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Multiple Cantilever K-wiring Technique for Severely Comminuted Articular
Fragments in Neglected Distal Humerus Fracture with Anterior Elbow
Dislocation: A Case Report
Article in Journal of Orthopaedic Case Reports · January 2022
DOI: 10.13107/jocr.2022.v12.i01.2600
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1 1 1 1 1
Sanjay Dhar , Sachin Yashwant Kale , Sushmit Singh , Aditya Rajendra Gunjotikar , Vaibhav Koli ,
1
Suraj Sharma
Elbow dislocation is a serious injury requiring immediate
surgical intervention, especially when neglected and associated
withfractures[1].Thegoalshouldbetoprovidegoodfixationto
the bony fragments with better handling of soft tissues for which
anyavailablemethodcanbeusedbythesurgeon.Theseverityof
osseous trauma in combination with soft-tissue damage may
affect the function in the elbow region [2]. Here, we present an
unusual case of a 5-week-old unreduced anterior dislocation of
the elbow joint with medial epicondyle and lateral condyle
humerus fracture in a 30-year-old male patient and describe a
unique technique for fixation of comminuted articular
fragments.
There have been many challenges faced by the medical and
surgical community worldwide after the spread of COVID-19
around the world. The surgical management of patients has also
been affected severelyand the impact of delay in surgeriescan be
seeninprimarysurgicaloutcomes.Withtheincreasingburdenof
COVID-19 on the hospitals, cases of conservatively managed
fractures and dislocations with adverse outcomes have become
moreprevalent.
Introduction
Author’s Photo Gallery
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sa/4.0/ , which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms
DOI:10.13107/jocr.2022.v12.i01.2600
22
Conclusion:Neglected fracture-dislocation of the elbow is challenging and is further complicated by comminuted fragments with loss of bone
stock.AuniqueuseofmultipleKirschnerwiresinacantileverfashionprovidesagoodfixationalternativeforsuchcases.
CasePresentation:A30-year-oldmanpresentedwithpain,deformity,andlimitedrangeofmovementofhisrightelbowjointandanon-healing
wound over the olecranon after he had a road traffic accident 5 weeks back. The patient had been initially treated in a local hospital where he
tested positive for COVID-19 and was managed conservatively. Radiographs revealed lateral condyle and medial epicondyle humerus fracture
andanunreducedanteriordislocationoftherightelbowjoint.
Introduction:Anteriordislocation oftheelbowiscomparativelylessfrequentandisoftenassociatedwithfracturesofthedistalhumerus.Such
injuries require surgical intervention at the earliest but with the surge of COVID-19 pandemic and different protocols being followed by
surgeons, such cases are getting neglected. We present a 5-week-old neglected anterior dislocation of the right elbow joint with lateral condyle
andmedialepicondylehumerusfractureandauniquecantileverK-wiringtechniqueusedforitstreatment.
Keywords:Anteriorelbowdislocation,neglectedelbowinjury,cantileverK-wiring.
Abstract
Dr. Sachin Yashwant Kale Dr. Vaibhav Koli
Dr. Sanjay Dhar Dr. Sushmit Singh Dr. Aditya Rajendra
Gunjotikar
Learning Point of the Article:
SeverelycomminutedfracturesofdistalhumerusarechallengingtotreatandmultiplecantileverK-wiringcanbeusedasapreferablealternative
forfixation.
Multiple Cantilever K-wiring Technique for Severely Comminuted
Articular Fragments in Neglected Distal Humerus Fracture with Anterior
Elbow Dislocation: A Case Report
Case Report Journal of Orthopaedic Case Reports 2022 January: 12(1):Page 22-25
Access this article online
Website:
www.jocr.co.in
DOI:
10.13107/jocr.2022.v12.i01.2600
1
Department of Orthopaedics, Dr. D. Y. Patil Medical College and Hospital, Navi Mumbai, Maharashtra, India.
Dr. Sushmit Singh, Senior Resident
Address of Correspondence:
Department of Orthopaedics, Dr. D. Y. Patil Medical College and Hospital, Navi Mumbai, Maharashtra, India.
E-mail: drsushmits@gmail.com
Dr. Suraj Sharma
© 2022 Journal of Orthopaedic Case Reports Published by Indian Orthopaedic Research Group
|
Submitted: 11/07/2021; Review: 21/10/2021; Accepted: November 2021; Published: January 2022

www.jocr.co.in
On examination, the right elbow joint had flexion deformity
and wasting of muscles of arm and forearm was evident. On
palpation, the olecranon process was found to be displaced
anteriorly from the olecranon fossa of the right humerus,
crepituscouldbefeltandanon-healingwoundwaspresentover
theolecranon(3*2cm).Therewerenosignsofactiveinfection,
and therefore, blood culture was not done. The flexion
deformity was 30° with further flexion up to 60°. Pronation was
restricted at 10° and supination was possible till 40°. On further
examination, valgus laxity could be appreciated with no
associatedneurovasculardeficit.Onradiographicexamination,
the right elbow was found to be anteriorly dislocated with
medial epicondyle fracture and comminuted lateral condyle
fracture (Fig. 1). A computed tomography (CT) with 3D
reconstruction(Fig.2)confirmedananteriordislocationofthe
right elbow joint with the associated distal humerus, lateral
sagittal, partial articular, trans-trochlear multi-fragmentary,
epiphyseal-metaphyseal lateral condyle fracture, and medial
epicondylefracture(AO/OTAClassification–13-B1.3).
Weplannedanopenreductioninternalfixationwithplatingasit
was an already delayed presentation and was an unreduced
fracture dislocation of elbow. Surgery was performed under
general anesthesia with intubation. The patient was positioned
laterally with the elbow flexed on a sidearm fixed to the table. A
pneumatic tourniquet was applied and we performed an open
reduction and internal fixation of the elbow by taking a midline
posterior approach. The dissection was done in layers and the
ulnar nerve was identified and preserved avoiding any kind of
traction or pressure injuries. We took a paratricipital approach,
and after further dissection and extensive release of fibrous and
osteoidtissues,weweresuccessfulinrelocatingtheelbowjoint.
Specialcarewastakentoprotectthemedialandlateralcollateral
ligaments which were found to be intact. Any overlapping
cartilage was further trimmed to attain bleeding metaphyseal
bone. During the exposure, the articular cartilage was carefully
handled to preserve it and avoid the nibbling of soft tissues
around it. The small articular fragments were preserved and
disimpacