 With advancement in technology,
Middle 40 (61.5) femur IM nail has evolved as the gold standard for
Distal 5 (7.7) treatment of femur shaft fractures irrespective of their
Type of Nail location (proximal, middle or distal).4 Various advantages
Anterograde 60 (92.3) of IM nailing of femur include short hospital stay, early
Retrograde 5 (7.7) functional mobilization of limb and high union rates.10

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-6
Despite multiple advantages, femur IM nail also has some difficulty during intra-operative reduction and are prone
associated complications. Malalignment of femur after to varus malalignment due to strong forces acting on
treatment with IM nail is one of the most feared proximal femur segment by surrounding musculature
complications which may result in non-union and need including abductors (e.g Gluteus medius and minimus)
for second surgery.6 Presence of mal-rotation after and adductors.3,16
fixation and limitation in functional outcomes and
quality of life have also been reported in international The results of the current study are comparable to
literature and are an area of concern for orthopaedic internationally reported literature and therefore show
surgeons.5,9,11 that IM nail can be successfully used in developing
countries for femoral shaft fractures.7 However, there is
Malalignment after IM nailing has been described as still considerable lack of literature on complications
either rotational or angular.11 Rotational malalignment associated with IM nail specially from developing
has been defined as presence of >15° of rotation either countries like Pakistan. In addition, post-operative
internally or externally. Numerous studies have evaluated malalignment is an important complication which can
its significance and its incidence has shown to vary from lead to non-union but there is very little international
22 to 52% in international literature.11-14 However, there literature available on its incidence and risk factors.
are very few studies evaluating angular malalignment Hence, there is need to conduct large multi-centre
which has been defined as >5° of varus or valgus studies from the developing world to evaluate its
deformity after fixation.7 incidence and add on to internationally available
literature.
A study conducted in Malaysia in 2017 with a sample
size of 179 patients showed a frequency rate of 2.8% for Conclusion
angular malalignment after IM nail for femoral shaft
fractures. All patients were noted to have proximal shaft The current study shows that incidence rate of
fractures although this finding was not found to be malalignment after IM nail for femoral shaft fractures in a
statistically significant.3 Similarly, in another study, developing country like Pakistan is comparable to
William MR et.al noted an angular malalignment rate of internationally reported literature and proximal femur
9% after IM nail for femur shaft fractures. They also fracture is a risk factor for malalignment.
found a significant association between unstable Disclaimer: None.
fracture pattern in addition to distal and proximal
fracture location with malalignment.7 In contrast, Wilson Conflict of Interest: None.
NM et. al conducted a study in 2019 to compare post-
Funding Disclosure: None.
operative alignment in femoral shaft fractures after
fixation with retrograde standard Surgical Implant References
Generation Network (SIGN) nail vs fixation with
1. Umer M, Niazi A, Hussain D, Ahmad M. Treatment of acute
retrograde Fin nail. They reported no case of fractures of the femoral shaft with reamed intramedullary
malalignment in both groups.15 interlocking AO nails. J Pak Med Assoc. 2004;54:423-6.
2. Xiong R, Mai QG, Yang CL, Ye SX, Zhang X, Fan SC. Intramedullary
The current study also shows a frequency of 9.2% for nailing for femoral shaft fractures in adults. The Cochrane
angular malalignment after femoral IM nail which is database of systematic reviews. 2018;2018(2).
comparable to previously reported literature.7 A slightly 3. Sadagatullah A, Nazeeb M, Ibrahim S. Incidence of varus
malalignment post interlocking nail in proximal femur shaft
increased rate can be attributed to the fact that this study fractures comparing two types of entry points. Malays. Orthop. J.
was conducted in a developing country with limited 2017;11:31.
resources and lack of awareness amongst general 4. Rudloff MI, Smith WR. Intramedullary nailing of the femur: current
population. As a result, most patients tend to present late concepts concerning reaming.. J. Orthop. Trauma.2009;23:S12-S7.
5. Lindsey JD, Krieg JC. Femoral malrotation following
which makes intra-operative reduction and appropriate intramedullary nail fixation. J Am Acad Orthop Surg 2011;
alignment even more challenging. 19:17-26.
6. Watanabe Y, Matsushita T. Femoral non-union with
This study also identified proximal femur fractures as a malalignment: reconstruction and biological stimulation with the
significant risk factor for malalignment as has been chipping technique. Injury. 2016;47:S47-S52.
described in international literature. Ricci WM et. al in 7. Ricci WM, Bellabarba C, Lewis R, Evanoff B, Herscovici D,
DiPasquale T, et al. Angular malalignment after intramedullary
their study concluded that fractures of proximal third of
nailing of femoral shaft fractures. J. Orthop. Trauma. 2001;15:90-5.
femur are at a considerably higher risk for 8. Lwanga SK, Lemeshow S. World Health Organization. Sample Size
malalignment.7 Proximal femur fractures pose great Determination in Health Studies: A Practical Manual; 1991

J Pak Med Assoc (Suppl. 5)

S-7 34th International Pak OrthoCon Conference 2021

9. Tufek T, Kinikli G?, Caglar O. sat0721-hpr investigation of decubitus position. SICOT-J. 2018;4.
functional outcomes and quality of life in young adults with 13. Liebrand B, de Ridder V, de Lange S, Kerver B, Hermans J. The
internal fixation surgery of femoral shaft fracture. Ann Rheum Dis. clinical relevance of the rotational deformity after femoral shaft
2019;78(Suppl 2):1462-. fracture treated with intramedullary nailing. C. 2002;10:86-93.
10. Winquist R, Hansen S, Clawson D. Closed intramedullary nailing of 14. Jaarsma R, Pakvis D, Verdonschot N, Biert J, Van Kampen A.
femoral fractures. A report of five. J Bone Joint Surg Am. Rotational malalignment after intramedullary nailing of femoral
1984;66:529-39. fractures. J Orthop Trauma. 2004;18:403-9.
11. Hüfner T, Citak M, Suero EM, Miller B, Kendoff D, Krettek C, et al. 15. Wilson NM, Shaw JT, Malaba M, Yugusuk FL, Nyambati P, Siy AB, et
Femoral malrotation after unreamed intramedullary nailing: an al. Satisfactory postoperative alignment following retrograde
evaluation of influencing operative factors. J Orthop. Trauma. SIGN Fin nailing for femoral shaft fractures: A case-control study.
2011;25:224-7. Ota International. 2019;2:e024.
12. Abubeih HM, Farouk O, Abdelnasser MK, Eisa AA, Said GZ, El-adly 16. McMillan TE, Stevenson IM. Subtrochanteric fractures of the hip. J
W. Femoral malalignment after gamma nail insertion in the lateral Orthop Trauma. 2016;30:109-16.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-8

RESEARCH ARTICLE
Frequency of osteoarthritis and functional outcome of operated tibial plateau
fractures: A minimum of 5 years follow up
Mohammad Tahir, Sandeep Kumar, Saeed Ahmed Shaikh, Allah Rakhio Jamali

Abstract
Objective: Tibial plateau is an important weight bearing surface and its fractures are the result of axial compressive
forces. Post-traumatic osteoarthritis (PTOA) occurs despite anatomical joint reconstruction. In this study we
determined the incidence of PTOA after primary management of tibial plateau fractures and determined the risk
factors of PTOA of patients whose results were published at 24 months and now we present a five year follow up of
the same patients.
Methods: In this study, we presented the prospective data of 109 patients who were managed for tibial plateau
fractures, from August 2009 to June 2018 a Jinnah postgraduate medical centre. Data of patients regarding clinical
and radiological, functional outcome (according to the American Knee Society criteria), post-procedural visual
analogue scale (VAS) pain score was included. Incidence of development of PTOA was noted in each patient using
the Ahlbäck classification.
Result: Out of 109 patients with tibial plateau fractures, 81 (74.3%) were male and 28 (25.7%) were female. Mean
time lag from injury to surgery was 10.14±9.07 days. Overall incidence of osteoarthritis was 50 (45.9%). Advanced
age >50 years (odds ratio 9.1 (3.7-22.1), p-value <0.0001), female gender (odds ratio; 3.40 (1.36-8.46), p-value 0.007),
VAS score >4 ((odds ratio; 73.28 (15.7-341.5), p-value <0.001)), Articular depression (odds ratio; 35.25 (11.49-108.1),
p-value <0.001) and degree of mal-alignment (odds ratio; 25.72 (9.30-71.12), p-value <0.001) were found to be the
risk factors of PTOA. While excellent functional outcomes were protective for PTOA (odds ratio; 4.8, p-value <0.001).
Thirty out of fifty patients (60%) suffering from secondary arthritis of the knee required knee replacement (TKR).
Twenty-one patients (70%) were males that underwent TKR.
Conclusion: There is a high proportion of osteoarthritis following tibial plateau fixation. The risk factors that related
to the development of secondary arthritis our cohorts were increased age, male gender, a decrease in AKSS and a
higher VAS group. Knee arthroplasty is the only option for our cohorts with severe posttraumatic arthritis.
Keywords: Osteoarthritis, tibial plateau fractures, American Knee Society and visual analogue scale.
(JPMA 71: S-8 [Suppl. 5]; 2021)

Introduction axis. Therefore, the presence of residual incongruity could

lead to joint stiffness and is a known contributing risk
Bicondylar fractures of the proximal tibia (Schatzker V and
factor for posttraumatic osteoarthritis (PTOA).7,8
VI) occur as a result of axial loading together with
varus/valgus applied forces, which leads to articular There is variable evidence of secondary arthritis present in
depression and malalignment.1,2 In the absence of a the literature, around 25% to 45% of patients with
unified treatment protocol for tibial plateau fractures, fractures of the tibial plateau having a radiological
these fractures represent with a broad spectrum of evidence of PTOA at long term follow up.1,5,9-12
severity ranging from simple injuries with predictably
excellent outcome after nonoperative treatment to The development of arthritis is related to the following
complex fracture patterns that challenges even most factors; increased age (increased chances of
experienced surgeons.3-5 Moreover, surgical osteoporosis), the complexity of the fracture, lower limb
management of these high-velocity fractures can be malalignment, mechanics of fracture, early range of
demanding and are prone to intra operative challenges of motion for cartilage nourishment and preservation have a
maintaining reduction, alignment and stability.6 significant impact on the overall prognosis and
development of osteoarthritis.1,11,12
As the knee is a weight-bearing joint, the anatomical
reduction is pivotal for the restoration of the mechanical Osteoarthritis leads to pain, swelling, stiffness, muscle
weakness and joint instability, all of which can result in
Department of Orthopaedics, Jinnah Postgraduate Medical Centre, Karachi, impairment of physical function, a decline of life quality
Pakistan. and may have significant socio-economic influence. Total
Correspondence: Mohammad Tahir. Email: doctor.muhammad.tahir@gmail.com knee replacement (TKR) remains the only viable option in

J Pak Med Assoc (Suppl. 5)

S-9 34th International Pak OrthoCon Conference 2021

severe cases of secondary arthritis of the knee. TKR allows fracture pattern, displacement of fragments, and
a painless joint, restoration of the alignment and provides depression of fragments were also noted. Preoperative
mobility to the patient. computed tomography (CT) scan findings, intraoperative
findings, and data regarding the course in the hospital
Since there are no studies published at national level that
describe the incidence of PTOA following tibial plateau were collected from the inpatient records.
fractures, the primary aims of this study were to assess the After discharge from the hospital, the patients had been
functional outcome in terms of the American knee society followed up in the outpatient clinic, and functional
score (AKSS) and Visual Analogue Scale (VAS) and to outcome was assessed using the American Knee Society
evaluate the frequency of PTOA after surgical
criteria and development of osteoarthritis using the
management of proximal tibia fractures after a minimum
Ahlbäck classification. The pain was assessed using the
of five years follow up. While the secondary aim was to
visual analogue scale (VAS) and patients who underwent
assess the frequency of patients undergoing TKR
secondary to PTOA following plateau fractures. total knee replacement was noted.
Data were analysed using SPSS Version 20. Mean, and the
Methods
standard deviation was calculated for quantitative data.
Following the permission of ethics review committee Frequency and percentages were calculated for
of the hospital, a prospective study was conducted in
qualitative variables. Univariate/multivariate analysis was
the Department of Trauma & Orthopaedic Surgery,
performed to determine the baseline and surgical risk
Jinnah Postgraduate Medical Centre, Karachi from
factors of PTOA after primary treatment and odds ratio
August 2009 to June 2018.
was calculated. Level of significance was taken as 0.05.
Inpatient records of all patients 18
years and above treated for Schatzker
type V and VI managed by two
different modalities dual plating and
Ilizarov between 2009 and 2014 were
traced from the medical record
department and included in the study.
Patients with pathological fractures,
floating knee, severe head injury,
polytrauma and significant
comorbidities like congestive heart
failure, hypertension, chronic liver
disease, stroke or obstructive lung
disease were excluded from the study.
Also, patients having a follow-up of
fewer than five years were excluded
from the study protocol (Figure-1).13
After finding the records of bicondylar
tibial plateau fractures that were
operated between august 2009 and
June 2014 patients were contacted
and 109/137 came to fracture clinic
and their patient reported outcomes
were recorded.
Preoperative data, including
demographic data, mode of injury, the
time lag between injury and primary
surgery and fracture classification,
according to Schatzker, was collected.
Radiographic findings, including the Figure-1: Consort diagram.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-10
Results 24.23±8.60 days, respectively. Functional outcome
according to the AKSS was excellent (80-100) in 17
A total of 109 patients with tibial plateau fractures who
(15.6%), good (70-79) in 35 (32.1%), whereas 24 (22%) had
met the eligibility criteria were enrolled in the study. The
a fair (60-69) outcome and 33 (30.3%) were rated as poor
mean age of the study population was 50.80±10.16 years
(less than60) results. Out of the total 109 patients, 50
with a male predominance of 74.3% (81). Mechanism of
(45.9%) patients developed PTOA with a mean follow up
injury distribution showed that 76 (69.7%) had a road
of 73.21±10.19 months. Thirty out of fifty patients (60%)
traffic accident, 20 (18.3%) had fallen from a height, and
suffering from secondary arthritis of the knee required
13 (11.9%) had gunshot injury. According to the fracture
knee replacement out of which 66.7% were of age >50
pattern, Schatzker Type VI were 61 (56%) cases, whereas
years. Twenty-one (70%) patients were males that
type V fractures accounted for 48 (44%) cases in the study
population, respectively (Table-1).
Table-2a: Data of study related variables.
Out of 109, 55 (50.5%) patients were managed by dual
plating, and 54 (49.5%) patients underwent Ilizarov. The Patient Characteristics Value
mean time lag between injury and primary surgery
was10.14±9.07 days, and time to weight-bearing was Mean duration between injury and
primary surgery (days) 9.07
Table-1: Data of baseline variables. Type of surgery Plating 55 50.5%
Patient Characteristics Value Ilizarov 54 49.5%
American knee society score Excellent 17 15.6%
Age Good 35 32.1%
Age group 15-50 Years 51 46.8% Fair 24 22%
>50 Years 58 53.2% Poor 33 30.3%
Gender Male 81 74.3% VAS Score I-III 71 65.1%
Female 28 25.7% IV-V 38 34.9%
Mechanism of injury RTA 76 69.7% Mean time to walking without aid (weeks) 24.45 8.60
Fall 20 18.3% Mean time to follow-up (months) 73.21 10.19
Gunshot 13 11.9% Osteoarthritis Yes 50 45.9%
Schatzker type V 48 44% No 59 54.1%
VI 61 56% Total knee replacement Yes 30 27.5%
No 79 72.5%
RTA: Road Traffic Accident

Table-2b: Risk factors of post-operative osteoarthritis.

Osteoarthritis Relative Risk P-value
Yes (50) No (59)

Age <50 Years 10 (19.6%) 41 (80.4%) 18.49 <0.001

>50 Years 40 (69%) 18 (31.0%)
Gender Male 31 (38.3%) 50 (61.7%) 0.56 0.006
Female 19 (67.9%) 9 (32.1%)
Schatzker type V 21 (43.8%) 27 (56.3%) 0.92 0.69
VI 29 (47.5%) 32 (52.5%)
Type of Injury RTA/Fall 42 (43.8%) 54 (56.3%) 8.57 0.17
Gunshot 08 (61.5%) 05 (38.5%)
Type of Surgery Dual plating 21 (38.2%) 34 (61.8%) 0.71 0.12
Ilizarov 29 (53.7%) 25 (46.3%)
American knee society score Excellent 0 (0.0%) 17 (100%) -4.8 <0.001
Good 4 (11.4%) 31 (88.6%) 3.54
Fair 13 (54.2%) 11 (45.8%) 3.87
Poor 33 (100%) 0 (0.0%) 2.80
VAS Score after Surgery I-III 14 (19.7%) 57 (80.3%) 0.21 <0.001
>IV 36 (94.7%) 2 (5.3%)
Articular Depression 0-2 mm 05 (9.6%) 47 (90.4%) 0.12 <0.001
3-7 mm 45 (78.9%) 12 (21.1%)
Degree of Mal-alignment 0-4 08 (14.0%) 49 (86.0%) 0.17 <0.001
>5° 42 (80.8%) 10 (19.2%)
VAS: Visual Analogue Score

J Pak Med Assoc (Suppl. 5)

S-11 34th International Pak OrthoCon Conference 2021

underwent TKR (Table-2a). noticed that older patients had more advanced secondary
osteoarthritis and unsatisfactory functional outcome at
On univariate/multi-variate analysis, advanced age >50 follow-up when compared with younger patients.15
years (odds ratio 9.1 (3.7-22.1), p-value <0.0001), female Honkonen et al. observed that patients under 50 years at
gender (odds ratio; 3.40 (1.36-8.46), p-value 0.007) were the time of tibial plateau fractures had signs of PTOA only
found to be the risk factors of posttraumatic osteoarthritis in the injured knee, whereas patients above 50 years had
(PTOA). While excellent functional outcomes according to findings of secondary osteoarthritis in both the injured and
AKSS were protective for PTOA (odds ratio; -4.8, p-value the uninjured knee.1
<0.001). VAS score more than IV was also found to be
significant factor of PTOA (odds ratio; 73.28 (15.7-341.5), Majority of patients 74.3% were males attributed to our
p-value <0.001). Articular depression (odds ratio; 35.25 social values that men work outdoor. These findings are in
(11.49-108.1), p-value <0.001) and degree of mal- keeping with another Indian study done by Jagdev et al.
alignment (odds ratio; 25.72 (9.30-71.12), p-value <0.001) who reported an incidence of PTOA in 73.3% of the
were also significantly associated with PTOA (Table-2b). population with a mean age of 41.28 years with male
domination of 51 out of 60 cases (85%) relating to our
Discussion society's norms.16
In this study we present the five year follow up results of Several scoring systems have been used to evaluate the
our previously published results of tibial plateau fractures functional outcome of tibial plateau fractures. We
at 24 months. There was a high proportion of patients assessed the outcome using the American Knee Society
(45.9%) that developed osteoarthritis following the functional score having scores between 0 and 100, with a
surgical management of tibial plateau fractures in our higher number indicating good prognosis. Our study
study which coincided with the works of Honkonen et al. showed a strong correlation with the functional outcome
who reported a 44% incidence of secondary arthritis of the of the patient (AKSS and VAS) and the development of
knee.1 Likewise, Rademakers et al. reported a 27% secondary arthritis (p-value 0.00, CI 95%).
incidence of arthritis with symptomatic degeneration in
cases with malalignment of more than 5 degrees over 14 The outcome of our study was excellent at 15.6% and
years, whereas Manidakis et al. reported osteoarthritis in good at 32.1%, whereas fair and poor were 22% and 30.3%
26.40% patients in his series of 125 patients over 20 respectively. Jagdev et al. graded his patients according to
months respectively.9,11 Another large study with follow the AKSS and achieved an excellent outcome in 86.67% of
up of 14 years by Volpin et al. reported the incidence of the cases, 6.66% were graded as good, whereas in 5% fair
secondary arthritis to be 23% which developed within 6-8 outcome was attained and in 1.67% patients had a poor
years of follow up in patients with tibial plateau fractures.12 result.16 Manidakis et al. reported good outcomes in 86
cases (69%), fair in 30 (24%) and poor in 9 (7%).9 The
Our results are comparable with other published studies difference between the occurrence of osteoarthritis and
such as Volpin et al. and Honkonen et al1,12. who observed AKSS group was statistically significant (p=0.001).
PTOA within 6-8 years. Mehin et al. reported endstage
arthritis with a mean delay of 4 years following treatment We found that VAS score >4 is a significant predictor of
of the initial injury.10 However, our results are only for PTOA in the follow-up period. Manidakis et al. also reported
bicondylar fractures of the proximal tibia, whereas the a similar outcome.9 This can be valuable in informing
patients about the outcome that can be expected.
previous studies have included all Schatzker fractures
ranging from I to VI, respectively. These studies have Furthermore, 30 (60%) patients required TKR out of which
emphasized the fact that metaphyseal fractures of the 70% were males, and 66.7% were of age >50 years. The
proximal tibia are hard to reduce, align and stabilise. In mean age reported in Scott et al. cohorts was 65.7 years17
addition, the pattern of injury, range of motion and Weiss et al. also reported a similar age of 63 years as
cartilage nourishment influence the development of compared to Scott et al.18
osteoarthritis.14
In the present study, we found very strong association of
Age and gender had an impact on the development of degree of malalignment (>5°) and articular depression >2
osteoarthritis in our cohorts with the maximum incidence mm with the onset of osteoarthritis in the follow-up
of PTOA observed in the age group > 50 (p=0.01). Stevens period. Parkkinen et al. also reported that mal-alignment
et al. pointed out that the age of the patient was strongly and articular depression have a very strong association
related to the development of secondary arthritis following with the development of PTOA in the follow-up period.
the injury of the proximal tibia.5 Likewise, Parkkinen et al. They further reported that PTOA is more severe is patients

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-12
with higher degree of malalignment.14 Another latest J Orthop Trauma. 1995;9:273-277.
study by Parkkinen et al. also reported similar results, they 2. Lansinger O, Bergman B, Korner L, Andersson GB. Tibial condylar
fractures. A twenty-year follow-up. J Bone Joint Surg Am.
reported that initial articular depression of >2 mm and 1986;68:13-19.
mal-alignment >4° is a significant predictor of PTOA after 3. Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB, Benirschke SK.
management of tibial plateau fractures.19 Functional outcomes of severe bicondylar tibial plateau fractures
treated with dual incisions and medial and lateral plates. J Bone
Our results are not immune to any shortcomings that the Joint Surg Am. 2006;88:1713-1721.
study was retrospective with a 24 month outcomes with a 4. Oh CW, Oh JK, Kyung HS, et al. Double plating of unstable
proximal tibial fractures using minimally invasive percutaneous
prospective follow up to a minimum five years per osteosynthesis technique. Acta Orthop. 2006;77:524-530.
patient, with different reported patient reported 5. Stevens DG, Beharry R, McKee MD, Waddell JP, Schemitsch EH.
outcomes instruments utilized in both studies, and The long-term functional outcome of operatively treated tibial
conducted at a single centre. On the other hand, the plateau fractures. J Orthop Trauma. 2001;15:312-320.
6. Barei DP, Nork SE, Mills WJ, Henley MB, Benirschke SK.
strengths of this study are a long follow up period and
Complications associated with internal fixation of high-energy
being conducted at an urban level 1 trauma centre. bicondylar tibial plateau fractures utilizing a two-incision
Furthermore, to our knowledge this is the first study from technique. J Orthop Trauma. 2004;18:649-657.
Pakistan that gives an insight on the midterm results of 7. Marsh JL, Buckwalter J, Gelberman R, et al. Articular fractures: does
surgically operated tibial plateau fractures. an anatomic reduction really change the result? J Bone Joint Surg
Am. 2002;84:1259-1271.
8. Papagelopoulos PJ, Partsinevelos AA, Themistocleous GS,
Conclusion Mavrogenis AF, Korres DS, Soucacos PN. Complications after tibia
There is a high proportion of osteoarthritis following tibial plateau fracture surgery. Injury. 2006;37:475-484.
plateau fixation. The risk factors that related to the 9. Manidakis N, Dosani A, Dimitriou R, Stengel D, Matthews S,
Giannoudis P. Tibial plateau fractures: functional outcome and
development of secondary arthritis in our cohorts were incidence of osteoarthritis in 125 cases. Int Orthop. 2010;34:565-570.
increased age, male gender, a decrease in AKSS and a 10. Mehin R, O'Brien P, Broekhuyse H, Blachut P, Guy P. Endstage
higher VAS group. Knee arthroplasty is the only option for arthritis following tibia plateau fractures: average 10-year follow-
our cohorts with severe posttraumatic arthritis. up. Can J Surg. 2012;55:87-94.
11. Rademakers MV, Kerkhoffs GM, Sierevelt IN, Raaymakers EL, Marti
Acknowledgements: The authors would like to thank RK. Operative treatment of 109 tibial plateau fractures: five- to 27-
year follow-up results. J Orthop Trauma. 2007;21:5-10.
Alexander Swenson for making the graphical abstract 12. Volpin G, Dowd GS, Stein H, Bentley G. Degenerative arthritis after
which was presented as an e-poster at the 40th SICOT intra-articular fractures of the knee. Long-term results. J Bone
World Congress in Muscat 2019 held between 4-7 Joint Surg Br. 1990;72:634-638.
December 2019. 13. Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC,
Devereaux PJ, et al. CONSORT 2010 explanation and elaboration:
Disclosure of Funding: This project was not funded by updated guidelines for reporting parallel group randomised trials.
any organization, and the authors received no financial Int J Surg. 2012;10:28-55
14. Tahir M, Kumar S, Shaikh S A, Jamali RA. Comparison of
support for the research, authorship, and/or publication Postoperative Outcomes Between Open Reduction and Internal
of this article. Fixation and Ilizarov for Schatzker Type V and Type VI Fractures.
Cureus 2019,11: e4902. doi:10.7759/cureus.4902
Disclosure: The study won the SICOT/ Hull Deformity 15. Parkkinen M, Madanat R, Mustonen A, Koskinen SK, Paavola M,
Course Award at the 40th SICOT World Congress in Lindahl J. Factors predicting the development of early
Muscat 2019 held between 4-7 December 2019. osteoarthritis following lateral tibial plateau fractures: mid-term
clinical and radiographic outcomes of 73 operatively treated
Conflict of Interest: The authors declared no potential patients. Scand J Surg. 2014;103:256-262.
16. Jagdev SS, Pathak S, Kanani H, Salunke A. Functional Outcome
conflicts of interest with respect to the research,
and Incidence of Osteoarthritis in Operated Tibial Plateau
authorship, and/or publication of this article. Fractures. Arch Bone Jt Surg. 2018;6:508-516.
17. Scott CE, Davidson E, MacDonald DJ, White TO, Keating JF. Total
Ethical Committee Approval: The study was approved knee arthroplasty following tibial plateau fracture: a matched
by the Institutional Review Board Committee of Jinnah cohort study. Bone Joint J. 2015;97-B:532-538.
Postgraduate Medical Centre, Karachi, Pakistan with the 18. Weiss NG, Parvizi J, Hanssen AD, Trousdale RT, Lewallen DG. Total
IRB number of NO.F.2-81/ GENL-2019/ 18270/ JPMC. knee arthroplasty in post-traumatic arthrosis of the knee. J
Arthroplasty. 2003;18:23-26.
19. Parkkinen M, Lindahl J, Mäkinen TJ, Koskinen SK, Mustonen A,
References Madanat R. Predictors of osteoarthritis following operative
1. Honkonen SE. Degenerative arthritis after tibial plateau fractures. treatment of medial tibial plateau fractures. Injury. 2018;49:370-5.

J Pak Med Assoc (Suppl. 5)

S-13 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
Functional and radiological outcomes of atypical femur fractures among elderly
in Karachi, Pakistan
Rizwan Haroon Rashid, Marij Zahid, Usama Khan, Yasir Mohib, Pervaiz Hashmi

Abstract
Objective: To assess the functional and radiological outcomes in a unique class of fractures i.e. atypical femur
fractures and to assess the effects of osteoblastic agents in healing.
Methods: It is a retrospective observational study conducted at Aga Khan University Hospital, Karachi, Pakistan. All
patients with atypical femur fractures who were surgically managed with intramedullary nailing from January, 2013
to June, 2017 and with a follow-up till December 2019, were included in the study. Radiological outcomes were
expressed as mean healing time and functional outcomes were recorded as mean Short Musculoskeletal Functional
Assessment (SMFA) score.
Results: A total of twenty-four patients were included in this study. Mean age of patients was 65.8 ± 8 years. Mean
healing time was 10 ±3.2 months post operatively. Two patients underwent redo procedures. No other
complications like paresthesia or weakness was observed in any patients. All the patients reported a good score on
SMFA ranging from 19% to 31%.
Conclusion: Intra-medullary nailing shows a promising result in treatment of atypical femur fractures. Use of post-
operative osteoblastic supplements showed statistically significant results with early healing time (p=0.008 [95%
CI]).
Keywords: Osteoporosis; Atypical femur fractures, Strontium, Teriperatide, Pathological fractures.
(JPMA 71: S-13 [Suppl. 5]; 2021)

Introduction atraumatic or low-energy trauma fractures located in the

sub-trochanteric region or femoral shaft.8 Patients usually
Over 200 million people suffer from osteoporosis
present with a history of prodromal pain in the affected
worldwide and is considered as a major health concern.1
thigh, months prior to the actual injury which should
Osteoporosis is considered to be the 2nd most critical
prompt a physician to ask specifically for bisphosphonate
health problem by the World Health Organization. In
use and then correlate with the radiology. Radiological
Pakistan the prevalence of osteoporosis is suggested to
features of AFFs are unique and include a simple
be 9.1 million and it is further estimated that this figure
transverse pattern with a uni-cortical break in an area of
was projected to rise by 11.3 million by the year 2020 cortical hypertrophy.7 The diagnosis of AFFs specifically
overburdening an already resource constrained excludes femoral neck fracture, high impact trauma
environment.2 These figures suggest a major burden of related fractures, pathological fractures associated with
osteoporosis in health sector of Pakistan. primary or secondary tumours, intertrochanteric
Bisphosphonates have been the first line therapy for fractures, and peri-prosthetic fractures.9 American Society
management of osteoporosis for the past 20 years.3,4 They for Bone and Mineral Research (ASBMR) has devised
reduce osteoclastic bone resorption and the net result is a criteria for diagnosing an atypical fracture with major and
rapid and substantial decrease in bone turnover markers minor features.10 Few drugs like bisphosphonates,
resulting in a modest increase in bone mineral density glucocorticoids, proton- pump inhibitors and medical
(BMD).5 It has been proposed that severe and prolonged conditions such as diabetes, rheumatoid arthritis and
suppression of bone turnover may impair the ability of vitamin D deficiency are included in the minor criteria.10
bone re-modelling leading to an accumulation of micro
damage and reduction of bone strength5-7 resulting in Understanding the scarce literature and need for
iatrogenic fractures. evaluation of these fractures this study was carried out for
better understanding of the outcomes of surgically
Atypical femoral fractures (AFFs) are defined as managed AFFs.

Department of Orthopedic Surgery, Aga Khan University Hospital, Karachi, Materials and Methods
Pakistan. This study was a retrospective observational study
Correspondence: Marij Zahid. Email: marijzh@gmail.com conducted at Aga Khan University Hospital, Karachi,

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-14
Pakistan after the institutional ethics review committee Table-1: Patient demographics and fracture characteristics.
approval (ERC# 4759-Sur-ERC-17). Patients who were
diagnosed for AFFs according to the ASBMR criteria10 and Variable Mean/Count (%)
surgically managed with intra medullary nail between
Mean Age (years) 65.5±8.0
January, 2013 to June, 2017 were included in this study Gender
and data was analyzed after final follow-ups of all patients Male 3 (12.5%)
in December 2019. Sample size was calculated via WHO Female 21 (87.5%)
sample size calculator tool estimating population Steroid Use
proportion of 0.9811 with absolute precision required of Yes 5 (20.8%)
0.06, the sample size required for the study was 21 No 19 (79.2%)
patients. We included 24 patients in our study. Patient's Mechanism of Injury
Ground level fall 22 (91.6%)
demographic data including age, gender, occupation,
Non traumatic 2 (8.3%)
duration of previous bisphosphonate use, mechanism of Prodromal Pain
injury, fracture site of femur either sub-trochanteric or Yes 6 (25%)
femur shaft, duration of surgery and post-operative use of No 18 (75%)
bone remodeling agents were collected from the Fracture location
patients' charts and recorded on a preformed structured Sub-trochanteric 20 (83.3%)
proforma. Serial radiographs were viewed to ascertain the Femur shaft 4 (16.6%)
fracture healing and consolidation on regular follow-ups.
Patients were followed for a minimum period of 24 Table-2: Stratified healing times according to osteoblastic agents.
months post operatively. Short Musculoskeletal
Functional Assessment (SMFA) score12 was calculated via Use of Supplement Mean (months) Significance
telephonic interview after verbal consent and used to
Yes (n=17) 7.24±2.0
assess the functional outcome of patients with a lesser Healing time No (n=7) 12.71± 3.3 0.08
score indicating better outcome. Categorical variables (months) Strontium (n=11) 7.36 ± 2.1
were recorded as frequency and percentages and chi- Teriparatide (n=6) 7.00 ± 2.0 0.73
square test or Fischer exact test was applied for analysis.
Continuous variables were expressed as means with for fracture healing was 10.8 ± 3.2 months. Five (20.83%)
standard deviation, Data was checked for normality via patients had dynamization of nail 3 months after index
Shapiro-Wilk test and student t-test was applied to surgery. Two (8.3%) patients underwent additional
compare means for analysis. A p-value of less than 0.05 procedures at 5th and 7th month respectively due to
was considered significant for inferential analysis. delayed union and were subjected to bone grafting. Both
Statistical package for the social sciences (SPSS) version patients healed after 4 months of second surgery. All the
20 was used for all analysis. patients reported a good score on SMFA with mean
26.29% ± 2.89 (range 19% to 31%). Mean follow up time
Results was recorded as 26.4±2.75 months (Range 24-35). All the
A total of 24 patients were included in this study of whom patients stopped using bisphosphonate after surgery.
21 were females and 3 were males. Mean age of the
patients was 65.5±8 years. Majority of the patients Interestingly accelerated fracture healing was associated
sustained ground level fall. Twenty (83.3%) fractures with use of osteoblastic agents like Strontium Ranelate
occurred in sub-trochanteric region while 4 (16.7%) were and Teriperatide which was given to the patients as per
femoral shaft fractures. Five patients out of 24 (20.8%) had surgeons' discretion. Patients who used any osteoblastic
a history of steroid use. Twenty-two patients took supplements post operatively showed a better mean
bisphosphonates for osteoporosis while 2 patients had healing time of 7.2 ± 2 months while mean healing time
never used them. Mean duration for bisphosphonates of 12.7 ± 3.3 months was observed in those patients who
usage was 6.4±1.3 years. None of the patients took any were not prescribed any agent (p=0.008). Eleven patients
other medication for osteoporosis prior to the fracture. Six were prescribed Strontium Ranelate as per treating
patients reported a history of prodromal thigh pain with a surgeons' discretion while 6 used Teriparatide as
mean duration of 1.6± 0.7 months (Table-1). osteoblastic agents. Patients using Strontium had a mean
healing time of 7.36±2.1 months while for Teriparatide
All the patients were surgically managed with group it was 7.0±2 months. Comparison of Strontium and
intramedullary nailing device (Figure-1 & 2). Mean Teriparatide using patients and mean healing time was
duration of hospital stay was 6.75 ±2.3 days. Mean time not found to be statistically significant (Table-2).

J Pak Med Assoc (Suppl. 5)

S-15 34th International Pak OrthoCon Conference 2021

The association between long-term bisphosphonate use

and unusual diaphyseal fractures was first described in
2005 by Odvina et al.13 Many studies have documented
this association14 while according to Rizzoli et al, this case
is yet unproven.15 For the past 2 decades,
bisphosphonates have been the main stay treatment for
the prevention of osteoporosis related fractures. In year
2005, it was reported that prolonged use of BP has
association with an unusual diaphyseal fracture and later
it was termed as atypical femoral fracture by ASBMR.16
The first report from the ASBMR task force published in
2010 showed lack of studies regarding management and
outcomes for atypical femoral fractures.10
Egol et al. had reported a good outcome of surgically
managed atypical femoral fractures with 98% of fractures
healing at 12 months, and 60% becoming pain free post-
operatively11 whereas in our study, mean healing time
was 10 months. Ha et al. studied the necessity of surgical
management for atypical femoral fractures and their
Figure-1: (a & b) X-ray's pelvis AP and femur AP views of a 68 year old lady with trivial study population reported a 100% healing rate after
injury showing left sided sub-trochanteric fracture with oblique pattern. (c & d) surgical fixation17 which is comparable to our study.
Postoperative radiographs at 6 months follow up showing intra-medullary nail in situ
and good healing at post-op 6 months. A case series of 21 patients of atypical femoral fractures
showed a positive relation with smoking and steroid use
while all the fractures were managed with intra medullary
nailing and only one had non-union and rest healed
uneventfully.18 In our study none of the selected patients
had history of smoking and 5 patients used steroids.
There was no significant relationship found for the usage
of steroids or cigarette smoking.
Ekstrom et al reported 25% mortality at 2 year follow-up
in patients managed surgically for atypical femoral
fractures, while 52% did not achieve the pre-fracture
quality of life.19 There were no reported mortality of
subjects in our study. In our data the SMFA scores were
reported to be good in patients with early healing time.
High scores were encountered in patients with delayed
Figure-2: (a & b) 72 year old lady 8 years on bisphosphonates had a low energy ground
union or who underwent additional procedures. Weil et.al
level fall , radiographs show left sided sub-trochanteric fracture with oblique pattern conducted a study which showed much higher failure
and medial beak with cortical thickening pathognomic of atypical fracture. (c & d) Post- rates with intra medullary nailing for atypical femoral
operative radiographs at 6 month follow up showing intra-medullary nail in situ and fractures and requiring revision surgery, 54% achieved
good healing at post-op 6 months 21. fracture healing while 46% had to undergo a revision
surgery.20 Subramanian et.al reported a good surgical
Discussion outcome for atypical femoral fractures with all the
patients having uneventful healing while only one
Atypical femurs are not uncommon but still are tricky to
fracture developed non-union requiring revision
pick and require prompt careful history taking and
surgery.18 Our study results showed that only two
assessment. The mechanism of action and fracture
patients had to undergo redo surgery due to non-union
pattern on radiographs are the key to correct diagnosis.
after initial management but later achieved union.
Our study delineates various aspects of assessment
including specific questions while taking history such as There were no studies found to have comparison
prodromal pain, bisphosphonates use and its duration. between usage of post-operative supplements like

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-16
Teriperatide and Strontium. In our study we found an 2019;15:225-36.
association between early fracture healing with use of 6. Fiani B, Newhouse A, Sarhadi KJ, Arshad M, Soula M, Cathel A. Special
Considerations to Improve Clinical Outcomes in Patients with
osteoblastic drugs warranting better SMFA as compared Osteoporosis Undergoing Spine Surgery. Int. J. Spine Surg. 2021.
to those who did not use it. Since this was an observation, 7. Pearce O, Edwards T, Al-Hourani K, Kelly M, Riddick A. Evaluation
further studies are required to look in this association and management of atypical femoral fractures: an update of
more closely. current knowledge. Eur J Orthop Surg Traumatol. 2021;31:825-
840. doi: 10.1007/s00590-021-02896-3.
The strengths of the study is its adequate follow up period 8. Giusti A, Hamdy NA, Papapoulos SE. Atypical fractures of the
femur and bisphosphonate therapy: A systematic review of
to delineate union and occurrence of any re-fracture.
case/case series studies. Bone. 2010; 47:169-80.
Moreover it provides an association between use of 9. Teo BJ, Koh JS, Goh SK, Png MA, Chua DT, Howe TS. Post-operative
osteoblastic agents and healing time. The limitations of outcomes of atypical femoral subtrochanteric fracture in patients
our study were a small sample size, its retrospective on bisphosphonate therapy. Bone Joint J, 2014; 96: 658-64.
nature, and the functional outcome assessed over a 10. Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N,
et al. UK clinical guideline for the prevention and treatment of
telephonic interview. osteoporosis. Arch. Osteoporos. 2017;12:43.
11. Egol KA, Park JH, Rosenberg ZS, Peck V, Tejwani NC. Healing
Conclusion delayed but generally reliable after bisphosphonate-associated
This study reported comparatively good outcome for complete femur fractures treated with IM nails. Clin Orthop Relat
Res. 2014;472:2728-34.
patients with atypical femoral fractures when managed 12. De Graaf MW, Reininga IH, Wendt KW, Heineman E, El Moumni M.
with intra-medullary nailing. Use of post-operative The Short Musculoskeletal Function Assessment: a study of the
osteoblastic supplements showed statistically significant reliability, construct validity and responsiveness in patients
results with early healing time, hence warranting further sustaining trauma. Clin Rehabil. 2019;33:923-35
13. Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY.
prospective studies and randomized controlled trials to
Severely suppressed bone turnover: a potential complication of
study the relationship and association of Teriparatide or alendronate therapy. J Clin Endocrinol Metab. 2015;90:1294-301.
Strontium Ranelate with healing after surgical 14. Prasarn ML, Ahn J, Helfet DL, Lane JM, Lorich DG. Bisphosphonate-
management. associated femur fractures have high complication rates with
operative fixation. Clin Orthop Relat Res, 2012;470:2295-301.
Disclaimer: The study was conducted after approval of 15. Rizzoli R, Åkesson K, Bouxsein M, Kanis JA, Napoli N, Papapoulos S,
institutional Ethical review committee and informed et al. Subtrochanteric fractures after long-term treatment with
bisphosphonates: a European Society on Clinical and Economic
verbal consents from the patients. Aspects of Osteoporosis and Osteoarthritis, and International
Osteoporosis Foundation Working Group Report. Osteoporos Int,
Conflicts of Interest: The authors declare that they have 2011; 22: 373-90.
no conflict of interest. 16. Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM,
et al. Atypical subtrochanteric and diaphyseal femoral fractures:
Funding Disclosure: There is no funding source. second report of a task force of the American Society for Bone and
Mineral Research. J Bone Miner Res, 2014; 29: 1-23.
References 17. Ha YC, Cho MR, Park KH, Kim SY, Koo KH. Is surgery necessary for
1. Al Anouti F, Taha Z, Shamim S, Khalaf K, Al Kaabi L, Alsafar H. An femoral insufficiency fractures after long-term bisphosphonate
insight into the paradigms of osteoporosis: From genetics to therapy? Clin Orthop Relat Res. 2010;468:3393-8.
biomechanics. Bone rep. 2019; 11:100216. 18. Subramanian S, Parker MJ. Atypical femur fractures - Patient
2. Roy DK, O'Neill, Terence W, Finn JD, Lunt M, Silman AJ. characteristics and results of intramedullary nailing for a series of
Determinants of incident vertebral fracture in men and women: 21 patients. Acta Orthop Belg.2016; 82:376-81.
results from the European Prospective Osteoporosis Study (EPOS). 19. Ekstrom W, Nemeth G, Samnegard E, Dalen N, Tidermark J. Quality
Osteoporos Int. 2014;14:19-26. of life after a subtrochanteric fracture: a prospective cohort study
3. Mithal A, Dhingra V, Lau E. The Asian audit: Epidemiology, costs on 87 elderly patients. Injury. 2009; 40:371-6.
and burden of osteoporosis in Asia. Beizing, China: Osteoporos 20. Weil YA, Rivkin G, Safran O, Liebergall M, Foldes AJ. The outcome
Int. 2019 of surgically treated femur fractures associated with long-term
4. Anagnostis P, Paschou SA, Mintziori G, Ceausu I, Depypere H, bisphosphonate use. J Trauma, 2011; 71:186-90.
Lambrinoudaki I, et al. Drug holidays from bisphosphonates and 21. Shane E, Burr D, Abrahamsen B, Adler RA, Brown TD, Cheung AM,
denosumab in postmenopausal osteoporosis: EMAS position et al. Atypical subtrochanteric and diaphyseal femoral fractures:
statement. Maturitas. 2017;101:23-30 second report of a task force of the American Society for Bone and
5. Seeman E, Martin T. Antiresorptive and anabolic agents in the Mineral Research. Journal of Bone and Mineral Research. 2014;
prevention and reversal of bone fragility. Nat Rev Rheumatol. 29:1-23.

J Pak Med Assoc (Suppl. 5)

S-17 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
Comparison of physiotherapy with and without intra-articular corticosteroid
injection for treatment of frozen shoulder: A comparative study
Rana Dawood Ahmad Khan,1 Khawar Shahzad,2 Shahzad Khan,3 Mahwish Israr,4 Faisal Maqbool Zahid5

Abstract
Objective: To compare the combination of corticosteroid injection and physiotherapy with physiotherapy alone in
patients of frozen shoulder in terms of SPADI score.
Methods: This study included 80 patients of either gender from PMC and affiliated hospitals of Faisalabad with ages
between 18-55 years having frozen shoulder of either gender with more than 1 month duration. Patients having
frozen shoulder secondary to trauma, cerebrovascular accident and taking steroid injections were excluded.
Combination of corticosteroid injection and physiotherapy was performed in combination therapy group (n=40)
and physiotherapy alone was performed in Single therapy group (n=40).
Results: A total of 80 patients, 30(37.5%) males and 50(62.5%) females were selected for the study. Each group,
combination therapy and single therapy had 40 patients each.
The combination therapy group included 18(45.0%) males and 22(44.0%) females whereas the single therapy group
comprised of 12(39.9%) males and 28(70%) females.
The treatment method was independent of duration of disease (p= 0.251 for c2= 1.317). After six weeks of
treatment, the t-test applied on SPADI score showed that combined treatment is better than the single treatment
method (p= 0.016). However, both treatment methods were found same after stratification of duration of disease.
Conclusion: Combination of corticosteroid injection and physiotherapy is more effective than the physiotherapy
alone in resolving the shoulder pain and disability of shoulder.
Keywords: Frozen shoulder, Cerebrovascular accident, physiotherapy, corticosteroid injection.
(JPMA 71: S-17 [Suppl. 5]; 2021)

Introduction Physiotherapy is commonly used as it is cheaper and non-

invasive.6 It involves exercise, therapy and pain reducing and
Frozen shoulder, a very common presentation
controlling techniques.7 Pain can be affectively controlled by
encountered in the surgical as well as orthopaedic
steroids and NSAIDs. Steroid provides effect and rapid
departments, is actually a syndrome in which movement
reduction in the pain. In cases of capsulitis, intra-articular
at the shoulder joint is restricted, both with active and
steroids along with exercise provide significant reduction in
passive motion.1 This condition resolves in 1 to 3 years
and is usually managed conservatively.2 According to the pain and swelling and improvement in the movements.1
most of the consultants and pathologists, inflammation of In a study conducted by Maryam M et al shoulder pain
synovial membrane is the reason of pain and hence the and disability index score (SPADI)8 after 6 weeks of
condition under discussion. The joint-capsule becomes treatment in group of combination of corticosteroid
less distensible and adhesions are formed inside the joint injection and physiotherapy was found to be 23.14±20.05
space involving the head of the humerus.3 and in physiotherapy alone group, it was 40.56±20.55.3
Frozen shoulder affects almost 4% of the population and Frozen shoulder is one of the common problem
about 36% of diabetes patients, more commonly women presenting in tertiary care hospitals. In routine practice
in the their 50s.4 Among the various modes of treatment physiotherapy alone is used as a first line of treatment for
of this condition are only taking rest; use of NSAIDs, frozen shoulder. When physiotherapy becomes
regular mobilization with physio, oral and/or intra- ineffective, health care providers move to the other
articular steroids, hydro-dilatation, capsular release and treatment modalities. This study was conducted to
suprascapular nerve blockage.5 compare the results of two modes of treatment,
physiotherapy alone or physiotherapy in combination
1Department of Orthopedics, Faisalabad Medical University, 2,3Department of with intra-articular steroid injection for frozen shoulder.
Orthopedics, DHQ Hospital Faisalabad, 4Social Security Hospital, Faisalabad,
5Department of Statistics, Government College University Faisalabad. Patients and Methods
Correspondence: Rana Dawood Ahmad Khan. Email: doc_dawood@yahoo.com The comparative study was performed in the

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-18
orthopaedics department of the PMC affiliated Hospital, duration of disease and SPADI score was evaluated.
Faisalabad, 80 patients meeting the inclusion criteria Frequency and percentage was calculated for qualitative
were studied. Inclusion criteria were described as follows: variables as gender and side of frozen shoulder. SPADI
'All patients of either gender of age ranging between 18- score was compared by using independent sample t-test
55 years, having frozen shoulder (as per operational between both groups. p-value < 0.05 was considered
definition), with duration of symptoms > 1 month and significant. Effect modifiers like age, gender and duration
having SPADI score > 30 at presentation. Using WHO of disease were controlled by stratification and
sample size calculator9 for 2 means with the population independent sample t-test was used to see the statistical
mean of = 40.56,3 Test value of population mean = 23.14,3 significance.
Pooled standard deviation = 20.3, Power of study = 80%
and Level of significance = 5%. The sampling technique Results
used was non-probability consecutive sampling. For the whole sample of 80 patients, 30 (37.5%)males
and50 (62.5%) females, the age range was between 29
The objective of the study was to compare the and 55 years with a mean age of 45.18±7.29 years. The
combination of corticosteroid injection and minimum and maximum duration of the disease was one
physiotherapy with physiotherapy alone in patients of and six months respectively
frozen shoulder in terms of SPADI score. Hypothesis for
this study was that the combination of intra-articular The combination therapy group comprised of 40 patients
glenohumeral steroid injection and physiotherapy is of whom 18(45.0%) were males and 22 females. Minimum
better than physiotherapy alone in patients with frozen and maximum age was same as for the whole sample. The
shoulder in terms of mean SPADI score. mean age and the duration of disease was 43.95±7.43
years and 3.33±1.58 months respectively.
Operational definitions used were: Any shoulder pain of
one month duration along with restriction of active and Of the 40 patients in the single therapy group, there were
passive range of motion in the glenohumeral joint and 12(30.0%) males and 28(70.0%) females. The age range
25% as compared to contra lateral shoulder in at least 2 was 30-55 years with a mean of 46.4±7.02 years. The mean
directions: abduction, internal and external rotation, with time period of the disease was 3.25±1.69 months.
normal X-rays of the affected glenohumeral joint. SPADI
The number of patients with right sided frozen shoulder
questionnaire (attached as annexure) with thirteen
was 41 (51.3%), 24 (60%) and 17 (42.5%) among the whole
variables of two categories A: pain and B: disability was
sample, combination therapy group and single therapy
used. Pain was scored on 10cm scale (visual analogue
group respectively. Similarly, the frequencies of left sided
scale) and SPADI is scored 0-100 by averaging the scores
frozen shoulder was 39 (48.8%), 16 (40.0%), and 23
of 2 subscales. It was measured at presentation and then
(57.5%).
at 6 weeks of post treatment. Patients having frozen
shoulder secondary to inflammation, degeneration, The number of patients with the duration of 1-3 months
trauma, septic arthritis and cerebrovascular accident and and 4-6 months were 49 (61.25%) and 31 (38.75%)
those who had steroid injection therapy and/or physical respectively for the whole sample, 22 (55%) and 18 (45%)
therapy in six months were not included. respectively for combination therapy group, and 27
(67.5%) and 13 (32.5%) respectively for single therapy
After obtaining the approval from the Ethics Review
group.
Board of the institution approval, patients were selected
randomly and placed in two groups, A and B. Group A The association between the duration of disease and the
received combination of intra-articular corticosteroid treatment method was tested using c2 test. The
injection (mixture of 2ml methylprednisolone and 1 ml hypothesis of independence of these two attributes was
lignocaine 2%) and physiotherapy (transcutaneous accepted with p-value = 0.251 for c2 = 1.317. A t-test was
electrical nerve stimulation, active ROM exercises and ice
application in 10 sessions). Group B received Table-1: SPADI score among both groups.
physiotherapy alone. Physiotherapy was performed by a
trained physiotherapist. SPADI score was assessed after 6 SPADI score Group p-value
weeks of treatment as per operational definition. Follow Corticosteroid injection + Physiotherapy
up was done on telephone. physiotherapy alone

Data was analyzed in SPSS 16 with descriptive statistics At baseline 71.68±7.67 71.88±6.74 0.902
mean and standard deviation of numerical values for age, After 6 weeks 36.7±5.28 39.78±5.89 0.016

J Pak Med Assoc (Suppl. 5)

S-19 34th International Pak OrthoCon Conference 2021

Table-2: SPADI score among both groups according to duration of disease.

Duration of disease SPADI score Group p-value

Corticosteroid injection + physiotherapy Physiotherapy alone

1-3 months At baseline 72±8.44 71.93±7.25 0.974

After 6 weeks 36.73±5.75 39.37±5.74 0.116
4-6 months At baseline 71.28±6.82 71.77±5.8 0.835
After 6 weeks 36.67±4.81 40.62±6.34 0.058

applied on SPADI scores obtained after six weeks from the studies were conducted comparing physical therapy with
two treatment groups. The data were tested for normality steroid injections therapy.3 Simple physical therapy was
with Shapiro-Wilk test and found normal for both samples considered as the most suitable initial therapy in many
obtained from combined treatment and single treatment studies. It has been seen that more than a third of total
method with p= 0.075 and 0.099 respectively. The two cases presenting to departments of physical therapy have
groups differed significantly at 5% level of significance some complaint regarding shoulder. Physical therapy is
with a p= 0.016 in favour of combined treatment group cost effective and cheap when compared to the cost of
showing the combination method to be superior to the other management strategies.
single treatment technique Table-1.
If the physical therapy fails to improve the conditions,
SPADI score at baseline and after 6 weeks were also pain experts and/or surgical intervention are considered.
compared between the two groups with respect to The longer the history of pain, the more chance of the
stratification of duration of disease as described in Table- development of chronic pain; so the management best
2. However, the results showed no significant difference suitable for the individual cases should be started as early
among two treatment methods at this level. as possible to avoid chronicity.7
Discussion Our study showed that most of the cases were of 46-55
It has been recorded that about 10 out of 1000 patients in (52.5%) and frozen shoulder was more common in
the Out Patients Department in the primary healthcare females (62.5%) than males (37.5%). In most of the
settings present with shoulder complaints. This varies patients right side of shoulder is involved (51.3%). In
among different population groups from 6.9% to 26%. combination of corticosteroid injection and
Shoulder pain disturbs the daily routine and ends in physiotherapy group, SPADI score was noted after 6
chronic state with complications.6 weeks of treatment as 36.7±5.28 and in only
physiotherapy group it was 39.78±5.89.
Adhesive capsulitis is defined in its purest sense as
idiopathic painful restriction of shoulder movement Similar to the results of our trial, Blanchard V, et al
resulting in global restriction of the glenohumeral joint".10 reported that steroid injections in these patients
In about more than half of the cases of frozen shoulder, compared with physical therapy for frozen shoulder have
patients condition improve with conservative a better outcome and in a shorter duration.11
management in about 1 to 3 years; some studies report
Mariyam M et al.3 conducted a study in Iran similar to our
that about 20% to 50% remain clinically active even till
trial. They observed that the average age of the patients
ten years.2
was 53 years and most of the patients were females. Right
Many strategies of management of the disease under sided shoulder is more involved than the left one.
discussion have been described by consultants, these Average SPADI score after 6 weeks of treatment in
include physical therapy, NSAIDs, oral or intra-articular corticosteroid and physiotherapy group was 23.14 and in
injection of steroids, arthrography, closed manipulation, physiotherapy alone group it was 40.56. They concluded
open surgical technique, and arthroscopic capsular that combination therapy is better than physical therapy
release. Among all the management plans, the target was therapy alone. These results match with the results of our
to reduce pain and improvement of shoulder mobility.10 study.
Although, this disease or condition is very common, but
Carette S et al.12 conducted the same trial and reported
no consensus on effective management plan is seen.2
that on the 6th week of trial, SPADI score showed
In the past, physical therapists treated this condition, and significant improvement in combination therapy versus
later steroid injection therapy was started and many physical therapy alone (mean improvement in score =

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-20
46.5) versus (mean improvement in score = 22.2). treatment of idiopathic frozen shoulder. J Surg Pak. 2012;
Supervised physical therapy alone with a single shot of 17:57-60.
2. Sharma S, Jacobs L. Management of frozen shoulder -
steroid in the joint cavity showed significant conservative vs surgical? Ann R Coll Surg Engl. 201;93:343.
improvement in movement, favouring our results. 3. Maryam M, Zahra K, Adeleh B, Morteza Y. Comparison of
corticosteroid injections, physiotherapy, and combination
Windt D et al.13 conducted the same trial and observed therapy in treatment of frozen shoulder. Pak J Med Sci. 2012;
that mean change in SPADI score in corticosteroid 28:648-51.
injection and physiotherapy was greater (39±27) than the 4. Nagy MT, MacFarlane RJ, Khan Y, Waseem M. The frozen shoulder:
myths and realities. Open Orthop J. 2013; 7 Suppl 3: S352-5.
physiotherapy alone (14±27). They concluded that the 5. Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: the
corticosteroid injection and physiotherapy works better effectiveness of conservative and surgical interventions-
than the physiotherapy alone. Similar is the case with our systematic review. Br J Sports Med. 2011; 45:49-56.
study. 6. Kromer TO, Bie RA, Bastiaenen CHG. Effectiveness of
individualized physiotherapy on pain and functioning compared
Ryans I14 et al. observed that after six weeks, the shoulder to a standard exercise protocol in patients presenting with clinical
signs of subacromial impingement syndrome. A randomized
disability questionnaire showed better results in the controlled trial. BMC Musculoskelet Disord. 2010; 11:114.
steroid therapy group (P = 0.004). After physical therapy, 7. Chester R, Shepstone L, Daniell H, Sweeting D, Lewis J, Jerosch-
passive external rotation improved significantly with a Herold C. Predicting response to physiotherapy treatment for
significant p-value. Better results with steroid injection and musculoskeletal shoulder pain: a systematic review. BMC
Musculoskelet Disord. 2013; 14:203.
physical therapy combination were observed in our study. 8. Roach KE, Budiman?Mak E, Songsiridej N, Lertratanakul Y.
Development of a shoulder pain and disability index. Arthritis
Unlike other studies, Arslan S et al.15
reported that they Rheumatol.1991; 4:143-9.
followed up the patients till two weeks and later again till 9. World Health Organization. Epidemiological, & Statistical
twelve weeks but could not observe significant outcome. Methodology Unit. (1986). Sample size determination: a user's
manual. World Health Organization.
Conclusion 10. Amir-Us-Saqlain H, Zubairi A, Taufiq I. Functional outcome of
frozen shoulder after manipulation under anaesthesia. J Pak Med
Combination of corticosteroid injection and Assoc. 2007; 57:181-5.
physiotherapy is more effective than the physiotherapy 11. Blanchard V, Barr S, Cerisola FL. The effectiveness of corticosteroid
alone in resolving the shoulder pain and disability of injections compared with physiotherapeutic interventions for
adhesive capsulitis: a systematic review. Physiotherapy 2010;
shoulder. It can be used as a first line of treatment on 96:95-107.
frozen shoulder in future as it is more successful in 12. Carette S, Moffet H, Tardif J, Bessette L, Morin F, Fremont P, et al.
improving patients discomfort in terms of SPADI score Intraarticular corticosteroids, supervised physiotherapy, or a
than the physiotherapy alone. combination of the two in the treatment of adhesive capsulitis
of the shoulder: a placebo-controlled trial. Arthritis &
Disclaimer: None. Rheumatism. 2003; 48:829-38.
13. vander Windt DA, Bouter LM. Physiotherapy or corticosteroid
Conflicts of Interest: None. injection for shoulder pain? Ann Rheum Dis. 2003;62:385-7.
14. Ryans I, Montgomery A, Galway R, Kernohan WG, McKane R.
Funding Disclosure: None. Randomized controlled trial of intraarticular triamcinolone and or
physiotherapy in shoulder capsulitis. Rheumatology (Oxford).
2005; 44:529-35.
References 15. Arslan S, Celiker R. Comparison of the efficacy of local
1. Siraj M, Anwar W, Iqbal MJ, Rehman N, Kashif S, Khan A, et al. corticosteroid injections and physiotherapy for treatment of
Effectiveness of intra-articular corticosteroid injection in the adhesive capsulitis. Rheumatol Int. 2001; 21:20-3.

J Pak Med Assoc (Suppl. 5)

S-21 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
Unilateral versus simultaneous bilateral total knee arthroplasty: A comparative
study
Obaid-ur-Rahman, Sohail Hafeez, Muhammad Suhail Amin, Jahanzeb Ameen, Rana Adnan

Abstract
Objective: To compare pre-operative characteristics and peri-operative findings in patients undergoing unilateral
total knee arthroplasty (UTKA) and simultaneous bilateral total knee arthroplasty (BTKA). To work out safety criterion
for selection of patients for simultaneous BTKA.
Methods: Patients undergoing UTKA (39) and BTKA (36) in Department of Orthopaedic Surgery, Combined Military
Hospital, Rawalpindi from March 2014 to August 2014 were compared in terms of patient characteristics, underlying
pathology, peri-operative blood loss, transfusion requirements and in hospital complications.
Results: The mean age of patients undergoing UTKA was 61±11 years and those undergoing BTKA was 64±8 years,
with similar male to female ratio (1:1.8) in both groups. Males undergoing BTKA were significantly older than other
patients (71±6 years). Primary osteoarthritis was the most common initial diagnosis (59% in UTKA and 89% in BTKA,
p<0.05) followed by rheumatoid arthritis. Average blood loss per knee was higher in BTKA procedures but
difference did not reach statistical significance. Blood transfusion requirements in BTKA patients not receiving
antifibrinolytic agent were significantly higher than in similar UTKA patients (75% vs 17%, p<0.05) but were
significantly reduced with peri-operative administration of antifibrolytic therapy (30% BTKA, p<0.05). Complication
rates, low in both, were more frequent in BTKA patients with co-morbidities.
Conclusion In patients requiring bilateral knee replacements, staged total knee replacement [i.e. the two knees are
replaced with a gap of at least 3 months] is a safe approach. Unilateral knee replacement is associated with lesser
complications and blood transfusion requirements as compared to simultaneous bilateral total knee replacements
Keywords: Total knee arthroplasty, staged bilateral TKA, simultaneous bilateral TKA, Complications.
(JPMA 71: S-21 [Suppl. 5]; 2021)
Introduction both knees are performed under one anaesthetic session
on the same day. Performing simultaneous BTKA has its
Total Knee Arthroplasty (TKA) was first performed in 1968.
advantages such as a single anaesthetic session, reduced
It has evolved to be one of most frequently done
cost, better rehabilitation in severely deformed bilateral
orthopaedic surgery performed in the west in the present
era. More than 600,000 procedures are reported in joints and early recovery time.3 Controversies still exist
America annually.1 It has consistently been reported to be about the safety of this procedure.
a successful means of relieving pain and restoring The current study compared the pre-operative patient
function in end stage arthritis: Also implant survival after characteristics, underlying pathology, peri-operative
TKA is reported to be 92-98 % at 15 years.2 blood loss, transfusion requirements and in hospital
Compared to the west, knee arthroplasty is still in its complications in simultaneous BTKA patients versus
infancy in Pakistan. The Pakistan National Joint Registry unilateral or staged bilateral arthroplasty [UTKA] patients.
reported 761 knee arthroplasties for the year 2014. This To our knowledge this is the first prospective comparative
figure in reality is short of actual procedures being done, study from Pakistan focusing on this issue.
as not all cases are being registered.
Methods
Patients with end stage arthritis of knees present with A prospective comparative study was conducted on 75
symptoms that often require bilateral TKA. Such patients consecutive knee arthroplasty patients, between March
are offered either a "staged bilateral TKA" i.e. 2 separate 2014 and August 2014, in department of Orthopaedic
unilateral TKAs (UTKA) within one year; or a "simultaneous Surgery, Combined Military Hospital, Rawalpindi,
bilateral total knee arthroplasty (BTKA)" i.e. arthroplasty of Pakistan.

Department of Orthopaedic Surgery, Rawalpindi Medical College, Rawalpindi, Patients subjected to unilateral knee replacement or
Pakistan. bilateral knee replacement were included in the study.
Correspondence: Obaid-ur-Rahman. Email: drobaid@hotmail.com Patients with predominant unilateral knee involvement

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-22
underwent UTKA. Patients with severe bilateral knee Statistical analysis: Sample size was calculated by
symptoms, confirmed clinically and radiologically, were keeping the level of significance at 5%. the power of test
accepted for simultaneous BTKA; after careful screening = 95%. Pooled standard deviation = 89%. Test value of the
for comorbidities. Patients with history of severe population mean= 3.3. Anticipated population mean =
ischaemic heart disease, bleeding diatheses, 2.3. Sample size (n) = approximately 35 patients in each
thromboembolic disease and past surgery on the knee to group. After checking the data for normality. Student's t
be operated were excluded from the study. test was applied to determine the differences in the age,
blood loss and number of transfused units between the
Patient's demographics, routine investigations,
groups using SPSS version 23.0. Other parameters such as
echocardiography and anaesthesia evaluation were
number of patients with various pathologies in the two
carried out prior to surgery.
groups, the number of patients who were given blood
About half the patients were randomly selected to receive transfusion and those with complications were assessed
the antifibrolytic agent tranexamic acid [16/39 in UTKA by the chi square test using www.socscistatistics.com.
and 20/36 in BTKA group] administered parentally in two Level of significance was set at p<0.05 for all calculations.
doses in the perioperative period.
Results
Surgery was carried under spinal or combined spinal and The 75 patients included in the study underwent 110
epidural anaesthesia in all patients. They were operated primary total knee replacements. Of these 39(52%) had
by two arthroplasty surgeons [SH and MSA] using unilateral or staged knee arthroplasty UTKA while
cemented implants from DePuy or Zimmer and similar 36(48%) had simultaneous BTKA (Table-1). In both UTKA
operative technique in both groups. UTKA, either primary and BTKA groups male to female ratios were similar (1:
or as part of staged bilateral procedure, was performed in 1.8) as were the mean ages of the patients. However the
39 patients and 36 patients underwent simultaneous mean age of males in BTKA group was 71±6 years (range
BTKA. 59-79) and females was 60±6 years (45-74) and this
During surgery the volume of blood loss was calculated difference in male and female ages was significant (p
from the amount collected in suction bottles and number <0.05). There was also statistically significant difference in
of blood soaked sponges. Postoperatively, the volume of the mean age of male patients undergoing Bilateral knee
blood collected via intra-articular drains up to two days replacement and Unilateral knee replacement (Table-1).
was recorded in the wards. The distribution of underlying joint pathology in the two
Blood transfusion was given when haemoglobin was groups is given in Table-1. Primary osteoarthritis was seen
below 8.5 gm/dl in otherwise healthy patients or between to be the commonest underlying pathology in both
8.5 and 10 gm/dl in patients who clinically appeared groups. However its incidence was much higher in
anaemic. During surgery, based on patient's clinical patients undergoing BTKA 32(89%), than in those
condition, especially in patients undergoing bilateral TKA, requiring UTKA 23(59%) and this difference is statistically
blood transfusions were made on the assessment of the significant. It was followed by rheumatoid arthritis but the
anaesthetist. Blood transfusions were counted as the
number of units of Red Cell Concentrate (RCC) given Table-1: Patient demographics.
during the hospital stay.
Unilateral Total Knee Bilateral Total p-value
All patients who underwent BTKA were nursed in high Arthroplasty Knee Arthroplasty
dependency unit for 24-48 hours post operatively.
Total patients 39 [52%] 36 [48%] Ns
Majority of patients who underwent UTKA were shifted to
Females 25 [64%] 23 [64%] Ns
wards or rooms postoperatively, after observing for 2-3 Males 14 [36%] 13 [36%] Ns
hours in recovery room. UTKA patients were discharged Average age (yrs) 60±11 64±8 0.12 ns
generally on 3rd to 4th post-operative day and BTKA Females 60±12 60±6 0.92 ns
patients on 5th to 6th post-operative day. Males 62±10 71±6 0.006 s
Underlying Disease
During the hospital stay cardiovascular, neurological, Osteoarthritis 23 [59%] 32 [89%] 0.003 s
thromboembolic and wound complications were noted. Rheumatoid arthritis 9 [23%] 3 [8%] 0.08 ns
In case of suspicion of pulmonary embolism, CT Post-traumatic arthritis 6 [15.5%] Nil 0.014 s
pulmonary angiography (CTPA) was performed to Gouty arthritis 1 [3%] Nil Ns
confirm the diagnoses. Pigmented VN arthritis Nil 1 [2.5%] Ns

J Pak Med Assoc (Suppl. 5)

S-23 34th International Pak OrthoCon Conference 2021

Table-2: Intra-operative and Post-operative complications.

Unilateral Total Knee Arthroplasty Bilateral Total Knee Arthroplasty p-value

Blood Loss
Blood loss, ml/knee (Non-transamine patients) 555±245 648±239 0.188 ns
Total operative blood loss ml/lmee (Non-transamine patients) 555±245 1296 ±462 < .001
Blood loss, ml/knee (Transamine patients) 388 ±174 422± 169 0.482 ns
Total operative blood loss ml (Transamine patients) 388 ±174 843 ±290 <.001 s
Transfusion Requirements
Number of patients transfused (Non-transamine patients) 4 [17%] 12 [75%] 0.0003 s
Average pints per transfused patient (Non-transamine patients) 1.25±0.5 1.17±0.39 0.73 ns
Number of patients transfused (Transamine patients) 2 [12.5%] 6 [30%] 0.209 ns
Average pints per transfused patient (Transamine patients) 1 ±0 1.33 ±0.52 0.42 ns
Complications
Total complications 1 3 0.27 ns
Pulmonary complications 1 1 0.95 ns
Cardiac complications Nil 2 0.146 ns

difference between two groups was not significant. Post expired on 5th postoperative day due to myocardial
traumatic and gouty arthritis required unilateral infarction. Another female, 62 years of age, in ASA grade-
intervention. II, had a cardiac arrest in the recovery bay, half an hour
after surgery. She, however, recovered completely after
Average blood loss per knee although higher in BTKA, was
resuscitation.
not statistically different between UTKA and BTKA
patients undergoing similar protocols (Table-2). However Discussion
difference in total operative losses of two knees versus
one knee was obviously much larger. Thus in patients When comparing the demographic data of patients in our
who did not receive antifibrinolytic medication BTKA was study, unilateral or bilateral TKA, females outnumbered
associated with a significantly higher proportion of males, with female to male ratio being similar in both
patients requiring blood transfusion than UTKA (75% vs. groups i.e. 1.8:1. The presence of gender difference in
17%, p<0.05). Among those transfused, the numbers of osteoarthritis knees, higher female risk is well
units per transfused patient in BTKA and UTKA groups documented in the meta-analysis done by Srikanth.4 The
were similar (Table-2). Framingham knee OA study found incident knee
osteoarthritis to be 1.7 times higher in women than in
In BTKA, patients who were administered tranexamic acid, men,5, very similar to our patient distribution.
the proportion of patients requiring transfusion were
significantly reduced in relation to those who were not Although the average age of patients in both groups was
administered this medication (p<0.05). Also, the around 60 years, interestingly a difference of 10 years was
difference between the segment of patients requiring observed in the mean age of male patients (mean 71 years,
transfusion in UTKA and BTKA was no longer significant range 59-79) undergoing BTKA as compared to all other
when tranexamic acid was administered. Among those patients, male or female, and this is statistically significant
transfused the number of units required in BTKA and (Table-1). Primary osteoarthritis of knees was the leading
UTKA groups was similar. underlying cause for arthroplasty in both groups,
accounting for nearly 90% of BKTA patients. From this data
In our series of seventy-five patients, 4 patients (1 male, 3 it can be inferred that end stage primary osteoarthritis is
females) developed complications during their hospital more likely to manifest in older age in males as compared
stay. These were the patients in the older age group (61, to females. A recent study from Spain has also found that
62, 65 and 75 years of age), having pre-existing co- incidence rates increased continuously in males peaking
morbidities (ASA grade 2 or 3). Pulmonary complications only in oldest ages >85 years.6
in the two groups were comparable. There was one case
of pulmonary embolism, confirmed on CTPA, in each Controversy exists regarding amount of blood loss in the
group. They were treated medically and had a complete UTKA and BTKA procedures. While few papers have stated
recovery. Cardiac complications occurred in two patients that blood loss per knee is almost equal in the two groups;
of BTKA. A male patient, 75 year of age, in ASA grade-III, most showed significantly more blood loss and higher
developed ventricular fibrillation post operatively. He transfusion requirement with simultaneous procedures.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-24
This is perhaps because of greater stress placed on the should be kept under close observation in the recovery in
coagulation cascade with simultaneous procedures.7 In the initial one hour after deflation of tourniquet, followed
our study we found the average blood loss per knee was by HDU/ICU care for next 24 hours.
higher in BTKA than in UTKA procedures although the
difference did not reach statistical significance. However Preoperative thorough evaluation of the patient by the
total operative losses in BTKA patients necessitated blood surgeon and the anaesthetist is of utmost importance before
transfusions in significantly greater proportion of patients embarking on this voyage. Jain et al published a study in
as compared to UTKA (75% of BTKA and 19% of UKTA which all their simultaneous bilateral TKA candidates
patients, Table-2). The blood loss and transfusion underwent dobutamine stress echocardiography for
requirements in both groups were significantly reduced detection of any silent cardiac co-morbidity by a cardiologist.
by use of tranexamic acid (an antifibrinolytic agent). It TKA was deferred in those with positive results. In their series
should be used as a safe adjunct to prevent blood loss and of 150 simultaneous procedures none of the patients suffered
transfusions.8 any cardiac or pulmonary complication postoperatively.3

Many of the recent studies have shown the safety of Looking at the financial aspects, simultaneous bilateral
simultaneous BTKA when comparing it with unilateral or knee replacements can reduce hospital charges by 18 to
staged procedures.3,9-11 Some studies still question the 50% compared with staged procedures.3,9 This is due to
safety of BTKA and reveal that it is associated with overall decrease in operative time and total duration of
significantly larger number of in hospital complications as hospital stay.
compared to UTKA.1,12-14 A metanalysis, comparing over 4
We believe that elderly patients with co morbidities (ASA-
million hospital discharges of unilateral, bilateral, and
2 or above) are at higher risk for complications in
revision TKA procedures, over a 14-year period, found
simultaneous bilateral knee replacement. Adding to it,
that bilateral TKA had higher complication and mortality
the significant blood loss, puts these patients, with
rates than either unilateral or revision TKA.15 In our small
already low physiological reserves, under tremendous
series the frequency of hospital complications was quite
stress. The risks associated with staged and simultaneous
low but more frequent in BTKA patients (8.3% vs 2.6%),
but there was no statistically significant difference approaches should be clearly taught to the patient and
between the two groups (Table-2). his attendants, before deciding about the procedure.
Simultaneous BTKA procedures should preferably be
Simultaneous bilateral knee replacement appears to be carried out by high volume surgeons in high volume
safe in carefully screened patients with age less than 70 hospitals with backup facilities like ICU and HDU.
years.3,11,16-19 Several studies have recommended that
simultaneous BTKA should not be carried out in patients The strength of the study is that it is prospective, focusing
more than 80 years age. Lynch et al compared 98 patients sharply on ongoing blood loss, transfusions and
older than 80 years who underwent either a simultaneous complications rather than relying on recorded data as in
BTKA or a UTKA. They found that cardiac complications retrospective studies. The relatively smaller number of
were observed in 22% of simultaneous BTKA as compared patients is its weakness.
to 6% of UTKA.20
Conclusion
It has been documented that tourniquet deflation is In patients requiring bilateral knee replacements, staged
associated with release of accumulated metabolic wastes total knee replacement (i.e. the two knees are replaced with
from the ischaemic limb into arterial blood. This may lead a gap of at least 3 months) is a safe approach. Unilateral
to enhanced minute ventilation and rarely arrhythmias.21 knee replacement is associated with lesser complications
Trans-oesophageal echocardiography has shown a and blood transfusion requirements as compared to
phenomenon called snow storm like echogenic particles simultaneous bilateral total knee replacements.
for several minutes after the deflation of tourniquet which
may lead to adverse events.22 Old age patients and Disclaimer: None.
females are more prone to tourniquet related
complications. Patients in ASA-2 or ASA-3 have higher Conflicts of Interest: None.
odds of tourniquet related complications.23 We have also Funding Disclosure: None.
observed signs of thromboembolism just after release of
tourniquet in 3 patients who underwent simultaneous References
bilateral knee replacements. We consider that patients 1. Kurtz S, et al, Projections of Primary and Revision Hip and Knee
undergoing simultaneous bilateral knee replacement Arthroplasty in the United States from 2005 to 2030. J Bone Joint

J Pak Med Assoc (Suppl. 5)

S-25 34th International Pak OrthoCon Conference 2021

Surg Am 2007; 89:780-5. Associated Factors After Simultaneous Bilateral Versus Unilateral
2. Victor J, Ghijselings S, Van Damme G, Deprez P, Arnout N, Van Der Total Knee Arthroplasty. J Bone Joint Surg Am. 2014; 96:1058-
Straeten C. Total knee arthroplasty at 15-17 years: does implant 1065.
design affect outcome? Int Orthop. 2014; 38:235-41. 13. Patil N, Wakankar H, Pros and cons of simultaneous bilateral total
3. Jain S, Wasnik S, Mittal A, Sohoni S, Kasture S, Simultaneous knee arthroplasty including morbidity and mortality rates.
bilateral total knee replacement: a prospective study of 150 Orthopaedics 2008; 31:780
patients. J Orthop Surg 2013; 21:19-22 14. 15-Bullock DP, Sporer SM, Shirreffs TG Jr. Comparison of
4. Srikanth VK , Fryer JL, Zhai G, Winzenberg TM, Hosmer D, Jones G. simultaneous bilateral with unilateral total knee arthroplasty in
A meta-analysis of sex differences prevalence, incidence and terms of perioperative complications. J Bone Joint Surg Am. 2003;
severity of osteoarthritis. Osteoarthritis Cartilage. 2005; 13:769-81. 85-A:1981-6.
5. Felson DT, Zhang Y, Hannan MT, Naimark A, Weissman BN, 15. Memtsoudis SG, Gonzalez Della Valle A, Besculides MC, Gaber L,
Aliabadi P, Levy D. The incidence and natural history of knee Sculpo TP. In-hospital complications and mortality of unilateral,
osteoarthritis in the elderly. The Framingham Osteoarthritis bilateral and revision TKA: based on estimate of 4,159,661
Study. Arthritis Rheum. 1995; 38:1500-5. discharges. Clin Orthop Relat Res 2008; 466:2617-27.
6. Prieto-Alhambra D, Judge A, Javaid MK, Cooper C, Adolfo Diez- 16. Kiran EK, Malhotra R, Bhan S. Unilateral vs one stage bilateral total
Perez A and Arden NK. Incidence and risk factors for clinically knee replacement in rheumatoid and osteoarthritis -A
diagnosed knee, hip and hand osteoarthritis: influences of age, comparative study. Indian J Orthop 2005; 39:14-20
gender and osteoarthritis affecting other joints" Ann Rheum Dis. 17. Ekinci Y, Öner M, Karaman I, Kafadar IH, Mutlu M, Argün M.
2014;73:1659-1664. Comparison of simultaneous bilateral with unilateral total knee
7. Mihalko WM, Arthroplasty of knee. Canale ST, Beaty JH: arthroplasty. Acta Orthop Traumatol Turc 2014; 48:127-135
Campbell's Operative Orthopaedics, 12th Ed. Philadelphia 18. Hersekli MA, Akp?nar S, Özkoç G, Özalay M, Cesur N, Uysal M, et al.
Pennsylvania, Mosby Elsevier, 2013; pp 393-395. Single-staged bilateral total knee arthro- plasty: the role of elderly
8. Karam JA, Bloomfield MR, Diiorio TM, Irizarry AM, Sharkey PF. age (70+ years) on perioperative complications. Joint Dis Rel Surg
Evaluation of the efficacy and safety of tranexamic Acid for 2005; 16:1-4.
reducing blood loss in bilateral total knee arthroplasty J 19. Gill GS, Mills D, Joshi AB. Mortality following primary total knee
Arthroplasty. 2014; 29:501-3. arthroplasty. J Bone Joint Surg Am 2003;85- A:432-5
9. Spicer E, Thomas GR, Rumble EJ. Comparison of the major 20. Lynch NM, Trousdale RT, Ilstrup DM, Complications after
intraoperative and postoperative complications between concomitant bilateral total knee arthroplasty in elderly patients.
unilateral and sequential bilateral total knee arthroplasty in a Mayo Clin Proc.1997; 72:799-805.
high-volume community hospital. Can J Surg.2013; 56: 311-317. 21. Mariiano ER. Anaesthesia for Orthopedic Surgery. In: Butterworth
10. Bini SA, Khatod M, Inacio MC, Paxton EW. Same-day versus staged JF, Mackey DC, Wasnick JD editors. Morgan & Mikhail's Clinical
bilateral total knee arthroplasty poses no increase in complications Anaesthesiology. 5th ed. New York: Mc Graw Hill 2013; p. 791-798.
in 6672 primary procedures. J Arthroplasty. 2014; 29:694-7 22. Tai TW, Lin CJ, Jou IM, Chang CW, Lai KA, Yang CY. Tourniquet use
11. Choi Y, Lee H, Ho Jong Ra, Hwang D, Kim T, Shim S. Perioperative in total knee arthroplasty: a meta-analysis Knee Surg Sports
Risk Assessment in Patients Aged 75 Years or Older: Comparison Traumatol Arthrosc. 2011; 19:1121-1130.
between Bilateral and Unilateral Total Knee Arthroplasty, Knee 23. Olivecrona C, Lapidus LJ, Benson L, Blomfeldt R. Tourniquet time
Surg Relat Res. 2014; 26: 222-229. affects postoperative complications after knee arthroplasty
12. Odum SM, Springer BD. In-Hospital Complication Rates and Orthop. 2013; 37:827-832.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-26

RESEARCH ARTICLE
The timing of closed unstable ankle fracture fixation and major wound
complications — an observation from a UK major trauma centre
Conrad Lee,1 Efthymios Iliopoulos,2 Sohail Yousaf3

Abstract
Objective: A retrospective cohort study was performed at a UK major trauma centre to identify whether timing of
surgical fixation of closed unstable ankle fracture affected the rate of major wound complications.
Methods: Consecutive cases of unstable ankle fractures treated with open reduction internal fixation (ORIF)
between March 2014 to December 2016 were included in this retrospective cohort study. Data were collected from
2018 onwards allowing a minimum follow-up of 2 years. Patients under the age of 18, polytrauma, open fractures
and those requiring external fixation were excluded. Timing of ORIF were categorised into early (within 24 hours of
injury) and delayed (after 24 hours of injury). Primary outcome was major soft tissue complications (defined as deep
wound infections or wound breakdown that required further surgery). Secondary outcomes included fixation
failure, and symptomatic metal work requiring removal.
Results: A total of 235 consecutive cases were included. There were 108(46%) patients in the early fixation group,
and 127(54%) patients in the delayed fixation group. Seven major wound complications were identified. Five of
which were in the early group, and 2 in the late group. There was no statistically significant difference in the major
wound complication rates between the early and delayed surgery groups (p = 1.000).
Conclusion: No significant difference was observed in the rate of major soft tissue complications between early and
delayed fixation for isolated unstable ankle fractures.
Keywords: Trauma, Ankle fracture, ORIF, Complications. (JPMA 71: S-26 [Suppl. 5]; 2021)

Introduction The optimal timing of surgery for closed ankle fractures

Ankle fractures are amongst one of the most common has been debated in the literature.6-17 Early fracture
fractures encountered in the adult population.1,2 In the fixation within 24 to 48 hours from injury has been
UK, the rate of ankle fractures is 10.4 per 10,000 person- advocated to reduce wound complications, reduce
years for people aged 50 years or over, and 7.5 per 10,000 hospital length of stay as well as promote early return to
person-years for people aged between 19 and 49.3 The function. However, the window of opportunity for early
total incidence of ankle fractures is expected to rise with surgical stabilisation is short due to the onset of soft tissue
the aging population.4,5 swelling. Typically when swelling is deemed too great for
safe incision and closure of surgical wound, then the
Surgery for unstable ankle fractures is associated with a surgery is postponed till the swelling subsides. Some
number of serious complications such as implant failure, units allow patients to go home for limb elevation and
mal-union, non-union and wound complications. Wound then return to hospital for surgery as outpatient, thus
complications from ankle fracture surgery include saving the costs of hospitalisation.18-20 Some units admit
superficial infections, wound dehiscence, wound edge the patient for strict limb elevation for checking the
necrosis and deep wound infections, all of which can be swelling daily. Surgery is performed once the swelling
challenging to rectify. In some patients, fracture and subsides. However, despite being treated as an in-patient,
surgical factors can contribute to risk of wound delays can occur due to operating theatre capacity and
complications. Surgical factors that are potentially logistical factors, especially seen in major trauma centres
controllable are of particular interest to reduce wound where other cases may need to be prioritised. BOAST
complications. Tissue handling, placement of incision, guidelines recommends early fixation on the day or day
implant selection and the timing of surgery are all after injury for patients under 60 years.21 AO group have
important modifiable factors that surgeons should pay recommended surgery within 6 to 8 hours from injury, or
attention to whilst planning for ankle fracture fixation. postponed to 4 to 6 days if early surgery is not possible.22
1,2RoyalSussex County Hospital, Brighton, 3Epsom and St Helier Hospital, The consequences of delay in surgery have been
London, England. conflicting in literature, some view that surgical delay
Correspondence: Sohail Yousaf. Eamil: drsohailyousaf@gmail.com leads to increased postoperative wound complications,

J Pak Med Assoc (Suppl. 5)

S-27 34th International Pak OrthoCon Conference 2021

whilst others have reported that no difference is found. cannot be achieved were stabilised with a bridging plate
With this factor in mind, we reviewed the results of (DCP, LC-DCP, recon plate) or distal fibular locking plate
surgery for isolated closed ankle fracture and associated (DePuy Synthes Distal Fibula locking compression plate
clinically significant wound complications at a major (LCP) or Smith and Nephew 3.5mm PERI-LOC VLP). Medial
trauma centre in the UK. malleolus fractures were stabilised with two cancellous
compression screws. Posterior malleolus fractures were
Methods stabilised with a posterior antiglide plate. Syndesmosis
In this cohort study, 369 consecutive patients were stability was examined intraoperatively with stress tests
admitted to Royal Sussex County Hospital, Brighton, under intraoperative imaging, and if diastasis was noted,
England (Major Trauma Centre) with unstable ankle this would be stabilised with one or two trans-
fractures requiring operative fixation between March syndesmosis cortical screws.
2014 to December 2016. The patients were identified
Operations were performed by a consultant, trauma
retrospectively in 2018 using Bluespier (Bluespier™,
fellow or supervised registrar or house officer. All
Bluespier International UK), which is used as our local
operations were done with thigh tourniquet applied with
hospital information system after approval from the
preoperative prophylactic antibiotics administered by
clinical governance committee. Data on any readmissions
anaesthetist. Post-operatively, patient were allowed to
to hospital related to the same ankle injury were collected
full weight bear in a walking boot on the discretion of the
retrospectively.
surgeon, based on intraoperative findings of fixation
Exclusion criteria were open fracture, polytrauma, age stability and bone quality. All patients were followed up at
under 18, external fixator or hindfoot nail used as initial 2 weeks and at 6 weeks for reviews.
treatment, transferred to other hospital for treatment and
The timing from presentation to surgery was largely
cases lost to follow up beyond 24 months after surgery.
dependent on soft tissue swelling. Daily swell check using
With these criteria, 134 patients were excluded (22
paediatric, 39 polytrauma, 7 hindfoot nail, 36 external the skin wrinkle test was performed by the ward
fixation, 11 open fractures, 9 treated at other centre and consultant on duty for amenability for surgery. Whilst
10 others). A total of 235 patients with closed unstable waiting for surgery, all admitted patients were instructed
ankle fractures having open reduction internal fixation as to strictly elevate the injured limb with supervision by
the primary index procedure were included in the study nursing staff. Other factors causing delay to surgery
for detailed analysis. includes limited theatre capacity when other cases may
need to be prioritised, and for patients with unstable
Patient medical records and radiographs were reviewed injury found subsequently in the follow up clinic which is
by two surgeons to verify recorded diagnosis and often between 1 to 2 weeks after injury. Timing of surgical
procedures. Data on patient demographics (age, gender), fixation was categorised into early (ORIF within 24 hours
date of injury, fracture pattern, fixation method, implants of injury) and delayed (ORIF after 24 hours of injury).
used, number of days from presentation to surgery,
length of hospital stay and details for any complications In view of complications, we only report those with severe
requiring further surgery on the same ankle were complications that have required further hospital
recorded. admission for intravenous antibiotics or surgical
management such as wound washout and debridement,
Unstable ankle fractures were defined as lateral malleolar metal work removal, and revision fixation. As such,
fracture with talar shift, medial malleolar fractures with superficial wound infections that did not lead to
syndesmotic injury or associated maisonneuve pattern, admission or surgical treatment were not classed as major
and bi/trimalleolar fractures. complications in our study. Data was analysed with
Statistical Package for the Social Sciences (SPSS) version
Surgical fixation was performed for bimalleolar and
16.0 (SPSS, Chicago, IL) and p value of 0.05 was
trimalleolar fractures, unstable isolated lateral or medial
considered significant.
malleolar fractures and isolated syndesmotic diastasis.
In our institution, lateral malleolus fractures that are Results
amenable for anatomical reduction were stabilised with Two hundred and thirty-five patients with isolated closed
lag screw combined with one-third tubular neutralisation unstable ankle fractures were analysed in detail. The
plate. Those with communicated fracture patterns or poor average age was 48±19.6 years with a range of 18 to 93
bone quality where anatomical reduction at fracture site years. One hundred and thirty-four (57%) were females.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-28
Table-1: Demographics and procedural factors in early and delayed fixation groups.

Early fixation (n=108) Delayed fixation (n=127) Total P-value

Fracture pattern 0.007b

Bimalleolar 38 44 82
Trimalleolar 25 15 40
Lateral malleolar 40 46 86
Medial malleolar / maisonneuve fracture 5 21 26
Others 0 1 1
Demographics
Mean age (years),(range) 48±18.25 (18-88) 49±19.97(18-93) 48±19.16 (18-93) 0.7535a
Female 61 73 134 0.8955b
Male 47 54 101
Clinical pathway
Admission status <0.0001b
Inpatient surgery 108 63 171
Outpatient surgery 0 64 64
Mean Postoperative length of stay (days) (range) 4.11±11.46 (0-77) 4.47±6.78 (0-38) 4.03±9.2 (0-77) 0.88045c*
3.42±5.28*(0-48)
Complications 0.093b
Major wound complications 5 2 7 1.000b
Symptomatic metalwork 3 9 12
Fixation failure 1 5 6
a T test, b Fisher's exact test, c Mann-Whitney U test, * outlier case excluded (prolonged postoperative hospital stay due to medial reasons).

Table-2: Comparison between patients groups with or without wound complication.

Major wound complications (n= 7) No wound complication (n=228) P-value

Clinical pathway
Mean time to surgery and range (days) 1.9± 2.04 (0 to 6) 3.5±4.27 (0 to 23) 0.2757c
Fracture pattern 0.008b
Bimalleolar 3 72 0.6916b
Trimalleolar 4 31 0.0132b
Lateral malleolar 0 86
Medial malleolar / maisonneuve fracture 0 25
Demographics
Mean age and range (years) 57±24.46 (19 to 88) 48±18.97 (18 to 93) 0.2697c
Female 6 128 0.2437b
Male 1 100
Diabetes 0 15 1.0000b
Surgeon grade 0.5567b
Consultant 4 87
Trauma fellow 0 24
Registrar 3 115
Senior House Officer 0 2
Lateral Implant type 0.0323b
One-third tubular plate 1 121
Synthes fibular locking 3 31 0.0645b
Smith and Nephew VLP 1 24
Recon plate 1 4
LC-DCP 0 16
No lateral implant 1* 32
*medial malleolus screw.
a T test, b Fisher's exact test, c Mann-Whitney U test.

J Pak Med Assoc (Suppl. 5)

S-29 34th International Pak OrthoCon Conference 2021

Table-3: Details of cases with major wound complications.

Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7

Age (years) 66 88 61 37 82 49 19
Gender M F F F F F F
Comorbidities Fit and well Fit and well Hypertension Asthma CKD on dialysis Hypertension Fit and well
Fracture pattern Bimalleolar Bimalleolar Trimalleolar Bimalleolar Trimalleolar Trimalleolar Trimalleolar
Timing of surgery (days) 1 1 3 6 1 1 0
Implant used One-third Synthes fibula Medial malleolus Smith and Nephew Synthes Synthes fibula Synthes fibula
tubular locking Compression screws only VLP periloc Recon plate locking locking
Surgeon grade Consultant Registrar Registrar Consultant Consultant Registrar Consultant

The female group had a greater mean age of 51 As expected, more severe fracture pattern such as
compared to 41 in male. trimalleolar ankle fractures were associated with the
highest risk of wound complications. In our study, 63% of
The overall mean time from injury to fixation was 3.5±4.23 trimalleolar fractures were surgically stabilised within 24
days (range 0 to 23 days) with a mode of 1 day. To account hours of injury, whilst more than half of bimalleolar,
for outpatient surgeries, the mean number of days from unimalleolar fractures and equivalents were treated
hospital admission to surgery was 1.2±4.9 days (range 0 beyond 24 hours. Contrary to some reports in literature,
to 23). Early fixation (within 24 hours) was undertaken in
we found that severe wound complications trended
108 (46%) patients. Fourty-seven (20%) patients had
towards injuries with early fixation within 24 hours, whilst
fixation on day 6 or more after injury. The overall average
no patient treated beyond 1 week developed any wound
postoperative length of hospital stay was 3±9.2 days
complications. The figures in our study however were too
(range 0-76). Patients were divided into early fixation (less
low in numbers to show a statistical difference.
than 24 hours) and delayed fixation groups, patient and
injury characteristics are summarised in Table-1. Although difficult with our retrospective study to
determine the cause of wound complications in this early
Complications were noted in 25 patients. Seven patients
operative group, a potential reason could be attempting
had fixation failure and revision ORIF. Twelve patients had
to operate on ankles too early when they had massive
symptomatic metalwork causing irritation with
swelling. Excessive skin tension on closure of swollen
subsequent metal work removal. Specifically, major
tissue as well as excessive retraction may cause more
wound complications (deep wound infections, wound
tissue damage intraoperatively. As also highlighted by
dehiscence) occurred in 7(2.98%) patients. Six of these
Tantigate et al, surgery performed too soon could lead to
patients had deep surgical site infection and required
wound complications due to severe swelling.15 The
wound debridement, washout and removal of metal. One
degree of soft tissue swelling varies from case to case
patient was re-admitted and treated with intravenous
owing to the mechanism of injury, patient comorbidities
antibiotics only. Of the 7 patients with major wound
and ability to provide ice, rest and elevation to the injured
complications, 5 were in the early fixation group. Soft
limb early after injury. With this in mind, suitability for
tissue complication rates of 10%, 3.8% and 0% were
early surgery should be determined on a case to case
observed in trimalleolar fractures, bimalleolar fractures
basis, rather than subjecting patients to surgery even if
and unimalleolar fractures respectively. A comparison of
the tissues are grossly swollen. Tissue swelling and
the demographics and surgical factors between cases
fracture blisters are notably major factors for delaying
with or without major wound complications is shown in
surgery, and therefore patients should be instructed for
Table-2. Details of each case with major wound
strict elevation of the injured limb, with clinical
complications is shown in Table-3.
assessment of skin swelling performed daily if the patient
Discussion is admitted in hospital.
Wound complication is a devastating consequence of If timing of surgery is not a key factor to wound
ankle fracture surgery in which many scholars are looking complications, perhaps we should be focusing more on
for ways to optimise the modifiable risks factors such as other factors. Miller et al have found patient factors such
timing to surgery. In our study, we found no significant as open fractures, diabetes, peripheral neuropathy,
statistical difference in the rate of severe wound wound compromising medications and postoperative
complications with the timing of surgery for isolated noncompliance to be more predictive for postoperative
closed ankle fractures treated with internal fixation. wound complication than the timing of surgery.23

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-30
Significant predictors for surgical site infections as complication was found between early versus delayed
reported by Sun et al included high-energy injury, open surgical fixation for isolated closed unstable ankle
injury, older age, greater BMI, incision cleanliness grade 2 fractures. Whist early surgical fixation has been advocated
to 4, surgeon level, chronic heart disease, history of to reduce healthcare related costs and promote early
allergy, and preoperative neutrophil count of >75%.24 return to function, suitability for early intervention should
Although these risk factors are important to note, in the be assessed on a case to case basis. Further studies should
acute setting of ankle fracture, many patient factors such focus on other modifiable factors related to postoperative
as obesity and diabetes are not simply modifiable prior to wound complications.
surgery.
Disclaimer: None.
Our study did not find a link between surgical timing with
Conflicts of Interest: None.
wound complications, and therefore we believe further
studies are required to investigate into other modifiable Funding Disclosure: None.
risk factors for wound complications. A recent study by
Gowl et al found increased intraoperative time to be an References
independent risk factor for surgical site infections.25 1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A
Implant selection is also another modifiable factor that review. Injury [Internet]. 2006 Aug [cited 2014 Nov 10]; 37(8):691-7.
has been investigated with association of postoperative Available from: http://www.ncbi.nlm.nih.gov/pubmed/16814787.
2. Sporer SM, Weinstein JN, Koval KJ. The geographic incidence and
wound infections. Schepers et al reported a wound treatment variation of common fractures of elderly patients.
complication rate of 17.5% in the use of locking plates Journal of the American Academy of Orthopaedic Surgeons.
versus 5.5% in the conventional fixation with one-third American Association of Orthopaedic Surgeons; 2006; 14:246-55.
3. Curtis EM, van der Velde R, Moon RJ, van den Bergh JPW, Geusens
tubular plate (p = 0.019) over a 6 year period.26 In our
P, de Vries F, et al. Epidemiology of fractures in the United
study, we found that 4 out of 7 patients with wound Kingdom 1988-2012: Variation with age, sex, geography, ethnicity
complications had been stabilised with distal fibula and socioeconomic status. Bone.2016; 87:19-26.
locking plates. Our complication rate with the use of 4. Kannus P, Niemi S, Parkkari J, Sievänen H. Declining incidence of
fall-induced ankle fractures in elderly adults: Finnish statistics
fibular locking plate was 6.8% versus 0.8% with one-third
between 1970 and 2014. Arch Orthop Trauma Surg. 2016;
tubular plates. Our findings resonate with the results from 136:1243-6.
Schepers' study and suggests caution when using locking 5. Kannus P, Palvanen M, Niemi S, Parkkari J, Jrvinen M. Increasing
plates,26 however a larger study would be useful to number and incidence of low-trauma ankle fractures in elderly
people: Finnish statistics during 1970-2000 and projections for
determine the significance of this factor.
the future. Bone. 2002; 31:430-3.
6. Pietzik P, Qureshi I, Langdon J, Molloy S, Solan M. Cost benefit
Lastly, our study also found no significant difference in
with early operative fixation of unstable ankle fractures. Ann R
the postoperative length of stay. The findings are mixed Coll Surg Engl [Internet]. 2006 Jul [cited 2015 May 24]; 88(4): 405-
in the literature on early versus delayed surgery on the 7. Available from URL: http://www.pubmedcentral.nih.gov/
postoperative length of stay. Whilst a large proportion of articlerender.fcgi?artid=1964648&tool=pmcentrez&rendertype=
abstract
studies have shown a reduced length of stay with early 7. Sukeik M, Qaffaf M, Ferrier G. Ankle fractures: impact of swelling
surgery,13 few studies, including our study have not on timing of surgery, length of hospital stay and the economic
demonstrated this.15 Our findings could be resulting from burden. Inj Extra.2010; 41:133-4.
out-patient surgery for ankle fractures, where a number of 8. Adamson SP, Trickett R, Hodgson P, Mohanty K. Ankle fractures:
Impact of timing of surgery. Inj Extra. 2009; 40:224.
patients with reliable compliance were allowed home, for 9. Singh BI, Balaratnam S, Naidu V. Early versus delayed surgery for
strict elevation and scheduled back to hospital for ankle fractures: A comparison of results, Eur J Orthop Surg
planned procedure. The so called "home therapy" has Traumatol. 2005; 15:23-27.
been adopted by many orthopaedic units, with ankle 10. Singh RA, Trickett R, Hodgson P. Early versus late surgery for
closed ankle fractures. J Orthop Surg. 2015; 23:341-4.
fractures fixation performed as outpatient settings found 11. Saithna A, Moody W, Jenkinson E, Almazedi B, Sargeant I. The
to be safe and cost effective in selected patients.19,20 influence of timing of surgery on soft tissue complications in closed
Although the costs of an acute trauma bed is ankle fractures. Eur J Orthop Surg Traumatol. 2009; 19:481-4.
approximately £225 per day and early surgery may seem 12. Konrath GA, Karges D, Watson JT, Moed BR, Cramer K. Early versus
delayed treatment of severe ankle fractures: A comparison of
to be logical solution to be cost-effective, it may not be in results. J Orthop Trauma. 1995; 9:377-80.
the best interest of the patient if their soft tissue is not 13. James LA, Sookhan N, Subar D. Timing of operative intervention in
suitable for early intervention. the management of acutely fractured ankles and the cost
implications. Injury. 2001; 32:469-72.
Conclusion 14. Schepers T, De Vries MR, Van Lieshout EMM, Van der Elst M. The
timing of ankle fracture surgery and the effect on infectious
No significant difference in the rate of major soft tissue complications; a case series and systematic review of the literature.

J Pak Med Assoc (Suppl. 5)

S-31 34th International Pak OrthoCon Conference 2021

Int Orthop [Internet]. 2013 Mar [cited 2015 May 24]; 37(3):489-94. inpatient compared with outpatient surgical procedures for ankle
Available from URL: http://www.pubmedcentral.nih.gov/ fractures. J Bone Jt Surg - 2016; 98:1699-705.
articlerender.fcgi?artid=3580081&tool=pmcentrez&rendertype=a 21. BOA Standards for Trauma and Orthopaedics (BOASTs) [Internet].
bstract [cited 2020 Feb 11]. Available from: https://www.boa.ac.uk/
15. Tantigate D, Ho G, Kirschenbaum J, Bäcker H, Asherman B, standards-guidance/boasts.html
Freibott C, et al. Timing of Open Reduction and Internal Fixation 22. Muller ME, Allgower M, Schneider R, Willeneger H. Manual of
of Ankle Fractures. Foot Ankle Spec [Internet]. 2019 Oct [cited internal fixation. Techniques recommended by the AO Group..
2020 Feb 1]; 12(5): 401-8. Available from URL: Second Edition, Expanded and Revised. Springer-Verlag, Berlin.
http://www.ncbi.nlm.nih.gov/ pubmed/30426777. 1979. pp 292-296
16. Naumann MG, Sigurdsen U, Utvåg SE, Stavem K. Associations of 23. Miller AG, Margules A, Raikin SM. Risk factors for wound
timing of surgery with postoperative length of stay,
complications after ankle fracture surgery. J Bone Jt Surg - Ser A.
complications, and functional outcomes 3-6 years after operative
2012; 94:2047-52.
fixation of closed ankle fractures. Injury.2017; 48:1662-9.
24. Sun Y, Wang H, Tang Y, Zhao H, Qin S, Xu L, et al. Incidence and risk
17. Høiness P, Strømsøe K. The influence of the timing of surgery on
factors for surgical site infection after open reduction and internal
soft tissue complications and hospital stay: A review of 84 closed
ankle fractures. Ann Chir Gynaecol. 2000; 89:6-9. fixation of ankle fracture. Med (United States). 2018; 97.
18. Lloyd JM, Martin R, Rajagopolan S, Zieneh N, Hartley R. An innovative 25. Gowd AK, Bohl DD, Hamid KS, Lee S, Holmes GB, Lin J. Longer
and cost-effective way of managing ankle fractures prior to surgery - Operative Time Is Independently Associated With Surgical Site
home therapy. Ann R Coll Surg Engl [Internet]. 2010 Oct [cited 2020 Infection and Wound Dehiscence Following Open Reduction and
Feb 2]; 92(7):615-8. Available from: http://publishing.rcseng.ac.uk/ Internal Fixation of the Ankle. Foot Ankle Spec [Internet]. 2019
doi/10.1308/003588410X12699663904358. Mar 27 [cited 2020 Feb 1]; 1938640019835299. Available from:
19. Khakha R, Berber O, Patel A, Kurar L, James L. Ankle Home Stay http://www.ncbi.nlm.nih.gov/pubmed/30913923
Programme:- A review of ankle fracture management and costs at 26. Schepers T, Lieshout EMMV, Vries MRD, Van Der Elst M. Increased
a busy district general hospital. Ann Med Surg. 2020; 50:6-9. rates of wound complications with locking plates in distal fibular
20. Qin C, Dekker RG, Blough JT, Kadakia AR. Safety and outcomes of fractures. Injury. 2011; 42:1125-9.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-32

RESEARCH ARTICLE
An experience with soft transforaminal lumbar interbody fusion in
postoperative discitis not responding to conservative treatment
Irfan Anwar, Waseem Afzal, Muhammad Talha, Muhammad Mahmood Ahmad, Shahzad Ahmed Qasmi,
Muhammad Asad Qureshi

Abstract
Objective: To determine the effect of soft Transforaminal Interbody Lumbar Interbody Fusion (sTLIF) in
postoperative discitis not responding to conservative treatment.
Methods: This cross-sectional study was conducted in Department of Spine Surgery, CMH Rawalpindi from August
2016 to July 2019. Patients who underwent discectomy were observed and those presenting with postoperative
discitis were included in the study. Pain was noted on visual analogue scale before and after the intervention and
differences in two readings were noted. Data was collected on predesigned proforma. Statistical analysis was done
on SPSS 20.0.
Results: Mean age of these patients was 45±12.34 years. The mean pain score on VAS before treatment was
8.33±0.65 and after treatment was 2±0.95. There was statistically significant reduction in pre-treatment and post-
treatment pain on VAS (p=0.000).
Conclusion: Postoperative discitis is present among a small number of patients after spine surgery and pain is
significantly reduced after the treatment of discitis with TLIF.
Keywords: Post-operative Discitis, Soft TLIF, VAS. (JPMA 71: S-32 [Suppl. 5]; 2021)

Introduction postoperative discitis. Its frequency ranges from 4.4% to

15% in available data.7,8 However Pakistani studies are
Discectomy as treatment of disc prolapse is one of the
available for only few patients and none of them have
most common surgery done in spine surgery.
described outcomes of disease. Thus the objective of this
Postoperatively discitis is one of the dreaded
study is to devise a protocol for management of discitis in
complications of this surgery. It is described as vertebral
our setup.
end plate inflammation and inter-vertebral disc space
infection after discectomy.1 Although it occurs rarely it Patients and Methods
has been noticed in about <1% individuals2 in west and
This study was conducted in Department of Spine
3.6% in India.3 It may be localized to disc space or
Surgery, Combined Military Hospital Rawalpindi-a tertiary
disseminate under the fascia and include discitis, epidural
care hospital, from August 2016 to July 2019. Patients
abscess, and spondylitis. Post-operative discitis often
who underwent discectomy in lumbar spine in our
presents with severe back pain, muscle spasm, and fever.
hospital and later developed discitis were observed and
The causative organism can only be identified in half of
included in study.
patients.4 Staphylococcus is the most common etiological
agent of pyogenic discitis; followed by aerobic Gram- The symptoms of rest pain aggravated by movements
negative bacilli. Other rare cases were fungal: clostridium and fever in postoperative patients were noted after one
perfringens, Haemophilus species, and Aspergillus to two weeks of surgery. They had initial relief of sciatica
fumigates.3 and back pain in early post-operative period. The
complete blood count, erythrocyte sedimentation rates
The management of postoperative discitis starts usually
and levels of C-reactive protein (CRP) were noted for every
with conservative method which includes antibiotics,
patient at the time of admission. X-ray lumbosacral spine
lumbar corsette and bed rest.5 In case of non-responders
anteroposterior and lateral view and MRI spine with
they are treated by debridement, pedicle screw fixation
contrast was performed. Discitis was considered when
with or without bone grafting.5,6
patients had symptoms, leukocytosis with neutrophilia
Studies done in Pakistan have shown higher rates of and mostly raised ESR and increased levels of CRP. On X-
rays disc space was reduced with or without erosion of
Combined Military Hospital, Rawalpindi, Pakistan. end plates. On MRI hyperintensity of the disc on T2-
Correspondence: Irfan Anwar. Email: nafrianwar@gmail.com weighted imaging, paraspinous or epidural

J Pak Med Assoc (Suppl. 5)

S-33 34th International Pak OrthoCon Conference 2021

inflammation/ abscess and contrast enhancement of the Pseudomonas aeruginosa in 1 (8.3%).

disc and adjacent bone marrow was observed. Blood
samples were sent for culture and sensitivity (C/S) and The mean pain score on VAS before treatment was
results were noted. Antibiotics were given initially 8.33±0.65 and after treatment was 2±0.95. There was
empirically (Injection Vancomycin 500milligram twice I/V statistically significant reduction in pre-treatment and
and Injection Nezkil 600 milligram twice I/V) and later if post-treatment pain on VAS (p=0.001).
required according to sensitivity. Antibiotics were given Discussion
intravenously for initial two weeks and then for six weeks
orally. Our study shows that discitis is present in a small number
of patients after spine surgery. Multiple organisms can be
In case the patients did not respond to conservative isolated from almost less than half number of patients.
treatment for one week they were offered surgery. After However it can be treated well with surgery increasing the
getting anaesthesia fitness they were shifted to the morbidity associated with the procedure.
operation theatre next day. Under general anaesthesia
they were placed prone over silicon pads. Area was All patients presented with back pain. This was also noted
cleaned, draped and wound opened, paraspinal muscles by Chang et al. as in their study, 90% patients complained
were retracted and complete laminectomy done. Pedicle of back pain and 40% patients with sciatica.9 Khan et al.
screws were applied in adjacent vertebrae. Disc space was also reported back pain to be the most common
cleared of all necrotic tissue and washed thoroughly. symptom.7 The culture and sensitivity reports showed no
Specimens were taken for C/S and histopathology. Bone bacterial growth in 66.7% of patients in this study. These
graft was harvested from iliac crest and placed inside disc results are similar to previous studies reported in by Basu
space and packed. Wound was washed again, et al.4 The most common organism found was
Vancomycin was sprinkled, drain was placed and wound Staphylococcus aureus which is similar to that reported in
was closed. Patient was mobilized in bed the next day and literature.10 The frequency of discitis present in our study
was out of bed when pain free, usually on second or third group is considerably higher than those in the west. This
day. Antibiotics were continued for eight weeks. study shows the frequency to be 3.15% compared to <1%
in the west.2 However it is comparable to the study by
Pain was noted on visual analogue scale before and after Singh et al.3 who had frequency of 3.6%. Discitis was
the intervention and differences in two readings were much less than the results of the study conducted by
noted. Data was collected on predesigned proforma. Siddiqui et al.8 and slightly less when compared to the
results of the study by Khan et al.7 This data shows that
Statistical analysis was done on SPSS 20.0. Results were
frequency of discitis varies among different study groups.
described as percentage for categorical variables and as
It may be attributed to different sample sizes or may be
mean ± SD for continuous variables. Two sample t-test
dependent on the skill of the surgeon performing the
was performed for comparing means of pain before and
spine surgery as well as postoperative care of the patients.
after the intervention and p-value of <0.05 was
considered significant. TILF was mainstay of treatment in our patients compared
to conservative management which depended on the
Results clinical status of the patients. However the recovery rate
The number of discectomies performed during this time was similar to other studies reported in literature.3-5,7-9 All
was 381. Out of these patients, only 12 cases developed these studies show that discitis can be treated with
post-operative discitis which did not respond to medical surgery. The mean pain score reported in this study is
treatment and were subjected to sTLIF. Mean age of these similar to those reported by Change et al. before and after
patients was 45±12.34 years. There were 7 (58.33%) males the treatment.9
and 5 (41.66%) females.
The study by Koutsoumbelis et al11 identified four
The mean duration of presentation after initial surgery procedure-related risk factors: (1) long duration of
was 2.0±0.5 weeks. Back pain was present in all patients surgery; (2) intraoperative blood loss/need for
(100%) but fever was present only in 5 (41.66%) patients. transfusion; (3) incidental dural tear and (4) >10 people in
Mean ESR was 32.75±19.39 at 1 hour. Mean TLC count was the operation theater (OT), specifically cautioning against
10.55±4.87/mm3. MRI findings of typical discitis were unnecessary nurses. The previous studies have also
present in all patients (100%). Culture and sensitivity identified increased operative time, multilevel surgery,
showed no growth of organisms in 8 (66.7%), revision surgery, and an increased number of people in
Staphylococcus aureus in 2 (16.7%), E. Coli in 1 (8.3%) and the OT as important predisposing factors for

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-34
postoperative spinal infections.12 3. Singh DK, Singh N, Das PK, Malviya D. Management of
postoperative discitis: a review of 31 patients. Asian J Neurosurg
This study is one of few studies conducted in Pakistan. 2018; 13:703-706
Although the frequency of discitis is much less as 4. Basu S, Ghosh JD, Malik FH, Tikoo A. Postoperative discitis
following single-level lumbar discectomy: our experience of 17
compared to studies conducted 20 years ago in cases. Indian J Orthop 2012; 46: 427-433.
Pakistan.8 It is still a nightmare for spine surgeons. 5. Hong HS, Chang MC, Liu CL, Chen TH. Is aggressive surgery
Disctis should be considered in any patient presenting necessary for acute postoperative deep spinal wound infection?
with back pain after spine surgery. If not treated it may Spine (Phila Pa 1976). 2008; 33:2473-2478
6. Lu DC, Wang V, Chou D. The use of allograft or autograft and
lead to deleterious outcomes for the patients. Further expandable titanium cages for the treatment of vertebral
studies are needed in this regard to evaluate the exact osteomyelitis. Neurosurgery. 2009; 64:122-129.
incidence of discitis in patients after spine surgery in 7. Khan NM, Noman MA, Riaz RU, Dawar S, Nasir A, Ayub S.
Pakistan. Frequency of Discitis in Lumbar Discectomy Patients: A Two Year
Study Pak. J. of Neurol. Surg. 2019; 23:328-332.
Conclusion 8. Siddiqui AR, Luby SP. High Rates of Discitis Following Surgery for
Prolapsed Intervertebral Discs at a Hospital in Pakistan. Infect.
Postoperative discitis is present among a small number of Control Hosp. Epidemiol. 1998; 19:526-529.
patients after spine surgery and pain is significantly 9. Chang CW, Tsai TT, Niu CC, Fu TS, Lai PL, Chen LH, Chen WJ.
Transforaminal Interbody Debridement and Fusion to Manage
reduced after the treatment of discitis with sTLIF.
Postdiscectomy Discitis in Lumbar Spine. World Neurosurg. 2019;
1:e755-60.
Disclaimer: None.
10. Shashank V. Gandhi, MD; Michael Schulder. Spinal infections. Am
Assoc Neurol Surg. Available from URL: https://www.aans.org/en/
Conflict of Interest: None.
Patients/Neurosurgical-Conditions-and-Treatments/Spinal-
Funding Disclosure: None. Infections. Cited on 15. May 2021.
11. Koutsoumbelis S, Hughes AP, Girardi FP, Cammisa FP, Jr, Finerty
EA, Nguyen JT, et al. Risk factors for postoperative infection
References following posterior lumbar instrumented arthrodesis. J Bone Joint
1. Turnbull F. Postoperative inflammatory disease of lumbar discs. J Surg Am. 2011; 93:1627-33.
Neurosurg. 1953; 10:469-73. 12. Chahoud J, Kanafani Z, Kanj SS. Surgical site infections following
2. Ford LT, Key JA. Postoperative infection of intervertebral disc spine surgery: Eliminating the controversies in the diagnosis.
space. South Med J. 1955; 48:1295-1303. Front Med (Lausanne) 2014; 1:7.

J Pak Med Assoc (Suppl. 5)

S-35 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
Complex tibial plateau fractures: Clinical and radiological outcome following
plate osteosynthesis
Hisham Khan Gandapur, Suhail Amin

Abstract
Objective: To assess the clinical and radiological outcome of complex tibial plateau fractures treated with single or
dual plate osteosynthesis and augmentation of metaphyseal defects with bone graft substitute.
Methods: A retrospective review was conducted on patients presenting with tibial plateau fractures (TPF) between
January 2018 and June 2019. Of the 62 patients who presented in this period, 33 met the inclusion criteria of
complex type TPF. Simple split fracture types and open fractures were excluded. All patients were operated in the
supine position and anatomical locking plate or low profile buttress plates for additional fragments were used.
Synthetic bone graft substitute was used in filling of the metaphyseal defects. Patients were evaluated clinically
using the Knee Society Score and with radiographic examination using the Heiney-Redfern Scale.
Results: All the patients were followed for an average of 13.39±4.63 months (range 6 - 24 months). All the included
patients were males with the mean age of 41.3±12.84 years (range18-70 years). Objective knee society score graded
excellent in 24 (72.8%) patients, good in 8 (24.2%) and fair in 1 (3%). Functional score, on the other hand, was
excellent in 21 (63.6%), good in 9 (27.3%) and fair in 3 (9.1%) patients. Radiological outcome evaluated on x-rays and
according to the H-R scale was good in 23 (69.8%) and fair in 10 (30.2%). Fracture union was achieved in all patients
with no secondary loss of reduction.
Conclusion: The treatment of complex tibial plateau fractures with plate osteosynthesis and graft augmentation of
metaphyseal defects has shown optimal results both clinically and radiologically. Excellent joint motion and knee
society score is achieved by early rehabilitation following stable fixation. However, long-term risk of post-traumatic
arthritis and its severity following complex TPF needs to be determined in different methods of fixation.
Keywords: Tibial Plateau Fractures, Complex, Plate Osteosynthesis, Bone Graft Substitute, Knee Society Score.
(JPMA 71: S-35 [Suppl. 5]; 2021)

Introduction TPF often have metaphyseal defects in the subchondral

zone that require filling either with autograft, allograft or
Tibial Plateau fractures (TPF) account for 1-2% of all
synthetic bone graft substitutes for augmentation.7 Bone
fractures and usually result from high energy trauma.1 TPF
graft substitutes (BGS) are synthetic biomaterials that
with increasing complexity and vulnerable soft tissue
have been reported to provide reduced fracture site pain,
envelope require optimal treatment which poses a
and better radiological and functional outcome
surgical challenge.2 The ultimate goal in these fractures is
compared to the use of cancellous autografts.6,8
to restore the articular surface anatomically, stable
Furthermore, the risks of donor-site morbidity, allograft
fixation to allow early movements of the joint and
associated disease transmission and shortage of autograft
minimal soft tissue invasion allowing ideal healing
or allograft is also eliminated with the use of BGS.9
environment.3 Several methods of fixation for complex
TPF exist in the literature from column specific fixation to The present study aimed at providing report on outcome
minimal invasive techniques and percutaneous hybrid or of complex tibial plateau fractures (AO types 41.B3, 41.C1,
ring external fixators with good to excellent results.4,5 The 41.C2 and 41.C3), based on clinical and radiological
decision of definitive management depends on fracture evaluation, in which single or dual plate fixation were
configuration, local soft tissue status and patient's done along with filling of the bony voids with BGS.
condition.
Patients and Methods
Recent advances in locked anatomical plates with raft After the local ethics committee approval, we
screws and minimal invasive techniques have decreased retrospectively identified patients presenting with
the complication rates and secondary loss of reduction.6 complex tibial plateau fractures (Schatzker Type II, IV, V &
VI) or (AO 41 B3, C1, C2 & C3) to the Orthopaedic Surgery
Department of Orthopedics, Combined Military Hospital, Rawalpindi, Pakistan. department of Combined Military Hospital (Rawalpindi,
Correspondence: Hisham Khan Gandapur. Email: hishamkhan002@gmail.com Pakistan) from January 2018 to June 2019. Unicondylar

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-36
fractures (Schatzker II & IV) with articular comminution pneumatic tourniquet placed high above over thigh.
and depressed fragments that needed elevation and graft Thirty patients had their surgery within 48 hours of injury
augmentation of the subchondral defect were also whereas 3 had to wait for about a week till resolution of
included. The exclusion criteria were open fractures, soft tissue swelling. Fracture blisters were initially
simple split or depressed fractures or neurological managed with limb elevation, non-adherent dressings
conditions that would affect post-operative and long leg cast, as is also described by Tolpinrud et al.10
rehabilitation.
Preoperatively, all the patients had standard radiologic
Using a convenient sampling technique, a total of 62 protocol of X-rays and CT scan with three dimensional
patients presenting with proximal tibia fractures during reconstructions. Fracture morphology and type were
the assigned time period were contacted on phone and identified according to AO and Schatzker
requested for follow up in the out-patient department. classifications.11,12 Schatzker types V and VI were most
Among the 45 patients who responded, 33 met the frequent (23 cases), followed by type II (9 cases) and type
inclusion criteria of complex tibial plateau fracture. The IV (1 case). All the bicondylar fractures (Schatzker type V &
included patients were operated by one of the authors. VI) were fixed with dual medial or posteromedial and
lateral plates. Silicon containing coralline hydroxyapatite
All patients were operated in the supine position with bone graft substitute was used in the filling of

Figure-1: The knee society clinical rating system.14

J Pak Med Assoc (Suppl. 5)

S-37 34th International Pak OrthoCon Conference 2021

Figure-2: (Case 1): A 40 year old patient with complex tibial plateau fracture. (a) Pre-operative radiograph showing severe comminution of the lateral articular surface. (b) Six months
post-operative AP and lateral X-ray with coloured markings for medial proximal tibial angle (green), tibial plateau widening (red) and posterior proximal tibial angle (yellow). Black
arrows indicating the structural void filler support with synthetic bone graft substitute.

metaphyseal defects to augment the articular posterior proximal tibial angle (PPTA) or sagittal
reduction.13 alignment, tibial plateau widening (TPW), articular
reduction, fracture union, post-traumatic arthritis and
The minimum follow-up in the present study was 6 structural void filler support (Figure-2). The results were
months with the maximum follow up being 24 months. then summarised according to the Heiney-Redfern scale
Patients were clinically evaluated for knee function using (H-R scale) Table-1.15
the knee society score (KSS).14 The main parameters of
knee score include pain, range of motion, alignment SPSS software (version 23) was used in the statistical
(varus & valgus), and stability in mediolateral and analysis of the data. Mean and standard deviation were
anteroposterior planes. Patient's functional score was calculated for descriptive analysis. Pearson's rank
assessed in part two of the form which considers walking correlation coefficient was applied to the functional
distance and stair climbing, and also deductions for scores and the radiological outcome (H-R Scale) with p-
walking aids used (Figure-1). value of < 0.01 considered as significant.
Seven radiographic parameters were evaluated; medial Results
proximal tibial angle (MPTA) or coronal alignment,
In our study, complex tibial plateau fractures occurred
due to high energy trauma between the age group 18-70
Table-1: The Heiney-Redfern Scale.15 years with the mean age of 41.3±12.84 years. All the
33(100%) patients included were males. Females were
H-R Scale 0 1 2
either in the exclusion criteria or lost to follow-up. The
MPTA* <80° or >94° 80°-84° or 91°-94° 85° - 90° mean follow-up was 13.39±4.63 months (range 6-24
PPTA* <3° or >15° 3°-5° or 13°-15° 6°-12° months).
TPW* >5mm >2-5mm 0-2mm
Articular Step-off >5mm >2-5mm < 2mm
Functional and radiological outcome was assessed on the
Fracture Union No evidence Partial Complete last follow-up. Objective knee society score graded
Post-traumatic Arthritis Severe Moderate None excellent in 24(72.8%) patients, good in 8 (24.2%) and fair
Structural Void in 1 (3%). Functional score, on the other hand, was
Filler Support Incorrect position Partial void Correct position excellent in 21 (63.6%), good in 9 (27.3%) and fair in 3
and insufficient filling and and sufficient (9.1%) patients (Table-2).
concentration concentration concentration
Sum Scale: 11-14 good result, 7-10 fair result and 0-6 poor result.
Radiological outcome on the H-R scale was good in 23
*MPTA: Medial Proximal Tibial Angle, *PPTA: Posterior Proximal Tibial Angle, *TPW: Tibial Plateau (69.8%) and fair in 10 (30.2%) of the x-rays evaluated. The
Widening. mean H-R score was 11.6 ± 3.24 points.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-38
Table-2: Patient and postoperative data.

Fracture Type (Frequency) Age/Sex Knee Score Functional Outcome Radiological Outcome (H-R Scale)

Schatzker Type II (27.3%)

27/M 95 Excellent 90 Excellent 12 Good
35/M 100 Excellent 100 Excellent 14 Good
50/M 85 Excellent 90 Excellent 10 Fair
30/M 100 Excellent 100 Excellent 14 Good
55/M 100 Excellent 90 Excellent 14 Good
28/M 100 Excellent 100 Excellent 14 Good
60/M 88 Excellent 70 Good 12 Good
28/M 100 Excellent 100 Excellent 13 Good
38/M 95 Excellent 90 Excellent 14 Good
Schatzker Type IV (3%)
42y/M 88 Excellent 80 Excellent 13 Good
Schatzker Type V (24.2%)
34/M 89 Excellent 80 Excellent 10 Fair
41/M 99 Excellent 90 Excellent 11 Good
50/M 100 Excellent 100 Excellent 14 Good
60/M 73 Good 70 Good 10 Fair
34/M 90 Excellent 90 Excellent 11 Good
53/M 95 Excellent 100 Excellent 11 Good
32/M 92 Excellent 90 Excellent 13 Good
34/M 68 Fair 70 Good 10 Fair
Schatzker Type VI (45.5%)
34/M 78 Good 70 Good 10 Fair
18/M 90 Excellent 100 Excellent 13 Good
47/M 89 Excellent 90 Excellent 11 Good
56/M 87 Excellent 80 Excellent 13 Good
33/M 94 Excellent 90 Excellent 11 Good
42/M 72 Good 70 Good 8 Fair
53/M 78 Good 65 Fair 12 Good
47/M 82 Excellent 80 Excellent 12 Good
40/M 100 Excellent 90 Excellent 13 Good
28/M 77 Good 70 Good 10 Fair
70/M 94 Excellent 70 Good 10 Fair
44/M 71 Good 60 Fair 7 Poor
21/M 79 Good 65 Fair 10 Good
65/M 75 Good 70 Good 12 Good
34/M 80 Excellent 70 Good 11 Good

There was a significant positive relationship between the plate osteosynthesis and bone graft substitute
knee score and the radiological score (Heiney-Redfern scale), augmentation successfully achieves normal or near
r = .71, n = 33, p <0.001. This indicated the direct correlation normal knee joint biomechanics with optimal functional
of quality of reduction on X-rays with the clinical outcome. outcome Figure-3 & 4. Rigid constructs used for fixation in
this study allowed early movements in the knee joint
Skin complication occurred in 1(3%) patient which was
leading to excellent functional outcome in most of the
managed successfully with local wound care. Mild to
patients Table-2.
moderate post-traumatic secondary arthritis was seen in
4(12%) patients. Another 2(6%) had their implants In a CT scan based study, McGonagle et al reported 72%
removed at one year due to discharging sinus (late onset) and 91% effectiveness of modern locking plates for lateral
on the medial side. None of the patients developed non- and medial tibial plateau fractures, respectively.16 Lateral
union or secondary loss of reduction in this series. proximal tibia anatomical plate with rafting screws and
low profile buttress plates for medial or posteromedial
Discussion fixation were mostly sufficient as is confirmed by our
Treatment of complex tibial plateau fractures (TPF) with results with no secondary loss of reduction. Minimal soft

J Pak Med Assoc (Suppl. 5)

S-39 34th International Pak OrthoCon Conference 2021

Figure-3: 50 years old male with Schatzker type V Figure-5: Complex injury of the lateral tibial plateau (a-b) in a
fracture. Pre-op CT scan of the knee (a-e) and immediate 38 years old male. Post-op X-rays (c-d) showing plate
post-op X-rays (f-g). Follow-up X-rays (h-i) and range of osteosynthesis and augmentation with bone graft substitute
motion (j-k) at 16 months. (Bone Medik - S).

confirmed its non-inferiority to

cancellous autograft.18
In a study by Ollivier et al, the mean H-R
score was 12.3 ± 3.8 points in the bone
substitute group compared to the bone
graft group.6 Similarly, the mean H-R
score in our study was 11.6±3.24 points
also ranging in the good outcome
criteria.
Excellent objective and subjective knee
society score was achieved in 72.8% and
63.6%, respectively in the present study.
Several authors including Citak et al,
Rohra et al and A.D. et al have all
Figure-4: 34 years old male with complex Schatzker type VI fracture (a-g). Immediate post-op X-rays (h-i). Follow- reported similar results in their series
up X-rays (j-k) at 18 months. Knee range of motion (l-m) at 18 months. with plate osteosynthesis of the TPF.19-21

tissue invasion was our preference due to which Conclusion

difficulties were faced in few dealing with the The treatment of complex tibial plateau fractures with
posterolateral fractures (Figure 3 & 4). Newer trends in plate osteosynthesis and graft augmentation of
patient-specific designed implants and pre-operative metaphyseal defects has shown optimal results both
templating on 3D printed models may further improve clinically and radiologically. Excellent joint motion and
surgical precision.17 knee society score is achieved by early rehabilitation
following stable fixation. However, long-term risk of post-
Silicon containing coralline hydroxyapatite bone graft
traumatic arthritis and its severity following complex TPF
substitute used in filling of subchondral defects worked
needs to be determined in different methods of fixation.
excellent as a scaffold with minimal resorption observed
at last follow-up Figures-3, 4 & 5. Studies have also Disclaimer: None.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-40
Conflict of Interest: None. https://classification.aoeducation.org/?_ga=2.175941995.870565
190.1579456856-1819590405.1576907693.
Funding Disclosure: None. 12. Schatzker J, McBroom R. The tibial plateau fracture. The Toronto
experience 1968-1975. Clin Orthop Relat Res. 1979; 138:94-104.
13. Blunn G. Bone graft substitute materials [Internet]. Vol. 06, Journal of
References Biotechnology & Biomaterials. 2016 [cited 2019 Aug 15]. Available
1. Kokkalis ZT, Iliopoulos ID, Pantazis C, Panagiotopoulos E. What's from: http://www.meta-biomed.com/product/product_view/51.
new in the management of complex tibial plateau fractures? 14. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of The Knee
Injury. 2016; 47:1162-9. Society clinical rating system. In: Clin Orthop Relat Res. 1989;
2. Mthethwa J, Chikate A. A review of the management of tibial 248:13-14.
plateau fractures. Musculoskelet Surg. 2018; 102:119-27. 15. Heiney JP, Redfern RE, Wanjiku S. Subjective and novel objective
3. Chang SM, Hu SJ, Zhang YQ, Yao MW, Ma Z, Wang X, et al. A radiographic evaluation of inflatable bone tamp treatment of
surgical protocol for bicondylar four-quadrant tibial plateau articular calcaneus, tibial plateau, tibial pilon and distal radius
fractures. Int Orthop. 2014; 38:2559-64. fractures. Injury. 2013; 44:1127-34.
4. Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for 16. McGonagle L, Cordier T, Link BC, Rickman MS, Solomon LB. Tibia
complex tibial plateau fractures. J Orthop Trauma. 2010; 24:683- plateau fracture mapping and its influence on fracture fixation. J
92. Orthop Traumatol. 2019; 20:.
5. Ricci WM, Rudzki JR, Borrelli J. Treatment of complex proximal 17. Nie W, Gu F, Wang Z, Wu R, Yue Y, Shao A. Preliminary application
tibia fractures with the Less Invasive Skeletal Stabilization system. of three-dimension printing technology in surgical management
J Orthop Trauma. 2004; 18:521-7. of bicondylar tibial plateau fractures. Injury. 2019; 50:476-83.
6. Ollivier M, Bulaïd Y, Jacquet C, Pesenti S, Argenson J noel, Parratte 18. Hofmann A, Gorbulev S, Guehring T, Schulz AP, Schupfner R,
S. Fixation augmentation using calcium-phosphate bone Raschke M, et al. Autologous Iliac Bone Graft Compared with
substitute improves outcomes of complex tibial plateau fractures. Biphasic Hydroxyapatite and Calcium Sulfate Cement for the
A matched, cohort study. Int Orthop. 2018; 42:2915-23. Treatment of Bone Defects in Tibial Plateau Fractures: A
7. Adams D, Patel JN, Tyagi V, Yoon RS, Liporace F. A simple method Prospective, Randomized, Open-Label, Multicenter Study. J Bone
for bone graft insertion during Schatzker II and III plateau fixation. Joint Surg Am. 2020; 102:179-193.
Knee Surgery, Sport Traumatol Arthrosc. 2019; 27:850-3. 19. Citak C, Kayali C, Ozan F, Altay T, Karahan HG, Yamak K. Lateral
8. Goff T, Kanakaris NK, Giannoudis P V. Use of bone graft substitutes locked plating or dual plating: A comparison of two methods in
in the management of tibial plateau fractures. Injury. 2013; simple bicondylar tibial plateau fractures. CiOS Clin Orthop Surg.
44(SUPPL.1). 2019; 11:151-158.
9. Lobb DC, DeGeorge BR, Chhabra AB. Bone Graft Substitutes: 20. Rohra N, Suri HS, Gangrade K. Functional and radiological
Current Concepts and Future Expectations. J Hand Surg. 2019; outcome of Schatzker type V and VI tibial plateau fracture
44:497-505.e2. treatment with dual plates with minimum 3 years follow-up: A
10. Tolpinrud WL, Rebolledo BJ, Lorich DG, Grossman ME. A case of prospective study. J Clin Diagnostic Res. 2016; 10:RC05-RC10.
extensive fracture bullae: A multidisciplinary approach for acute 21. Anjaneyulu RD, Krishna RP. A prospective study to analyse the
management. JAAD Case Reports. 2015; 1:132-5. outcome of locking compression plating by minimally invasive
11. AO Foundation. AO/OTA Fracture Classification [Internet]. 2018 percutaneous plate osteosynthesis technique in proximal tibial
[cited 2019 Aug 6]. p. 1-13. Available from URL: fractures. Int J Res Orthop. 2018; 4:442-7.

J Pak Med Assoc (Suppl. 5)

S-41 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
Empty Bursa SIGN: Significance in arthroscopic sub acromial decompression —
an audit of consecutive patients 2003 to 2020
Nikhil Arvind Khaddabadi,1 Kishen Parekh,2 Danial Shah,3 Usama Bin Saeed,4 Munawar Shah5

Abstract
Objectives: To establish a relationship between sub acromial bursa and shoulder impingement by determining its
presence or absence in sub acromial space. To determine the novel prospects and favourable outcome after surgery
in shoulder impingement syndrome.
Methods: Over 1000 patients with the diagnosis of shoulder impingement were studied from 2003 to 2020 at
Manor Teaching Hospital, Walsall, UK. During Arthroscopy, the findings were noted and documented. The sub
acromial bursa and its presence or absence was noted along with kissing lesion of supraspinatus confirmed at
Arthroscopy. Functional outcome in all patients was assessed with q-Dash score and pain relief was documented
with VAS (Visual Analogue Scale).
Results: Sub acromial decompression did not completely resolve symptoms in 649(64.9%) patients having
adequate bursa and no kissing lesion. Therefore, a cause other than acromion impingement was considered.
However, in 351(35.1%) patients without any bursal tissue, sub acromial decompression alone had better results.
Mean post-operative q-DASH score in group A (Bursa present) was 49.21±41 and in group B (Empty Bursa) it was
35.73±23. Mean post-operative VAS (Visual Analogue Scale) score in group A was 6.5±2.3 and in group B, it was
4.1±2.1.
Conclusion: We report that the presence of kissing lesion and an empty Bursal space under the acromion is a high
predictor of successful outcome after arthroscopic decompression.
Keywords: Acromioclavicular Joint, Empty Bursal Sign, Shoulder Impingement, Sub acromial Decompression.
(JPMA 71: S-41 [Suppl. 5]; 2021)

Introduction supraspinatus tendon causes pain in stressful positions

and acromio-humeral space keeps getting narrower with
Shoulder impingement syndrome being a clinical
time. A vicious cycle starts and symptoms gradually get
diagnosis requires a thorough history and clinical findings
worse. On MR images and ultrasound, indirect signs can
exhibited by the patients. Shoulder is an area surrounded
be appreciated mainly, bone excrescences in acromion
by a complex anatomy that is dynamically affected and
and acromioclavicular joint, thickening of coracoacromial
the patient presents with a subtle complaint which is
ligament and low-lying acromion.2,3 Some nonspecific
sometimes not easy to correlate with the evaluation to
changes like signal intensity alterations in the substance
reach a diagnosis. Shoulder impingement is one of these
of supraspinatus tendon can also be seen. Neer
problems with various types, mainly sub acromial and sub
introduced acromioplasty in 1971 and Ellman was the first
coracoid. to report arthroscopic sub acromial decompression in
Sub acromial space is formed by the acromion above, 1987.4,5 Results began to improve after these procedures
humeral head below and coracoacromial arch interrupted by a series of papers that stated supervised
constituting coracoid, coracoacromial ligament and physiotherapy is equally effective as sub acromial
medially the acromioclavicular joint.1 Close proximity of decompression. With refining the objective and close
these structures makes them prone to injury every time follow up of large sample sized cohorts, it was made clear
when there is excessive use and trauma. Repetitive that sub acromial decompression is a better choice and
trauma brings in oedema and inflammatory reaction to improves symptoms. Since then, it has flourished
the supraspinatus tendon and there is reactive synovitis extensively and now it is an established alternate
with resultant synovial hypertrophy and bursitis in sub technique as compared to open surgery.6,7 We on average
acromial space. Pressure from the bursa and perform more than 150 shoulder arthroscopic procedures
in our unit per year.
1,5Trauma & Orthoapedics, 2Visiting Student, 3Medical Student, 4Visiting Purpose of the study was to evaluate patients with
Felow, Walsall Manor Hospital, United Kingdom. shoulder impingement and investigate the relationship
Correspondence: Usama Bin Saeed. Email: osamabinsaeed@hotmail.com between bursal presence and shoulder impingement.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-42
Significance of the presence of Bursa in the sub acromial Table-1: Distribution of age (years) ranging (30 to 75 years) in both groups.
space and its relationship to the sub acromial
impingement as a cause of shoulder pain was found to be Group N Min Max Mean
significant. Arthroscopic decompression procedures
Bursa 649 30 75 51.69±10.68
performed in 1000 patients showed that in the presence No Bursa 351 30 75 50.93±10.38
of thick and complete Bursal tissue, acromion is not the
cause of impingement and sub acromial decompression
Table-2: Mean Pre and Post op q-DASH Scores in Both the groups.
alone does not significantly improve the preoperative
symptoms. In these cases, the cause of impingement was Mean Pre op q-Dash Score Mean Post op q-Dash Score
either internal impingement or ACJ impinging on the
rotator cuff. We present our series with pre- and post- Group A (Bursa Present) 87.3±74 49.21±41
operative evaluation of the patients and arthroscopic Group B (Empty Bursa) 81.32±93 35. 73±23
images.

Methods
This clinical audit was conducted at Manor Teaching
Hospital, Walsall, UK and patient data were collected from
July 1st, 2003 to June 30th, 2020. Patients with isolated
shoulder pain without any comorbids, which were the
inclusion criteria, were included. Patients with secondary Figure-1: Bursa in instability patient no impingement (Normal).
frozen shoulder or history of previous shoulder injury
were excluded. The patients were stratified in two groups
based on arthroscopic findings. Sample size was
calculated according to Cochran's Sample Size Formula.8
Group A comprised of patients with presence of Bursal
tissue in subacromial space and group B had patients
without any bursa (Empty Bursa Sign). Diagnosis of sub
acromial impingement was made by the history and
clinical examination. Neers sign and Hawkins Kennedy
test were employed to diagnose impingement clinically
and confirmed with Neers Test (steroid injection relieved
pain for minimum of four hours).9 MR images and
Dynamic Ultrasonography was also used to further
strengthen our findings before embarking on the
procedure.10-12 After informed consent and explaining the
risks and benefits of the surgery and outcome, the
Consultant surgeon (Senior Author) performed the
procedure of Arthroscopic decompression. Pre- and post-
operative data were collected to compare the results.
Patients were observed for having the signs of
Figure-2: Bursa empty in multiple patients with Impingement.
impingement and thick Bursa in sub acromial space on
diagnostic arthroscopy. Both Groups (A; Bursa and B: No
bursa) were followed prospectively and their functional (54.7%) were females with age ranging from 30-75 years
outcomes score (qDASH) and VAS for pain relief was and mean age 51.42±10.59 years. Of all the patients
documented to see the improvement. evaluated for absence of Bursa, 649 (64.9 %) displayed
presences of bursa in subacromial space and 351 (35.1%)
Data was analyzed by using SPSS V-23. Mean and patients showed no fat pad (Empty Bursal sign) when an
standard deviation was calculated for quantitative arthroscope was inserted into the joint (Table-1). Mean
variables and frequency and percentage was calculated post-operative q-DASH score in group A was 49.21±41.
for qualitative variables. Whereas mean post-operative q-DASH score in group B
was 35.73±23. (Table-2). Mean post-operative VAS (Visual
Results Analogue Scale) score in group A was 6.5±2.3 and in
Out of 1000 patients 453 (45.3%) were males and 547 group B, it was 4.1±2.1 (Table-3). It was observed that in

J Pak Med Assoc (Suppl. 5)

S-43 34th International Pak OrthoCon Conference 2021

Table-3: Mean pre- and post-op vas score in both the group. shoulder impingement.13 Holt et al, produced MR images
and techniques to correctly identify the degenerative
Group N Pre Post % Pre % Post % Change
wear that causes the symptoms of impingement.10
Bursal 649 8.52±1.72 6.5±2.36 85 65 20 Khoury et al, explained the use of ultrasonography in
No Bursa 351 8.94±3.23 4.1±2.12 89 41 48 diagnosing the impingement before embarking on the
treatment plan.10 Graichen et al, measured the width of
sub acromial space and its deterioration in impingement
and improvement after the sub acromial impingement.
however, symptoms did not improve in their long-term
analysis and there were no significant association
between sub acromial decompression alone.13 Hohmann
et al,14 exquisitely defined a few indications of sub
acromial decompression and reported a reasonable
outcome following the procedure provided rotator cuff
muscles were intact and there was no bias affecting the
Figure-3: Kissing lesion. study outcomes.

patients having a thick pad of fat in the sub acromial We also used VAS and according to Bird et al, a change of
space (Figure-1), decompression alone did not relieve the 12 to 20% is significant and as our result shows that the
symptoms which lead to the hypothesis that acromion improvement in patients with no Bursa was significant.18
was not the cause of their impingement as compared to In all the studies referred here, there was a clear emphasis
the patients without any Bursa (Figure-2) in sub acromial on performing the procedure and observing the outcome
space and a Kissing lesion (Figure-3). which was better than non-operative treatment.
Discussion Conclusion
Finding a relationship between empty Bursal sign and Comparing the results with other studies, it could be
shoulder impingement has been a difficult struggle concluded, that sub acromial decompression alone did
during the last decade. In this study, the relationship was not improve the symptoms in patients with a cause other
studied and results reported. In patients where empty than acromion. This is thus a useful procedure producing
Bursal sign was clearly not present, it was observed that good functional outcome in patients with acromion
simple sub acromial decompression alone did not morphology causing the symptoms of shoulder
improve any symptoms emphasizing another cause for impingement. However, the results need validation by a
shoulder pain other than acromion.13-15 longer follow up of these patients.
However, the current available studies do present design
Disclaimer: None.
flaws, namely statistical under powering, particularly in
type III acromion morphology; inadequate short-term Conflicts of Interest: None.
follow-up; lack of imaging data to assess cuff healing; and
insensitive outcome measures to capture the theorized Funding Disclosure: None.
benefits of sub acromial decompression. References
Additionally, several relevant merits of acromioplasty 1. Brossmann J, Preidler KW, Pedowitz RA, White LM, Trudell D,
have been reported, including decreased abrasive wear Resnick D. Shoulder impingement syndrome: influence of
with prominent type III acromial morphology, release of shoulder position on rotator cuff impingement--an anatomic
study. Am J Roentgenol. 1996; 167:1511-5.
natural growth factors to improve rotator cuff healing, 2. Singh B, Bakti N, Gulihar A. Current concepts in the diagnosis and
and improved visualization during rotator cuff repair.16,17 treatment of shoulder impingement. Indian J orthop. 2017;
51:516.
Jarvis et al, found no significant correlation between the 3. Tsai YH, Huang TJ, Hsu WH, Huang KC, Li YY, Peng KT, Hsu RW.
two and they also concluded that performing sub Detection of subacromial bursa thickening by sonography in
acromial decompression is the surgeon's discretion and is shoulder impingement syndrome. Chang Gung Med. J. 2007;
30:135.
decided pre operatively and during the time of 4. CHARLES S NEER II. Anterior acromioplasty for the chronic
arthroscopic evaluation.18 Lenza et al, reported an impingement syndrome in the shoulder: a preliminary report. J
interesting case with sub deltoid lipoma with a cause of Bone Joint Surg Am. 1972; 54:41-50.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-44
5. Ellman H. Arthroscopic subacromial decompression: analysis of radiographic, and US findings. Radiographics. 2005; 25:1591-607.
one-to three-year results. Arthroscopy. J Arthroscopic & Related 12. Lenza M, Lenza MV, da FrotaCarrerra E, Ferretti M. Subdeltoid
Surg. 1987; 3:173-81. lipoma causing shoulder impingement syndrome-a case report.
6. Soker G, Gulek B, Soker E, Kaya O, Inan I, Arslan M, Esen K, Memis Einstein. 2014; 12:351.
D, Yilmaz C. Sonographic assessment of subacromial bursa 13. Graichen H, Bonel H, Stammberger T, Haubner M, Rohrer H,
distension during arm abduction: establishing a threshold value Englmeier KH, Reiser M, Eckstein F. Three-dimensional analysis of
in the diagnosis of subacromial impingement syndrome. J Med the width of the subacromial space in healthy subjects and
Ultrason. 2018; 45:287-94. patients with impingement syndrome. Am J Roentgenol. 1999;
7. Leschinger T, Wallraff C, Müller D, Hackenbroch M, Bovenschulte 172:1081-6.
H, Siewe J. Internal impingement of the shoulder: a risk of false 14. Hohmann E, Shea K, Scheiderer B, Millett P, Imhoff A. Indications
positive test outcomes in external impingement tests? Biomed for arthroscopic subacromial decompression. A level V evidence
Res Int. 2017; 20: clinical guideline. Arthroscopy: J Arthroscop Relat Surg. 2020;
8. Sample Size in Statistics (How to Find it): Excel, Cochran's Formula, 36:913-22.
General Tips. Available from URL: https://www.statisticshowto.com/ 15. Behrens SB, Compas J, Deren ME, Drakos M. Internal
probability-and-statistics/find-sample-size/. Cited on 07-July 2021. impingement: a review on a common cause of shoulder pain in
cuff disease. Shoulder & elbow. 2014; 6:215-21. throwers. Phys. Sportsmed. 2010; 38:11-8.
9. Holt RG, Helms CA, Steinbach L, Neumann C, Munk PL, Genant HK. 16. Read JW, Perko M. Ultrasound diagnosis of subacromial
Magnetic resonance imaging of the shoulder: rationale and impingement for lesions of the rotator cuff. Australasian J
current applications. Skeletal Radiol. 1990; 19:5-14. Ultrasound Med. 2010; 13:11.
10. Khoury V, Cardinal É, Bureau NJ. Musculoskeletal sonography: a 17. Jarvis DL, Waterman BR, Verma NN. Is Acromioplasty Ever Indicated
dynamic tool for usual and unusual disorders; Am J Roentgenol. During Rotator Cuff Repair? Arthroscopy. 2019; 35:1639-40.
2007; 188: W63-73. 18. Bird SB, Dickson EW. Clinically significant changes in pain along
11. Moosikasuwan JB, Miller TT, Burke BJ. Rotator cuff tears: clinical, the visual analog scale. Ann Emerg Med. 2001; 38:639-43.

J Pak Med Assoc (Suppl. 5)

S-45 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
An experiment of Mega-prosthesis in bone tumours: A retrospective
cross-sectional study in a tertiary care hospital
Masood Umer, Eraj Khurshid Khan, Javeria Saeed

Abstract
Objective: To evaluate the oncological and functional outcomes of bone tumour patients who underwent
reconstruction with mega prosthesis.
Methodology: A retrospective study was conducted in the department of Orthopaedics Aga Khan University
Hospital, Karachi. All the paediatric and adult age group patients diagnosed with malignant, benign and metastatic
bone tumours and meeting the inclusion criteria were selected and analysed. Retrospective data was collected from
January 2008-January 2018.
Result: Sixty-two patients, 30 (48.4%) females and 32 (51.6%) males. were included in the study. Of these 57 (92%)
cases had involvement of the lower limb. The mean age was 36.95±19.1 years with a range of 9-81 years. The
duration of patients follow up was from 1-124 months (mean 32.7±36.43 months). There were 29 (47%) malignant
cases. The most commonly occurring tumour site was distal femur and proximal femur. There were 53 (85%) primary
surgeries (first time conducted surgeries) while 9(15%) revision surgeries were done. Major complications were
encountered in 19 (30.6%) patients and 13 (20.9%) had minor complications. Post-surgery local recurrence occurred
in 2 (3.2%) patients while 7 (11.2%) had distant metastasis. In functional outcomes the mean MSTS score of our
patients was 72.09±26.43. The survival rate was 69.8% with 45 patients recovered.
Conclusion: With a good patient selection, adherence to the principles of tumour surgery and an adequate applied
knowledge of mega prosthesis insertion, a good functional outcome was achieved.
Keywords: Bone neoplasm, Lower extremity, Femur, Recurrence. (JPMA 71: S-45 [Suppl. 5]; 2021)

Introduction In the light of these factors, there had been an evolution

over the past three decades, in the biomedical
Since the introduction of first endoprosthesis in 1943 by
engineering and refinement of surgical technique to
Austin Moore, made of Vitallium (Chromium Cobalt Alloy),
enhance the oncological and functional outcome of
and the description of Total Femur Replacement by
endoprosthesis replacement which has, since then,
Buchanan in 1950, there had been a significant change in
become the primary modality of choice for limb salvage
the management of extremity bone tumours in favour of
surgery.4,5 However, in the developing world, cost has
limb salvage surgery.1,2 The introduction of
been the most decisive limitation in the use of these
chemotherapy particularly neo-adjuvant chemotherapy,
implants. In a country where public has to pay for these
the advances in surgical and diagnostic techniques, and services from their own resources, it becomes an
the multidisciplinary approach allowed limb salvage expensive and unaffordable modality of choice and thus,
procedures for sarcoma, with no obvious detectable presents a different kind of challenge.5 This is further
differences in oncologic or functional results when aggravated by the non-availability of allograft in the
compared with amputation.3,4 Hence, since 1980s, mega country and absence of a bone bank. We are presenting
prosthesis had become the cornerstone of limb salvage our experience with functional outcome of mega endo-
surgeries, owing to their facilitation in early return to prosthetic replacement over the past decade. A previous
function, ability to bear weight, easy availability and study was carried out by us in 2012, which has been the
better cosmetic appearance. Their use, in general, has only work on mega-prosthetic replacement in Pakistan to
drastically increased since the introduction of off-the- this date.5
shelf modular prosthesis instead of previously used
custom prosthesis. It is due to all of these factors that the Methods
limb salvage surgery is now indicated in up to 90% of the A retrospective study was conducted in the Aga Khan
musculoskeletal tumours.4 University Hospital, department. of Orthopaedics after
ERC approval. All the patients diagnosed with malignant,
Aga Khan University Hospital, Karachi, Pakistan. benign and metastatic bone tumours were included. All
Correspondence: Javeria Saeed. Emal: javeria.saeed@aku.edu paediatric and adult age group patients were considered

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-46
eligible for inclusion in the study. The medical records of Table-1: Management of post-surgery complications.
patients from January 2008 to January 2018 were
reviewed and the follow-up was taken till October 2018. Variables No. of Patients Percentage
There were 58 patients who were included in study. For
Non Operative 13 21
assessing functional outcomes in treated patients, Open/Closed Reduction 6 9.6
Musculoskeletal Tumour Society (MSTS) scoring system Wound Debridement 2 3.2
was used. This system assigns numerical values (0-5) for Wound Debridement + Flap Coverage 4 6.4
each of six categories: pain, and function and emotional Revision 3 4.8
acceptance in the upper and lower extremities; supports, Amputation 3 4.8
and walking and gait in the lower extremity; and hand Others 2 3.2
positioning, and dexterity and lifting ability in the upper
extremity.6 These values were added, and the functional arthroplasty, and 5(8%) had total femur replacement
score was presented as a percentage of the maximum while 5 underwent proximal humerus replacement.
possible score. The results were graded according to the
Regarding oncological outcome, margins were negative
following scale: excellent 75-100%; good 70-74%;
in all primary bone tumours. Two patients had local
moderate 60-69%; fair 50-59 %; and poor 50 % based on
recurrence while 7 had distant metastasis. Four patients
our previous study.2 Post-surgery complications and
were lost to follow up, however, they remained disease
patient's status either with local disease or metastatic
free till their last documented follow up.
disease were noted. Data was analyzed on statistical
software SPSS version 22. Frequencies and descriptive MSTS functional score was assessed in 34 patients, which
statistic were calculated for categorical quantitative gave a mean score of 72.09±26.43 (Range 27-100).
variables respectively. Chi2- Test was run for analyzing Excellent outcome was achieved in 18, good outcome in
associations among variables and P-value < 0.05 was 6, fair in 5 while poor outcome was reported in 6 cases.
considered as significant for finding associations among There was an inverse relationship between age and MSTS
variables. Kaplan-Meier test was used for calculating score which was significant with p<0.01. No significant
survival status of patients. difference was found in the functional score of hip and
knee surgery patients or secondary to difference in
Results gender.
The study included 62 patients, 30 (48.4%) females and 32
(51.6%) males with an average age of 36.95±19.1 years Complications occurred in 32 patients with 19 having
(Range: 9-81 years) and a mean follow up of 32.71±36.43 major complications which required prolonged hospital
months (Range: 1-124 months). Regarding the nature of stay or readmissions, a second invasive intervention or a
the tumour, 16 (25.4%) were benign while 29(47%) were change in patient's functional status, while 13 patients
malignant primary tumours, whereas, 17(27.4%) cases had minor complications that required non-operative
were of metastatic bone disease. Considering the intervention without any change in functional status of
presentation of the disease, 6(9.7%)
were recurrence of the tumour while
4(6.5%) were residual disease after
marginal excision elsewhere. The
remaining 52 (84.4%) cases belonged
to the initial presentation group. The
most frequent sites were proximal
and distal femur, while there were 9
(15.3%) cases of proximal tibia and
5(8.5%) of proximal humerus.
Regarding the nature of surgery, 53
(85%) cases had primary surgery
while 9(15%) were undergoing
revision of a failed implant. In terms
of implant type, 30 (48.4%) patients
underwent distal femur mega endo-
prosthesis, 22(35.5%) had proximal
femur replacement with hip Figure-1: Types of post-surgery major complications. DVT: Deep Vein Thrombosis

J Pak Med Assoc (Suppl. 5)

S-47 34th International Pak OrthoCon Conference 2021

Custom built prosthesis were introduced

in 1949 initially by Stanmore, however,
they gained popularity in 1970s because
of the advent of neo-adjuvant
chemotherapy and advancements in
diagnostic modalities. Over the next
decade, introduction of modular
prosthesis ensured not only the easy
availability and cheaper cost but also
more flexibility during resection.7
Moreover, though these implants have
been introduced primarily for oncological
indications but they have also been of
paramount utilization in the event of
revision surgeries with large osseous
defects, aseptic loosening, peri-prosthetic
fractures and pseudo-arthrosis.9
These custom prosthesis used to replace
the femur, the hip joint, part of the pelvis,
the knee joint, the humerus and shoulder
joint, and parts of the ulna and radius
which are the most common predilection
Figure-2: Survival curve of patients with regard to nature of tumor. sites of primary bone tumours.10 In
addition to these, custom and modular
the patients. Major complications included deep implants have also been involved in management of
infections, dislocation, aseptic loosening, soft tissue metastatic bone disease particularly in the setting of a
failure, neurovascular damage and local recurrence pathological fracture and wherever the intent is
(Figure-1). For management of complications, 6 required palliative.11,12 The most usual site, in case of metastatic
open or closed reduction, 6 had wound debridement with disease, has been proximal femur.12
4 of them requiring additional flap coverage. Three
Mega-prosthetic reconstruction has many advantages.
patients needed revision surgery while three more ended
The load-bearing characteristics of prosthetic
up having amputation. One patient required tendon
reconstruction surgery offer immediate postoperative
transfers for radial nerve injury (Table-1).
stability and facilitate rapid rehabilitation. However,
Out of the 62 patients, 17 expired thus the survival rate appropriate patient selection is paramount to obtain
was 69.8%. Mean survival time was 76.3 months with better and more consistent results. The involvement of
standard error of 8.55. Survival rate of primary malignant major structures is considered an important factor in
bone tumours was 80% (Figure-2). determination of limb salvage vs amputation. The
decision is to be made once patients are re-evaluated
Discussion after the neo-adjuvant treatment, through which, some
The mean MSTS score was 72.09% and 52% patients had patients who are not candidates of limb salvage initially,
some complications in the presented study. A major may experience shrinkage in tumour size and thus
complication was seen in 31% patients requiring a second increase in chances of limb salvage. Another patient
invasive intervention or lead to a change in functional group is the one with poor prognostic factors like
metastasis on presentation, bone metastatic disease and
status. These included wound dehiscence, deep tissue
ineffective response to chemotherapy. Mega endo-
infection, major neurovascular damage, aseptic loosening
prosthetic reconstruction is a viable option in such
or dislocation. Minor complications as delayed wound
patients to improve quality of life when compared to
healing, cellulitis and superficial infection requiring
debilitating radical management, wherever there is a
antibiotics therapy was encountered in 21% patients. Our
limited life expectancy.13
mean functional score was comparable to our previous
study.2 However, it remained lower than Tan et al. and Endo-prosthetic reconstruction has now comparable
Tunn et al. which were 78% and 77% respectively.7,8 results with amputation regarding oncological outcome

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-48
Table-2: Comparison of our surgical and functional outcomes with international literature.

Author No. of Type of MSTS Aseptic Loosening / Implant Infection

cases prosthesis (%) Dislocation (%) fracture (%) (%)

Qadir et. al.2 16 Mix 72.3 12.5 0 12.5

Malawer et. al.6 68 Mix 75 17 0 13
Tan et. al.7 19 Mix 78.3 10.5 0 31.5
Natarajan et. al.16 17 Total Femur 66.6 11.8 0 11.8
Futani et al.26 22 Distal Femur 74 22.7 9.1 27.3
Current Series 62 Mix 72.1 4.9 0 9.6

Figure-3A: Patient developed deep infection and wound dehiscence. Flap coverage Figure-3B: X-ray showing inadequate cement mantle causing aseptic loosening.
was attempted twice which failed.

and long-term survival but also with better functional outcomes, deep infection and concomitant pathology
outcome in terms of Musculoskeletal Tumour Society e.g., advanced osteoarthritis or AVN of ipsilateral joints
(MSTS) score. Since, bone sarcomas are the fourth most also has an influence.15,16 Comparison with other studies
common cancer in individuals under the age of 25, this in literature is displayed in Table-2.
demands longevity of the reconstructions. Furthermore,
On comparison with other studies17-19 with the rates of 4% to
cancer patients are more prone to complications, due to
30%, 9.6% of our patients showed peri-prosthetic infection
the impaired immune system, longer surgery time, and
which is one of the most common complication after mega
greater loss of tissue and structures.14 These mega-
endo-prosthesis apart from local recurrence (Figure-3A). This
prosthesis also have worse long-term results compared to
is attributed to various risk factors like tumour disease,
conventional total joint replacements.15
chemotherapy-induced immunosuppression, poor soft
Nevertheless, all of these studies were based on primary tissue situation due to radiation therapy, long operation time
bone tumours while our work also incorporated the cases and inadequacy of coverage.20 One patient with
of metastatic bone disease. In terms of functional metastatic renal carcinoma underwent tumour debulking

J Pak Med Assoc (Suppl. 5)

S-49 34th International Pak OrthoCon Conference 2021

and proximal femur replacement while four with primary important one was the small sample size despite a long
malignant bone tumours received neo-adjuvant as well as span of 10 years. This is because of the financial
adjuvant chemotherapy. Another case was that of a 14 limitations of our patient group. Secondly, we used
year old girl with Ewing's Sarcoma who developed peri- prosthesis from different providers, which may have a
prosthetic infection after 5 years of index surgery, though bearing upon mechanical complications and long-term
in literature, majority of the cases present within first two survival of the implants. However, it had no bearing upon
years.20 No significant difference was found in the resection plan and margins. Moreover, the follow up is too
infection rate between hip and knee surgeries. Recent short in some cases to have any implications upon
studies have shown the promising results of silver coated recurrence rate, functional score and particularly survival.
mega-endoprosthesis in terms of decreased infection
rate, however, no long-term level 1 data is available yet. Recommendations
Moreover, cost and availability have also been major Future refinements in technique and technology would
deterrents of those implants in our setting.21,22 certainly improve the outcome and minimize the
complications associated with limb salvage.
Three amputations had been observed in our study in
which 2 of them had infection and patients underwent Disclaimer: None.
multiple wound debridement and coverage. In the third
case, however, there was recurrence after undergoing Conflict of Interest: None.
intramedullary nailing of the pathological fracture of Funding Disclosure: None.
femur secondary to a Leiomyosarcoma, which was found
out on subsequent biopsy. Our overall limb salvage rate References
was 95%. 1. Hwang JS, Mehta AD, Yoon RS, Beebe KS. From amputation to
limb salvage reconstruction: evolution and role of the
Among the patients who required revision surgery, we endoprosthesis in musculoskeletal oncology. J Orthop Traumatol.
performed revision of femoral components only. Both 2014; 15:81-6.
remained disease free, however, one of them developed 2. Qadir I, Umer M, Baloch N. Functional outcome of limb salvage
coronal instability after 10 years of initial surgery (Figure- surgery with mega-endoprosthetic reconstruction for bone
tumors.Arch Orthop Trauma Surg. 2012; 132:1227-32.
3B). One of the rare complications and cause of revision is 3. Pala E, Trovarelli G, Calabrò T, Angelini A, Abati CN, Ruggieri P.
failure of hinge mechanism, which was also experienced Survival of modern knee tumor megaprostheses: failures,
by one of our patients. He eventually developed knee functional results, and a comparative statistical analysis. Clin.
dislocation. Polyethylene (PE) bushing failure had been Orthop. Relat. Res. 2015; 473:891-9
4. Schwartz AJ, Kabo JM, Eilber FC, Eilber FR, Eckardt JJ. Cemented
the likely mechanism in our case, which is also reported as
distal femoral endoprostheses for musculoskeletal tumor:
one of the reasons of this type of failure.23 improved survival of modular versus custom implants. Clin.
Orthop. Relat. Res.2010; 468:2198-210.
Our recurrence rate in primary malignancies remained 9% 5. Natarajan MV, Sivaseelam A, Ayyappan S, Bose JC, Kumar MS.
which is comparable with literature. Both Ham et al. and Distal femoral tumours treated by resection and custom mega-
Malawer et al. reported 6% rate of local recurrence.6, 24 prosthetic replacement. Int Orthop. 2005; 29:309-13.
6. Malawer MM, Chou LB. Prosthetic survival and clinical results with
Overall survival rate of our patients was 67.8%, whereas, use of large-segment replacements in the treatment of high-
mean survival time was 76±8.55 months. These were grade bone sarcomas. J Bone Joint Surg (American volume). 1995;
77:1154-65.
primarily patients with metastatic bone disease. Among 7. Tan PK, Tan MH. Functional outcome study of mega-
those with primary malignant bone tumours, survival rate endoprosthetic reconstruction in limbs with bone tumour
had been 80%. surgery. Ann Acad Med Singap. 2009; 38:192.
8. Tunn P, Pomraenke D, Goerling U, Hohenberger P. Functional
Conclusion outcome after endoprosthetic limb-salvage therapy of primary
bone tumours-a comparative analysis using the MSTS score, the
Mega-endoprosthetic reconstruction is a good option, in TESS and the RNL index. Int. Orthop 2008; 32:619-25.
terms of functional outcome, for limb salvage after bone 9. Veth R, Nielsen H, Oldhoff J, Koops HS, Mehta D, Oosterhuis J, et al.
tumour resection, with an acceptable rate of Megaprostheses in the treatment of primary malignant and
metastatic tumors in the hip region. J Surg Oncology. 1989;
complications. However, cost has been a major deterrent. 40:214-8.
Patient selection and rehabilitation is of paramount 10. Fakler JK, Hase F, Böhme J, Josten C. Safety aspects in surgical
importance for a good outcome. treatment of pathological fractures of the proximal femur-
modular endoprosthetic replacement vs. intramedullary nailing.
Limitations Patient Saf. Surg 2013; 7:37.
11. Hattori H, Mibe J, Yamamoto K. Modular megaprosthesis in
There were numerous limitations in our study. Most metastatic bone disease of the femur. Orthopedics. 2011; 34:e871-e6.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-50
12. Henshaw R, Malawer M. Review of endoprosthetic reconstruction Silver-Coated Hip Megaprosthesis in Oncological Limb Savage
in limb-sparing surgery. Musculoskeletal cancer surgery: Surgery. Biomed Res Int. 2016; 2016:6.
Springer, Dordrecht 2004; p. 383-403. 19. Orlic D, Smerdelj M, Kolundzic R, Bergovec M. Lower limb salvage
13. Holm CE, Bardram C, Riecke AF, Horstmann P, Petersen MM. surgery: modular endoprosthesis in bone tumour treatment. Int.
Implant and limb survival after resection of primary bone tumors Orthop. 2006; 30:458-64.0.
of the lower extremities and reconstruction with mega- 20. Hardes J, Ahrens H, Gosheger G, Nottrott M, Dieckmann R,
prostheses fifty patients followed for a mean of forteen years. Int. Henrichs M-P, et al. Komplikationsmanagement bei
Orthop. 2018; 42:1175-81. Megaprothesen. Der Unfallchirurg. 2014; 117:607-13.
14. Mercuri M, Papagelopoulos PJ. Megaprosthetic reconstruction for 21. Hardes J, Henrichs MP, Hauschild G, Nottrott M, Guder W,
malignant bone tumors: complications and outcomes. J Long Streitbuerger A. Silver-coated megaprosthesis of the proximal
Term Eff Med Implants 2008; 18: tibia in patients with sarcoma. J. Arthroplasty. 2017; 32:2208-13.
15. Holm CE, Bardram C, Riecke AF, Horstmann P, Petersen MM. 22. Donati F, Di Giacomo G, D'adamio S, Ziranu A, Careri S, Rosa M, et
Implant and limb survival after resection of primary bone tumors al. Silver-coated hip megaprosthesis in oncological limb savage
of the lower extremities and reconstruction with mega- surgery. Biomed Res.Int. 2016; 2016:9079041. doi:
prostheses fifty patients followed for a mean of forteen years. Int 10.1155/2016/9079041
Orthop. 2018; 42:1175-81. 23. Chuang M-Y, Chang T-K, Huang C-H, Huang T-Y. Failure of the
16. Natarajan MV, Balasubramanian N, Jayasankar V, Sameer M. rotating-hinge knee megaprosthesis. J Arthroplasty. 2013; 28:543.
Endoprosthetic reconstruction using total femoral custom mega e5-. e8.
prosthesis in malignant bone tumours. Int Orthop. 2009; 24. Ham SJ, Koops HS, Veth RPH, van Horn JR, Molenaar WM, Hoekstra
33:1359-63. HJ. Limb salvage surgery for primary bone sarcoma of the lower
17. Funovics PT, Hipfl C, Hofstaetter JG, Puchner S, Kotz RI, Dominkus extremities: Long-term consequences of endoprosthetic
M. Management of septic complications following modular reconstructions. Ann. Surg. Oncol 1998; 5:423-36.
endoprosthetic reconstruction of the proximal femur. Int. Orthop.
2011; 35:1437-44.
18. Donati F, Di Giacomo G, #x, Adamio S, Ziranu A, Careri S, et al.

J Pak Med Assoc (Suppl. 5)

S-51 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
Inter-observer variation of the Schatzker and Khan classification of Tibial
plateau fractures: Cohort study
Mansoor Ali Khan, Sateesh Pal, Syed Kamran Ahmed, Muhammad Amin Chinoy

Abstract
Objective: To compare the inter-observer reliability of Shatzker classification and Khan Classification of Tibial
plateau fractures.
Methods: This retrospective cohort study was conducted at The Indus Hospital, Karachi, Pakistan. Radiographs of
50 patients who presented with tibial plateau fractures from March 2015 to November 2016 were collected. Two
observers classified these cases independently according to Shatzker and Khan Classification. Gwet's AC1 statistics
applied to assess inter-observer reliability of both the classification systems.
Results: Moderate inter-observer agreement for Schatzker classification (p<0.001) and slight inter-observer
agreement on Khan Classification (p=0.738) was observed.
Conclusion: Khan Classification is more comprehensive in classifying tibial plateau fractures and can be used for
clinical research purpose, while Shatzker classification with better inter-observer reliability is applicable for routine
clinical practice.
Keywords: Tibial plateau fractures, Reliability, Classification. (JPMA 71: S-51 [Suppl. 5]; 2021)

Introduction classification system was ideal.6 Mellema et al claimed that

the Schatzker classification has better inter-observer reliability
Tibial plateau fractures constitute 1-2% of all fractures in the
than the Luo classification.7 Schatzker classification is the
human body. As they are intra-articular fractures, they need
most reliable classification particularly when CT scan is used
to be reduced anatomically which is usually done by means
of surgery. Different classification systems have been Table-1: Tibial plateau fractures: Khan classification.10
proposed for tibial plateau fractures for the ease of
S.No. Topographic Features Morphologic Features
understanding and planning treatment. Ideal classification
should be simple to memorize, guide in treatment planning, 1 Lateral tibial plateau fractures L1-Wedge
predict the prognosis of the fracture and help in clinical L2-Pure depression
research.1,2 L3-Wedge and depression
L4-Total condyle
Schatzker and AO classification for tibial plateau fractures are L5-Entire condyle
the most frequently used classifications in clinical practice, 2 Medial tibial plateau fractures MI –Wedge
but they both have significant drawbacks. They are based on M2-Pure depression
anteroposterior radiographs only, not on lateral radiographs, M3-Wedge and depression
so there is high chance of missing coronal split fractures that M4-Total condyle
can lead to significant changes in knee joint biomechanics M5-Entire condyle
resulting in significant knee pain and early knee 3 Posterior tibial plateau fractures P1 -Posterolateral split
osteoarthritis.3 Mandarino et al found that Schatzker P2-Posteromedial split
4 Anterior tibial plateau fracture A1 -Anterolateral split
classification has moderate inter-observer reproducibility.4
A2-Anteromedial split
Rafii et al. showed that computed tomography (CT) is 5 Rim fractures R1-Rim avulsion fractures
superior to conventional X-rays in tibial plateau fractures.5 R2-Rim compression fractures
Maripuri et al compared the Schatzker, AO, and Hohl and R3-Rim combination fractures
Moore classifications of tibial plateau fractures. They 6 Bicondylar fractures B1 -Nonarticular bicondylar
observed that Schatzker classification has better inter- B2-Articular lateral
observer reliability and intra-observer reproducibility than AO B3-Articular medial
and the Hohl and Moore classification, but none of the B4-Articular lateral and medial
7 Subcondylar fractures S1-Subcondylar lateral
S2-Subcondylar medial
Department of Orthopedics, The Indus Hospital, Karachi, Pakistan. S3-Subcondylar bicondylar
Correspondence: Mansoor Ali Khan. Email: makbonedoc65@gmail.com S4-Su bcondylar bicondylar with split

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-52
to assess the tibial plateau fracture configuration. On the the first viewing and no feedback was given to observers.
other hand, revised Duparc classification has a poor reliability
due to its complexity and different morphological subtypes.8 Data included age and gender of patients, Shatzker and
Khan classification of all tibial plateau fractures by 2
Schatzker et al described classical and simple classification different observers. Data from both observers was
for tibial plateau fractures which included anatomical entered on Microsoft excel sheets. Data was then
characteristics of fracture and its location, guided in transferred to SPSS version 21.0 for analysis. Mean ± SD
treatment plan and provided some estimate of prognosis.9 computed for age. Frequency and percentage computed
Khan et al introduced a more comprehensive classification for gender. Gwet's AC1 statistics12 was applied to assess
for tibial plateau fractures, which included most of the inter-rater reliability of both the classification systems.
fracture types, especially fractures in lateral radiographs to
improve understanding of fracture configuration (Table-1).10 Results
Total of 50 patients with tibial plateau fractures who met
This study was performed to compare the inter-observer
the inclusion criteria and had good quality
reliability of Shatzker classification and Khan Classification
of tibial plateau fractures, to develop a still more reliable
classification system.

Methods
This was a retrospective cohort study conducted at The
Indus Hospital, Karachi, Pakistan. Patients who were
skeletally mature and presented with tibial plateau
fracture, had good quality anteroposterior (AP) and lateral
radiographs of proximal tibia with knee joint were
included in the study. Data was collected from March 2015
to November 2016. The estimated sample size was derived
from the online Raosoft sample size calculator.11 Sample
size was calculated based on a response rate of 50%, a
confidence interval of 90%, and a margin of error of 5%.
All the cases were arranged on a proforma and numbered
randomly. Two observers who were orthopaedic residents
at different levels of training (Observer I: Orthopaedic
resident year 3, Observer II: Orthopaedic resident year 2)
classified these cases independently according to Shatzker9
and Khan Classification.10 Before the start of study, each
observer completed a training session on both classification
systems. Both observers were given adequate time for
assessing the radiographs. Clinical details of patients 20 to 30 years: 8 (16%); 30 to 40 years: 20 (40%)
including their presentation or management were not 40 to 60 years: 21 (42%); 60 to 70 years: 1 (2%)
provided to observers. Classifications choices were made at Figure-1: Age of the patients.

Table-2: Inter-observer variation of Shatzker classification (Observer I in rows and Observer II in columns).

Schatzker Schatzker classification by Obsever II Total P-value

classification I III IV V VI Gwet's AC1 (95% CI)
by Observer I n (%) n (%) n (%) n (%) n (%) n (%)

I 1 (2) 0 (0) 0 (0) 0 (0) 1 (2) 2 (4)

II 0 (0) 8 (16) 0 (0) 0 (0) 0 (0) 8 (16)
III 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 1 (2)
IV 1 (2) 0 (0) 9 (18) 3 (6) 0 (0) 13 (26) p<0.001**†
V 0 (0) 1 (2) 0 (0) 4 (8) 7 (14) 12 (24) 0.50 (0.34-0.67)
VI 0 (0) 0 (0) 0 (0) 0 (0) 14 (28) 14 (28)
Total 2 (4) 10 (20) 9 (18) 7 (14) 22 (44) 50 (100)

J Pak Med Assoc (Suppl. 5)

S-53 34th International Pak OrthoCon Conference 2021

Table-3: Inter-observer variation of Khan Classification (Observer I in rows and Observer II in columns).

Khan classification Khan classification by Obsever II

by Observer I B2 B4 L1 L2 L3 L5 M3 M4 M5 S1 S2 S4 Total P-Value
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Gwet's AC1 (95%Cl)

B4 1 (2) 4 (8) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) 1 (2) 0 (0) 8 (16)
L2 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2)
L3 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2)
L4 1 (2) 0 (0) 1 (2) 0 (0) 5 (10) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 7 (14)
L5 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2)
M3 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2)
M4 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 0.738†
M5 0 (0) 2 (4) 1 (2) 0 (0) 0 (0) 0 (0) 1 (2) 2 (4) 4 (8) 0 (0) 0 (0) 0 (0) 10 (20) 0.26 (0.12-0.39)
P1 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2)
P2 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 0 (0) 1 (2)
S1 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) 0 (0) 0 (0) 2 (4)
S3 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) 2 (4)
S4 1 (2) 2 (4) 0 (0) 0 (0) 0 (0) 1 (2) 0 (0) 0 (0) 0 (0) 4 (8) 3 (6) 3 (6) 14 (28)
Total 3 (6) 9 (18) 2 (4) 1 (2) 8 (16) 1 (2) 2 (4) 3 (6) 4 (8) 8 (16) 4 (8) 5 (10) 50 (100)
B2-Articular lateral, B4-Articular lateral and medial, L2-Pure depression, L3-Wedge and depression, L4-Total condyle,
L5-Entire condyle, M3-Wedge and depression, M4-Total condyle, M5-Entire condyle, P1 -Posterolateral split
P2-Posteromedial split, S1-Subcondylar lateral, S2-Subcondylar medial, S3-Subcondylar bicondylar,
S4-Su bcondylar bicondylar with split.

between 60 to 70 years (Figure-1). There were 49 (98%)

males and only 1 (2%) female (Figure-2).
Regarding inter-observer variation, moderate inter-
observer agreement for Schatzker classification was
observed (p<0.001) (Table-2). Both the observers agreed
on 29 (58%) cases while disagreed on 21(42%) cases.
Slight inter-observer agreement on Khan Classification
(p=0.738) was observed (Table-3). Both the observers
agreed on 15 (30%) cases only while disagreed on 35
(70%) cases. Many subtypes of Khan classifications were
not found in provided radiographs by both the observers.

Discussion
A useful classification in orthopaedic surgery which
reliably categorizes fracture type, helps in communication
in clinical practice, guides in treatment and is an aid in
clinical research. Most frequently used classifications in
tibial plateau fractures include Schatzker and AO
classifications. There are multiple modifications and new
proposals of classifications systems but they need to be
reliable in terms of intra and inter-observer variation.
Males: 49 (98%); Females: 1 (2%) There are many comparisons among the current
Figure-2: Sex of patients. classifications of tibial plateau fractures.13
anteroposterior (AP) and lateral radiographs of proximal Fractures of tibial plateau are common and difficult to
tibia with knee joint were enrolled in the study. Mean age treat and optimum treatment is matter of controversy. The
of patients was 40 ± 9.45 years. Eight (16%) patients were anatomic differences between medial and lateral tibial
between 20 to 30 years, 20 (40%) between 30 to 40 years, plateau should be considered when planning to fix these
21 (42%) between 40 to 60 years and 1 (2%) patient was injuries. Apparently, dividing tibial plateau fractures into

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-54
unicondylar or Bicondylar fractures and those with a pure widespread applicability of Shatzker classification in routine
split or articular depression with or without split can be a practice, but Khan classification is more comprehensive in
more reliable approach. Recently, several studies classifying tibial plateau fractures and can be used for
concluded that a multi-planar CT scan increases the clinical research purpose while Shatzker classification is easy
reliability in classifying tibial plateau fractures but depends to remember and applicable for routine clinical practice.
on its availability in hospitals and the cost of investigation.
The major drawback of Schatzker and AO classification is Disclaimer: Abstract was presented as oral presentation
that they do not include a coronal fracture which occurs as at 31st Pakorthocon 2017 in Peshawar, Pakistan.
a result of varus or valgus forces combined with axial Conflict of Interest: None.
loading leading to postero-medial or anterior coronal
splits. These coronal fractures are burning issues and they Funding Disclosure: None.
are getting more and more attention by trauma surgeons
across the world. They are prevalent in most complex References
bicondylar tibial plateau fractures as a result of high 1. Albuquerque RP, Giordano V, Pallottino A, Sassine T, Canedo R,
energy trauma. Resulting comminution, especially with Pina J, Amaral NP. Analysis of the reproducibility of tibial plateau
fractures' classification.Rev Bras Ortop. 2009;44:225-9
fractures involving the posterior aspect of the tibial 2. Gradl G, Neuhaus V, Fuchsberger T, Guitton TG, Prommersberger
plateau, makes the interpretation of fracture patterns KG, Ring D. Radiographic diagnosis of scapholunate dissociation
difficult and prone to misconception. Among 111 among intra-articular fractures of the distal radius: interobserver
bicondylar tibial plateau fractures evaluated by plain reliability. J Hand Surg Am 2013;38:1685-90
3. Zhu Y, Hu CF, Yang G, Cheng D, Luo CF. Inter-observer reliability
radiographs, Higgins et al found postero-medial fragment assessment of the Schatzker, AO/OTA and three-column
in 59% cases. Failure to recognize and fix the postero- classification of tibial plateau fractures. J Trauma Manag
medial fragment may lead to rotation of medial femoral Outcomes 2013;7:7.
condyle and early knee osteoarthritis.14 4. Mandarino EM, Person A, Guimarães JAM. Evaluation of the
reproducibility of the Schatzker classification for tibial plateau
Tibial plateau fractures are a group of injuries with fractures. INTO 2004; 2:11-8.
5. Rafii M, Lamont JG, Firooznia H. Tibial plateau fractures: CT
differences in topographic features, morphological
evaluation and classification. Crit Rev Diagn Imaging. 1987;
features, pathomechanics and prognosis. The Khan's 27:91-112.
classification is comprehensive because it includes all 6. Maripuri SN, Rao P, Manoj-Thomas A, Mohanty K. The
fracture types reported in literature. A new fracture classification systems for tibial plateau fractures: how reliable are
(subcondylar and bicondylar with coronal split) has been they? Injury. 2008;39:1216-21
7. Mellema JJ, Doornberg JN, Molenaars RJ, Ring D, Kloen
classified for the first time. An alphanumeric system has P.Interobserver reliability of the Schatzker and Luo classification
been developed that has made nomenclature easy to systems for tibial plateau fractures. Injury. 2016;47:944-9.
remember and use.10 Although in our study we found 8. Taskesen A, Demirkale I, Okkaoglu MC, Özdemir M, Bilgili MG,
that Inter-observer reliability of Khan's classification is less Altay M. Intraobserver and interobserver reliability assessment of
tibial plateau fracture classification systems. Jt Dis Relat Surg.
than Schatzker's classification, the reason may be 2017;28:177-81.
widespread applicability of Shatzker classification in 9. Schatzker J, McBroom R, Bruce D: The tibial plateau fractures: The
routine practice, but we need to combine all types of Toronto experience 1968-1 979. Clin Orthop 138:94-104, 1979.
tibial plateau fractures under one umbrella which needs 10. Khan RM, Khan SH, Ahmad AJ, Umar M. Tibia1 Plateau Fractures
A New Classification Scheme. Clin Orthop Relat Res. 2000;
its routine use and applicability in routine practice. The 375:231-42.
Khan classification for tibial plateau fractures is more 11. http://www.raosoft.com/samplesize.html. Cited on 27. June, 2021
comprehensive and can classify all types of tibial plateau 12. Gwet K. Computing inter-rater reliability and its variance in the
fractures but due to its complexity, it is difficult to use in presence of high agreement. Br J Math Stat Psychol. 2008;
61:29-48.
daily clinical practice while Shatzker classification is
13. Charalambous CP, Tryfonidis M, Alvi F, Moran M, Fang C, Samarji
simple and easy to remember for routine clinical use but R, Hirst P. Inter- and intra-observer variation of the Schatzker and
fails to address all types of tibial plateau fractures. AO/OTA classifications of tibial plateau fractures and a proposal of
a new classification system. Ann R Coll Surg Engl 2007; 89: 400-
Conclusion 404
14. Higgins TF, Kemper D, Klatt J. Incidence and morphology of the
Although Inter-observer reliability of Khan classification is posteromedial fragment in bicondylar tibial plateau fractures. J.
less than Schatzker classification, the reason may be Orthop. Trauma. 2009;23:45-51.

J Pak Med Assoc (Suppl. 5)

S-55 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
Ilizarov fixator pin site infection: A comparison between transverse wires and
half pins
Asadullah Makhdoom, Raheel Akbar Baloch, Muhammad Faraz Jokhio, Syed Muhammad Ali, Zameer Hussain Tunio, Jehanzaib,
Tahir Ahmed

Abstract
Objective: To evaluate the difference in the infection rates between Ilizarov wires and half-pins in
routine practice.
Methods: This was an observational, prospective; single-centre study approved by the institutional
ethics committee. Hundred cases were treated from June 2014 to May 2018 at Ilizarov Surgery Unit,
Department of Orthopaedic Surgery & Traumatology Liaquat University of Medical & Health Sciences
Jamshoro Sindh Pakistan. All patients were subjected to an evaluation of half-pins and Ilizarov wires.
Patients with monolateral fixators were excluded from the study. The demographic data included
patient's age and sex, surgical indication, application and removal of Ilizarov fixator, follow-up
duration and type of pin (transverse wire or half pin) used. Non probability consecutive sampling
technique was used and sample size was calculated randomly.
Result: Of the total 100 cases, 79(79%) were male and 21(21%) were female with a mean age of 42.8±8.2
years. A total of 890 pins were applied in 100 patients with 170(19.10%) Half pins and 720(80.89%)
wires. The transverse wire's infection rate according to Paley's grading system of Pin tract infection was,
46(53.48%), 25(29.06%) and 15(17.44%) in Grade I, Grade II and Grade III respectively. In case of half
pin's infection, the majority of the cases were categories in grade II 22(55.0%) followed by Grade I
12(30.0%) and Grade III 06(15.0%).
Conclusion: The tensioned transverse wires had a significantly low infection rate as compared to half
pins.
Keywords: Ilizarov Fixators, Transverse wires, Half pins, Pin infection. (JPMA 71: S-55 [Suppl. 5]; 2021)

Introduction nevertheless, its use is also associated with significant

The magician of Kurgan (Russia), Prof. Gravil Ilizarov rates of pin tract infection.6 It is the most common
revolutionised the treatment of complicated expected orthopaedic problems, or even an almost
musculoskeletal disorders.1 He is the first to discover inevitable complication, may mainly arise from
the biological principles of modern distraction percutaneous pins or wires. In comparison with the
osteogenesis by its successful technique of Ilizarov, now results of various studies, the pin infections range from
the key tool in numerous orthopaedic conditions.2 The 10 to 100%.7,8 The discrepancy in the infection range is
Ilizarov fixator is widely used for fracture fixation and mainly due the study duration, the external fixator
stabilization, deformity correction, limb lengthening application technique, patient population, and the pin
and reconstructive surgery. 3 A number of fixator site care protocol used. Thus, PTI remains a clinical
systems are available ranging from the tensioned fine challenge, specifically in cases of limb lengthening or
wire circular fixators (Monticelli-Spinelli, Ace-Fischer), deformity correction. Ilizarov frame is a form of ring
to the axially dynamic unilateral designs to which the fixator, traditionally constructed using transverse wires.
Orthofix and AO fixators belong.4 However, Ilizarov's The transverse wires can cause damage to nerves and
original ring fixator design, by virtue of its inherent blood vessels, whereas, half pins in comparison with
versatility and biocompatibility, remains the most transverse wires is safer and easier to apply.9 Whereas in
uniquely suited to the tasks of lengthening, case of pin infections, according to the past literature,
simultaneous or staged three dimensional deformity the rates of wire and half-pin infection for external
correction, and intercalary bone transport.5 Though the fixation ranging from 0.5 to 30% and more common in
management by Ilizarov fixation is well established, half pin as compared with the transverse wires.10 There
are multiple studies conducted on the Ilizarov frame
Department of Orthopaedic Surgery & Traumatology, Liaquat University of technique reflecting the importance and evaluating the
Medical & Health Sciences, Jamshoro, Sindh, Pakistan. clinical outcome of Ilizarov fixator,11 but there are
Correspondence: Asadullah Makhdoom. Email: asadmakhdoom@gmail.com limited data for the comparison of pin site infection in

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-56
transverse wires and half pins especially in case of the In this study, 100 cases were selected as per
local Pakistani population. The aim of this study was to inclusion/exclusion criteria. The mean age was 42.8±8.2
evaluate the difference in the rates of Pin site wound years with 48(48.0%) patients between 18 and 35 years,
sepsis between transverse wires and half-pins in 27(27.0%) between 36-50 years and 25(25.0%) patients
patients with Ilizarov circular fixator. were in the age group above 50 years. There were
79(79.0%) males, and 21(21.0%) females. The bones
Methods involved in the traumatic injury included, tibia as the
It was a single-centre, prospective, observational study on commonest 60(60.0%) while the second most common
100 patients who underwent distraction osteogenesis bone was femur IE; 23(23.0%), followed by, humerus and
using Ilizarov circular fixator. The study was conducted at radius/ ulna with a percentage of 14(14.0%) and 3(03.0%)
the Orthopaedic department of Liaquat University of respectively. Road traffic accident was the most common
Medical & Health Sciences (LUMHS), Jamshoro from the mode of injury in 70(70.0%) cases, while history of fall
period of June 2014 to May 2018. Non probability was recorded in 18(18.0%) patients, firearm injury in
consecutive sampling technique was used and sample 08(08.0%) patients and 04(04.0%) patients were
size was calculated randomly. assaulted. Total pins applied were 890. Among them, half
pins used were 170(19.10%) and wires were 720(80.89%).
As per study exclusion criteria, patients with pre-existing
Of the wires used, 690(95.83%) were Plain wires and
infection and co-morbidities that may enhance the risk of
30(4.16%) were beaded.
getting pin site wound sepsis such as diabetes mellitus,
renal and liver failure, tumours and smoking were Half pins were found more infected as compared to
excluded. The study population consisted of all skeletally wires. Of 170 half pins 40(23.52%) were infected, while
mature patients who underwent distraction osteogenesis out of 720 transverse wires, 86(11.94%) were infected.
using Ilizarov circular fixator. After the application of According to Paley's grading system of Pin tract
Ilizarov external fixation, the first dressing of wires and pins infection, transverse wire's infection rate was found in:
was applied after 48 hours and appropriate intravenous 46(53.48%) in the Grade I, 25(29.06%) in grade II and
antibiotic was given for 3 days followed by 5 days of an 15(17.44%) in Grade III. According to the Paley's
oral antibiotic if required. The patients were reassessed grading system of Pin tract infection, half pin's
after every 72 hours. The pins and wires were cleansed infection rate was found in majority of the cases,
with a single gauze soaked with pyodine solution, or 22(55.0%) in Grade II, followed by 12(30.0%) in Grade I
hydrogen peroxide if the pin tract infection developed. and 06(15.0%) in Grade III.
The designed CRF recorded the patients' medical and
demographic data including age and sex, surgical Discussion
indication, application and removal of Ilizarov fixator, The Ilizarov frame provides a versatile fixation system,
follow-up duration, type of pin (transverse wire or half pin), however the Pin site infection is almost an inevitable
total number of wires and half pins found infected. complication associated with this successful frame
Grading was done according to Paley's classification and technique.13 Its frequency ranges from 11.3 to 100%.
treated according to the given guidelines.12 Studies have shown figures of 24.1% by Grant et al, 52% by
All patients were trained to clean their wires and pins Schalamon et al, 26.25% by Ferreira N et al, 26% by Toksvig
during their stay in the hospital. After discharge, patients et al, 70% by Mostafavi et al, 25% by Rose R et al, 11.2% by
were followed up every 2-weeks through the outpatient Parameswaran et al, 18% by Chan CK et al and 85% by
department until the fracture was united and pins and Aronson J et al.10,14-20 In our study, the rate of transverse
wires were removed. wire's infection was reported as 17% and majority of the
cases (55%) had half pin infection and were placed in
For analysis of the data, SPSS version 20 was used. A p grade II category. The variation in the reported rates
value < 0.05 was considered significant. All variables were among studies is partly due to lack of a standardized,
summarised using the number of observations, mean, validated and comparable grading system.14,21
standard deviation or standard error, median, minimum
and maximum, ± 95% confidence intervals were provided There are only a few studies which compare the infection
in the inference tables where applicable. All hypothesis rate between thin transverse wires and threaded half
tests were two-sided and conducted using a 0.05 pins in patients with Ilizarov circular fixator. Some
significance level unless otherwise stated. advocate there is the lowest rate of pin site wound sepsis
in threaded half pins.17,22 At the same time, there are
Results several prior studies which have significantly higher

J Pak Med Assoc (Suppl. 5)

S-57 34th International Pak OrthoCon Conference 2021

infection rate, but the raw data in all these studies a lower infection rate. The tensioned transverse wires had
demonstrated higher infection rate in half pin site.19 a significantly lower infection rate as compared to half
pins.
In a study carried out with 124 wires and 95 half pins sites
in 21 patients, pin site wound infection was noted in Disclaimer: None.
55(25%) pins, 6.3% of which developed in half pins and
Conflict of Interest: None.
18.7% in the wire sites. Of the 21 patients, 19(90.4%) had
pin tract infections.17 In our study, of the 100 patients, half Funding Disclosure: None.
pins were found more infected as compared to wires, as
well as out of 170 half pins 40(23.52%) were infected, Ethics Approval: The study protocol and follow-up
while out of 720 wires, 86(11.94%) were infected. Our analysis were approved by the Ethics Committee of
study results were endorsed by a previous study which LUMHS.
observed that the frequency of pin tract infection was References
higher with a half pin (8.0%) than with fine wires (5.3%)
1. Paul GW. The History Of External Fixation. Clin Podiatr Med Surg.
with the difference being significantly higher for half pin 2003;20:1-8.
sites in the distal segment. Similarly, another comparative 2. Battaloglu E, Bose D. The History Of Ilizarov. Trauma. 2013;15:257-62.
study on two different solutions reported that Half-pin 3. Spiegelberg B, Parratt T, Dheerendra SK, Khan WS, Jennings R,
sites were more likely to become infected than wire sites Marsh DR. Ilizarov Principles Of Deformity Correction. Ann. R. Coll.
Surg. Engl.2010;92:101-5.
(25% vs 15%). In addition, Antoci V et al reported that the 4. Ferreira N, Mare PH, Marais LC. Circular External Fixator
rate of pin tract infection to be significantly higher with Application For Midshaft Tibial Fractures: Surgical Technique. SA
half-pin site (78%) than that of fine wire site infection Orthop. J. 2012 ;11:39-42.
5. Marais LC, Ferreira N. Bone Transport Through An Induced
(33%) using fine wire site infection in hybrid external
Membrane In The Management Of Tibial Bone Defects Resulting
fixator.7 Overall, the previous studies' results when From Chronic Osteomyelitis. Strategies Trauma Limb Reconstr.
compared with the transverse wire site, shows the half- 2015;10:27-33.
pin site to be more prone to pin tract infection. Also, the 6. Xu X, Li X, Liu L, Wu W. A Meta-Analysis Of External Fixator Versus
Intramedullary Nails For Open Tibial Fracture Fixation. J Orthop
rate of additional surgeries and interventions for treating Surg. Research. 2015;9:10.
pin site infection was higher with the half-pin site. 7. Antoci V, Ono CM, Antoci Jr V, Raney EM. Pin-Tract Infection
During Limb Lengthening Using External Fixation. Am J Orthop
While the above mentioned studies support half pins (Belle Mead NJ). 2008; 37:E150-44.
infection, some studies reported no significant difference 8. Parameswaran AD, Roberts CS, Seligson D, Voor M. Pin Tract
in infection between half pins and transverse wires.22 The Infection With Contemporary External Fixation: How Much Of A
Problem?J.Orthop.Trauma. 2003; 17:503-7.
study on 1093 half pins and 951 wires in 218 patients 9. Oh JK, Lee JJ, Jung DY, Kim BJ, Oh CW. Hybrid External Fixation Of
showed 3.11% half pin sites and 4.73% wire sites to be Distal Tibial Fractures: New Strategy To Place Pins And Wires
infected with no significant difference in infection rates Without Penetrating The Anterior Compartment. Arch Orthop
Trauma Surg. 2004; 124:542-6.
between wires and half pins sites.22 10. Schalamon J, Petnehazy T, Ainoedhofer H, Zwick EB, Singer G,
Hoellwarth ME. Pin Tract Infection With External Fixation Of
The results of our study together with those of other Pediatric Fractures. J. Pediatr. Surg. 2007; 42:1584-7.
researchers, showed that the exceptional circular fixator 11. Morasiewicz P, Dejnek M, Orzechowski W, Urba?ski W, Kulej M,
Ilizarov technique application is not only more stable than Dragan S?, et.al.. Clinical Evaluation Of Ankle Arthrodesis With
the conventional external fixture, but there is a Ilizarov Fixation And Internal Fixation. BMC. Musculoskelet.
Disord. 2019; 20:167.
discordance with another previous study which showed a 12. Paley D. Problems, Obstacles, And Complications Of Limb
lower risk for pin-site infections with the traditional Lengthening By The Ilizarov Technique. Clin. Orthop. Relat. Res.
Ilizarov.23-25 Further comparing infection rates between 1990; 250:81-104.
pins and wire shows transverse wires to have a 13. Kazmers NH, Fragomen AT, Rozbruch SR. Prevention Of Pin Site
Infection In External Fixation: A Review Of The Literature.
significantly lower infection rate as compared to half pins Strategies Trauma Limb Reconstr. 2016; 11:75-85.
as noted in this study which is comparable to the results 14. Grant S, Kerr D, Wallis M, Pitchford D. Comparison Of Povidone-
published in most other studies. However, a significant Iodine Solution And Soft White Paraffin Ointment In The
Management Of Skeletal Pin-Sites: A Pilot Study. J. Orthop. Nurs.
relationship was not noted between the location of the 2005; 9:218-25.
Ilizarov circular fixator and the development of pin site 15. Ferreira N, Marais LC. Pin Tract Sepsis: Incidence With The Use Of
wound sepsis (p>0.05). Circular Fixators In A Limb Reconstruction Unit. SA Orthopaed
J.2012; 11:40-7.
Conclusion 16. Mostafavi HR, Tornetta III P. Open Fractures Of The Humerus
Treated With External Fixation. Clin Orthopaed Rel. Res. (1976-
The circular fixator Ilizarov technique is more stable with 2007). 1997; 337:187-97.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-58
17. Rose R. Pin Site Care With The Ilizarov Circular Fixator. J. Orthop. fixation: a comparison of infection rates between wires and
Nurs.Surg.2010;16 conical half-pins with threads outside or inside the skin. J. Trauma
18. Parameswaran AD, Roberts CS, Seligson D, Voor M. Pin tract Acute Care Surg. 2006; 61:1186-91.
infection with contemporary external fixation: how much of a 23. Catagni MA. Treatment of fractures, nonunions, and bone loss of
problem?. J.Orthopaed. Trauma. 2003; 17:503-7. the tibia with the Ilizarov method, il quadratino. Milan, Italy. 1998;
19. Chan CK, Saw A, Kwan MK, Karina R. Diluted povidone-iodine 10:1-29.
versus saline for dressing metal-skin interfaces in external fixation. 24. Cattaneo R, Catagni MA, Guerreschi F. Treatment of radial
J Orthopaed.Surg 2009; 17:19-22. agenesis with the Ilizarov method. Rev Chir Orthop Reparatrice
20. Aronson J, Tursky EA. External fixation of femur fractures in Appar Mot. 2001;87:443-50.
children. J pediat orthopedics. 1992; 12:157-63. 25. Guerreschi F, Holman JA, Cattaneo R. Distraction osteogenesis in
21. Saw A, Chua YP, Hossain G, Sengupta S. Rates of pin site infection the treatment of stiff hypertrophic nonunions using the Ilizarov
during distraction osteogenesis based on monthly observations: a apparatus. Clin orthopaed and related research. 1994; 301:159-63.
pilot study. Journal of Orthopaedic Surg. 2012; 20:181-4.
22. Catagni MA, Ottaviani G, Combi A, Elhence A. External circular

J Pak Med Assoc (Suppl. 5)

S-59 34th International Pak OrthoCon Conference 2021

RESEARCH ARTICLE
Osetosynthesis of Fractures neck femur with cannulated screws: Evaluation of
risk factors for post-operative complications
Saeed Ahmed Shaikh, Sajid Hussain, Muhammad Qasim Ali Samejo, Nadeem Ahmed, Allah Rakhio Jamali

Abstract
Objective: To evaluate the risk factors for postoperative complications in fracture neck femur treated with
cannulated screws.
Methods: This cross sectional series was performed at the Department of Trauma and Orthopaedics, Jinnah
Postgraduate Medical Centre, Karachi from January 2015 to December 2019. A Total of 149 patients with close
fracture neck femur of either gender between 20-60 years of age were included in the study. Patients with hip
arthritis and pathological fractures such as tumours were excluded. Minimum three cannulated screws were used
to fix the fracture with parallel configuration in compression mode. Patients were followed and evaluated for
fracture healing and related complications such as nonunion and Avascular necrosis for two years. Descriptive
statistics were calculated and stratification was done. Post stratification chi square test was applied taking p-value ?
≤0.05 as statistically significant.
Results: There were 113 (75.8%) male and 36 (24.2%)female patients. Mean age was 37.54±10.66 years. Mean
operation time was 38.56±4.61 minutes. Out of these, 93 (62.4%) injuries were caused by motor vehicle accident,
34(22.8%) fall and 22(14.8%) by sports injury. Garden type III fracture was observed in 69 (46.3%) patients followed
by 41 (27.5%) fractures of grade-IV. Fracture union was observed in 126 (84.6%) patients at a mean time of
4.0±1.1months and non-union in 23 (15.4%) cases whereas rate of avascular necrosis was noted in 28 (18.8%) cases
and were significantly associated with age, injury mode, time from injury to surgery and fracture classification. Non-
union was significantly associated with open reduction and delayed fixation of fracture for more than 24 hours.
Conclusion: Although cannulated screws are a universally accepted method of fixation for femoral neck fractures,
the incidence of complications such as Avascular necrosis and non-union is quite high particularly in young males
meeting a motor vehicle accident, undergoing open reduction for displaced fractures even with early diagnosis and
treatment.
Keywords: Avascular Necrosis, Fracture Neck Femur, Cannulated Screws. (JPMA 71: S-59 [Suppl. 5]; 2021)

Introduction around to preserve native femoral head and to restore

normal hip anatomy and mechanics.1 For that reason
Femoral neck fracture (FNF) is a common injury in elderly
early reduction and fixation of the fracture is preferred
people resulting from trivial trauma due to osteoporosis
which is achieved by the placement of multiple screws
accounting for almost half of the fractures around the hip1
across the fracture and may be performed by either
and its incidence is rising in parallel with an increase in
closed or open reduction using a standard lateral
aging population.2 However fracture neck femur in young
approach or a more limited percutaneous technique.7,8
patients constitute only a small proportion of 3% of all
However this method is not free of risks and treatment
fractures around the hip3 resulting from high velocity
failure can lead to complications such as failure of fixation,
injury such as road traffic accident, sports related trauma
non-union, infection and avascular necrosis.2,3,9
and falls from a height.4 This fracture has been designated
as "unsolved fracture" since the treatment has been The incidence of Avascular necrosis (AVN), fixation failure
controversial whether to save the head or replace it.5 and fracture non-union following internal fixation of the
The treatment of choice in low demand elderly people is femoral neck fracture was reported to be 20 to 30%, 8 to
joint replacement allowing early mobility and avoiding 15% and 10 to 30% respectively.2,10,11 Avascular necrosis
problems of prolonged recumbency and revision is a devastating complication of femoral neck fractures
surgery.6 In contrast young patients with high functional and may lead to femoral head collapse and subsequent
demand and good bone stock, treatment options revolve osteoarthritis.6 Tenuous blood supply to the head of
femur and higher intracapsular pressures have been
Jinnah Postgraduate medical Centre, Karachi, Pakistan. demonstrated as the possible mechanism of
Correspondence: Saeed Ahmed Shaikh. Email: drsashaikh2003@yahoo.com development of avascular necrosis after fracture neck

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-60
femur.11-13 In undisplaced fractures where the capsule is and lateral view. In cases of inadequate close reduction,
intact Raised intra-capsular pressure can cause a open reduction was performed through anterolateral
tamponade effect compromising blood supply to the approach. Three guide wires were passed with the control
head of the femur leading to avascular necrosis.11-13 in anterior, posterior and inferior direction in an inverted
Furthermore, fracture displacement can damage blood triangle fashion, from lateral side of the shaft to the neck
vessels and disrupt blood flow to the head of femur.14,15 and head of femur at or just above the level of lesser
Possible causes of poor outcome due to other trochanter. In some cases two guide wires were passed
complications such as non-union, infection and fixation superiorly and inferiorly. Drilling was done over the guide
failure due to loss of reduction may be related to a variety wires with cannulated drill bits and length of the screws
of factors such as patients' age, fracture displacement at was measured. Parallel Cannulated screws were used to
the time of injury, time to fixation, anatomical reduction fix the fracture in compression mode. Postoperatively, in
of the fracture, method of reduction and placement of bed mobilization was done on the evening of the surgery
screws.6,9 Therefore the aim of this study was to evaluate and non-weight bearing mobilization out of bed was
the risk factors for postoperative complications in fracture allowed as the pain tolerated. Weight bearing was
neck femur treated with cannulated screws. gradually progressed till six weeks postsurgery when
patients were allowed to bear full weight.
Patients and Methods
The patients were followed at two and six weeks and
This cross sectional study was conducted on patients every three months thereafter for two years for clinical
presenting to Jinnah Postgraduate Medical Centre and radiological assessment. The principal outcome
(JPMC), Karachi, with fracture neck femur from January measures were fracture union, and related complications
2015 to December 2019. Convenient sampling method such as non-union and AVN. Union was defined as
was used by recruiting patients prospectively in a asymptomatic patient with no pain at fracture site and
consecutive manner from emergency and outpatient obliteration of the fracture line and re-establishment of
departments for the initial three years of the study and trabecular pattern on anteroposterior and lateral
were followed up for a minimum duration of two years to radiographs.9 When there was persistence fracture line on
note complications. radiographs and pain at the fracture site at least six
Skeletally mature patients of either gender with closed months after surgery, it was labeled as non union.9
fracture neck of femur presenting within two weeks of Presence of subchondral sclerosis and segmental collapse
injury were included. Patients with open or infected of femoral head on X-rays was termed avascular necrosis.9
fractures, with hip arthritis and pathological fractures The data were recorded on the Performa. Confounding
were excluded. variables and biasness were controlled by strictly
following inclusion criteria.
The study was conducted after approval from institutional
review board. Patients meeting the inclusion criteria were Data were compiled and analyzed using statistical
enrolled in the study. Informed consent was obtained package for social sciences (SPSS) version 21. Mean and
from all the patients. The diagnosis and degree of standard deviations were calculated for the quantitative
displacement of fracture neck of femur was established variables like age, height, weight, Body Mass Index (BMI),
by taking the history, performing a physical examination, operation time, intra operative bleeding, time from injury
and examining X-rays of the involved hip (Antero- to surgery and follow-up time. Frequencies and
posterior and lateral views). Fractures were divided percentages were calculated for the qualitative variables
according to Garden classification.15 Time from injury to like gender, mode of injury, number of screws inserted,
fracture type (I/II/III/1V), open vs close reduction, union
surgery was recorded in days.
achieved and avascular necrosis (AVN). Variables such as
Surgery was performed upon traction table in supine age, gender, BMI, mode of injury, operation time, fracture
position. After the induction of anaesthesia, close type (I/II/II/IV) and open vs close reduction were
manipulation and reduction of the fracture was done controlled through stratification to see the effect of these
under fluoroscopy. Quality of reduction was assessed on outcome variables. Post stratification chi square test
using garden alignment index (GAI) in both were applied taking p-value <0.05 as statistically
anteroposterior and lateral views.16 The GAI is an angle significant.
measured between medial shaft of femur and the central
axis of medial compressive trabeculae in femoral head Results
and considered acceptable between 160-180° in both AP Of 149 patients, 113(75.8%) were males and 36(24.2%)

J Pak Med Assoc (Suppl. 5)

S-61 34th International Pak OrthoCon Conference 2021

Table-1: Demographics of patients. Table-3: Rate of Avascular Necrosis with respect to variables.

Variable Mean±SD Range Variable AVN (No) AVN (Yes) P value

N=121 N=28
Age (years) 37.5±10 24-56
Height in meters 1.6±0.08 1.5-1.8 Gender Male 90 (79.6%) 23 (20.4%) 0.387
Weight in Kg 71.7±11.1 54-89 Female 31 (86.1%) 5 (13.9%)
BMI in kgm2 27.0±5.9 17.2-39.6 Age (years) <35y 60 (73.2%) 22 (26.8%) 0.005
Operative time in minutes 38.6±4.6 30-45 >35y 61 (91%) 06 (9%)
Intraoperative bleeding in ml 24.3±3.8 20-40 Injury mode MVA 70 (75.3%) 23 (24.7%) 0.021
Union time in months 4.0±1.1 2-6 Falls 33 (97.1%) 1 (2.9%)
AVN time in months 10.0±2.3 6-15 Sports related 18 (81.8%) 4 (18.2%)
Time from injury to surgery in days 3.8±3.0 1-13 Fracture type Type 2 27 (96.4%) 1(3.6%) 0.024
AVN: Avascular Necrosis. Type 3 53 (76.8%) 16 (23.2%)
Type 4 30 (73.2%) 11 (26.8%)
Table-2: Union rate with respect to variables. Time from injury to surgery <24h 30 (90.9%) 03 (9.1%) 0.106
>24h 91 (78.4%) 25 (21.6%)
Variable Union Non union P value Reduction type Open 09 (40.9%) 13 (59.1%) 0.001
N=126 N=23 Close 112 (88.1%) 15 (11.8%)

Gender Male 99 (87.6%) 14 (12.4%) 0.068 Fracture union was achieved in 126 (84.6%) patients with
Female 27 (75%) 09 (25%) mean union time of 4.0±1.1 months whereas 23 (15.4%)
Age (years) <35y 71 (86.6%) 11 (13.4%) 0.450
fractures remain un-united at six months. Out of 23 non
>35y 55 (71.4%) 12 (28.6%)
Injury mode MVA 80 (86%) 13 (14%) 0.281 unions, five patients developed infection and seven
Falls 26 (76.5%) 8 (23.5%) patients had loss of reduction and failure of screws. Rate of
Sports related 20 (90.9%) 2 (9.1%) development of avascular necrosis was noted in 28
Fracture type Type 2 27 (96.4%) 1 (3.6%) 0.073 (18.8%) cases with the mean AVN time of 10.0±2.3 months.
Type 3 56 (81.2%) 13 (18.8%) Five patients had concomitant non-union and AVN.
Type 4 32 (78%) 9 (22%)
Time from injury to surgery <24h 32 (97%) 1 (3%) 0.025 The results showed that non-union was more common in
>24h 94 (81%) 22 (19%) cases in which surgery was delayed for more than 24
Reduction type Open 12 (54.5%) 10 (45.5%) 0.001 hours (n=22, 14.76%), (p=0.025) and fractures in which
Close 114 (89.8%) 13 (10.2%) open reduction was performed (n=10, 6.71%), (p=0.001).
Association of non-union with gender (p=0.068), age
females with an overall mean age of 37.54±10.66 years.
(p=0.450), mode of injury (p=0.281) and fracture type
More than half of the patients (82,55%) were aged <35
(p=0.073) was insignificant (Table-2).
years whereas 67 (45%) patients were >35 years. The
overall mean height and weight was 1.64±0.08 meters There was a significant association of avascular necrosis
and 71.76±11.16 kg respectively. The overall mean BMI with age (p=0.005), injury mode (p=0.021), open
was 27.07±5.98 kg/m2. BMI of >30 kg/m2 was noted in 56 reduction of the fracture (p=0.001) and fracture
(37.58%) patients and they were considered as obese. classification (p=0.024) while no significant association
Whereas majority of the patients (n=93, 62.41%) had BMI was found with respect to gender (p=0.387) and time
of <30 kg/m2 (Table-1). from injury to surgery (p=0.106) (Table-3). Out of 82
patients in age group <35 years, 22 (26.8%) patients
Mean time from injury to surgery was 3.8±3.0 days. Close
developed avascular necrosis whereas only six (9%) out of
fracture reduction was done in 127(85.23%) patients and
67 patients of age group >35 years had avascular necrosis.
open reduction was performed in remaining 22(14.77%)
Out of 93 patients with motor vehicle injuries 23 (24.7%)
patients. The overall mean operation time was 38.56±4.61
developed avascular necrosis, whereas in the remaining
minutes and the mean intra operative bleeding was
five patients either fall or sports trauma was the
24.32±3.79 ml. Motor vehicle trauma was the most
mechanism of injury. Avascular necrosis was observed in
common injury mechanism accounting for 93(62.4%)
13 (59.09%) out of 22 patients in whom open reduction
cases while 34(22.8) fractures were caused by fall and
was performed.
remaining 22(14.8%) cases were due to sports related
trauma. It was observed that 11(7.4%) patients were A significant association of avascular necrosis was
classified in garden-I, 28(18.8%) in garden-II, 69(46.3%) in observed with fracture type. Majority of the patients had
garden III, and 41 (27.5%) in garden type IV fractures. either garden type III or IV fracture; 16 (23.2%) with type III

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-62
and 11 (26.8%) with garden type IV fracture (Table-3). AVN. The literature is sparse in this regard. In a recent
study however it may be related to the fact that motor
Discussion vehicle accidents are high velocity trauma leading to
Fracture union was achieved in more than 80% of the multiple injuries and more displacement of the fracture
patients. Acceptable reductions whether open or close fragments and damage to the blood supply creating
was seen in all but two patients. In total, 46 (18.8%) more possibilities of AVN.21 In addition diagnosis of
patients developed complications of AVN, non-union fracture neck femur may be delayed or missed in
(15.4%), infection (3.4%) and loss of reduction and fixation polytrauma patients which can cause more complications
failure (4.7%). It was imperative to find that fracture such as AVN or non-union. Mechanism of injury was not
displacement, mechanism of injury, younger age, time related to development of non-union in our series.
from injury to surgery and open reduction of the fracture
Main strength of our study is that it represents a large
when close reduction cannot be achieved has a major
number of young patients with prospective analysis and
impact on the development of these complications.
no loss to follow up. However we still did not include
Interestingly there was higher frequency of AVN and non-
patients with comorbids such as diabetes, Hypertension
union in our cases where open reduction of the fracture
etc to see their relationship with complications of non-
was performed. The reason for increased incidence of
union, infection, fixation failure and AVN. In addition this
complications in such cases may be related to the fact
was a single centre based study and multicentre studies
that multiple attempts of closed reduction were tried to
should be conducted to generalize the results.
achieve acceptable reduction failing which open
reduction was done. Multiple attempts of close reduction Conclusion
may damage blood supply to the femoral head leading to
Cannulated screws are the universally accepted fixation
higher chances of non-union and AVN.1,16
method for femoral neck fractures in young adults and
Kim JY et al8 found association of AVN with fracture despite early diagnosis and treatment, the incidence of
displacement. In their series of 52 patients, all the patients complications such as avascular necrosis and non-union is
who developed AVN (n=12, 23%) had either garden III or quite high particularly in young males with motor vehicle
IV type displaced fractures. Similarly all five cases of non- accident, delayed fixation and displaced fractures.
union were related to displaced type III or type IV
Disclaimer: None.
fractures in their series. In our series almost all cases with
non-union (96%) and AVN (96%) were found to have Conflict of Interest: None.
displaced fractures. The rate of AVN seen in our series was
reaching up to 18.8%, slightly less than that found by Kim Funding Disclosure: None.
JY et al,8 although the figure for AVN in the literature is References
very wide ranging from 0% to 86%.6,10-14,17,18
1. Pauyo T, Drager J, Albers A, Harvey EJ. Management of femoral
We found AVN more in patients younger than 35years neck fractures in the young patient: A critical analysis review.
World J Orthop 2014;5:204-217 doi:10.5312/wjo.v5.i3.204
comparable to national data18 where more than half of
2. Kang JS, Moon KH, Shin JS, Shin EH, Ahn CH, Choi GH. Clinical
the patients were more than 35 years of age who results of internal fixation of subcapital femoral neck fractures.
developed AVN with fracture neck femur. International Clinics Orthop Surg. 2016; 8:146-52.doi: 10.4055/cios.2016.8.2.146
data also suggest a higher incidence of AVN in the 3. Robinson CM, Court-Brown CM, McQueen MM, Christie J. Hip
fractures in adults younger than 50 years of age: Epidemiology
younger population.6,10,11 However some studies reveal
and results. Clin OrthopRelat Res.1995;312:238-46.
no impact of age on the frequency of development of 4. Rai SK, Vikas R, Sharma V, Wani SS, Varma R. Fracture neck of femur
AVN in fracture neck femur.2 In contrast, in a retrospective treated with hemiarthroplasty and cannulated cancellous screw
analysis by Kenan S et al19 on 27 patients with fracture fixation: a comparative study. Inter J Res Orthop 2017;3:849-
53.DOI:10.18203/issn.2455-4510.IntJResOrthop20172885
neck femur treated with cannulated screws, four (14.8%)
5. Biber R, Brem M, Bail HJ. Targon® Femoral Neck for femoral-neck
patients developed AVN or non-union and all patients fracture fixation: lessons learnt from a series of one hundred and
were older than 50 years. In our series age had no impact thirty five consecutive cases. Int Orthop. 2014;38:595-599.doi:
on the development of non-union. 10.1007/s00264-013-2176-y
6. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in
Most of the studies suggest a history of fall as the most young adults. J Bone Joint Surg (Am)2008; 90:2254-2266 [PMID:
18829925 DOI: 10.4103/0019-5413.38574].
common mechanism of injury,9,20 however in our analysis,
7. Chen WC, Yu SW, Tseng IC, Su JY, Tu YK, Chen WJ. Treatment of
motor vehicle injuries were the most common cause of undisplaced femoral neck fractures in the elderly. J Trauma.2005;58:1035-
fracture neck femur and subsequent development of 1039.DOI: 10.1097/01.ta.0000169292.83048.17

J Pak Med Assoc (Suppl. 5)

S-63 34th International Pak OrthoCon Conference 2021

8. Kim JY, Kong GM, Park DH, Kim DY. Multiple cannulated screw head avascular necrosis following neck fracture. OrthopTraumatol
fixation of young femoral neck fractures. Pak J Med Sci. Surg Res 2011;97:79-88. DOI: 10.1016/j.otsr.2010.06.014
2015;31:1517-1520. doi: 10.12669/pjms.316.8356 15. Garden RS. Low-angle fixation in fractures of the femoral neck. J
9. Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of Bone Joint Surg. 1961; 43-B:647-63.https://doi.org/10.1302/0301-
intracapsular fractures of the femoral neck in young patients: risk 620X.43B4.647
factors for failure. J Bone Joint Surg Br. 2011;93:811-816. 16. Garden RS.Malreduction and avascular necrosis in subcapital
doi:10.1302/0301-620X.93B6.26432 fractures of the femur. J Bone Joint Surg [Br] 1971;53-B:183-97.
10. Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. 17. Sadat-Ali M, Ahlberg A. Fractured neck of the femur in young
Delayed internal fixation of fractures of the neck of the femur in adults. Injury 1992;23:311-13.
young adults. J Bone Joint Surg Br. 2004;86:1035-40.DOI: 18. Khan HU, Jan AW, Khan AS. Fracture neck of femur; avascular necrosis
10.1302/0301-620x.86b7.15047 with cannulated screws. Professional Med J. 2015; 22.949-53.
11. Protzman RR, Burkhalter WE. Femoral-neck fractures in young 19. Kenan S, Gold A, Salai M, Steinberg E, Ankory R, Chechik O. Long-
adults. J Bone Joint Surg Am.1976;58:689-95. Term Outcomes Following Reduction and Fixation of Displaced
12. Swiontkowski MF, Winquist RA, Hansen ST. Fractures of the Subcapital Hip Fractures in the Young Elderly. Isr Med Assoc J.
femoral neck in patients between the ages of twelve and forty- 2015;17:341-5.
nine years. J Bone Joint Surg Am. 1984;66:837-46. DOI: 20. Koaban S, Alatassi R, Alharbi S, Alshehri M, Alghamdi K. The
10.2106/00004623-198466060-00003 relationship between femoral neck fracture in adult and avascular
13. Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. necrosis and nonunion: A retrospective study. Ann Med Surg
Operative treatment of femoral neck fractures in patients (Lond). 2019;39:5-9. doi: 10.1016/j.amsu.2019.01.002.
between the ages of fifteen and fifty years. J Bone Joint Surg 21. Barney J, Piuzzi NS, Akhondi H. Femoral Head Avascular Necrosis.
Am.2004;86:1711-6.DOI: 10.2106/00004623-200408000-00015 (Updated2019 Sep 3). In: StatPearls [Internet]. Treasure Island (FL):
14. Ehlinger M, Moser T, Adam P, et al. Early prediction of femoral StatPearls Publishing; 2020 Jan.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-64

RESEARCH ARTICLE
Outcome of minimally invasive plate osteosynthesis using locking compression
plate in long bone fractures
Muhammad Ali,1 Arif Mustafa Khan,2 Muhammad Hamza Azhar,3 Muhammad Tahir Javed,4 Muhammad Saleem,5 Zahid Hafeez6

Abstract
Objective: To evaluate radiological and clinical outcome of minimally invasive plate osteosynthesis (MIPO) using
locking compression plate in long bone fractures.
Methods: This was a prospective study for the long bones fracture managed by MIPO using locking compression
plate in thirty patients from January to December 2017. All the skeletally mature patients and the patients with
osteoporotic bones were included. Patients with open injuries, paediatric patients and plating done in non-
traumatic conditions were excluded. Patients were followed as outpatient after one week, six weeks, after three
months and then after 6 months.
Results: Among 30 patients, 12(40%) were males and 18 (60%) females with male to female ratio 1:1.5. Average age
of 30 patients was 59.5 ± 16.72 years (Range =21 to 91 years). Mean duration of surgery was 98.0±27.1 (Range=50
to 150) minutes. Majority 14(46.7%) had operative time 90-110 minutes. There were two complications, one (3.3%)
had screw pull out and other had deep infection.
Conclusion: LCP system is a reliable and safe tool that extends the options for fixation by plating and has
advantages over the other systems in term of stability that can be achieved with it especially in osteopenic bones.
Keywords: Locking compression plate, long bone fractures, MIPO, radiological and clinical fracture healing.
(JPMA 71: S-64 [Suppl. 5]; 2021)

Introduction site resulting in delayed and nonunion.8-10 There is

For the management of long bones fractures, with and change of emphasis from mechanical to biological
without inter-articular involvement, there are multiple priorities in the fracture fixation in recent decade. Thus
options available. These include plating, intramedullary with the aim to minimize stripping of the soft tissue
nailing and external fixator.1-3 The final decision about around the fracture, minimally invasive plate
which treatment modality is to be used depends upon the osteosynthesis (MIPO) has been developed where by the
fracture configuration, soft tissue involvement and plate is placed through small incision with little soft tissue
quality of bone as well as patient-related factors.4,5 For the disruption.11-13 In order to avoid direct contact and
diaphyseal fractures intramedullary nailing is commonly friction between the conventional plate and bone, the
used. For metaphyseal fracture with and without articular new so called locked internal fixator have been
involvement, plating is commonly employed. If the soft developed, consisting of plate and screw systems where
tissue sleeve is intact, plating is the choice and if there is the screw are locked in the plate, so that there is no need
soft tissue compromise, external fixator is selected.5-7 for the plate to touch the bone at all.5,14,15 The
Intramedullary nailing of diaphyseal fracture is perhaps interlocking of screws within the plates allows
the most elegant method preferred. With the minimization of bone to implant contact. Instead the
development of proximal and distal locking, there is bone is fixed at each point along the length of fixator.16-18
negligible chance of rotational malalignment. These plates have combi holes allowing placement of
Intramedullary nailing has its limitations in articular and both locking and conventional screws. The first locking
periarticular fractures. Nailing a metaphyseal fracture plate was introduced about two decades ago for use in
results in malaligment. Plate fixation of fractures provide spinal and maxillofacial surgery.5,7,19,20 The objective of
good mechanical stability but the traditional technique study was to evaluate the outcome of locking
requires extensive soft tissue disruption. Extensive soft compression plate fixation using MIPO technique in
tissue exposure disrupts the blood supply of the fracture skeletally mature patients with long bone fractures.

1,3-6Department of Orthopaedic Surgery, Shalamar Hospital, Lahore,

Methods
2Department of Orthopaedic Surgery, Nishter Medical and Dental University, This study was conducted in a tertiary care trauma centre
Multan, Pakistan. from January -December 2017. A sample size of 30 cases
Correspondence: Muhammad Ali. Email: muhammadali19782002@yahoo.com was calculated with 95% confidence level and 12%

J Pak Med Assoc (Suppl. 5)

S-65 34th International Pak OrthoCon Conference 2021

Appendix: Proforma absolute precision `while taking expected frequency of

failure of LCP to be 13%. Total 30 patients of long bones
Outcome of minimally invasive plate osteosynthesis (MIPO) using Locking
fracture fixed with locking plates using MIPO technique
Compression Plate in long bones fractures.
were managed and evaluated during the study period.
MR. NO ____-____-____ Name: _________________ Age ____ years The inclusion criteria in our study was all skeletally
mature patients of both sexes with epiphyseal-
Sex: M [ ] F [ ] Co-morbids: DM [ ] HTN [ ] IHD [ ] Other ___________ metaphyseal fractures of long bones, age more than 18
years and patients with osteoporotic bones. Patients with
Date of Fracture __________ Fracture Classification (AO): __________ open injuries, paediatric patients and plating done in
non-traumatic conditions were excluded from the study.
O.R. DETAILS Through history and physical examination was done by
Operating time (incision to skin closure) ________ min
primary investigator. All those patients fulfilling the
Blood Loss Intra-op _______ ml Post-op ______ ml
Haemoglobin Preop ______ gm% Post-op ______gm% inclusion criteria were enrolled for the study. The study
Operative procedure was explained to the patients and informed consent was
Approach _________________ taken. Data was recorded on a proforma, (Appendix)
Plate size _________________ starting from patient admission. The proforma includes
No of screws _________________ details about the patient, fracture characteristic,
Technical difficulties operative procedure and follow-up with outcome. For
Additional procedure the follow-up, patients were called to the out-patient
clinic at second week, fourth week, three months and six
EARLY COMPLICATIONS: Wound infection Y [ ] N [ ]. Other ________________
Hospital stay ______ days months and assessment of clinical and radiological
healing was done.
FOLLOW-UP:
Week 2 post-op
The data collected from the conducted research study
Ambulation status NWB [ ] PWB [ ] FWB [ ] Bed to chair was analyzed as follows; gender of participants were
Range of motion Not permitted [ ] Partial [ ] Full [ ] represented by M: F ratio. Mean and standard deviation
Wound Healed [ ] Dehiscence [ ] Infection [ ] Remark______________ were used to scrutinize continuous response variables
X-ray Fixation maintained Y [ ] N [ ] such as age, duration of surgery and amount of blood
loss. To compare the per-operative and post-operative
Week 6 post-op blood loss and haemoglobin levels independent sample
Ambulation status NWB [ ] PWB [ ] FWB [ ] Bed to chair t-test was applied. Before application of bivariate
Range of motion Not permitted [ ] Partial [ ] Full [ ]
analyses, data normality was checked via Kolmogorov-
Clinical healing [ ]
Radiological healing: Gap bridged [ ] External callus [ ] Medullary callus [ ] Smirnov and Shapiro-Wilk tests which shed data to be
Plate breakage [ ] Screw pull out [ ] Screw breakage [ ] normal (p >0.05). Patients were followed up to evaluate
qualitative response variables such as early
3 months' post-op complications, post-op ambulation status, range of
Ambulation status NWB [ ] PWB [ ] FWB [ ] Bed to chair motion, wound healing, radiological healing, outcome of
Range of motion Not permitted [ ] Partial [ ] Full [ ] clinical union and indication for revision surgery. For
Clinical healing [ ] these qualitative response variables, frequencies and
Radiological healing: Gap bridged [ ] External callus [ ] Medullary callus [ ]
percentages were used. Chi-square analyses were used to
Plate breakage [ ] Screw pull out [ ] Screw breakage [ ]
study the significance of changes in ambulation status,
6 months' post-op range of motion, clinical union and radiological union
Ambulation status NWB [ ] PWB [ ] FWB [ ] Bed to chair over the follow up period. P-value <0.05 was considered
Range of motion Not permitted [ ] Partial [ ] Full [ ] statistically significant.
Clinical healing [ ]
Radiological healing: Gap bridged [ ] External callus [ ] Medullary callus [ ] Results
Plate breakage [ ] Screw pull out [ ] Screw breakage [ ]
Among 30 patients of long bone fracture who underwent
Revision surgery
fixation with locking compression plate (LCP), 12 (40%)
Aseptic complications were males and 18 (60%) females with male to female
Septic complications ratio 1: 1.5.
Implant failure
Remarks _______________________________________________ Average age of patients was 59.5±16.72 (Range = 21 to
___________________________________________________ 91) years. The commonest age group was 61-70 years in

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-66
Table-1: Long Bone characteristics among patients.

Bone & Region Number of participants (%)

Humerus 12 (40.0)
l Humerus proximal 8
l Humerus midshaft 3
l Humerus distal 1
Femur distal 12 (40.0)
Tibia 5 (16.7)
l Tibia proximal 3
l Tibia distal 2
Radius/ulna Proximal 1 (3.3)

Table-2: Radiological healing time at 6weeks, 3 months and 6 months.

Follow up Radiological healing

Gap bridge No bridging of gap

6 weeks 20 (66.7)* 10 (33.3)

3 months 25 (83.3)* 5 (16.7)
6 months 28 (93.3)* 2 (6.7)
Chi-square test, *Changes in proportion over time significant at p < 0.001. Figure-1: Complication of locking compression plate of long bones.
Values given in parenthesis are percentages.

Table-3: Clinical union at 6 weeks, 3 months and at 6 month. Postoperatively, the limbs were protected in a brace for 2
weeks until subsidence of swelling and removal of
Follow up Clinical union stitches. Active and passive range of-motion exercises
Yes No were allowed at the respective joints at 2 weeks to
prevent stiffness and to strengthen the muscles.
6 weeks 28 (93.3)* 2 (6.7) Postoperative range of motion at 2 weeks showed that 29
3 months 28 (93.3)* 2 (6.7) out 30 (96.7%) patients had partial range of motion at
6 months 28 (93.3)* 2 (6.7)
their respective joints while only one (3.3%) patient of
Chi-square test, *Changes in proportion over time not significant. upper limb fracture had full range of motion at their
Values given in parenthesis are percentages.
respective joint. However, at 6 weeks, 27 out of 30(90%)
which 11 (36.7%) patients were observed. patients had full range of motion at their respective joints
while only 3 (10%) had partial range of motion at their
Regarding bone involvement, 12 (40%) patients had respective joints. Full range of motion was observed in 29
humerus fracture in which 8 were proximal, 3 mid shaft (96.7%) out of 30 patients at 3 months follow up but one
and 1 distal humerus fractures. Fracture of distal femur patient having upper limb fracture was not permitted
was found in 12 (40%) patients. Tibia fracture was seen in ROM due to pain however this patient had partial range of
5 (16.7%) patients, proximal in 3 and distal tibia fracture in motion at 6 months postoperative follow up.
2 patients. Proximal Radius/ ulna fracture was found in 01
(3.3%) patient as shown in (Table-1). Regarding postoperative ambulation status 14 (46.7%)
out of 17 patients having lower limb fractures had started
Diabetes mellitus was the commonest comorbidity that non weight bearing (NWB) and 3 (10%) had bed to chair
was found in 8 (26.7%) patients followed by ischaemic ambulation. Similarly, after 6 weeks 14 (46.7%) patients
heart disease in 3 (10%), hypertension in 2 (6.7%) and were non weight bearing (NWB) and 3 (10%) had partial
other comorbids were observed in 2 (6.7%) patients. weight bearing ambulation (PBW) (p=0.001). At 3 months,
Fifteen (50%) patients had no comorbidities. Mean significantly high number of patients i.e. 13 (76.5%) were
duration of surgery was 98.0±27.1 (Range = 50 to 150) full weight bearing(FWB) and 4 (23.5%) patients were
minutes. Majority (46.7%) of the patients had operative partial weight bearing(PWB) (p=0.001). All 17 patients of
time 90 - 110 minutes. Early complications were observed lower limb fracture had full weight bearing (FWB)
in only two patients such that 01(3.3%) patient had shown ambulation at 6 months' postoperative follow up.
screw pull-out and 01(3.3%) had deep infection as shown Postoperative wound healing was observed in
in Figure-1. significantly high number of patients i.e. 29 (96.7) patients

J Pak Med Assoc (Suppl. 5)

S-67 34th International Pak OrthoCon Conference 2021

bones, therefore, locked plate technique was evolved.11

The evolution of screw torque and plate bone interface,
friction is unnecessary with locked plate design. This
technique significantly minimizes the amount of soft
tissue compromise required for plating, conserving the
periosteal blood supply and facilitating the use of MIPO
technique. With the advent of locked plate, orthopaedic
surgeons can manage the fracture with indirect
reduction.12 The ease of application and fewer
complication in early clinical trials have contributed to the
proliferation of this technique.
We use this technology in all skeletally mature patients
with long bones fractures and fractures in osteopenic
bones.
The mean duration of surgery in our study was 98.0±27.1
(range= 50-150) minutes. According to the study
conducted by Hasenboehler et al,10 the mean operative
time was 86.6 min (range= 50-170) which is comparable
Figure-2: (A-D): X-rays showing fracture of midshaft humerus (A), treated by LCP to our study. We achieved good results regarding
fixation (B). Patient presented after 3 weeks with failure of screws (C), which was ambulation and union rates. All patients with lower limb
managed successfully with revision of fixation with longer plate and bone grafting (D). fractures showed full weight bearing (FWB) at 6 months
(range= 12-24 weeks). In the study conducted by Hazarika
(p<0.001), but one (3.3%) patient had wound dehiscence. et al.11 Time to full weight bearing (FWB) for the lower
limb fracture was 18.1weeks (range= 8-32 weeks). These
At 6 weeks, radiological healing response showed that 20
results are comparable to our study. Full range of motion
(66.7%) out 30 patients had gap bridged and 10 (33.3%) (ROM) at respective joint was observed in 29(96.7%) at 3
patients had no bridging of gap. Significant number of months. Out of twenty-nine, twelve patients had upper
patients i.e. 25 (83.3%) had gap bridged on 3 months limb fractures and 17 had lower limb fractures. One
follow up. At the time of postoperative follow up after 6 patient of humerus shaft fracture was not permitted full
months except 2(6.7%) patients who had no bridging of range of motion (ROM) at 3 months due to pain but was
gap, 28 (93.3%) patients had gap bridged (Table-2). Data permitted partial range of motion (ROM) at 6 months
reveals significant response of healing on radiological postoperative follow up. In a retrospective study
images (p=0.001). conducted by Hasenboehler, Ricci D et al,16 on application
of LCP using minimally invasive technique (MIPO) in 32
Out of 30, 28 (93.3%) patients were seen with complete
diaphyseal fractures and distal tibia fractures. All patients
clinical union at the time of postoperative follow up at 6
(100%) attained full range of motion (ROM) by about 9
weeks, but, 2 (6.7%) patients were not clinically united. A
months. These results are comparable with our study.
similar response of clinical union was observed till 6
months (Table-3). Data reveals significant proportion of We had only 01(3.3%) patient with wound related
patients with clinical union. (p=0.001). complication (wound dehiscence), while 29 (96,7%) had
no complications related to the wound. Fracture healing
Indication for revision surgery was seen in 2 (6.67%) patients, was defined as radiological evidence of bridging mature
01(3.3%) with screw pull-out in mid shaft of humerus as callus combined with pain free full weight bearing. Out of
shown in the radiographs where revision surgery in the form 30 patients, 28(93.3%) had complete healing at 6 months
of longer plate and bone grafting was performed as shown period. In 02 (6.7%) patients there was no radiological
in (Figure-2) and 01 (3.3%) with proximal humerus fracture healing at 6 months. Koukakis et. al.12 shared their
had deep infection which was debrided and was converted experience using proximal humerus interlocking
to hemiarthoplasty in the second stage. osteosynthesis (PHILOS) plate in proximal humerus
fracture. In their study over the span of three years, 20
Discussion patients with mean age of 62 years were treated with
In an effort to overcome the limitations associated with PHILOS plate. They reported 100% rate of fracture union.
traditional plating methods, primarily for osteoporotic These results are comparable to our study. We had 2

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-68
complications, one with screw pullout and another had Conclusion
deep infection. Both of them required revision surgery.
The invention of locking compression plate (LCP), which
The patients with screw pullout from the humeral shaft
has been in practical use since 2001, has revolutionized
required removal of plate and screws followed by redo-
the plating system for treating fractures of long bones.
plating with longer LCP and bone grafting. The patient
This helps orthopaedic surgeons to reduce the risk of
with deep infection following fixation with PHILOS was
complications observed earlier. The results of our study
managed with wound debridement, removal of plate and
prove that LCP system is a reliable and safe tool that
intravenous antibiotics. He was later on managed with
extends the options for fixation by plating and has
shoulder hemiarthoplasty.
advantages over the other systems in terms of stability
Sommer et al20 in a case series of 144 patients 169 achieved in osteopenic bones. Our results showed, 28
fractures, treated with locking compression plate (LCP) (93.3%) patients with complete clinical union at six weeks
reported 27 complications (16%), including 5 implant postoperative follow up and 29 out of 30 patients to
loosening and four cases of implant breakage. According acquire full ROM at three months. One patient with
to him implant failure was the result of intraoperative Humerus fracture could achieve partial range of
technical error, including the use of two short plates and movement at this time. We can conclude that the LCP
those that did not have adequate spanning segments system is a reliable and safe tool, that extends the options
(empty screw hole) over the fracture site. for fixation by plating and has advantages over the other
system in terms of stability achieved specially in
Button et. al.2 reported 4 (18%) cases of LISS (Less invasive osteopenic and pathological bones.
stabilization system) failure in distal femur fractures. Out
of these 4 cases 2 included implant breakage. Premature Disclaimer: None.
weight bearing without evidence of fracture healing was
Conflict of Interest: None.
attributed cause in both patients. Two remaining cases of
failure involved proximal screw pullout. According to the Funding Disclosure: None.
author, two anterior plate placement resulted in
insufficient proximal fixation. References
1. Brunner A,Thormann S, Babst R. Minimally invasive percutaneous
Vallier et al21 reported on a failure locking compression plating of proximal humeral shaft fractures with the Proximal
plate (LCP) fixation in 6(13%) out of 46 distal femur Humerus Internal Locking System (PHILOS)J Shoulder Elbow Surg.
fixation. In the series, 2 failures were due to plate 2012;21:1056-63.
2. Button G, Wolinsky P, Hak D. Failure of less invasive stabilization
breakage secondary to fatigue from the motion through system plates in the distal femur: a report of four cases. J Orthop
non-union. The remaining 4 cases failed secondary to Trauma 2004; 18:565-70.
screw breakage at screw-plate interface. Interestingly 3. Cantu RV, Koval KJ. The use of locking plates in fracture care. J Am
each of these reported cases had medical comorbidities Acad Ortho Surg 2006; 14:183-90.
4. Curtis R, Goldhahn J, Schwyn R, Regazzoni P, Suhm N. Fixation
like DM, obesity, tobacco use and osteoporosis. principles in metaphyseal bone- a patent based review.
Osteporosis Int 2005; 16:54-64.
We had 12 patients with distal femur fracture treated with
5. Egol KA, Kubaik EN, Fulkerson E, Kummer FJ, Koval KJ.
Locking compression plate (LCP-DF), with no Biomechanics of locked plates and screws. J Orthop Trauma 2004;
complications regarding the plate breakage, screw 18: 488-93.
pullout, varus drift, malalignment, delayed and nonunion. 6. Fulkerson E, Egol KA, Kubiak EN, Liporace F, Kummer FJ, Koval KJ.
Fixation of diaphyseal fractures with a segmental defect: a
Our results in distal femur fractures was better (100%) as
biomechanical comparison of locked and conventional plating
compared to studies mentioned above. But we had a techniques. J Trauma 2006;60:830-5.
small sample size. 7. Giannoudis PV, Schneider E. Principles of fixation of osteoporotic
Fractures. J Bone Joint Surg Br 2006; 88-B:1272-8.
There are several limitations in our study. Firstly, our study 8. Greiwe RM, Archdeacon MT. Locking plate technology: current
included two surgeons performing the procedure. While a concepts. J Knee Surg 2007; 20:50-55.
9. Hanif M, Shakeel K, Ghauri SK, Bhutta AI, Arshad R.Management of
standard protocol was applied for all the surgeries, slight
Close Comminuted Femoral Shaft Fractures in adults: Comparison
variations in surgical technique as well as individual of Closed Interlocking Intramedullary Nailing and Minimally
learning curve associated with performing a new Invasive Plate Osteosynthesis. Biomedica 2003; 19:18-23.
procedure or use of a new implant could have influenced 10. Hasenboehler E, Rikli D, Babst R. Locking Compression Plate with
minimallyinvasive plate osteosynthesisdiaphyseal and distal tibial
the result of the study. Secondly there was no control
fracture: A retrospective study of 32 patients. Injury. 2007; 38:365-70.
group of the patients treated conservatively or with an 11. Hazarika S, Chakravarthy J, Cooper J.Minimally invasive locking
alternative implant. plate osteosynthesis for fractures of the distal tibia--results in 20

J Pak Med Assoc (Suppl. 5)

S-69 34th International Pak OrthoCon Conference 2021

patients. Injury. 2006; 37:877-87. 17. Senthilkumar M, Vanaj P, Sujith H, Anandan H. Distal Tibial
12. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation Fractures Managed with Locking Compression Plate using
of proximal humerus fractures using thePHILOS plate: early Minimally Invasive Plate Osteosynthesis Technique: A Case Study.
experience. Clin Orthop Relat Res 2006; 442:115-20. Int J Sci Stud. 2016;4:43-47.
13. Kubiak EN, Fulkerson E, Strauss E, Egol KA. The Evolution of 18. Shrestha D, Acharya BM, Shrestha PM. Minimally invasive plate
Locked Plates. J Bone Joint Surg Am 2006; 88:189-200. osteosynthesis with locking compression plate for distal
14. Namazi H, Mozaffarian K. Awful considerations with LCP diametaphyseal tibia fracture. Kathmandu Univ Med J (KUMJ).
instrumentation: a new pitfall. Arch Orthop Trauma Surg 2007; 2011;9:62-8.
127:573-5. 19. Smith WR, Ziran BH, Anglen GO, Stahel PF. Locking Plates: Tips
15. Niemeyer P, Südkamp NP. Principles and clinical application of the and Tricks. J Bone Joint Surg. Am 2007; 89:298-307.
locking compression plate (LCP). Acta Chir OrthopTraumatol Cech 20. Sommer C, Babst R, Muller M, Hanson B. Locking compression
2006; 73:221-8. plate loosening and late breakage: A report of4 cases. J Orthop
16. Ricci WM, Loftus T, Cox C, Borrelli J. Locked plates combined with Trauma. 2004; 18:571-7.
minimally invasiveinsertion technique for the treatment of 21. Vallier HA, Hennessey TA, Sontich JK, Patterson BM. Failure of LCP
periprosthetic supracondylar femur fractures above a total knee condylar plate fixation in thedistal part of the femur. A report of
arthroplasty. J Orthop Trauma 2006; 20:190-6. six cases. J Bone Joint Surg Am. 2006; 88:846-53.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-70

AUDIT
Outcome of percutaneous screw fixation of posterior pelvic ring injuries
Hussain Wahab, Pervaiz Hashmi, Haroon Kasi, Naveed Baloch, Tasfheen Ahmad, Haroon Rashid, Masood Umer

Abstract
Objective: To evaluate the clinical outcome of percutaneous fixation for unstable pelvic ring injury.
Methods: This retrospective study was conducted at orthopaedics section of Aga Khan University Hospital Karachi,
Pakistan from July 2015 to December 2018. Data was retrieved from trauma registry from July 2015 till December
2018, including all patients who underwent percutaneous fixation for pelvic ring injury. Majeed pelvic score was
used to determine the functional outcome.
Results: A total number of 30 patients were included, 27(90.0%) adults, and 3(10.0%) paediatrics patients. There
were 21(70.0%) males and 9(30.0%)females. . Mean age of patients was 37.1±16.1 years. Post op mean Majeed
functional pelvic Score was 85.8. Of the 30 patients, 18 (60.0%) had Excellent, 10 (33.3%) good and 02(6.7%) fair
scoring.
Conclusion: Percutaneous fixation of posterior ring injuries has excellent functional outcome, with minimal blood
loss and no soft tissue striping.
Keywords: Percutaneous fixation, posterior pelvic ring injuries, Majeed Pelvic score, Polytrauma.
(JPMA 71: S-70 [Suppl. 5]; 2021)

Introduction described by Routte et al in 1993.3,7 As compared to open

reduction and internal fixation, percutaneous fixation has
Motorisation has made life easier but at the same time
the advantage of less soft tissue exposure, no associated
there are complications associated with it. Road traffic
risk of wound infection, less blood loss and can be
accident is a major public health problem due to the
performed in supine position in a poly traumatized
mortality and morbidity associated with it. According to
patient.6
the World Health Organization (WHO), approximately
1.35 million people die per year secondary to RTAs.1,2 The outcome of pelvic injury management depends on
early intervention, anatomic reduction and stable fixation
Most of pelvic injuries are associated with high energy which in term results in early mobilization and pain
trauma; road traffic accidents, fall from heights or blunt management. There has been evolution in the
trauma. Mortality rate associated with pelvic injury is 10 to management of pelvis fixation with time, for posterior
20%, which is mostly secondary to haemorrhage or pelvic injuries percutaneous fixation is considered to be
associated thoracic injury or head injury.3 It is estimated the choice of treatment.8
that 15 to 45% of pelvic injuries involve the sacrum or
there is sacro-iliac joint disruption.4,5 Posterior pelvic The purpose of this study was to evaluate the clinical
injury is critically important in pelvic injuries, which may outcome of percutaneous fixation for unstable posterior
involve fracture of the ilium, sacrum or sacro-iliac joint pelvic ring injuries.
disruption. Different options for management of posterior
ring injuries are conservative management, open
Methods
reduction internal fixation with plating, sacral bar and The retrospective study was conducted at Section of
triangular fixation systems or percutaneous fixation with Orthopaedics, Department of Surgery, Aga Khan
cannulated screws.6 University Hospital, Karachi, Pakistan from July 2015 to
December 2018 with a minimum follow up of 10 months.
Open reduction internal fixation is done in prone position Data was retrieved from the trauma registry. All patients
and requires extensive dissection of the soft tissue which who underwent percutaneous fixation with ilio-sacral
leads to an increased chance of wound infection (up to screws for posterior pelvic rings injuries in the study
25%) and anaesthesia complications. period, were included. No formal sample size was
calculated. Patients undergoing open reduction internal
Percutaneous fixation of posterior ring injuries was
fixation with plate or managed conservatively were
excluded.
Aga Khan University Hospital, Karachi, Pakistan.
Correspondence: Hussain Wahab. Email: dr.hussainwahab@gmail.com Post operatively patients were evaluated with Majeed

J Pak Med Assoc (Suppl. 5)

S-71 34th International Pak OrthoCon Conference 2021

Pelvic Score.9 The most common mechanism of injury

observed was road traffic accident, car roll over followed
by motor bike accidents. Total 31 patients met the
inclusion criteria, 1 patient was excluded (patient died
post operatively during same admission due to
haemorrhagic shock). The hospital charts were reviewed
for mechanism of injury, pre and post op Radiology and
results of CT scans.
Surgery was performed under general anaesthesia in
supine position for all patients on a radiolucent table.
Bowel preparation was done for patients and before
surgery. Pelvis antero-posterior, inlet, outlet and lateral
views were obtained to confirm proper position of the
patient using fluoroscopy. Image-2: Photograph of titanium partially threaded cannulated cancellous screws and
washers.
External fixator was applied where required to help in
reduction. Initially closed reduction with help of
manipulation of the external fixator or traction was operatively on follow up visits. Majeed Score is used
achieved and confirmed under image intensifier. Once specifically for assessment of pelvic injury functional
reduction was confirmed then guide wire was passed from outcome and it includes seven items, severity of pain,
lateral aspect of ilium in the safety zone into sacrum, working capabilities, sitting, sexual intercourse, standing
perpendicular to the fracture line, confirming its position in and gait without support and walking distance.
AP, inlet, outlet and lateral view in fluoroscopy as shown in
Majeed score of 80 - 100 is considered as best. Patients
Image-1. Once confirmed under image intensifier, the
who worked before injury are graded as excellent with a
position of the guide wire then reaming was determined.
score >85, good with a score of 70-84, fair with a score of
Cannulated screws of size 73 mm were inserted (implant
55-69 and poor with a score <55.9-13
photograph shown in Image-2). If required, second and
third cannulated screws were also used for fixation using All data was analyzed by statistical package for the social
the same method. Post operatively patients were sciences (SPSS software) version 21. Continuous variables
monitored for bleeding, vitals and distal neurological status. were recorded as means with standard deviation and
Majeed Score9 was used to assess clinical outcome post categorical variables were expressed as frequencies and
percentages.

Results
Total 31 patients met the inclusion criteria. Of them one
was excluded due to mortality on 1st post op day
secondary to haemorrhagic shock. Out of 30 patients 21
(70.0%) were male and 9 (30.0 %) were female. Overall
mean age was 37.1±16.1 years. Twenty-seven (90.0%)
were adult patients and 3 (10.0%) were from the
paediatric group. Patients were further divided into three
groups according to age, the percentage of patients in

Table-1: Distribution of different mechanisms of injury causing the pelvic ring injuries
in the patients.

Mechanism Number of patients Percentage

Car roll over 13 43.3 %

Motor bike accident 10 33.3 %
Fall of heavy object/ blunt trauma 03 10.0 %
Image-1: Intra-operative fluoroscopic image showing lateral view of the sacrum. Fall from height 02 6.7 %
Screws are visible within the zone of safety. Run over injuries 02 6.7 %

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-72
Table-2: Other associated injuries in patients with posterior pelvic ring injuries.

Associated injury Number of patients

Orthopaedic Injuries
Acetabulum fracture 06 (20%)
Femur shaft fracture 03 (10%)
Tibia shaft fracture 03 (10%)
Tibial Plateau Fracture 02 (6.67%)
Neck of femur Fracture 02 (6.67%)
Humerus fracture 03 (10%)
Distal radius fracture 02 (6.67%)
Ilium blade fracture 01 (3.33%)
Non-Orthopaedic Injuries
Pneumothorax and ribs fracture 06 (20%)
Lung contusion without pneumothorax 03 (10%) Figure-2: Frequency distribution of Majeed Pelvic score.
Urological injury 03 (10%)
Facial bones fracture 02 (6.67%)
Abdominal viscera injury (spleen/liver/kidney) 02 (6.67%)
stricture dilatation later) facial bones fracture, abdominal
Head injury (sub-Dural haematoma, temporal bone viscera injury (spleen, liver, kidneys), and head injury (sub-
fracture, scalp haematoma) 02 (6.67%) dural haematoma, temporal bone fracture, scalp
haematoma) as presented in Table-2.
each group is shown in Figure-1. Post op Majeed score was calculated and out of 30
Different mechanisms of injury were Car roll over, motor patients 18 (60.0%) patients had excellent, 10 (33.3%) had
bike accidents, fall of heavy object/ blunt trauma, fall from good and 02 (6.7%) had fair results. The details are shown
height, and run over injuries details shown in Table-1. in Figure-2.

Other associated orthopaedic injuries in these patients Three of our patients had complications post op. one
were, acetabulum fracture, femur shaft fracture, tibia patient died on 1st post op day due to haemorrhagic
shaft fracture, tibia plateau fracture, neck of femur shock and was excluded from the study, 2 had implants
fracture, humerus fracture, distal radius fracture, and ilium failure.
blade fracture, details are shown in Table-2. One had back out of SI screws and the other had
Patients with poly trauma who had other systems loosening of symphysis pubic plate, so revision surgery
involved were initially admitted under trauma team and was done for symphysis pubic fixation and also ilio-sacral
once stabilized then operated for orthopaedic injuries. screws were revised.
Non-orthopaedics injuries present in patients were, chest
Discussion
injuries (pneumothorax, lung contusion without
pneumothorax), Urological injuries (bladder injury, Unstable pelvic ring fracture management has been
urethral injury) (two out of them underwent urethral challenging for orthopaedic/pelvic surgeons. Injuries of
the posterior pelvic ring which include sacroiliac joint
disruption, sacro-iliac joint fracture dislocation or sacrum
fracture leads to posterior ring instability. The goal of the
treatment is to save life and achieve stable fixation after
reduction and return to functional life.
There has been gradual evolution in the management of
pelvic ring injuries over time, initially conservative
management, application of external fixator, open
reduction internal fixation and then closed reduction and
internal fixation with cannulated screws.
Open reduction and internal fixation of SI joint with screw
was first performed by Letournel in 1978. With
advancement in radiology and development of better
Figure-1: Distribution of patients according to age group. imaging modalities Ebrahim et al in 1987 and Routt et al

J Pak Med Assoc (Suppl. 5)

S-73 34th International Pak OrthoCon Conference 2021

in 1993 described percutaneous fixation of SI joint under Taiwan (January 2002 to September 2009). Their study
fluoroscopy in supine position.14,15 showed better outcome with percutaneous fixation for
posterior pelvic ring injuries. Out of 15 patients, 8 were in
Studies have shown that patients with pelvic injuries have excellent group, 4 in good, 2 in fair and 1 in poor group.22
poor functional out come when treated conservatively.16-19
Operative management of pelvic injuries have better Conclusion
functional outcome.20
Stabilization and fixation of posterior ring injuries with
Results of the present study supported Majeed Pelvic percutaneous screw fixation is a better option with
Score as a tool for evaluation of pelvic injuries. In our reduced blood loss, better stability without stripping off
study the mean age of patients was 37 years. Out of 30 of soft tissue and avoiding wound infection and early
patients, 21 (70%) were males and male predominance in mobility.
pelvic injury cases has been reported previously by Ayoub
Limitations
MA et al,1 Amin et al,4 and Po Han Chen et al.22 Only one
study showed female predominance conducted by Ayvaz Limitations of our study were a small sample size and a
M et al at Hacettepe University, Ankara, Turkey.23 retrospective design. It was an audit so all those patients
However, our study reported, the post op mean Majeed who met the inclusion criteria were included and there
Pelvic score as 85.76 on follow up. Out of 30 patients 18 was no need of sample size calculation.
(64%) were in excellent, 10(29%) in good and 2(7%) in fair
group. Our study suggested promising outcomes in
Recommendations
patients with Percutaneous fixation of posterior ring Further studies with larger sample size are needed. Our
injuries with cannulated screws, which showed excellent recommendation is posterior pelvic injuries should be
functional outcome, with minimal blood loss and managed with percutaneous fixation with cannulated
avoiding soft tissue striping. screws, as it avoids extensive exposure for open fixation,
less wound complications and reduced blood loss.
Results of the previous studies from literature review were Combined with fixation of anterior ring when indicated
as follows; for stable fixation and better functional outcome.
Zaki et al showed excellent, good and fair outcome in Disclaimer: None.
50%, 30% and 15% patients with stabilization of sacroiliac
joint by plates and screws.24 Conflict of Interest: None.

Ayvaz M et al, conducted a study in 2011 at Turkey, a Funding Disclosure: None.

retrospective review of 20 cases with 2 years follow up, 19
References
showed excellent Majeed pelvic score and 1 patient was
in good group. One ilio-sacral screw was changed for 1. WHO | World Health Organization. Global Status Report on Road
Safety Summary 2018. [cited 2019 Apr 23]. Available from:
treatment of pseudoarthrosis. No fixation failures were https://www.who.int/violence_injury_prevention/road_safety_st
reported.23 atus/2018/English-Summary-GSRRS2018.pdf.
2. Naghavi M, Abajobir AA, Abbafati C, Abbas KM, Abd-Allah F, Abera
Ayoub AM et al, conducted a retrospective study in Egypt SF, Aboyans V, Adetokunboh O, Afshin A, Agrawal A, Ahmadi A.
(March 2002 to January 2009) with 1 year follow up. Global, regional, and national age-sex specific mortality for 264
causes of death, 1980-2016: a systematic analysis for the Global
Including 42 patients [Male: 33 (78.6 %) and Female: 09
Burden of Disease Study 2016. The Lancet. 2017 Sep
(21.4%)]. Their results were; 18 patients in Excellent group, 16;390(10100):1151-210.
13 in good, 05 in Fair and 06 in poor group, according to 3. Giannoudis PV, Tzioupis CC, Pape HC, Roberts CS. Percutaneous
Majeed pelvic score.21 fixation of the pelvic ring: an update. J Bone Joint Surg. British
volume. 2007 ;89:145-54.
Amin et al, conducted a prospective study in Pakistan 4. Denis F, Davis S, Comfort T. Sacral Fractures: An Important
Problem Retrospective Analysis of 236 Cases. Clin. Orthop. Relat.
(March 2008 to June 2014) with 1 year follow up including Res.. 19881; 227:67-81
50 patients (Male 66%, female 34 %). Their results were 5. Ramprasath DR, Thirunarayanan V, Basheer Ahmed S.
excellent in 26(52%) cases, good in 17(34%) and fair in Percutaneous screw fixation for sacral &sacro iliac joint injuries:
5(10%) cases. Besides, 2(4%) patients had poor Majeed Case series Internat J Orthop Sci.2017;3:669-74.
6. Amin MS, Habib MK, Khalid A. Percutaneous ilio-sacral screw
pelvic grade.6 fixation for unstable pelvic ring injuries. J Pak Med Assoc.
2016;66(Suppl 3):S112-5.
Po Han Chen et al, conducted a retrospective analysis of 7. Tonetti J, Van Overschelde J, Sadok B, Vouaillat H, Eid A.
32 consecutive patients with unstable pelvic ring in Percutaneous ilio-sacral screw insertion. Fluoroscopic techniques.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-74
OrthopTraumatol Surg Res. 2013;99:965-72. 17. Zwingmann J, Eberbach H, Strohm PC, Südkamp NP, Lauritsen J,
8. Ayaz M, Caglar O, Yilmaz G, Guvendik GI, Acaroglu RE. Long term Schmal H. Decision-making, therapy, and outcome in lateral
outcome and quality of life of patients with unstable pelvic compression fractures of the pelvis-analysis of a single center
fractures treated by closed reduction and percutaneous fixation. treatment. BMC musculoskeletal disorders. 2019;20:1-9.
Ankara: sn, TJTES Ulus Travma Derg.2011,17:261-6. 18. Leung KS, Chien P, Shen WY, So WS. Operative treatment of
9. Majeed SA. Grading the outcome of pelvic fractures. J. Bone Jt. unstable pelvic fractures. Injury. 1992;23:31-7.
Surg.British 1989;71:304-6. 19. Khorrami M, Mehdi Nasab SA, Zakeri AH. Functional Outcome of
10. Ismail HD, Lubis MF, Djaja YP. The outcome of complex pelvic Unstable Pelvic Ring Fractures: A Comparative Study between
fracture after internal fixation surgery. Malays. Orthop. J.. Operative and Non-Operative Treatment. Jundishapur. J. Health.
2016;10:16. Sci.. 2012;11:421-430.
11. Majeed SA. External fixation of the injured pelvis. The functional 20. Matta JM, Tornetta P 3rd. Internal fixation of unstable pelvic ring
outcome. J. Bone Jt. Surg.British. British volume. 1990;72:612-4. injuries. Clin OrthopRelat Res 1996;329:129 40
12. Lefaivre KA, Slobogean GP, Ngai JT, Broekhuyse HM, O'Brien PJ. 21. Ayoub MA. Type C pelvic ring injuries in polytrauma patients: can
What outcomes are important for patients after pelvic trauma? percutaneous iliosacral screws reduce morbidity and costs? Eur. J.
Subjective responses and psychometric analysis of three Orthop. Surg. Traumatol.. 2012;22:137-44.
published pelvic-specific outcome instruments. J. Orthop. 22. Chen PH, Hsu WH, Li YY, Huang TW, Huang TJ, Peng KT. Outcome
Trauma. 2014;28:23-7. analysis of unstable posterior ring injury of the pelvis: comparison
13. Lefaivre KA, Slobogean GP, Valeriote J, O'Brien PJ, Macadam SA. between percutaneous iliosacral screw fixation and conservative
Reporting and interpretation of the functional outcomes after the treatment. Biomed J. 2013;36:289-294
surgical treatment of disruptions of the pelvic ring: a systematic 23. Ayvaz M, Caglar O, Y?lmaz G, Guvendik G?, Acaro?lu RE. Long-term
review. . J. Bone Jt. Surg.British 2012;94:549-55. outcome and quality of life of patients with unstable pelvic
14. Tonetti J, Van Overschelde J, Sadok B, Vouaillat H, Eid A. Percutaneous fractures treated by closed reduction and percutaneous fixation.
ilio-sacral screw insertion. Fluoroscopic techniques. Orthop TJTES.(Turkish Journal of Trauma & Emergency Surgery).
Traumatol Surg Res . 2013 ;99:965-72. doi: 10.1016/j.otsr.2013.08.010. 2011;17:261-266
15. Routt Jr MC, Kregor PJ, Simonian PT, Mayo KA. Early results of 24. El-SayedZaki M, Abd-AllaElsawy M, El-DeenHannout YS, El-
percutaneous iliosacral screws placed with the patient in the Dakhakhney BA. Stabilization of Sacroiliac Joint Disruption
supine position. J. Orthop. Trauma. 1995; 9:207-14 through Anterior Approach by Plates and screws. J Am Sci 2014;
16. Henderson RC. The long-term results of nonoperatively treated 10: 66-72.
major pelvic disruptions. J Orthop Trauma 1989; 3: 41-7

J Pak Med Assoc (Suppl. 5)

S-75 34th International Pak OrthoCon Conference 2021

AUDIT
Treatment and outcomes of soft tissue sarcoma of groin, hip and thigh: a
retrospective review from a tertiary care hospital
Masood Umer, Javeria Saeed, Zaid Shamsi, Muhammad Usman Tariq

Abstract
Objective: To study the frequency of the thigh, hip and groin soft tissue sarcomas and retrospectively analyse the
management, treatment results, and outcomes of these uncommon malignant tumours, in a tertiary care hospital
of the city of Karachi.
Methodology: Data of soft tissue tumours registered from 2017-2018 was retrieved during January 2019 to March
2019 from Aga Khan University Hospital, Karachi bone and soft tissue tumour registry. A retrospective review was
performed and all soft tissue tumour cases treated with surgical intervention (with adjuvant /neoadjuvant therapy)
or palliative intention were included.
Result: Total 119 cases of soft tissue tumours (STS) were identified out of which 85 were malignant cases (sarcomas)
while 30 were benign. On presentation 84 (70.6%) were primary cases. On topographical distribution, there were 25
patients who had hip, groin and thigh sarcoma. Of these, 15 were males and 10 were females. As treatment, neo-
adjuvant radiation was done in 4 (16%) patients and adjuvant chemo/radio therapy was given to 13 (52%) patients.
Wide margin excision was performed in 19 (76%) patients and 4 (16%) had amputation. Reconstruction was offered
to 3 (12%) patients. In post-surgical complications, 1 (4%) patient had wound infection. On final surgical
histopathology, majority of the sarcomas were liposarcomas, myxofibrosarcoma, synovial sarcoma and
Leiomyosarcoma. Post-surgery recurrence occurred in 7 (28%) patients. Overall survival was 76%.
Conclusion: In treatment of soft tissue sarcoma, limb salvage is an achievable option and survival results are also
good.
Keywords: Limb salvage, Synovial sarcoma, Radiotherapy, Recurrence, Leiomyosarcoma.
(JPMA 71: S-75 [Suppl. 5]; 2021)

Introduction tumours.5 This has drastically changed the outcomes of

these sarcomas with more and more cases now being
Sarcomas are a diverse group of tumours, malignant in
treated with curative and/or limb sparing intent. This was
nature, with different clinical features and outcome.
earlier considered as untreatable and hence dealt with a
These rare tumours arise from skeletal and extra-skeletal
palliative goal.6-9 This was majorly true for sarcomas
connective tissues including the peripheral nervous
occurring in retroperitoneum and pelvis where they often
system. They primarily affect the limbs, pelvic girdles and tend to involve major blood vessels, putting the oncology
the retro-peritoneum but can occur in any part of the clinicians and orthopaedic surgeons in a difficult
body.1,2 During recent years, a few case series have been situation.10
published enhancing our understanding of the natural
history following resection of these tumours.3 Although, In a developing country like Pakistan, where good health
our research has evolved greatly, these tumours are still care facilities are still a dream yet to be achieved, having a
resistant to chemotherapy and radiation in most cases tertiary care set up like The Aga Khan University Hospital,
hence surgical resection remains the mainstay of with a dedicated musculoskeletal oncology team
treatment.4 comprising of highly trained oncologists, an orthopaedic
tumour surgeon and vascular surgeons, is a blessing.
Due to the relative rarity of these tumours, there is only a However, the management and outcomes of soft tissue
handful of literature available even during this day and sarcomas in our part of the world have never been
age. The treatment strategies have changed over the evaluated. Hence this study reviews the management and
years but one approach has been universally accepted by outcomes of soft tissue sarcomas, showing the frequency
all tumour facilities around the globe which is the of the thigh, hip and groin sarcomas at our institute.
application of multimodal approach towards these
Methods
Aga Khan University Hospital, Karachi, Pakistan. Data of soft tissue tumour patients registered from 2017-
Correspondence: Javeria Saeed. Emal: javeria.saeed@aku.edu 2018 was retrieved during January 2019 to March 2019

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-76
from Aga Khan University Hospital bone and soft tissue treated with palliative intent. Of all the patients, 19 (76%)
tumour registry. A retrospective review of cases was underwent wide margin excision and 4(16%) had
conducted at the Aga Khan University Hospital, Karachi, amputation, 2(8%) had only diagnostic biopsies.
department of Orthopaedics after getting exemption Reconstruction was offered to 3(12%) patients which
from the institute ethical review committee. The data was included vascular repair of femoral artery with
retrieved from the bone and soft tissue registry proforma contralateral reversed greater saphenous vein
which had been filled at the initial visit of the patient and interposition graft, soft tissue graft and intramedullary
completed at the final follow up. The detailed proforma nailing with free vascular fibula graft. In post-surgical
comprised of patient demographics (age, gender, complications, 1 (4%) patient had wound infection which
comorbidities, hospital medical record number etc.), was treated with oral antibiotics while 1 (4%) had
tumour related details, investigation details, treatment iatrogenic injury in another hospital and was presented to
details, surgical details and post treatment details us for a redo procedure. On final surgical histopathology,
(complications, recurrence, survival). All soft tissue
tumour cases treated with surgical intervention (with
Table: Summary of Surgical and Non-Surgical Intervention.
adjuvant /neo-adjuvant therapy) or palliative intention
were included irrespective of age and gender. For tumour Variables n %
staging, American joint commission center (AJCC) staging
system was used.11 Data was stratified later as per Curative surgery 23 92
objective requirements by topographic distribution as Palliative surgery 2 8
cases of hip, groin and thigh. Data was entered and Neo Adjuvant radiotherapy 4 16
analyzed on statistical software SPSS 21. Descriptive No Neo Adjuvant radiotherapy 21 84
Adjuvant chemo/radiation 13 52
statistics was calculated for quantitative variables while
No adjuvant chemo/radiation 12 48
frequencies were calculated for qualitative variables. Wide margin excision 19 76
Amputation 4 16
Result Diagnostic biopsy 2 8
There were 119 cases of soft tissue tumours (STS) out of Reconstruction 3 12
which 85(71.4%) were malignant cases (sarcomas) while No reconstruction 22 88
30(25.2%) were benign and
4(3,36%) were borderline. On
presentation there were 84 (70.6%)
primary cases, 24 (20 %) recurrent
cases and 6 (5%) metastatic cases
while 5 (4.2%) were residual. Since
our focus was on analysing
management outcomes in groin,
hip and thigh soft tissue sarcomas
there were total 25 (21%) patients,
out of which 19 (76%) cases of
thigh, 5 (20%) of hip and 1 (4%) of
groin sarcoma. On presentation,
the mean age of patient at the time
of diagnoses was 46±15 (17-70)
years. The mean follow up of
patients was 19±11.9 months.
There were 15 (60%) males and 10
(40%) females. For treatment, neo-
adjuvant radiation was done in 4
(16%) patients whereas adjuvant
therapy, chemo/radiation was
given to 13 (52%) patients (Table).
Curative intent was applied to 23
(92%) patients while 2 (8%) were Figure: Post surgery histopathological findings of patients (tumour).

J Pak Med Assoc (Suppl. 5)

S-77 34th International Pak OrthoCon Conference 2021

majority of the sarcomas were liposarcomas as it was significantly lower than other studies. Song et al. and
reported in 6(24%) patients, 3(12%) patients had Adelani et al. reported wound complication rate of 36%
Leiomyosarcoma (Figure). Nine (36%) patients were of and 50% respectively.15,21
stage III B followed by 6 (24%) cases of stage IV and 2 (8%)
It is possible to obtain reasonably good survival rates with
were stage II and rest were stage I cases. Post-surgery
careful pre-operative planning and appropriate and
recurrence occurred in 7 (28%) patients, out of which 5
timely intervention. Recurrence of tumour remains an
(20%) had recurrence with Mets, 1(4%) had recurrence
issue however. The use of adjuvant therapy in patients
without Mets and 1(4%) had only distant metastasis to
with limb sparing surgery for extremity STS has been
lungs. Two (8%) patients had positive margins on final widely accepted. Schwarzbach et al. report recurrence in
histopathology report. Out of 25 patients, 19(76%) 15.8% (n=3) of 19 patients in their study.10 A slightly
patients were alive in the two-year period, while only 6 higher figure of 21% has been reported by Song et al.15
(24%) expired due to recurrence and metastasis. Our study reports a recurrence rate of 28% (n=7) of 25
Discussion patients, 5 of which had recurrence with metastatic
disease, one developed recurrence without metastasis
The present report highlights the advantages of having and one had only distant metastasis (lungs). This high
large focused prospective databases in tumour entities recurrence rate despite the fact that 52% of our patients
that are rare. Such datasets can be utilized not only for the received adjuvant therapy but still the survival rate in our
prediction of prognostic factors but can identify varied patients was 76%.
and variable prognostic events at the time of presentation
which influence the type of recurrence, i.e. disease Soft tissue sarcomas are classified histologically according
specific survival, metastasis free survival, or overall to the soft tissue cell of origin, although the cell type is not
survival.12-14 part of the prognostic staging system. Additional studies,
including electron microscopy, histochemistry, and flow
Most importantly, they provide a stable description of cytometry, cytogenetic and tissue culture studies may
patient specific outcomes in a series of rare diseases, allow identification of particular subtypes within the
giving a baseline for predicted outcome and risk. major histologic categories. Malignant fibrous
We conducted a retrospective analysis of prospectively histiocytoma is the most common histologic type (28%).
collected data to assess the management strategies of Others are leiomyosarcoma (12%), liposarcoma (15%),
these rare commodities employed at our institute and synovial sarcoma (10%), and malignant peripheral nerve
their outcomes with respect to histological type, post- sheath tumour (6%).22 In our study however, liposarcoma
operative complications, local recurrence, metastasis and was the most common histological type occurring in 24%
overall survival. Vascular reconstruction was not of the patients. Other types included myxofibrosarcomas,
considered a contraindication in our setup and vessel synovial sarcoma and Leiomyosarcoma each reported in
reconstruction was done wherever desired. 12% patients. Other less common types included
pleomorphic sarcoma, malignant peripheral nerve sheath
A multidisciplinary team was essential to our surgical tumour and rahabdomyosarcoma that were found in 8%
approach. The preoperative team approach allowed for patients.
better surgical planning, removal of previously thought
inoperable tumours based on outside hospital Conclusion
evaluations, more effective reconstruction, and improved The treatment of patients with STS involves a
outcomes. multidisciplinary team approach and most patients are
eligible for limb-salvage surgery, usually combined with
This series consisted of 25 patients (15 males, 10 females)
radiation. Following treatment the majority of patients
which is comparable to other case series previously
can expect a painless and functional extremity.
published.10,15-17 Twenty-three (92%) patients were
treated with curative intent while only 2 (8%) were Limitations
treated for palliation. Limb salvage was possible in 82% of
patients treated with curative intent. Comparably, similar This study, however, has some limitations. Firstly this
rates of limb salvage ranging from 80% to 100%.18-20 have study has a retrospective design which makes the inferior
been reported in the previously published case series level of evidence compared to prospective studies and
with similar number of cases. also this study is inherently prone to recall bias. Secondly,
the sample size is very small and are thus not
We reported a wound complication rate of 4% which is representative of the general population.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-78
Disclaimer: None. Vasc. Surg.2006; 44:46-55.
11. Tanaka K, Ozaki T. New TNM classification (AJCC eighth edition) of
Conflict of Interest: None. bone and soft tissue sarcomas: JCOG Bone and Soft Tissue Tumor
Study Group.Jpn. J. Clin. Oncol. 2019; 49:103-7.
Funding Disclosure: None. 12. Singer S, Antonescu CR, Riedel E, Brennan MF. Histologic subtype
and margin of resection predict pattern of recurrence and survival
References for retroperitoneal liposarcoma. Ann. Surg. 2003; 238:358.
13. Pisters PW, Harrison LB, Leung D, Woodruff JM, Casper ES,
1. Group EESNW. Gastrointestinal stromal tumors: ESMO Clinical Brennan MF. Long-term results of a prospective randomized trial
Practice Guidelines for diagnosis, treatment and follow-up. ANN of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol.
ONCOL: official journal of the European Society for Medical 1996; 14:859-68.
Oncology. 2012; 23:vii49. 14. Pisters PW, Leung D, Woodruff J, Shi W, Brennan MF. Analysis of
2. Stiller C, Trama A, Serraino D, Rossi S, Navarro C, Chirlaque M, et al. prognostic factors in 1,041 patients with localized soft tissue
Descriptive epidemiology of sarcomas in Europe: report from the sarcomas of the extremities. J Clin Oncol. 1996; 14:1679-89.
RARECARE project. Eur. J. Cancer. 2013; 49:684-95. 15. Song TK, Harris EJ, Raghavan S, Norton JA. Major blood vessel
3. Brennan MF, Antonescu CR, Moraco N, Singer S. Lessons learned reconstruction during sarcoma surgery. Arch Surg. 2009; 144:817-22.
from the study of 10,000 patients with soft tissue sarcoma. ANN 16. Nishinari K, Wolosker N, Yazbek G, Zerati AE, Nishimoto IN. Venous
SURG. 2014; 260:416. reconstructions in lower limbs associated with resection of
4. Bonvalot S, Raut CP, Pollock RE, Rutkowski P, Strauss DC, Hayes AJ, malignancies. J Vasc Surg. 2006; 44:1046-50.
et al. Technical considerations in surgery for retroperitoneal 17. Tsukushi S, Nishida Y, Sugiura H, Nakashima H, Ishiguro N. Results
sarcomas: position paper from E-Surge, a master class in sarcoma of limb?salvage surgery with vascular reconstruction for soft
surgery, and EORTC-STBSG.ANN SURG ONCOL. 2012; 19:2981-91. tissue sarcoma in the lower extremity: comparison between only
5. McGoldrick NP, Butler JS, Lavelle M, Sheehan S, Dudeney S, arterial and arterovenous reconstruction. J Surg. Oncol. 2008;
O'Toole GC. Resection and reconstruction of pelvic and extremity 97:216-20.
soft tissue sarcomas with major vascular involvement: current 18. Fortner JG, Kim DK, Shiu MH. Limb-preserving vascular surgery for
concepts.World J. Orthop.2016; 7:293. malignant tumors of the lower extremity. Arch Surg. 1977;
6. Enneking W. Giant cell tumor of bone: Musculoskeletal tumor 112:391-4.
surgery, New York. 1983; pp1435-68. 19. Karakousis CP, Karmpaliotis C, Driscoll DL. Major vessel resection
7. Enneking WF, Spanier SS, Goodman MA. The classic: A system for during limb-preserving surgery for soft tissue sarcomas. World J
the surgical staging of musculoskeletal sarcoma. Clin. Orthop. Surg. 1996; 20:345-50.
Relat. Res.2003; 415:4-18 20. Hohenberger P, Allenberg JR, Schlag PM, Reichardt P. Results of
8. Willard W. Comparison of amputation with limb-sparing surgery and multimodal therapy for patients with soft tissue
operations for adult soft tissue sarcoma of the extremity.Plast. sarcoma invading to vascular structures. Cancer: Interdisciplinary
Reconstr. Surg.1993; 91:571. International Journal of the American Cancer Society. 1999;
9. Suit HD, Mankin HJ, Wood WC, Proppe KH. Preoperative, 85:396-408.
intraoperative, and postoperative radiation in the treatment of 21. Adelani MA, Holt GE, Dittus RS, Passman MA, Schwartz HS.
primary soft tissue sarcoma. Cancer. 1985; 55:2659-67. Revascularization after segmental resection of lower extremity
10. Schwarzbach MH, Hormann Y, Hinz U, Leowardi C, Böckler D, soft tissue sarcomas. J Surg Oncol. 2007; 95:455-60.
Mechtersheimer G, et al. Clinical results of surgery for 22. Puri A, Gulia A. Management of extremity soft tissue sarcomas.
retroperitoneal sarcoma with major blood vessel involvement. J Indian J Orthopaed. 2011; 45:301.

J Pak Med Assoc (Suppl. 5)

S-79 34th International Pak OrthoCon Conference 2021

AUDIT
Prevention of falls in hospital: Audit report from a Tertiary care hospital of
Pakistan
Anum Sadruddin Pidani, Tashfeen Ahmad, Nasreen Panjwani, Shahryar Noordin

Abstract
Objective: The study aims to assess the fall incidents in past 5 years and fall assessment practices at the Aga Khan
University Hospital, Karachi.
Methods: We performed a single-center retrospective audit at Aga Khan University Hospital from October 2019 to
December 2019. A list of all patients admitted to Aga Khan University Hospital under the Musculoskeletal and Sports
Medicine Service Line was obtained using the Hospital Information Management System (HIMS) from Jan 2017 to
June 2018. Data including fall assessment scores was collected retrospectively from medical record files.
Results: A total of 1499 patients were admitted during this time period, of whom 5 patients had a fall incident
during their hospital stay. The mean Morse Scale scores of patients who had a fall was 50 ±16 whereas, patients with
no fall incidence had mean score of 31±22. Fall assessment was documented in nursing notes for 100% of the
patients.
Conclusion: Our findings show that fall policy is implemented strictly within our hospital. In order to reduce the risk
of a fall further, more in-depth assessment of high risk patients with involvement of physicians and physiotherapists
earlier on in the process for high risk patients may be beneficial.
Keywords: Fall assessment, Fractures, Elderly population. (JPMA 71: S-79 [Suppl. 5]; 2021)

Introduction significant consequence following a fall. Patients might

be traumatized or may develop fear of physical activity
Falls in elderly population are of major public health
even if they do not sustain substantial physical injuries,
significance. One in three older people experience one or
thus limiting their overall mobility.8
more falls each year.1 Falls during stay in healthcare
setups are very common and constitute 20-30% of all Fall prevention programmes in hospitals are an
incidents reported in hospitals.2 In the United States, innovative methodology to minimize fall experiences
more than 700,000 patients experience a fall during their during hospital admissions.9 These programmes involve
hospital stay each year.3 Despite unceasing advancement coordinated interdisciplinary approaches. Some aspects
in medical care, incidence of in hospital falls continue to of fall prevention programmes are part of routine care
rise with 8.9 falls per 1,000 bed-days.4 and standardised for all patients while other aspects need
to be tweaked based on individual needs.10 No physicians
Falls can result in a number of detrimental effects for the
working alone, can eliminate falls completely. Instead, fall
patients such as physical injuries and fractures,
prevention is always an approach which is achieved with
inadvertent drain removal, psychological trauma and
team work and coordination. It also requires an adaptable
exacerbation of future fear of falling, worsening of clinical
organizational culture, operational policies, and focused
parameters, increased hospital stays, morbidity and
practices such as communication and reporting in
mortality.5 Literature reports that overall 24% of patients
addition to individual expertise.4
with a hip fracture after the index fall, who are fifty years
or older, die within one year following the fracture.6 In Aga Khan University Hospital follows a fall assessment
addition to the direct effect on the patient, the economic policy approved by Joint Commission International
costs of falls are substantial. In Pakistan, 85% of patients Accreditation (JCIA). Fall prevention is the 6th JCIA
are out of pocket payers both for their treatment and international safety goals.11 As per policy, all patients
rehabilitation.7 In such circumstances, falls can pose admitted at AKUH are assessed for the risk of fall at the
considerable economic burden for both patients and the time of admission and are reassessed during their hospital
healthcare system. Psychological trauma is also one of the stay. Appropriate actions such as fall teaching,
environment safety, and documentation is implemented
Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan. to prevent falls in hospital. Besides, hospitals also examine
Correspondence: Anum Sadruddin Pidani. Email: anum.sadruddin@aku.edu any incident of fall event during hospitalisation and

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-80
causes of fall. This study aims to perform a clinical audit initiate fall risk care plan. The MFS scores on six variables
for patients admitted under musculoskeletal service line which consist of history of fall (within three months),
to assess fall prevention policy and its impact on fall secondary diagnosis, ambulatory aids, intravenous
incidences at AKUH. therapy, gait and mental status. Scores of 0 to 24 indicates
"No Risk" and requires basic good nursing care while
Methods scores > 51 indicates "High Risk" with implementation of
A single center retrospective audit was performed to fall prevention intervention. Fall teaching is a critical part
evaluate fall prevention practices at Aga Khan University of nursing care. We used nursing care notes to assess
Hospital (AKUH) in Karachi, Pakistan. We utilized an teaching given to patients on fall risk and precautions to
inpatient database of all adult admissions under be taken.
orthopaedic specialty from Jan 2017 to June 2018 which
We used STATA version 12.0 to perform all the analyses.13
is maintained by hospital information management
Descriptive statistics was used to evaluate fall prevention
system (HIMS) at AKUH. The data was collected from
practices at AKUH. We calculated number of falls during
October 2019 to December 2019.
the study period and number of times a fall was
The institutional review board (ethical review committee) documented in nursing notes. Mean and standard
exemption was obtained. Participants were all adult deviations were computed to analyze Morse Fall Scale
patients (aged 18 years and above) admitted under scores for patients who fell and those who did not fall.
musculoskeletal service line. The exclusion criteria for
study participants was unavailability of data records in
Results
data base. A total of 1499 patients were admitted under A total of 1499 patients were admitted under
orthopaedic specialty at Aga Khan University Hospital musculoskeletal and sports medicine service line at Aga
during this period. We performed simple random Khan University Hospital during Jan 2017 to June 2019.
sampling using patient medical record numbers to Five of 1499 patients had a fall incident during hospital
include 28 subjects in the fall prevention practices stay (Figure-1). We performed simple random sampling
evaluation at AKUH who did not fall, whereas 5 patients
who did fall were included as cases in the analysis.
Data were collected retrospectively from medical record
files of randomly selected control patients and cases. A
pre-structured questionnaire was used to collect
information from medical record files. We divided our
audit in to three basic indicators including incidence of
fall during January 2017 to June 2018, implementation of
fall risk assessment policy, and fall teaching by nurses. The
data collection was completed in 6 months after ERC
approval.
Fall is a quality indicator of AKUH and its data is Figure-1: Incidence of fall among Orthopaedic patients (1499).
maintained for each inpatient ward and outpatient clinics
by quality control department. We have an incident
report form to be filled by healthcare providers including
nurses and doctors at the time of each fall incident. Later,
a root-cause analysis is performed by quality control
department for each fall incident. A total of 5 patients had
fall during 2017 to 2018. We requested medical record
number of these 5 patients from department of quality
control at AKUH.
Fall risk assessment is performed for all patients
presenting to Aga Khan University Hospital using Morse
Fall Scale (MFS).12 It is a simple and validated tool used for
assessing a patient's likelihood of falling. Nurses
administer this tool within 30 minutes of admission and Figure-2: Comparison of Morse fall scores between fall cases and controls.

J Pak Med Assoc (Suppl. 5)

S-81 34th International Pak OrthoCon Conference 2021

using patient medical record numbers to include 28 fall, facilitate in clinical decision and reasoning and initiate
subjects in the fall prevention practices evaluation at fall care plan. Our study showed that fall assessment was
AKUH who did not fall, 8 (28.6%) were admitted with the documented in nursing notes for 100% of the patients
history of fall. Comparison of Morse Fall Scale scores which specifically included initiation of fall care plan,
showed that patients who had fall incident during teaching on fall risk, and fall precautions.
hospital stay had mean scores of 50±16 whereas, patients
with no fall incidence had mean score of 31±22 (Figure-2). Conclusion
In-patient hospital fall and its immediate and late
Fall assessment was documented in nursing notes for
outcome is concerning for patients.
100% of the patients which specifically included teaching
on fall risk and fall precautions. The results of the study indicates that AKUH has
implemented fall prevention policy very stringently,
Discussion ensuring timely assessment and accurate documentation.
The purpose of the present study was to audit fall However, periodic in-depth assessment of this policy
assessment practices and policy implementation at Aga specifically involving other multidisciplinary departments
Khan University Hospital. We found that fall and their role in fall prevention such as physicians and
documentation was completed in nursing notes for all the physiotherapists will give us an insight of internal
patients recruited in the study along with fall assessment liabilities and how we can solve the problems.
at the time of admission. The study also indicates that fall
Disclaimer: None.
assessment performed by healthcare providers at the
hospital can identify high risk patients to a great extent. Conflicts of Interest: None.
Falls are serious health concerns for older adults. Its Funding Disclosure: None.
occurrence increases with aging.14 Falls during hospital
stay are common sentinel events, often resulting in severe References
physical injury and even death.15 Although falls are 1. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among
common in older adults and fragile individuals, any elderly persons living in the community. N Engl J Med.
person with altered mental status related to medication, 1988;319:1701-7.
2. Kobayashi K, Ando K, Inagaki Y, Suzuki Y, Nagao Y, Ishiguro N,
procedure, and surgery can be at risk of falling.16 In Imagama S. Characteristics of falls in orthopedic patients during
contrast, physical environment should also be considered hospitalization. Nagoya J Med Sci. 2018;80:341.
as a potential risk factor for falls. Despite of these 3. Kiyoshi-Teo H, Northrup-Snyder K, Cohen DJ, Dieckmann N,
potential risk factors, falls are preventable especially in Stoyles S, Winters-Stone K, Eckstrom E. Older hospital inpatients'
fall risk factors, perceptions, and daily activities to prevent falling.
hospital settings.17 One of the most significant Geriatr Nurs. 2019;40:290-5.
component in preventing hospital falls is implementation 4. Hill AM, McPhail SM, Waldron N, Etherton-Beer C, Ingram K, Flicker
of appropriate fall prevention programmes. L, Bulsara M, Haines TP. Fall rates in hospital rehabilitation units
after individualised patient and staff education programmes: a
In our hospital, we have implemented fall prevention pragmatic, stepped-wedge, cluster-randomised controlled trial.
policy adopted from Joint commission international The Lancet. 2015;385:2592-9.
5. ARE F. Fall Prevention in Acute Care Hospitals. JAMA.
accreditation (JCIA).11 JCIA addresses in-hospital fall 2010;304:1912-8.
prevention strategy as 6th IPSG goal and aims fall 6. Foss NB, Kehlet H. Mortality analysis in hip fracture patients:
prevention through timely fall risk assessment, implications for design of future outcome trials. Br J Anaesth.
2005;94:24-9.
identification and analysis of fall cases, and training and
7. Rahman MM, Karan A, Rahman MS, Parsons A, Abe SK, Bilano V,
education for healthcare providers. Thus, this study aims Awan R, Gilmour S, Shibuya K. Progress toward universal health
to assess the effect of JCIA fall prevention policy on coverage: a comparative analysis in 5 South Asian countries.
incidence of falls and assessment of fall risk. JAMA Intern Med. 2017;177:1297-305.
8. Dykes PC, Carroll DL, Hurley A, Lipsitz S, Benoit A, Chang F, Meltzer
Our findings showed that only 5 patients had a fall from S, Tsurikova R, Zuyov L, Middleton B. Fall prevention in acute care
hospitals: a randomized trial. JAMA. 2010;304:1912-8.
2017 to 2018 and fall policy is implemented strictly within
9. Lin MR, Wolf SL, Hwang HF, Gong SY, Chen CY. A randomized,
our hospital. Also, fall assessment which is done via Morse controlled trial of fall prevention programs and quality of life in
fall scale can identify high risk patients to a great extent. older fallers. J Am Geriatr Soc. 2007; 55:499-506.
Fall prevention is the responsibility of all health care 10. Lord SR, Tiedemann A, Chapman K, Munro B, Murray SM,
Gerontology M, Ther GR, Sherrington C. The effect of an
providers. However, role of nurses is inevitable in
individualized fall prevention program on fall risk and falls in older
implementing fall prevention policy. Nurses play a pivotal people: a randomized, controlled trial. J Am Geriatr Soc. 2005;
role in identification and assessment of risk factors for a 53:1296-304.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-82
11. Yousefian S, Harat AT, Fathi M, Ravand M. A proposed adaptation and circumstances; National Health Interview Survey, 1997-
of joint commission international accreditation standards for 2007.
hospital--JCI to the health care excellence model. Adv Environ 16. Hempel S, Newberry S, Wang Z, Booth M, Shanman R, Johnsen B,
Biol. 2013; :956-68. Shier V, Saliba D, Spector WD, Ganz DA. Hospital fall prevention: a
12. Schwendimann R, De Geest S, Milisen K. Evaluation of the Morse systematic review of implementation, components, adherence,
Fall Scale in hospitalised patients. Age Ageing. 2006;35:311-313. and effectiveness. J Am Geriatr Soc. 2013 ;61:483-94.
13. StataCorp LL. Stata Statistical Software: Release 14. 2015. 17. Clyburn TA, Heydemann JA. Fall prevention in the elderly: analysis
14. Oliver D, Hopper A, Seed P. Do hospital fall prevention programs and comprehensive review of methods used in the hospital and in
work? A systematic review. J Am Geriatr Soc. 2000;48:1679-89. the home. J Am Acad Orthop Surg. 2011;19:402-9.
15. Chen LH, Fingerhut LA, Makuc DM, Warner M. Injury episodes

J Pak Med Assoc (Suppl. 5)

S-83 34th International Pak OrthoCon Conference 2021

AUDIT
Our experience of treating adult bone lymphoma, A retrospective cross-sectional
study in a tertiary care center, Aga Khan University Hospital, Karachi
Masood Umer, Muhammad Younus Khan Durrani, Javeria Saeed, Nasir Uddin

Abstract
Objective: To determine the experience at the Aga Khan University Hospital in diagnosing and treating adult
patients with primary lymphoma of bone.
Methodology: All patients with Primary lymphoma of bone (PLB) that were diagnosed and/or treated at Aga Khan
University Hospital, Karachi from 2005 to 2019 were included as part of this study.
Result: There were 17 patients with PLB including 13 (76.5%) males and 4 (23.5%) females with a mean age of 44 ±
16.5 years. Nine patients were between 30-59 years of age at diagnosis. The mean follow-up time of patients was
80±46.7 months. Six patients had tumours of pelvic bone followed by tibia (5) and femur (4). Four patients had a
pathological fracture at the time of presentation whereas 2 (11.8%) required surgical fixation of the pathological
fracture. The stage of the tumour was based on Ann Arbor classification. Nine (52.9%) cases had Stage 1 disease, 7
(41.2%) had stage IV disease with metastasis in extra nodal tissues. As for treatment, every patient received
chemotherapy whereas 5 (29.4%) received adjuvant radiotherapy. Complete remission in the size of the tumour was
seen in 11 (64.7%) patients while 6 (35.3%) had partial remission. Post-treatment, 4 (23.5%) patients expired. The
mean Overall Survival (OS) time was 80.18 ± 46.71months with a survival rate of 76.5%
Conclusion: Primary lymphoma of the bone can be treated with medical regime and good prophylactic surgeries
to avoid pathological fracture such as intramedullary nailing.
Keywords: Lymphoma, Pelvic bone, Pathological fracture, Survival, Metastasis. (JPMA 71: S-83 [Suppl. 5]; 2021)

Introduction pattern, or near normal which makes biopsy important.4,6

According to the WHO classification, primary lymphoma Due to the low prevalence even in countries with good
of the bone (PLB) is defined as a monostotic disease record maintainence as the United States, the information
involving a single skeletal site with or without the on PLB is scarce. This study aimed to determine the
involvement of the regional lymph nodes, or as a experience in diagnosing and treating adult patients with
polyostotic disease affecting multiple skeletal sites PLB in a tertiary care hospital of Karachi. The paediatric
without visceral or lymph node involvement.1 Primary population was excluded because PLB in children is
lymphoma bone (PLB) is extremely rare. The diagnosis is treated as a systemic disease rather than an isolated bone
based on cortical and adjacent soft tissue involvement. pathology.
On the contrary distant visceral and lymph node
involvement is part of PLB or not is controversial in the
Methods
literature. PLB affects 1.7/1,000,000 people in US with 5% A retrospective cross sectional study was conducted on all
of extra nodal involvement and 3% malignancies.2,3 It is a patients diagnosed with PLB or treated at AKU from 2005
tumour of lymphoid tissues as lymph nodes and spleen.4 to 2019. The diagnosis was based on a biopsy of the bone
It presents with pain or swelling of the affected area. The tumour. Patients were included in this study regardless of
tumour can be low grade, intermediate or high grade. sex, race, age and co-morbids. Moreover, patients who
Burkett's lymphoma is an example of a fast-growing had primary lymphoma other than bone or had received
tumour.4 PLB contributes to only 3% of all bone tumours treatment for a Secondary Lymphoma of bone were
and is usually seen in adult life. It can occur in all bones excluded.
but predominantly in bones with marrow and most are Approval for the study was obtained from the Ethical
large cells with B cell lineage, called diffuse large B-cell Review Committee of the institution. Patients who were
lymphoma (DLBCL).4,5 On plain x-ray, it can present with part of the study were identified using medical record
the lytic pattern, sclerotic pattern, increased density numbers. Noted were demographics of the patients
including their age, sex, site of tumour, Follow-up (in
Aga Khan University Hospital, Karachi, Pakistan. months), Co-morbids, Type of Lymphoma, Histological
Correspondence: Javeria Saeed. Email: javeria.saeed@aku.edu subtype of Lymphoma, size of the primary tumour, stage

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-84
of cancer, involved bone, presence of extra-lymphatic
spread, pathological fracture, modality of treatment
including Chemotherapy, Radiotherapy, Immunotherapy
and surgery, type of remission, number of relapses, size of
tumour after treatment (in case of incomplete remission)
and post-chemotherapy complications. The collected
data was analysed using Statistical Package for Social
Sciences v. 21 (SPSS). Means and frequency were
calculated along with survival analysis using the Kaplan-
Meier test.

Results
Medical records of 17 patients with PLB were reviewed.
There were 13 (76.5%) males and 4 (23.5%) females with a
mean age of 44±16.5 years. Out of which 4 (23.5%)
patients were less than 30 years of age, 9 (53%) patients
were between 30-59 years and 4 (23.5%) were equal to or
above 60 years of age at diagnosis. The mean follow-up Figure-2: Overall survival curve of patients.
time was 80±46.7 (8-184) months.
Some patients had comorbids along with the tumour in 2 (11.8%) had a lesion in the liver on PET CT, 3 (17.6%)
which 2 (11.8%) patients had Diabetes Mellitus type 2 and 2 presented with distant metastasis, and the remaining 9
had hypertension. Hepatitis B, Gilberts syndrome, and (52.9%) had solitary bone lesions with no skipped or
ischaemic heart disease were seen in only 1 (5.9%) case each. distant lesions on PET CT. Pathological fractures were
All the patients had non-Hodgkin lymphoma DLBCL type. noted in 4 (23.5%) cases at the site of the lesion. Surgical
fixation of the pathological fracture was required in only 2
Most of the patients had a tumour in the Pelvic bones (11.8%) patients.
followed by the femur, tibia, radius, and scapula (Figure-1).
Lesion on kidneys on PET- CT was seen in 3 (17.6%) cases, The staging of the tumour was based on Ann Arbor
classification7 Stage 1 disease was seen in 9 (52.9%)
patients; 7 patients (41.2%) had stage IV disease with
metastasis in extranodal tissues. One (5.9%) patient had
stage II disease. As for treatment, every patient received
chemotherapy: 16(94.1%) received RCHOP (Rituximab,
Cyclophosphamide, Doxorubicin, Vincristine, and
Prednisolone), 3 (17.6%) received a high dose
(Methotrexate) MTX along with RCHOP regime, 1 (5.9%)
was given RDHAP (Rituximab, Dexamethasone,
cytarabine, and Cisplatin). Five (29.4%) patients returned
with febrile neutropenia for which chemotherapy was
stopped and treatment was given. One (5.9%) patient
each presented with acute gastroenteritis and oral
thrush whereas 10(58.8%) patients tolerated
chemotherapy well.
Five (29.4%) patients received radiotherapy. Complete
remission in the size of the tumour was observed in 11
(64.7%) patients with 6 (35.3%) having partial remission.
Multiple relapses in the course of treatment were
encountered in 4(23.5%) patients. Out of 17 patients, 4
(23.5%) expired, making the overall survival rate of
76.5% with a median time of 144.6 months (SEM 16.70)
(Figure-2).
Figure-1: Bone tumor sites in patients of Bone lymphoma.

J Pak Med Assoc (Suppl. 5)

S-85 34th International Pak OrthoCon Conference 2021

Discussion most of the cases were of pelvic bone followed by tibia

and femur. In PLB patients mostly present with pain (80-
Primary bone lymphoma (PLB) is extremely rare presenting
95%), swelling in 30-40%, and pathological fracture in 10-
with pain and swelling on the affected area.2 The current
15%.9,10 The time between the disease onset and
study was carried out to share our experience of patients
presentation to the clinic is generally short (8 months).8
with PLB on their diagnosis and treatment. To our
Also, lymphoma in bones can develop around prosthetic
knowledge, this is the largest study done in the
devices especially anaplastic large cell lymphomas (ALCL)
subcontinent (Pakistan, India, and Bangladesh) which
which present with swelling and erythema at the surgical
discusses the patients with the disease and their prognosis.
Even the Surveillance, Epidemiology, and End Results (SEER) site a few years after implant surgery.10 According to the
database of the US does not include the data regarding the literature, the median age of diagnosis of PLB is 45-60
effect of chemotherapy on these patients.2 The principle to years while our patients mean age was 44 years which is
treat PLB is far different from sarcomas.3 In recent times consistent with international data. For this reason
much progress has been made to diagnose and stage the patients presenting with pain or swelling should be
disease by using PET CT. This provides the anatomical and advised plain X-ray to detect the lesion. In case a lesion is
physiologic activities of the lesion. But still, no significant noted, MRI should be performed which is the gold
change in the incidence and overall survival has been noted. standard for diagnosis of PLB. If PLB is in the bone with
This supports the need to prospectively conduct a study at local extension of the lesion, PET CT is recommended for
a multicenter and multinational level.2,5 Jacob et.al, also staging.5,8,11 In MRI more specific characteristics of PLB are
commented on the fact that appendicular tumour site is a present as compared to the plain X-ray film.6 For staging
predictor of survival compared to axial locations but some Ann Arbour system7 is used. Furthermore, metastatic
studies (which they describe in their publication) have workup and biopsy are done to know the nature of the
different observations due to confounding factors.2 disease and exclude other differentials, some studies
Differential diagnoses of such lesions include Ewing's suggest doing anchored multiplex PCR. Seven patients in
sarcoma and osteosarcoma.3,4 According to the literature, the presented series showed metastatic disease. Bone
PLB occurs most commonly in the femur followed by the tumours cannot be dealt with under the care of a single
pelvis. On the contrary in Japan, pelvis is the most common specialty. A multidisciplinary approach is recommended
site. PLB shows a variety of presentations on plain X-ray. The and at our center, such cases are discussed in Tumour
X-ray of a patient of our series, who presented with a lesion Boards where orthopaedic oncological surgeons, medical
in the right sacroiliac joint, showed patchy increased density and radio-oncologist specialists offer their expert opinion
along the right sacroiliac joint (Figure-3). In our study also, for the various treatment choices. The factors under
consideration include age, socioeconomic factors, and
marital status. Age is an important predictor of survival
which could be due to the ability to endure
chemotherapy and lesser comorbidities play a significant
role in giving treatment options to the patients. Higher
socioeconomic and married patients also show a better
prognosis when compared to their counterparts.2 The first
choice and evidence based treatment for DLBCL is
cyclophosphamide, doxorubicin, vincristine, and
prednisone (CHOP) plus etoposide. This has shown
complete remission. Immunotherapy with rituximab (R-
CHOP) is not well established in literature because most of
the data is from the time when rituximab was not
available in the market.4,6 Similarly, offering radiotherapy
is controversial and can be on case based need, still
further clinical trials are needed to prove its efficacy.8 It is
also recommended that immunotherapy should be given
before radiotherapy and currently R-CHOP is the first line
treatment for PLB.11 If PLB is in a weight bearing bone
then weight bearing limitations should be placed or the
Figure-3: X-ray Pelvis of our patient showing Patchy increased density noted along the patient should be in protected weight bearing to prevent
right sacroiliac joint. a fracture. At our institute the patients are discussed in

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-86
tumour boards and the board decides on case need basis Rep. 2017; 7:6.
that whether patient needs radiotherapy or not. On the 2. Jacobs AJ, Michels R, Stein J, Levin AS. Socioeconomic and
demographic factors contributing to outcomes in patients with
contrary, in a study patients with advanced-stage disease,
primary lymphoma of bone. J. Bone Oncol. 2015; 4:32-6.
who were treated with chemotherapy plus radiotherapy, 3. Hue SS-S, Iyer P, Toh LHW, Jain S, Tan EEK, Sittampalam K, et al.
had a poorer outcome compared with those who were Primary Bone Anaplastic Large Cell Lymphoma Masquerading as
treated with chemotherapy alone. Post treatment once Ewing Sarcoma: Diagnosis by Anchored Multiplex PCR. Pediatr.
remission is achieved, strict follow-up is required. Hematol. Oncol. 2018; 40:e103-e7.
Literature has reported a local relapse of 7-10% and 17- 4. Sahu A, Khan S, Singhania S, Gudhe M, Singh P, Karan Mane D, et
al. Non-Hodgkin's Lymphoma of Calcaneum, Inguinal & Popliteal
22% of distant metastasis.11
region: A rare case report. Int. j. adv. res. 2015; 3:945-9.
5. Okuyucu K, Alagöz E, Özaydin S, Güzelkücük Ü, Arslan N. Primary
Conclusion
sacral lymphoma initally supposed to be sacroiliitis on bone
This study proves that PLB can be treated without any scintigrapy. Gulhane Medical J. 2016; 58:327-328.
surgical intervention. Primary lymphoma of bone can be 6. Caracciolo JT, Rose T, Bui MM. Primary lymphoma of bone:
treated with good medical management. Prophylactic imaging findings to improve diagnosis of a rarely considered
disease prior to biopsy. J. Clin. Diagn. 2015; 5:97.
surgery is done to avoid pathological fracture for example
7. Rath S, Connors JM, Dolman PJ, Rootman J, Rootman DB, White
intramedullary nailing in the femur. In this situation VA. Comparison of American Joint Committee on Cancer TNM-
surgical morbidity can be avoided by early diagnosis and based staging system and Ann Arbor classification for predicting
a multidisciplinary approach. Chemotherapy and if outcome in ocular adnexal lymphoma. Orbit. 2014; 33:23-8.
needed radiotherapy is applied. 8. Beal K, Allen L, Yahalom J. Primary bone lymphoma: Treatment
results and prognostic factors with long-term follow-up of 82
Disclaimer: None. patients. Cancer: Interdisciplinary International Journal of the
American Cancer Society. 2006; 106:2652-6.
Conflict of Interest: None. 9. Vannata B, Zucca E. Primary extranodal B-cell lymphoma: current
concepts and treatment strategies. Chin. Clin. Oncol. 2015; 4:1-17
Funding Disclosure: None. 10. Tuck M, Lim J, Lucar J, Benator D. Anaplastic large cell lymphoma
masquerading as osteomyelitis of the shoulder: an uncommon
References presentation. BMJ Case Reports. 2016; 2016:bcr2016217317.
1. Zekry KM, Yamamoto N, Hayashi K, Takeuchi A, Tsuchiya H. 11. Steffner RJ, Jang ES, Danford NC. Lymphoma of Bone. JBJS
Primary lymphoma of the pelvis: a case report. J. Orthop. Case reviews. 2018; 6:e1.

J Pak Med Assoc (Suppl. 5)

S-87 34th International Pak OrthoCon Conference 2021

AUDIT
Functional outcomes and complications of total hip arthroplasty with dual
mobility cup : an audit
Muhammad Younus Khan Durrani, Javeria Saeed, Masood Umer, Pervaiz Hashmi

Abstract
Objective: To determine the functional outcomes in total hip arthroplasty with a dual mobility cup, performed in
our hospital.
Methods: After receiving an exemption from the Ethics review committee of the hospital, data collection for audit
was started in January 2019. Records from July 2016 to June 2018 were included. All patients who underwent total
hip arthroplasty with dual mobility prosthesis without any age limit were included. A proforma was prepared to
collect the required information. Data was entered and analyzed on SPSS v. 21.
Results: Two hundred and ten patients were included, 114 females and 96 males. Of the total, 188 patients
underwent unilateral surgery while 22 had bilateral hip arthroplasty. The mean postoperative hospital stay was
5.91±3.9 days. . Mean pre-op Harris score was 33.7±7.6 and the post-op mean score was 75.9± 5.34. Eighty-three
(39.5 %) patients had the neck of femur fracture, 31(14.8%) had osteoarthritis while 28(13.3%) had avascular
necrosis. Post-surgery complications included, wound infection, surgical site haematoma, NSTEMI, and only one
patient reported dislocation after use of dual mobility cup.
Conclusion: The dislocation rate which was the prime concern, has been reduced with the use of dual mobility
implant in total hip arthroplasty patients.
Keywords: Total hip replacement, Femoral head, Osteoarthritis, Arthroplasty, Wound infection.
(JPMA 71: S-87 [Suppl. 5]; 2021)

Introduction cup at our center.

Hip replacement has always being a challenging surgery Method
for orthopaedic surgeons. Regardless of awareness about
bone health, neck of femur fractures are on a rising trend in The project was started in January 2019, after obtaining
developed and developing countries.1 The implant to approval from the Ethical review committee of the Aga
choose is very difficult at times. Conventional total hip Khan University Hospital. Karachi. All patients who
arthroplasty (THA), bipolar hemiarthroplasty, and various underwent dual mobility cup for hip replacement were
other implants are available in femoral head replacement. selected from July 2016 to June 2018 regardless of age,
Amongst so many implants Dr. G. Bousquet came up with gender and pre-operative diagnosis.
a dual mobility implant.2 It has two articulation surfaces; The patients who were initially operated outside AKUH were
one is between the shell and the polyethylene (external excluded from the study. Since it was an audit, the patient's
bearing) and between the polyethylene and the femoral data was collected retrospectively (July 2016 to June 2018),
head (internal bearing). Movement occurs at the inner their medical records were checked and a proforma was
bearing; the outer bearing only moves at extremes of filled. The proforma had questions regarding age, gender
motion.3,4 Dual mobility is used for increased range of pre-operative diagnosis of the patients, ambulation, and
movement (ROM) and this implant specifically has reduced Hip Harris score before surgery (except the patient who had
the risk of dislocation.4 At various times hemiarthroplasty trauma), and their course was followed in the post-op clinic
has been preferred due to lesser dislocation rate compared and Harris hip score was retrieved from their files as it had
to total hip arthroplasty, However, THA has been shown to been noted on follow up visits.
provide better functional outcomes, lower rate of
reoperations, and less pain in some studies.1,5 The collected data was analysed using Statistical Package
for Social Sciences (SPSS, Inc, Chicago, IL, USA) version 21.
The purpose of this study was to determine the functional Descriptive analyses was done for all quantitative
outcomes of total hip arthroplasty with a dual mobility variables such as age, mean scores, follow up time, and
frequencies were calculated for all qualitative variables
Aga Khan University Hospital, Karachi, Pakistan. such as complication, indications of surgery, and weight
Correspondence: Javeria Saeed. Email: javeria.saeed@aku.edu bearing status.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-88
Results (6%) were on non-weight bearing ambulation and were
allowed ambulation on the first follow up. The mean pre-op
The total number of patients was 210 with 114 females
Harris score was 33.7±7.6 [range (20-45)] while the post-op
(54.3%) and 96 (45.7%) males. The mean age of the patients
score improved with a mean of 75.9±5.34 [range (70-92)].
was 59.14±15.64 years and maximum age was 90 years.
The maximum follow up of patients was 2±0.495 years with
Bilateral hip pathology was present in 22 patients and 188
a minimum of 1 year. Only 5 patients were lost to follow up.
had unilateral lesions. The mean postoperative hospital
stay was 5.91±3.9 days. Indications for surgery included, Discussion
neck of femur fractures in 83, osteoarthritis of the hip in 30
and 28 had Avascular necrosis (Table-1). Total 11 patients Hip replacement has always been a challenge to orthopaedic
had post-surgery complications which also included non- surgeons. Various implants are available for hemiarthroplasty
surgical complications in one patient who had dislocation and total hip arthroplasties. The choice of the implant itself
of the replaced Hip joints. Close reduction was done in 3 has to be a topic for debate over the past few decades. Dual
and one had to be taken to the operating room. Infection, mobility was introduced in 1970 and since then it has been
surgical site haematoma and implant failure were the main very popular amongst orthopaedic surgeons. It has gained
complications reported. Only one patient had the non- popularity due to dual articulating surfaces which has given
surgical complication of NSTEMI (Figure-1). None of the the patient added advantage which the single articulation
patients had aseptic loosening and implant breakage. A implants failed to provide. Dual mobility implant is famous
total of 195 (94.9%) patients were discharged with full due to reduced risk of dislocation, less impingement (Figure-
weight-bearing, 3 (1.4%) on partial weight-bearing, and 12 2), lower friction and lower wear, Increase range of motion
and Intra-prosthetic dissociation.3,6-8
Table-1: Total hip arthroplasty indications of surgery.
On the contrary, if a dislocation occurs, it is extremely difficult
Indication of Surgery to reduce using closed techniques. Furthermore, dual
Indication Number of patients % mobility cups lack screw holes. As with all monolithic cups,
the inability both to visualize the acetabula floor during
Neck of femur fracture 83 39.5 impaction and to use screws, may compromise fixation.3
Osteoarthritis 31 14.8 Various studies have compared dual mobility cup for total hip
Avascular necrosis (AVN) 28 13.3 replacement with other implants. Conventional THA rates of
Dynamic dysplasia of hip joint (DDH) 14 6.7
dislocation ranging from 1.9% to 5.8%.9-12 The dislocation
Pathological fracture 10 4.8
Infected hip implant 10 4.9
rate of conventional THA in revision surgeries are as high as
Austin Moore failure 6 2.9 21%.13 When compared to a bipolar hemiarthroplasty, dual
Rheumatoid arthritis 5 2.4 mobility has a reduced dislocation rate.14 Dual mobility has
Septic arthritis 2 1.0 reduced the possibility of acetabular erosion related to a
Others 16 8.4 bipolar hemiarthroplasty. Bensen et.al compared dislocation
rates and the difference was significant.
This study determined the dislocation
rate of Bipolar to be 14.6% and Dual
mobility to be 4.57%.14 In our study
dislocation rate was 0.5%. In the study
by Langlais et. al, dual mobility cup
showed a dislocation rate of 1.1% and
infection rate of 2.35%.15 Our wound
infection rate was 2.9%. Guyen et. al had
a dislocation rate of 5.5% and infection
rate of 5.5%.16 Philippot et.al had a
dislocation rate of 3.7%. In cases of
revision due to infection the dislocation
rate was 9% and in case of instability
arthroplasty revision 0%.17 In the latest
study published by Justinas et.al, 2%
required a re-surgery due to dislocation
compared to other implants out of
Figure-1: Post-surgery complications. NSTEMI: Non ST Elevated Myocardial Infarction which 9% required re-surgery due to

J Pak Med Assoc (Suppl. 5)

S-89 34th International Pak OrthoCon Conference 2021

Conflict of Interest: None.

Funding Disclosure: None.

References
1. Jobory A, Kärrholm J, Overgaard S, Pedersen AB, Hallan G,
Gjertsen J-E, et al. Reduced Revision Risk for Dual-Mobility Cup in
Total Hip Replacement Due to Hip Fracture: A Matched-Pair
Analysis of 9,040 Cases from the Nordic Arthroplasty Register
Association (NARA). J Bone Joint Surg 2019;101:1278-85.
2. Bousquet G, Gazielly D, Girardin P, Debiesse J, Relave M, Israeli
A. The ceramic coated cementless total hip arthroplasty. Basic
concepts and surgical technique. J Orthop Surg Tech.
1985;1:15-28.
3. Matsen Ko L, Hozack W, editor. The dual mobility cup: What
problems does it solve? Bone Jt. J. 2016; 98-B:60-63.
4. Rister DW, Lee SJ, Lee J. Lateralized dual-mobility assembly.
Google Patents; 2019.
Figure-2: Post-op X-ray of right hip total hip arthroplasty with dual mobility cup. 5. Kim YT, Yoo J-H, Kim MK, Kim S, Hwang J. Dual mobility hip
arthroplasty provides better outcomes compared to
hemiarthroplasty for displaced femoral neck fractures: a
dislocation.18 In our study, 0.48% hip-operated patients had
retrospective comparative clinical study. Int. Orthop2018;42:1241-6.
to be taken to the operating room and 1.43% were reduced 6. Plummer DR, Haughom BD, Della Valle CJ. Dual mobility in total
manually under sedation. Many countries have increased the hip arthroplasty. Orthop Clin North Am. 2014;45:1-8.
number of dual mobility cups like Lebanon has 88% steady 7. Philippot R, Boyer B, Farizon F. Intraprosthetic dislocation: a
and linear increase in usage of dual mobility cups from the specific complication of the dual-mobility system. Clin. Orthop.
Relat. Res.2013;471:965-970
year 2013-2017.13 In 2017 more than 60% of all total hip 8. Lachiewicz PF, Watters TS. The use of dual-mobility components
replacement implants were dual mobility cups. The same in total hip arthroplasty. J Am Acad Orthop Surg. 2012;20:481-6.
trend has been noted in France16 and the United States of 9. Lewinnek GE, Lewis J, Tarr R, Compere C, Zimmerman J.
America.6 Chahine et.al shows the mean Hip Harris hip score Dislocations after total hip-replacement arthroplasties. J Bone
Joint Surg Am. 1978;60:217-20.
to be as high as 94.8 to 98.713 and our post-operative mean 10. Meek RM, Allan D, McPhillips G, Kerr L, Howie C. Epidemiology of
Harris hip score was 75.9 which is a fair score as per criteria. dislocation after total hip arthroplasty. Clin. Orthop. Relat. Res.
The reason for this figure could be some of the complications 2006;447:9-18.
that are reported and sometimes patients do not respond 11. Sanchez-Sotelo J, Berry DJ. Epidemiology of instability after total
hip replacement. Orthop. Clin. North Am.. 2001;32:543-52.
properly in clinic. 12. Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J
Bone Joint Surg. 1982;64:1295-306.
Conclusion 13. Assi C, Mansour J, Caton J, Samaha C, Yammine K, Yammine K.
Total hip arthroplasty evolution of the use of dual mobility cups in
Overall, the Dual mobility cup is better in terms of dislocation lebanon. J Med Liban. 2018;66:233.
compared to other implants used for hip arthroplasties. The 14. Bensen AS, Jakobsen T, Krarup N. Dual mobility cup reduces
mean Harris hip score also showed fair results after surgery dislocation and re-operation when used to treat displaced
and patients' ambulation was also improved. femoral neck fractures.Int.Orthop 2014;38:1241-5.
15. Langlais FL, Ropars M, Gaucher F, Musset T, Chaix O. Dual mobility
Recommendations cemented cups have low dislocation rates in THA revisions. Clin.
Orthop. Relat. Res.2008;466:389-95.
We recommend a 5 years follow up prospective study to 16. Guyen O, Pibarot V, Vaz G, Chevillotte C, Béjui-Hugues J. Use of a
be conducted in our region to explain early and late dual mobility socket to manage total hip arthroplasty instability.
Clin. Orthop. Relat. Res. 2009;467:465-72.
functional scores and outcomes of total hip arthroplasty 17. Philippot R, Adam P, Reckhaus M, Delangle F, Verdot F-X, Curvale
with the dual mobility cup. G, et al. Prevention of dislocation in total hip revision surgery
using a dual mobility design. Orthop Traumatol Surg Res .
Limitations 2009;95:407-13.
18. Stucinskas J, Kalvaitis T, Smailys A, Robertsson O, Tarasevicius S.
The limitations of our study was the retrospective data Comparison of dual mobility cup and other surgical construts
collection which could have flaws in the figures retrieved. used for three hundred and sixty two first time hip revisions due
to recurrent dislocations: five year results from Lithuanian
Disclaimer: None. arthroplasty register. Int. Orthop. 2018;42:1015-20.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-90

CASE SERIES
Radiological outcome of acute subtrochanteric fractures fixed with Recon
intramedullary nailing, a retrospective case series
Shah Fahad, Ahmed Abdul Habib, Ashmal Sami, Haroon ur Rashid
Abstract When considering the management of subtrochanteric
fractures, surgeons are faced with multiple challenges
The aim of this study was to evaluate the radiological
because of the inherent complexity and instability of the
outcome of acute subtrochanteric fractures fixed with
region and the focus of the muscles in the region that act
Recon intramedullary nail.
on the proximal and distal fragments. The short proximal
Charts of 48 patients with subtrochanteric fractures fragments which are deformed by the hip flexors and
treated with Recon IM Nailing from January 2014 to adductors pose an additional challenge and make precise
December 2015 were retrospectively reviewed. Thirty reduction and fixation difficult. Owing to these
(62%) patients were male and 18 (38%) were female. The challenges, the outcome of these fractures has not been
mean age was 52±7 years. The most common mechanism very good with a high rate of non-union, malunion and
of injury was road traffic accident (RTA) which was in 27 fixation failure.3,4
(56%) patients followed by a history of fall in 18 (38%)
Over time, multiple modalities for the treatment of
patients. Mean Radiological Healing time was 14±2
subtrochanteric fractures have been devised, each with
weeks. The mean duration of surgery was 2.27±1 hours
its pros and cons. Non-operative management (traction)
while Mean Hospital Stay was 5±2 days. Four patients had
has by far produced the worst results with complications
delayed fracture healing. This study suggests that
including but not limited to shortening of the femur and
intramedullary nailing in Recon Mode is a reliable and
varus malformation.5 Operative management options
effective device especially for subtrochanteric fractures,
include the following: plating, AO angled blade,
leading to a high rate of bone union and minimal intramedullary (IM) nail, Enders nail, Zickel nail, hip screw,
complications. and most recently the reconstruction nail.5 Each of these
Keywords: Recon nail, Subtrochanteric fracture, Healing, operative interventions has been reported to have its own
Non-union. set of complications including, varus malformation,
shortening, lengthening, mechanical failure, protrusion of
Introduction various nails into the joint, nonunion and malunion.6-8
The subtrochanteric zone of the femur is the area that The ideal device for the sustainable treatment of
extends from the lesser trochanter to a point 5 cm distally. subtrochanteric fractures would be one that can
Subtrochanteric fractures are relatively less common effectively stabilize and reduce the fracture and prevent
compared to other fractures in this region, with a major complications from arising e.g. shaft medialization,
prevalence of about 7-15% of all hip fractures.1 These as well as rotation and varus angulation of the proximal
fractures exhibit a bimodal incidence, occurring in two fragment. Various biomechanical studies done in this
age groups: the young population and the elderly. In the particular area have suggested that among the various
young, the main cause of fracture is high energy trauma operative options available for the treatment of such
and road traffic accidents whereas, in the elderly fractures, intramedullary devices have proven to be the
osteopenic population, low energy ground-level falls are most feasible option in providing a stable construct for
commonly associated with subtrochanteric fractures. the subtrochanteric fractures.9-13
Histologically, the subtrochanteric area is primarily Intramedullary nailing is preferred as the implant of
composed of hard cortical bone with poor vascularity and choice in this regard since it is as close to the ideal implant
is under appreciable tensile stress biomechanically, owing as possible, with a short lever arm on the proximal
to the multiple shearing forces applied by the muscles in fixation, it has load shearing characteristics along with
that region.2 excellent rotational and axial control which allows for
early weight-bearing. It also allows for the preservation of
Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan. the local histology of the region since it does not damage
Correspondence: Shah Fahad. Email: shah.fahad@aku.edu the periosteum of the bone and the surrounding soft

J Pak Med Assoc (Suppl. 5)

S-91 34th International Pak OrthoCon Conference 2021

tissue extensively which makes it superior from the leg were also noted. Statistical analysis was performed
surgical point of view. using SPSS version 25.1. Parametric variables were
analyzed using z-test and displayed as mean ± standard
The Intramedullary nail in Recon Mode is a unique deviation. Non-parametric categorical variables were
intramedullary device with proximal fixation by two analyzed using chi square and displayed as frequency
screws placed through the nail into the femoral head. The percentages.
primary indication for this specialized intramedullary
device is high subtrochanteric fractures. It produces Results
favourable results in the long run and also prevents
The mean age of the patients was 52±7 years. There were
insufficiency fractures that are a common problem in
30 (62%) males while 18 (38%) were females. The most
these fractures.
common mechanism of injury was road traffic accident,
Material and Methods seen in 27(56%) participants followed by fall injuries
18(38%) with ground-level falls seen in the elderly and fall
The research was conducted at Aga Khan University from a height seen in the younger patients. A small
Hospital, Karachi in January-March 2017. This fraction of these injuries was due to firearms 3(6%).
retrospective case series comprised of 48 patients with Among the 48 participants of this series, pre-existing co-
acute subtrochanteric fractures treated with Recon morbidities were seen in 30 (62%) whereas 18(38%)
Intramedullary Nail at the Aga Khan University Hospital participants had no prior co-morbidities. The most
from January 2014 to December 2015. The medical common co-morbid being Hypertension followed by
records of all 48 patients were reviewed for age, gender, Type 2 Diabetes, Ischaemic Heart Disease, and Chronic
mechanism of injury, type of fracture, pre-existing Obstructive Pulmonary Disease, respectively. The baseline
comorbidities, mean duration of surgery, complications, ambulation status of the 48 patients revealed that
duration of hospital stay and healing time after surgery. 45(94%) were independent community ambulant and
The inclusion criteria for the study were all acute 3(6%) were on community ambulant support.
subtrochanteric fractures managed with Intramedullary
Recon Mode Nail, regardless of race, age, gender, etc. All The mean duration of presentation to surgery was 13±4
cases presenting with fractures other than hours. The mean operative time was 2.27±1 hours. The
subtrochanteric fractures, pathological subtrochanteric mean hospital stay was 5±2 days and the mean
fractures, and cases of nonunion during the same period radiological healing time was 14±2 weeks. All 48 cases
were excluded from the study. Postoperative plain were followed up by clinical and radiological examination
radiographs were reviewed for healing (Figure). External and none were lost to follow-up.
and internal rotation deformities and shortening of the
The weight-bearing status of the patients following
discharge revealed a full weight-
bearing in 40(83%) patients whereas
8(16%) patients were able to exhibit
only partial weight-bearing with
support. These 8 patients had been
involved in concomitant major injuries
along with subtrochanteric fracture
which hindered the healing process
and led to partial weight-bearing.
The only complication arising from this
method of reduction and fixation was
delayed union seen in 4(12.75%) cases
out of 48. Delayed union, is defined as a
union not having occurred even after
12 weeks post index surgery. These
patients were followed up until twelve
weeks and fracture lines were still
visualized on their plain radiographs.
Figure: Preoperative radiograph showing femur subtrochanteric fracture (A), postoperative radiographs showing Corrective dynamization of the
fixation of femur subtrochanteric fracture with recon nail (B), follow up radiographs showing union at fracture site (C). intramedullary nail had to be done in

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-92
these patients. The delayed union cases were victims of compared to extramedullary methods because it allows
high energy trauma and had other associated injuries. We for the preservation of surrounding tissue while operating
did not encounter implant failure and malunion. since it does not require a large incision to be made and
also prevents periosteal stripping which is seen with
Discussion extramedullary fixation. It is also reported to allow for
Subtrochanteric fractures of the femur pose a special earlier weight-bearing which improves the quality of life
challenge in orthopaedic traumatology with regards to of the patient.
treatment options and prognosis. This is because of the
Recon nail is an intramedullary device that is a unique
high rate of complications associated with their
treatment option for these complicated fractures that
management due to the inherent complexity and
allows placement of two interlocking screws into the
instability of patterns.3,4
femur head and distally in femur metaphysis. These
The deforming forces in this area are the pull of muscles: features make it possible to treat the subtrochanteric
the hip abductors; short external rotators; and iliopsoas, fractures that have medial comminution and fractures
which pull the proximal segment into a flexed, abducted with intertrochanteric extension to be treated with closed
and externally rotated position. This results in an overall intramedullary technique. Intramedullary nail in Recon
varus and apex anterior deformity at the fracture site. This Mode that has shown promising results in these fractures,
deformity makes closed reduction difficult. This causes a provide stable fixation, allowing for earlier weight-
high concentration of stresses and deforming forces in bearing and lowers the risk of insufficiency fractures,
this portion of the bone. The subtrochanteric area is made which improves the quality of life of the patient. However,
of mainly cortical bone with diminished blood flow to this the use of this device in fractures associated with high
region when compared to the metaphyseal bone of the energy trauma has not shown promising results.
intertrochanteric region. These factors contribute to the
This retrospective study was compared to the work done
complex nature of managing these subtrochanteric
previously at different institutes internationally in the
fractures as has been made evident throughout the
same field (Table). Broos et al did a study in 2002 with a
orthopaedic literature.
larger sample size than ours (80 patients) and calculated
As far as treatment options available are concerned, the an overall complication rate with the use of
conservative non-operative method of treating these intramedullary nailing in recon mode to be 21%. The
fractures has taken a backseat due to the highest rate of cases were categorized into non-union (21%) and implant
complications and poor outcomes.5 As far as operative failure (21%) which required intervention in 9% of the
management of these fractures is concerned, there has cases.14 Datir et al conducted a study in 2004 with a
been ongoing discourse over which method sample size of 55 patients who presented with
(intramedullary or extramedullary fixation) is more subtrochanteric fractures and were treated with
effective in terms of immediate healing time and later intramedullary nailing and his complication rate
complications. amounted to 21%, too. These were cases of non-union
(21%) and implant failure (21%) and required corrective
Multiple studies done over time have been in support of surgery in 13% of the cases.15 A recent study done at Aga
intramedullary fixation methods being superior to Khan University Hospital with a sample size of 50 patients
extramedullary fixation. This preference arises from the with subtrochanteric fractures had a complication rate of
fact that these intramedullary devices are thought to 26% cases.16
provide a shorter lever arm that transmits load medially
and provides resistance to head collapse into varus as The complications of this device include mechanical
compared to an externally placed plate with screws, complications like screws cut out, implant breakage. We
therefore, being biomechanically superior.9-13 From the did not encounter these complications in our study. The
surgical point of view, intramedullary fixation is superior biological complications include malunion, non-union

Table: Comparative analysis between different retrospective case series on use of IM in recon mode use for subtrochanteric fractures.

Study N Complication rate Nonunion Implant failure Delayed union Revision

1. Broos et al 200214 80 21% 21% 21% - 9%

2. Datir et al 200415 55 21% 21% 21% - 13%
3. Current study 48 12.75% - - 8.33% 8.33%

J Pak Med Assoc (Suppl. 5)

S-93 34th International Pak OrthoCon Conference 2021

and delayed union. In our study, the only complicated we References

encounter was delayed union in 4(12.75 %) cases. All 1. Rohilla R, Singh R, Magu NK, Siwach RC, Sangwan SS. Mini-incision
these 4 cases had a history of high energy trauma dynamic condylar screw fixation for comminuted subtrochanteric
associated with the fracture. These cases were hip fractures. J Orthop Surg (Hong Kong) [Internet]. 2008 [cited
successfully treated with corrective dynamization. Varus 2020 Feb 3];16:150-5. Available from URL:
http://www.ncbi.nlm.nih.gov/pubmed/18725662
malalignment is another complication; no cases of
2. Oh CW, Kim JJ, Byun YS, Oh JK, Kim JW, Kim SY, et al. Minimally
displacement or malalignment of the neck fracture were invasive plate osteosynthesis of subtrochanteric femur fractures
met. We conclude that, provided optimal reduction and with a locking plate: A prospective series of 20 fractures. Arch
adequate compression are achieved intra-operatively, a Orthop Trauma Surg. 2009;129:1659-65.
single proximal screw may suffice for the fixation of the 3. Haidukewych GJ, Berry DJ. Nonunion of Fractures of the
Subtrochanteric Region of the Femur. Clin Orthop Relat Res.
fracture. Lippincott Williams and Wilkins; 2004 pp185-8.
4. Parker MJ, Dutta BK, Sivaji C, Pryor GA. Subtrochanteric fractures
The current study on radiological outcomes of treating of the femur. Injury [Internet]. 1997 [cited 2020 Feb 3];28:91-5.
acute subtrochanteric fractures with the intramedullary Available from: http://www.ncbi.nlm.nih.gov/pubmed/9205572
nail in recon mode, we had a larger sample size of 48 5. Zickel RE. Subtrochanteric femoral fractures. Orthop Clin North
patients and this time, our complication rates were lower, Am. 1980;11:555-68.
i.e. 12.75%. The complications were seen in the form of 6. Velasco RU, Comfort TH. Analysis of treatment problems in
subtrochanteric fractures of the femur. J Trauma - Inj Infect Crit
delayed union (8.33%) and the cases with delayed union Care. 1978;18:513-23.
all had a history of high energy trauma associated with 7. Zickel RE. An intramedullary fixation device for the proximal part
the fracture. Corrective dynamization of the nail had to be of the femur. Nine years' experience. J Bone Joint Surg Am
performed in these patients for a full recovery. Except for [Internet]. 1976 [cited 2020 Feb 3];58:866-72. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/956232
8 out of 40 patients, all had full weight-bearing status 8. Alho A, Ekeland A, Strømsfe K. Subtrochanteric femoral fractures
after being discharged. Partial weight-bearing was seen in treated with locked intramedullary nails: Experience from 31
8 patients due to multiple other injuries that these cases. Acta Orthop. Informa Healthcare; 1991;62:573-6.
patients had, other than subtrochanteric fractures. In the 9. Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral
fractures: a biomechanical study to compare intramedullary and
previous studies, the delayed union was not evaluated as
extramedullary fixation. Injury. 1994;25:99-104.
a parameter of healing which was focused on in our study. 10. Kraemer WJ, Hearn TC, Powell JN, Mahomed N. Fixation of
The major limitation of this study is its retrospective segmental subtrochanteric fractures: A biomechanical study. Clin
design. Orthop Relat Res. Springer New York LLC; 1996. p. 71-9.
11. Liu P, Wu X, Shi H, Liu R, Shu H, Gong J, et al. Intramedullary versus
Conclusion extramedullary fixation in the management of subtrochanteric
femur fractures: a meta-analysis. Clin Interv Aging [Internet]. 2015
In summary, this study suggests that the use of [cited 2020 Feb 3];10:803-11. Available from URL:
Intramedullary Nail in Recon Mode is a viable treatment http://www.ncbi.nlm.nih.gov/pubmed/25960644
option for subtrochanteric fractures with a high success 12. Mahomed N, Harrington I, Kellam J, Maistrelli G, Hearn T, Vroemen
J. Biomechanical analysis of the gamma nail and sliding hip screw.
rate of bone union and a reduced rate of complications Clin Orthop Relat Res. Springer New York LLC; 1994 pp 280-8.
mainly delayed union. In contrast with other studies, the 13. Roberts CS, Nawab A, Wang M, Voor MJ, Seligson D. Second
complication rate was lower, this indicates that other generation intramedullary nailing of subtrochanteric femur
pathophysiological, demographic or operant reasons fractures: A biomechanical study of fracture site motion. J Orthop
Trauma. 2002;16:231-8.
could be the cause of the complications. Further studies
14. Broos PLO, Reynders P. The use of the unreamed AO femoral
are required to evaluate the effectiveness of this technique intramedullary nail with spiral blade in nonpathologic fractures of
in treating subtrochanteric fractures and to compare its the femur: experiences with eighty consecutive cases. J Orthop
effectiveness with other modalities of treatment. Trauma. LWW; 2002;16:150-4.
15. Datir SP, Bedi GS, Curwen CHM. Unreamed femoral nail with spiral
Disclaimer: None. blade in subtrochanteric fractures: experience of 55 cases. Injury.
Elsevier; 2004;35:191-5.
Conflicts of Interest: None. 16. Zubairi A, Rashid RH, Zahid M, Hashmi PM, Noordin S. Proximal
Femur Locking Plate for Sub-Trochanteric Femur Fractures:
Funding Disclosure: None. Factors Associated with Failure. Open Orthop J. 2017;11:1058-65.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-94

CASE SERIES
Clinical and functional outcomes following platelet rich plasma in the
management of knee osteoarthritis: A case series in a tertiary care hospital
Rahat Zahoor Moton,1 Zohaib Nawaz,2 Muhammad Latif,3 Muhammad Azeem Akhund,4 Zohaib Khan5
Abstract most debilitating diseases, affecting more than one-third
of the elderly population over the age of 65, with
Objective: To clinically assess the efficacy of Platelet rich
worldwide figures reaching more than 100 million
Plasma (PRP) in improving the functional movement in
people.1 The incidence of knee OA has risen dramatically
knee osteoarthritis.
in recent decades and continues to grow, owing in part
Methods: This prospective case series, on 89 patients, to a spike in the incidence of obesity and other risk
was studied in Sindh Rangers Hospital, Karachi, Pakistan factors.2 Increasing age, past knee fractures and elevated
from 1st October 2018 to 31st March 2019. The analysis BMI all tend to accelerate the mechanical tension and
involved all patients aged 30-65 years diagnosed with emerge as the significant risk factors for the
grade 1, 2 and 3 arthritis. PRP was administered in three development of OA.3 Unusual behaviour patterns such as
doses one month apart, and patients were evaluated for prolonged standing, lifting of heavy objects and certain
outcome measures after the third month of the third dose competitive sports are also implicated in the
of PRP. To measure functional improvement in knee development of OA due to more frequent fractures
osteoarthritis, the range of motion (ROM), McMaster culminating in defects of the cartilage.4
University Osteoarthritis index (WOMAC), Western Physical inactivity is also a major contributor to the rising
Ontario, and Visual analogue scale (VAS) were used. incidence of OA, raising the risk of knee injury due to less
robust and weakened joints. However, as opposed to
Results: PRP was infused into 89 patients, with a mean
past knee injuries, weakening of the knee extensor
age of 61.24±8.92 years. The average pre-treatment
muscles seems to be a minor risk factor.5 OA can have a
WOMAC score was 37.0 ±2.9, and it was lowered to 18.8±
detrimental effect on people's mental health in addition
5.2 after PRP (p<0.02). The pre-treatment VAS was 8.42
to their physical health. The Osteoarthritis Initiative (OAI)
±0.84, and it was reduced to 4.91±2.12, indicating mild to
analysis found that people with lower limb OA have a
moderate pain. Our PRP therapy was appreciated by 63 higher risk of experiencing psychological distress than
(70.07%) patients, while 17 (19.1%) were only partly those who did not have the condition. As a consequence
satisfied. However, 9 (10.1%) patients were dissatisfied. of this mental and emotional anguish, there is further
Conclusion: The results of this case series showed that prohibition of daily physical activity which ultimately
the use of PRP injections for treating osteoarthritis (grade leads to further knee discomfort and weight gain.6 There
1 to 3) proved to be successful in terms of improving is also a mounting evidence that OA is a contributing
functional outcomes and reducing pain intensity. factor for the occurrence of cardiovascular disease.
According to a meta-analysis, the likelihood of
Keywords: Osteoarthritis, Platelet rich plasma, Knee pain, myocardial infarction is tremendously enhanced in OA
Orthopaedics, Regenerative medicine. and other forms of arthritis.7 Since OA is a debilitating
condition with pain as the primary symptom, pain
Introduction control and dietary changes are ineffective, and the
Knee osteoarthritis (OA), a progressive degenerative disease is complicated to treat in situations where
disease of the knee, is caused by the gradual traditional symptomatic therapy has failed to improve
deterioration of articular cartilage. It is one of the top five quality of life, joint replacement surgery is the only
alternative remaining, rendering knee arthroplasty in OA
1Department
a breakthrough procedure.5 However, recent therapeutic
of Orthopaedics, Sindh Rangers Hospital, Karachi, 2Department
interventions such as intra-articular corticosteroid
of Orthopaedics, Aga Khan University Hospital, Karachi, 3Department of injections, hyaluronic acid injections and platelet-rich
Orthopaedic, Hamdard University, Karachi, 4Department of Orthopaedics, plasma (PRP), can also help to delay the progression of
Peoples University of Medical & Health Science Nawabshah, Sindh, the disease.
5Department of Orthopaedics, AO Clinic, Karachi, Pakistan.

Correspondence: Rahat Zahoor Moton. Email: Rahat_moton@hotmail.com With recent advancements in the treatment modalities,

J Pak Med Assoc (Suppl. 5)

S-95 34th International Pak OrthoCon Conference 2021

treatment of OA with the application of PRP has boosted, joint. After the injection, a small bandage was applied
and its use now has been endorsed by mounting without compression. All procedures were executed by a
evidence. Obtained from autologous blood, it aids in single researcher. PRP was given in three doses one
tissue regeneration and triggers the healing process.8 month apart and after the 3rd dose patients were
PRP can facilitate a favourable environment for joint assessed for outcome measures.
tissue healing, according to preclinical evidence.9
Prior to the PRP administration, Erythrocyte
Nonetheless, despite recent reviews showing positive
Sedimentation Rate (ESR) and C - reactive protein (CRP)
outcomes the use of PRP for the treatment of active
levels were measured in selected PRP patients (before
patients is still very scant, and more research is required
and after). The purpose of doing these two
to record potentials and shortcomings in terms of clinical
investigations prior to administration of PRP was to
progress in this population.10,11 In order to clinically
exclude other inflammatory conditions such as
assess the efficacy of PRP, we studied this series of
Rheumatoid Arthritis (RA). Patients follow up was done
patients to determine the functional improvement in
after the third month of receiving the third dose of PRP.
osteoarthritis knee treated with platelet-rich plasma in
The range of motion (ROM),13 Western Ontario and
Karachi, Pakistan.
McMaster University Osteoarthritis index (WOMAC)14
Patients and Methods and Visual Analogue Scale (VAS)15 was used to assess
functional change in knee osteoarthritis. WOMAC was
This prospective case series was conducted in Sindh
used to assess stiffness, discomfort, and normal physical
Rangers Hospital, Karachi Pakistan from 1st October 2018
exercise before and after treatment, while Visual
to 31st March 2019. The study was approved by
Analogue Scale (VAS) was used to measure pain before
Institutional Review Board of Sindh Rangers Hospital and
and after therapy. Patient satisfaction was assessed by
all participants provided the written informed consent.
simply asking as to "how much are you satisfied with
The study duration was 6 months from 1st October 2018
your treatment?" with options satisfied, partially
to 31st March 2019.
satisfied and not satisfied.
Patients were recruited based on the following The sample size was determined by estimating a
inclusion requirements: Patients between the ages of population proportion by WHO calculator16 with
30-65 years with bilateral knee osteoarthritis, both confidence interval of 95%, absolute precision 0.05 with
gender, positive history with pain/swelling (> 4 anticipated population proportion. The calculated sample
months), degenerative finding (X-rays) of joints without size was 93. Due to the loss to follow up and denial of
significant deformity and Kellgren Lawrence grading consent from patients, the selected study population
classification12 of grade 1, 2 and 3. However, excluded reduced to 89. SPSS v. 21 was used to analyse the data.
were patients over the age of 65 years, those who did Frequencies and percentages were included to express
not provide the informed consent, those with Diabetes descriptive figures. The significance level was determined
Mellitus, a history of knee articular, collagen vascular using a paired t-test. P>0.05 was regarded as statistically
disorder, malignant disorder, active infection/ wound significant.
on knee or nearby area and taking immunosuppressive
medications, anti-platelets disorder/ anti-coagulant Results
medication used within the last 10 days, NSAID used
A total of 89 patients with the mean age of 61.24±8.92
within the last 2 days, or systemic corticosteroids used
years were injected PRP. Overall, 37 (41.6%) patients were
within the last 3 months. Patients with genu valgum
male and 52 (58.4%) were females with 65 (73%)
(knee > 20 degree), Hepatitis B, C, and HIV/AIDS were
belonging to Urban and 24 (27%) to rural regions of the
also excluded.
country. Other demographic variables like weight and
Treatment and Evaluation: PRP was prepared by Arthrex BMI are shown in the Table.
ACP® (Autologous conditioned plasma). The unique
There was no statistically significant difference between
Arthrex ACP® has double syringe system for non-
inflammatory markers (ESR and CRP) of pre and post PRP
homologous fluids specifically platelet and growth factor
with P value = 0.32. The laboratory findings are shown in
enriched autologous conditioned plasma. The skin was
Table. According to KL grading, 28 patients had grade 1
cleaned and sterilized properly and the patella was
OA, 39 had grade 2 and 16 patients were in grade 3.
palpated with gloved hands. A 23-gauge needle was used
and injection site was approached superiolaterally in the The mean flexion for right knee was 110.23±4.5 degrees
supine position. 3 mL of PRP was injected in each knee and 112.35±3.4 degrees for left knee before PRP injection,

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-96
Table: Baseline characteristics of PRP population. have been made in the field of orthopaedics since
decades. Conservative or non-surgical treatment
Baseline All patients Male Female modalities have been introduced for OA.
characteristics (N = 89) N(%) = 37 (41.6) N(%)=52 (58.4)
Orthobiologics or regenerative medicine is one of the
Age (years) latest and most advanced method for OA therapy which
Mean ± SD 61.24 ± 8.92 60.17 ± 10.82 60.16 ± 10.61 is attracting a lot of attention nowadays. Among these
Median (range) 61 (41) 61(72) 61(72) treatment modalities, PRP injections are gaining
Weight (kg) popularity day by day.17 However, there is still lack of
Mean 81.60 ± 13.92 80.38 ± 15.82 80.26± 15.63 authentic evidence about improvement of the
Median (range) 80.5 (70) 80.25 (102.08) 80.25 (102.08) functional and clinical outcomes after PRP treatment. In
Regions N(%) order to find out the efficacy and effectiveness of PRP
Urban 65 (73%) 24 (37%) 41 (63%)
injection in OA, we conducted this study which showed
Rural 24 (27%) 13 (54%) 11 (46%)
BMI (kg/m2)
significant improvement in WOMAC and VAS scores
Mean 34.35 ± 6.18 33.72± 6.77 33.82± 6.78 after 3 months following PRP. Filardo G et al. 18
Median (range) 33.5 (28) 33 (45.42) 33 (45.42) conducted a study to evaluate the efficacy of PRP for
knee degenerative cartilage lesions. They included 91
patients and reported that PRP injection reduced pain
ESR (mm/hour) Before After Before After and discomfort at the knee joints and improved
functional outcomes. These findings are consistent with
Mean 28.61± 19.31 21.06 ± 16.70 22.81±7.8 23.68 ± 23.57 24.81±21.4 the results of our study. Sampson S et al.19 conducted a
CRP (mg/L)
single-center prospective study in which they evaluated
Mean 4.21±2.1 4.2±1.1 3.8±1.6 4.3±0.81 4.1±0.91
14 patients with PRP for primary and secondary knee
which improved to 119.35±1.5 degrees in right knee and OA. They had also measured cartilage thickness by
118.20±2 degrees in left knee joint. However, there was ultrasound. According to their findings, pain intensity
no statistical difference found between pre and post PRP reduced in all patients however femoral articular
flexion at knee joint (P=0.25). The overall pre-treatment cartilage thickness increased after 6 months of PRP
WOMAC score was 37.0±2.9 and it reduced after PRP to injection on ultrasound at the lateral condyle, medial
18.8±5.2. Statistically significant improvement was noted condyle, and intercondylar notch. In our study we did
in WOMAC score after PRP in all OA grades with P value= not perform any sonographic measurements of
0.02. cartilage, however pain intensity reduced in all of our
patients after PRP.
The pre -treatment VAS was 8.42±0.84 that indicated
severe pain. At 3 months follow up after PRP injection, In another study,20 effectiveness of PRP was evaluated in
VAS reduced to 4.91±2.12 which amounts to mild to 65 patients suffering from OA. Similar to our study, it
moderate pain. A total of 63 (70.07%) patients were reported good clinical and functional outcomes at knee
satisfied with the PRP treatment and 17 (19.1%) patients joints after PRP injection. This study also showed a
were partially satisfied. However, there were 9 (10.1%) statistically significant negative correlation between
patients who were not satisfied due to persisting pain and patient's age and PRP potential in VAS score and IKDC. In
no improvement in the symptoms. the current study, we only aimed to see clinical and
functional outcomes and did not predict or compare
Discussion variables with each other. Spaková T et al.21 conducted a
In this study there was significant improvement in comparative study to evaluate the effectiveness of PRP
WOMAC score among patients who received PRP and hyaluronic acid for knee arthritis. A total of 120
injection. The VAS also improved at three months patients with grade 1, 2 and 3 knee OA were enrolled
following PRP injection in all patients. Majority of our and divided into two groups. One group received three
patients were satisfied with PRP treatment. However, injections of PRP and the second group received three
among a total of 89 patients, 9 were not satisfied with the injections of hyaluronic acid. On comparing the
treatment. Our study shows improvement of functional functional outcomes, PRP group showed significantly
and clinical outcomes in 1,2 and 3 grades of OA. better results than hyaluronic acid group at 3 and 6
months after PRP injections. In the present study,
Osteoarthritis is a disease which significantly involves improvement in the symptoms were reported with
joints and has a great impact on the quality of life and better functional outcomes and reduced pain intensity.
mobility of an individuals. Many new advancements Another study was conducted to assess the outcome of

J Pak Med Assoc (Suppl. 5)

S-97 34th International Pak OrthoCon Conference 2021

intra-articular PRP injection for knee OA and also to Disclaimer: None.

evaluate the impact of cycling dosing of PRP on
Conflicts of Interest: None.
effectiveness of the treatment.22 They concluded that all
patients significantly (P-value< 0.005) improved from Funding Disclosure: None.
pre-treatment values. At 2 years follow up, the
functional score declined in both groups but remained References
better than pre-treatment scores with no significant 1. Bhatia D, Bejarano T, Novo M. Current interventions in the
difference between the two groups. However, patients management of knee osteoarthritis. J Pharm Bioallied
Sci.2013;5:30-8.
with two cycles showed higher mean values of mean 2. Wallace IJ, Worthington S, Felson DT, Jurmain RD, Wren KT,
scores. In our study, we also injected cyclic three doses Maijanen H, et al. Knee osteoarthritis has doubled in prevalence
of PRP at an interval of one month. Most of our patients since the mid-20th century. Proc Natl Acad Sci U S A.
2017;114:9332-6.
were satisfied with treatment and showed improvement
3. Vina ER, Kwoh CK. Epidemiology of osteoarthritis: literature
and mobility after 3 months following PRP. According to update.Curr Opin Rheumatol.. 2018;30:160-7.
the systematic reviews done by Khoshbin A et al.,23 intra- 4. Berenbaum F, Wallace IJ, Lieberman DE, Felson DT. Modern-day
articular PRP multi sequential knee injections improved environmental factors in the pathogenesis of osteoarthritis. Nat.
Rev. Rheumatol. 2018;14:674-681.
functional outcomes (WOMAC and IKDC) at 24 months 5. Hunter D.J., Bierma-Zeinstra S. Osteoarthritis. Lancet.
follow up. However, there was no benefit found 2019;393:1745-1759. doi: 10.1016/S0140-6736(19)30417-9.
between PRP and control group for other pain measures 6. Veronese N, Stubbs B, Solmi M,.SmithTO, Noale M, Cooper C et.al.
Association between lower limb osteoarthritis and incidence of
(visual analogue pain score) or over all patient
depressive symptoms: data from the osteoarthritis initiative. Age
satisfaction. Unlike the findings of this review, pain Ageing. 2017;46:470-476
intensity reduced in all our patient after 3 months of 7. Schieir O, Tosevski C, Glazier RH, et al. Incident myocardial
treatment and majority of them were over all satisfied infarction associated with major types of arthritis in the general
population: a systematic review and meta-analysis. Ann Rheum
but we did not have any comparison group. Dis. 2017;76:1396-
8. Smyth, NA, Haleem, AM, Ross, KA. Platelet-rich plasma may
Limitations improve osteochondral donor site healing in a rabbit model.
Cartilage. 2016; 7: 104-111.
There are certain limitations of this study. First, the 9. Altamura SA, Di Martino A, Andriolo L, Boffa A, Zaffagnini
presented study lacks a comparative group. We did not S,Cenacchi A, et al. Platelet-rich plasma for sport-active patients
compare our findings with any other treatment for OA. with knee osteoarthritis: limited return to sport. BioMed Research
International.2020; https://doi.org/10.1155/2020/8243865.
Therefore, it is difficult to check the superiority of PRP for
10. G. Filardo, E. Kon, A. Roffi, B. Di Matteo, M. L. Merli, and M.
OA management between other treatment options. The Marcacci, "Platelet-rich plasma: why intra-articular? A systematic
study reported results after 3 months of 3 cyclic doses of review of preclinical studies and clinical evidence on PRP for joint
PRP which is a very short duration to evaluate the long degeneration, Knee Surg. Sports Traumatol. Arthrosc.
2015;23:2459-2474
term effects of PRP on knee joint. 11. W.-L. Dai, A.-G. Zhou, H. Zhang, and J. Zhang, "Efficacy of platelet-
rich plasma in the treatment of knee osteoarthritis: a meta-
Recommendations analysis of randomized controlled trials," Arthroscopy. 2017;33:
659-670
Further studies should be done with long term follow ups 12. Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief:
to observe the effectiveness of PRP with time. This study Kellgren-Lawrence Classification of Osteoarthritis. Clin Orthop
was highly dependant on patient's perception with some Relat Res. 2016;474:1886-93.
objective assessment. Therefore, some experimental 13. van Rooijen DE, Lalli S, Marinus J, Maihöfner C, McCabe CS, Munts
AG, et al. Reliability and validity of the range of motion scale
studies should be done in future to assess the PRP efficacy (ROMS) in patients with abnormal postures. Pain Med. (Malden,
in an accurate manner. However, this study can serve as a Mass). 2015;16:488-93.
baseline for future experimental studies on the same 14. Gandek B. Measurement properties of the Western Ontario and
McMaster Universities Osteoarthritis Index: a systematic review.
subject. Arthritis Care Res. 2015;67:216-29.
15. Couper M, Tourangeau R, Conrad F, et al. : Evaluating the
Conclusion effectiveness of visual analog scales: A web experiment. Soc Sci
Comput Rev 2006;24:227-245.
PRP injection in cycling doses of three injections with 4 16. Calculator, s., 2021. Sample Size Calculator. [online] Calculator.net.
weeks interval is an effective way of managing knee OA Available from URL: <https://www.calculator.net/sample-size-
symptoms. It reduces the pain intensity and improves calculator.html> [Accessed 12 May 2021].
functional outcomes at knee joint. PRP can be considered 17. O'Connell B, Wragg NM, Wilson SL. The use of PRP injections in the
management of knee osteoarthritis. Cell Tissue Res..
as the choice of treatment for patients with knee 2019;;376:143-52.
osteoarthritis. 18. Filardo G, Kon E, Buda R, Timoncini A, Di Martino A, Cenacchi A,

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-98
et.al. Platelet-rich plasma intra-articular knee injections for the rich plasma in comparison with hyaluronic acid. Am J Phys Med
treatment of degenerative cartilage lesions and osteoarthritis. Rehabil. 2012 ;91:411-7.
Knee Surg. Sports Traumatol. Arthrosc. 2011;19:528-35. 22. Gobbi A, Lad D, Karnatzikos G. The effects of repeated intra-
19. Sampson S, Reed M, Silvers H, Meng M, Mandelbaum B. Injection articular PRP injections on clinical outcomes of early
of platelet-rich plasma in patients with primary and secondary osteoarthritis of the knee. Knee Surg. Sports Traumatol. Arthrosc.
knee osteoarthritis: a pilot study. Am J Phys Med Rehabil. 2015; 23:2170-7.
2010;89:961-9. 23. Khoshbin A, Leroux T, Wasserstein D, Marks P,
20. Jang SJ, Kim JD, Cha SS. Platelet-rich plasma (PRP) injections as an Theodoropoulos J, Ogilvie-Harris D, et.al. The efficacy of
effective treatment for early osteoarthritis. Eur J Orthop Surg platelet-rich plasma in the treatment of symptomatic knee
Traumatol. 2013;23:573-80. osteoarthritis: a systematic review with quantitative synthesis.
21. Spaková T, Rosocha J, Lacko M, Harvanová D, Gharaibeh A. Arthroscopy. 2013; 29:2037-48.
Treatment of knee joint osteoarthritis with autologous platelet-

J Pak Med Assoc (Suppl. 5)

S-99 34th International Pak OrthoCon Conference 2021

CASE SERIES
Long-term functional outcomes after total scapulectomy with dual suspension
reconstruction in children — A case series
Akbar Jaleel Zubairi,1 Mohammad Mustafa,2 Javeria Saeed,3 Masood Umer4
Abstract outcomes with local resection. However as amputation
is associated with considerable morbidity, the quest for
Implant reconstruction following scapulectomy in
a limb salvage option was not abandoned. Boris Linberg
children is a challenging task. Dual suspension
presented the first case series of limb sparing resection
reconstruction may offer an alternative but there is a
for malignant tumours of the upper extremity in 1928.4
dearth of literature on functional outcomes following But it was not until after 1970 owing to advances in pre-
this procedure for malignant tumours in children. A operative imaging and surgical techniques, that total
retrospective study was conducted at the Aga Khan scapulectomy gained acceptance as the procedure of
University Hospital, a tertiary care centre in Karachi, choice for these tumours where possible. This offered
Pakistan. Children with malignant tumours of the scapula an attractive alternative to amputation in terms of
who underwent total scapulectomy with dual being cosmetically, functionally and emotionally
suspension reconstruction (n=5) between Jan 2009 and accepted by the patients.5
June 2015 were included. Mean follow up was 50±13.39
months. There were four boys and one girl having mean As total scapulectomy involves resection of the glenoid
age of 11±3.57 years. All patients were Enneking Stage IIB along with the rotator cuff muscles, it has to be
with 4 patients diagnosed as Ewing's Sarcoma and 1 as accompanied by soft tissue reconstruction to minimize
osteosarcoma. The MSTS scores ranged from 20-25 the functional deficit. Rebuilding of shoulder function
points, with a median of 23. One patient developed after total scapulectomy is puzzling. Extracorporeal
postoperative surgical site infection requiring surgical irradiation and re-implantation is a well-known method of
debridement whereas all patients remained disease-free biological reconstruction in orthopaedic oncology; and
till last follow up. Our findings suggest that scapulectomy few reports in the literature describe its specific use in
with dual suspension reconstruction achieves tumours of the scapula.6,7 Various reconstruction
satisfactory functional results with low rate of techniques for the gleno-humeral articulation have been
complications. reported in literature, ranging from metallic prosthesis to
allograft reconstruction to simple proximal humeral
Keywords: Scapula, Retrospective study, Surgical wound suspension.8
infection, Ewing's sarcoma, Osteosarcoma.
There is a dearth of literature on functional and oncologic
Introduction outcomes of scapulectomy for malignant tumours as a
whole and specifically for children. Hence we decided to
The shoulder girdle is a common site for musculoskeletal
study and report our experience with total
tumours with Ewing's sarcoma being the most common scapulectomies in paediatric patients.
tumour of the scapula in children. The prevalence of
Ewing's Sarcoma is 2 per hundred thousand which Case Series
makes it as the 2nd most primary tumour after
A single institution retrospective study was conducted at
osteosarcoma.1,2 Aga Khan University Hospital, Karachi. This case series
Forequarter amputation was considered to be the included all patients operated between January 2009 and
treatment of choice for shoulder girdle tumours before June 2015. Patients with minimum follow up of 2 years
the 1970's, owing to the fear of local recurrence3 and were included in the study. Study was started after being
the close proximity of these tumours to the approved for exemption from Ethics review committee of
neurovascular bundle resulting in poor functional Aga Khan Hospital. Patients consent was taken for
publishing their data.
1,3,4Department of Orthopedics, Aga Khan University Hospital, Karachi, US Department of Health and the Food and Drug
2Department of GI Surgery, SIUT, Karachi, Pakistan. Administration Criteria for age definition was used to
Correspondence: Javeria Saeed. Email: Javeria.Saeed@aku.edu include all patients falling under 18 years of age as

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-100

Figure: a) MRI image of patient with Ewing sarcoma before surgery. b) Post-surgery follow up X-ray of patient showing dual suspension. c) Specimen radiograph. d) Patient showing
functionality at follow up.

paediatric patients. 9 A total of 23 children with muscles are transected from the bone starting from the
malignant tumours of the scapula were treated at our lowest point inferiorly including the rotator cuff. Soft
institution during this time. Of those 5 underwent total tissue reconstruction for shoulder stability is done
scapulectomy and the other patients were excluded as using dual-suspension technique with Dacron tape
they either had gross neurovascular invasion, or from the clavicle for static support and reattaching the
involvement of the chest wall leading to a more radical biceps and triceps muscles through drill holes.
excision or had been deemed inoperable. Surgical Tenodesing the deltoid to the pectoralis major and
staging was done on the principles of Enneking system10 trapezius muscles further enhances the stability. 6
with plain radiographs and CT/ MRI scans. Radiographs and follow up pictures of one of the cases
is presented in Figure (a, b, c, d).
These five patients included four boys and one girl. Their
mean age was 11±3.57 years (range: 8-16 years). Four Patients were provided a sling postoperatively, and
patients had Ewings Sarcoma in their scapulae, whereas motion was restricted until the incision healed. The
one had osteosarcoma. All patients were Enneking Stage sutures were removed at about 2 weeks after surgery.
IIB and all underwent total scapulectomy with dual Active motion of the elbow and hand was initiated to
suspension Reconstruction. The patients mean follow up preserve strength and range of motion and to help
was 50±13.39 months (range 33-65 months). minimize oedema. At about 2 weeks, the sling was
removed for passive shoulder range of motion (ROM) and
Indication for surgery included a malignant tumour pronation and supination at the wrist. Passive ROM of the
localised in the scapula without local invasion into the shoulder (flexion, abduction, and external and internal
axilla or chest wall nor any distant metastases. The rotation and pendulum exercise) with the help of a family
surgical technique used for total scapulectomy on our member or physical therapist was encouraged. Active
paediatric patients was based on Malawer's description ROM was started after 6 weeks. All patients were followed
of shoulder girdle resections and total scapulectomy up as a routine in the clinic by the chief surgeon at 1
(intra-articular scapular resection, type III)6 which was month, 3 months and every 3 months for at least 2 years
employed in all cases. Two limbs of the utilitarian then annually thereafter.
incision are utilised with the anterior incision being
used to mobilize the axillary vessels and nerves and the Musculoskeletal Tumour Society (MSTS score) was
posterior incision for exposure of the scapula, calculated by the operating surgeon as a routine during
rhomboids, latissimus dorsi, and teres muscles. All follow up clinic visits to assess the functional outcome.

Table-1: Patient demographics, diagnoses, functional outcome and complications.

S.No Age Sex Tumour Follow Up (Months) Complications MSTS Score Oncologic Outcome

1 8 Male Ewing's Sarcoma 52 Wound Infection 20 Disease free

2 8 Male Ewing's Sarcoma 65 None 22 Disease free
3 11 Male Ewing's Sarcoma 33 None 25 Disease free
4 12 Female Ewing's Sarcoma 60 None 23 Disease free
5 16 Male Osteosarcoma 40 None 23 Disease free

J Pak Med Assoc (Suppl. 5)

S-101 34th International Pak OrthoCon Conference 2021

This was subsequently extracted from the patients' allograft. Ahmed M. et al. used irradiated bone and
records. Similarly complications and their subsequent reported the mean MSTS scores as 87% and 8 out of 10
management was also extracted from medical records. patients in his study were able to achieve shoulder
Descriptive analysis was performed on IBM SPSS elevation above 90 degrees in scapular and forward
analytical software, version 20. plane. Over the follow up time, all patients function had
improved. In his study complications were also reported,
All children had an acceptable functional outcome with wound gaping occurred in 2 patients, 3 had dislocation of
restrictions mainly in overhead abduction and lifting
acromioclavicular joint while 50% patients had resorption
ability. Median MSTS score was 23 (Range 20-25). One
of scapular graft.7
(20%) patient developed post-operative infection which
required surgical debridement and a course of antibiotics In our study we used humeral suspension with the
after which it resolved. There was no local recurrence nor mean MSTS scores as 23 and all children had good
any distant metastases in any of the patients. All patients functional outcomes with more improvement seen in
were followed up till December 2019. Table shows over all our long term follow up. In earlier months of post-
patient demographics, diagnoses, functional outcome surgery, patients had only restriction issues of overhead
and complications. abduction. Out of our 5 patients, only 1 had
complication of wound infection requiring wound
Discussion debridement and antibiotic treatment. All of our
There is a dearth of literature on scapulectomies due to patients were disease free till the year 2019 follow up.
the rare occurrence of malignant tumours at this site. None of them reported for distant Metastasis.
Most studies available do not segregate adult and
We acknowledge limitations of this retrospective study.
paediatric patients while reporting survival and
First, the number of patients is small as with many
functional outcomes. As the paediatric population is
orthopaedic oncology studies and heterogeneity of the
different with regards to the aetiology of tumours and
patient population with no control group making any
remaining growth potential their outcomes need to be
comparison difficult. But our follow up time was
studied separately. Very few studies have addressed the
sufficient to report long term outcomes with regards to
paediatric population separately in terms of
disease recurrence, complications and functional
reconstruction options and functional outcomes.
outcomes.
Our study focussed on the long term follow up of
children < 18 years so that a better assessment of Conclusion
survival and functional outcomes of this population may Our findings suggest that scapulectomy with dual
be made. Our mean follow up was 50±13.39 months suspension reconstruction achieves satisfactory
which corresponded to skeletal maturity in most of our functional results with low rate of complications.
patients. Schmalzl J, et al. reported that shoulder Multicentre studies need to endorse these long term
function in their patients improved more at 5 to 8 years findings in comparison with other reconstruction options.
of follow up and the patients were disease free as well.1
Although scapula is an uncommon site for Ewing's Disclaimer: None.
sarcoma, 80% of our cases had Ewing's sarcoma.11 Conflict of Interest: None.
Multiple reconstructions techniques after total
scapulectomy have been described in literature ranging Funding Disclosure: None.
from no reconstruction, soft tissue reconstruction to
prosthetic reconstruction. No reconstruction leads to References
poor shoulder function and is not a recommended 1. Schmalzl J, Niks M, Moursy M, Scharf H-P, Lehmann L-J. Eight-year
option. Total Scapulectomies in paediatric patients follow-up after scapulectomy in a neonate with congenital Ewing
sarcoma of the scapula. J Shoulder Elbow Surg. 2018;27:e288-e93.
poses a unique challenge in soft tissue reconstruction 2. Brtková J, Nidecker A, Zídková H, Jundt G. Tumours and tumour-
owing to the remaining growth potential in this like lesions of scapula. Acta Medica (Hradec Kralove).
population. A prosthetic reconstruction is demanding 1999;42:103-10.
because the remaining growth of the patient and 3. Meterissian SH, Reilly JA, Murphy A, Romsdahl MM, Pollock RE.
Soft-tissue sarcomas of the shoulder girdle: factors influencing
estimated early wear of the implant limit its utility and
local recurrence, distant metastases, and survival. Ann. Surg.
survival. Oncol. 1995;2:530-6.
4. Sim FH, Pritchard DJ,Ivins JC. Forequarter amputation. Orthop Clin
Reconstruction techniques successfully used in paediatric North Am 1977;8:921-931.
patients include humeral suspension or irradiated bone/ 5. Williard W, Hajdu SI, Casper ES, Brennan MF. Comparison of

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-102
amputation with limb-sparing operations for adult soft tissue 2011;16:568-73.
sarcoma of the extremity.Ann. Surg.1992;215:269. 9. Hardin AP, Hackell JM, Committee On Practice And Ambulatory
6. Malawer MM. Tumors of the shoulder girdle. Technique of Medicine. Age limit of pediatrics. Pediatrics. 2017;140: e20172151;
resection and description of a surgical classification.Orthop Clin DOI:https://doi.org/10.1542/peds.2017-2151.
North Am1991;22:7-35. 10. Parafioriti A, Armiraglio E, Di Bernardo A.(eds) Classification of
7. El Ghoneimy AM, Zaghloul MS, Zaky I, Taha H, Elgammal A, El Primary Bone Tumors and of Osteosarcoma. Rehabilitation After
Sherbiny M, et al. Reconstruction of the scapula in pediatric and Limb Salvage Surgery. Springer International Publishing,Switzerland
adolescent patients after total scapulectomy. A report of 10 AG. 2021pp3-10. DOI10.1007/978-3-030-66352-0.
patients treated by extracorporeal irradiation and reimplantation 11. Malik SS, Tahir M, Ahmed U, Evans S, Jeys L, Abudu S. Outcome of
of the scapula. J Pediatr Orthop 2018;38:e91-e6. Ewing's sarcoma of the scapula-a long-term follow-up study.
8. Hayashi K, Karita M, Yamamoto N, Shirai T, Nishida H, Takeuchi A, Orthop Traumatol Surg Res. 2020;106:25-30.
et al. Functional outcomes after total scapulectomy for malignant
bone or soft tissue tumors in the shoulder girdle. Int J Clin Oncol

J Pak Med Assoc (Suppl. 5)

S-103 34th International Pak OrthoCon Conference 2021

CASE SERIES
Role of platelet rich plasma in fracture non-union of scaphoid — Case series
Muhammad Zeeshan Aslam,1 Josephine Ip,2 Syed Kamran Ahmed,3 Boris Fung4
Abstract Table-1: Herbert and Fisher Classification of Non-Union of scaphoid.

This case series of 4 patients was studied at Queen Mary Classification Decription
Hospital, Hong Kong from 2007 to 2011 to evaluate the
clinical and radiological outcome of scaphoid fracture A Stable fracture including incomplete or fracture of scaphoid tubercle
non-union treated with Open reduction and internal B Unstable fractures
fixation ORIF supplemented with Bone Graft (BG) from B1 Distal Oblique
B2 Complete Fracture at the waist
iliac crest and Platelet Rich Plasma PRP. The purpose was
B3 Proximal Pole Fracture
to achieve union with pain free adequate range of B4 Trans-scaphoid perilunate dislocation
movement. Patients presenting with scaphoid fracture C Delayed union
non-union were included in our study. D1 Fibrous Non-union
D2 Sclerotic Non-union/ Pseudoarthrosis
Total 4 patients with an average age of 35±7.7 years
(range 31 to 47 years) and mean follow-up of 21.75±14.97
months, (range 05 months to 3.5 years) were included. All and vertically oblique.2 While Herbert and Fisher classified it
patients achieved union with pain free Range of motion according to stability3 (Table-1).
of wrist as well as thumb. We recommend open reduction Non-union of scaphoid requires surgical intervention as
and internal fixation with bone graft along with platelets the aim is to achieve bone healing. It includes stable
rich plasma for non-union of scaphoid. internal fixation, Bone Graft, electrical or electromagnetic
Keywords: Scaphoid fracture, Non-union, ORIF, BG, PRP. stimulation either one or in combination. However Rate of
persistent non-union can be as high up to 35%. Schuind
Introduction et al. in their multicentre retrospective review on 138
patients with scaphoid non-union, performed ORIF with
Scaphoid non-union: Fracture of Scaphoid is commonest
k-wires or screw along with non-vascularised bone graft
among carpal bones with incidence of 60-70%. Majority of
(BG). He found persistent non-union in 25%.4 Treating the
the fractures occur at the waist. Herbert and Fisher
scaphoid non-union is always a challenge in orthopaedics
Classified non-union of scaphoid on the basis of anatomy,
and it is notorious for non-healing. Considering this high
delayed union and non-union (Table-1).
frequency of scaphoid non-union, inspired us to use
Treatment options for acute fracture management ranges another modality to enhance fracture healing hence we
from cast immobilisation, close reduction and added Platelet Rich Plasma (PRP) along with ORIF and BG.
percutaneous k wires to open reduction and internal
fixation (ORIF) with k-wires or Screws.
Patients and Methods
The case series of 4 patients was conducted at Queen
Scaphoid is notorious for non-healing and is difficult to Mary Hospital, Hong Kong from 2007 till 2011. Written
treat with a significant risk of non-union. By definition, informed consent was obtained from the patients
non-union of scaphoid is defined as absence of bone presenting with scaphoid fracture non-union. They were
healing at-least 3 months after initial injury.1 included in our study and treated with standard
Scaphoid non-union can lead to sequence of arthritic treatment of ORIF with BG and in addition with PRP to
changes with involvement of scaphoradial, scaphocapitatae enhance fracture healing. Demographic Data included
and capitulolunate joints. Non-union can be classified by was Age, Sex, Gender, Occupation, Dominant Hand, Site
of Injury (Table-2).
using Russe Classification as Horizontal oblique, transverse
Postoperative healing was assessed both clinically and
1,3The Indus Hospital, Karachi, Pakistan, 2,4Department of Orthopaedics and radiologically. Final outcome was measured in terms of
Traumatology, Queen Mary Hospital, Hong Kong. healing, Visual analogue score VAS for pain, Range of
Correspondence: Muhammad Zeeshan Aslam. motion (ROM) of wrist including pronation, supination,
Email: dr.mzeeshanaslam@gmail.com flexion, extension, radial and ulnar deviation (Table-3).

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-104
Table-2: Demographic data. 18.02.2008 and he was followed-up till 22 July 2010 (2.5
years follow-up).
Gender Side involved Dominant hand Age Site of fracture
Patient-2: 36 years old Right hand dominant male,
Patient 1 Male L scaphoid R handed 26 Waist salesman of herbal medicine by profession, acquired
Patient 2 Male R scaphoid R handed 36 Proximal pole injury while playing football on 29 Oct 2007. He presented
Patient 3 Male L scaphoid R handed 31 Waist Fracture to us 3 months later with fracture non-union of proximal
Patient 4 Male R scaphoid R handed 47 Waist Fracture
pole of Right scaphoid. Per-operatively following findings
were noted: Proximal pole fracture which was sclerotic
Range of motion of Thumb metacarpophalangeal joint
and had avascular margins with no solid remaining bone
(MCPJ) and Interphalangeal joint IPJ, pinch grip, power
except cartilage like an egg shell.
grip, Activity of Daily living (ADL) and thumb apposition
to little finger (Table-4). ORIF with BG from iliac crest was performed + PRP on 31
12 2007. Last follow up was done on 26 July 2011, (3.5
All 4 patients underwent open reduction and internal
years) (Figure-1).
fixation with iliac crest bone graft and PRP. Volar
approach was used for 3 patients with waist fracture and Patient-3: 31 years old male with Right hand dominant,
dorsal approach for one patient with proximal pole cook by profession, presented with non-union of Left
fracture. Internal fixation was done with k-wires. scaphoid waist, injured on 24 06 2007.
PRP was prepared by using centrifuging system to First operation ORIF with 3 k wires + BG was performed on
separate it from blood technique known as gravitational 27 06 2007 (Figure-2).
platelets separation (GPS). Patient's
autologous blood was centrifuged and 3
layers were obtained, bottom layer of red
cells, middle layer of platelets and white
blood cells (WBC) and top layer of plasma
rich in platelets.
Patient-1: 26 year old male with Right
hand Dominant, clerk by profession
presented with Fracture non-union of left
scaphoid waist with DISI deformity in
March 2007, pre-operative palmar flexion
of 50 degrees and dorsi-flexion of 50 was
noted. He was operated on 31.12. 2007.
Removal of k wires was done on Figure-1: Patient 2, Post-Operative Radiograph showing Union.

Table-3: Postoperative Range of motion of wrist.

Postoperative Post-Operative Post-Operative Post-Operative Post-Operative Post-Operative

Flexion Extension Ulnar Deviation Radial Deviation Pronation Supination

Patient 1 47 30 35 10 NA 75
Patient 2 45 61 30 7 NA NA
Patient 3 44 56 20 15 90 90
Patient 4 35 45 20 10 90 90

Table-4: Postoperative Range of Motion of Thumb, Opposition, Power Grip, Pinch Grip, ADL and VAS.

Pinch Power Thumb Thumb Thumb Thumb Opposition Activity of Daily VAS 1st Web
Grip Grip MCPJ ROM IPJ ROM TARM to Little Finger Living ADL space

Patient 1 1.9 kgf 17 kgf 0-40 0-78 118 Possible Back to work 0 NA
Patient 2 7 44 0-24 0-40 64 Possible Back to Work 0 NA
Patient 3 3.7 32 0-62 0-68 130 Possible Back to work 0 17 cms
Patient 4 4 20 20-70 0-76 126 Possible Back to work 0 19 cms

J Pak Med Assoc (Suppl. 5)

S-105 34th International Pak OrthoCon Conference 2021

incidence of persistent non-union

despite ORIF with BG. We consider
PRP to enhance fracture healing
along with ORIF and BG.
PRP is a fraction of the patients'
autologous whole blood with supra
physiological concentration of
platelets. It has been used in various
fields of Orthopaedics to regenerate
tissue including soft tissue and
bone.5 As it is autologous hence
there is no chance of disease
Figure-2: Patient 3, Postoperative Healing of Fracture non-union of scaphoid fracture. transmission and immunological
reactions. It contains 5 times higher
count of platelets than autologous
blood. Its a granules contain various
proteins including platelets derived
growth factors PDGF, transforming
growth factors TGF-B, platelets factor
4, interleukin 1, platelets derived
angiogenesis factor PDAF and many
others which enhance tissue healing.
PRP also contains proteins which
help in cell adhesion including fibrin,
fibronectin, vitronectin and
Figure-3: Patient 4, Per op Fluoroscopic Images showing Joy stick in proximal and distal fragment to help in reduction. thrombospondin.6 It also helps in
proliferation of bone cells.7

But it resulted in non-union despite Bone graft. The Clinical application of PRP was first
second operation was done, k wires were retained as they reported in 1994 for mandibular reconstruction.8 It has
were maintaining the reduction, fibrous tissue was been used in the treatment of tissue healing in lateral
removed by curette and power burr and bone graft with epicondylitis, open repair of tendo-achilles, and repair of
PRP was undertaken on 31 Dec 2007. Last follow-up was rotator cuff.
on 21 Oct 2008 i.e. 10 months after the second operation.
Various studies showed promising results of PRP in spinal
Patient-4: 47 years old male, Right hand dominant, fusion,9 osteogenesis distraction and callus formation and
Massager by profession, presented with Right scaphoid treating non-unions with revision surgeries.
waist fracture non-union of 3-4 years on 24 09 2008. ORIF Bielecki et al. treated 32 patients with delayed union and
with k -wire + BG+ PRP was performed on 06. 10. 2008. non-union with percutaneous PRP injections and
Last follow-up was on 16 March 2009 (5 months later) achieved 100 % success rate with union in all patients.10
(Figure-3).
Conclusion
There were 4 patients in our study with an average age of
35±7.77 years (range 31 to 47 years). The mean follow-up Open reduction and internal fixation with bone graft
was 21.75±14.97 months (range 05 months to 3.5 years). along with platelets rich plasma is the recommended
All the patients achieved union with pain free Range of technique for non-union of scaphoid.
motion of wrist as well as good total active range of
movement (TRAM) of thumb. All patients had good
Limitation
apposition of thumb with little finger and got back to The study size was small with only 4 patients included.
normal activity of daily living (ADL). Large multicenter studies should be conducted and
further Randomized Control Trial is required to compare
Discussion different treatment options to determine the union rate
Scaphoid non-union is always a challenge with high as well as complications related to each procedure.

Vol. 71, No. 8 (Suppl. 5), August 2021

34th International Pak OrthoCon Conference 2021 S-106
Disclaimer: None. 5. Alsousou J M. Thompson P, Hulley AN, Willett K. The Biology of
Platelet-Rich Plasma and Its Application in Trauma and
Conflict of Interest: None. Orthopaedic Surgery: A Review of the Literature. J Bone Joint Surg
Br. 2009; 91: 987-96.
Funding Disclosure: None. 6. Schilephake H. Bone Growth Factors in Maxillofacial Skeletal
Reconstruction. Int J Oral Maxillofac Surg. 2002; 31: 469-84.
References 7. Yang DJ, Chen ZJ, Jin D. Platelet-Derived Growth Factor (Pdgf)-Aa:
A Self-Imposed Cytokine in the Proliferation of Human Fetal
1. Osterman AL, Mikulics M. Scaphoid Nonunion. Hand Clin 1988; 4: Osteoblasts. Cytokine 2000; 12:1271-4.
437-55. 8. Tayapongsak PDA, O'Brien C B, Monteiro LY, Arceo-Diaz LY.
2. Russe, O. Fracture of the Carpal Navicular. Diagnosis, Non- Autologous Fibrin Adhesive in Mandibular Reconstruction with
Operative Treatment, and Operative Treatment. J Bone Joint Surg Particulate Cancellous Bone and Marrow. J Oral Maxillofac Surg.
Am. 1960; 42-A:759-68. 1994; 52:161-5.
3. Geissler WB, Adams JE, Bindra RR, Lanzinger WD, Slutsky DJ. 9. Lowery GL, Kulkarni S, Pennisi AE. Use of Autologous Growth
Scaphoid Fractures: What's Hot, What's Not. Instr Course Lect. Factors in Lumbar Spinal Fusion. Bone. 1999; 25: 47S-50S.
2012; 6:71-84. 10. BieleckiTS, Gazdzik T, Szczepanski T. Benefit of Percutaneous
4. Schuind F P, Haentjens F, Van Innis C, Vander Maren M, Garcia- Injection of Autologous Platelet-Leukocyte-Rich Gel in
Elias, Sennwald G. Prognostic Factors in the Treatment of Carpal Patients with Delayed Union and Nonunion. Eur Surg Res.
Scaphoid Nonunions. J Hand Surg Am. 1999; 24: 761-76. 2008; 40: 289-96.

J Pak Med Assoc (Suppl. 5)

S-107 34th International Pak OrthoCon Conference 2021

Vol. 71, No. 8 (Suppl. 5), August 2021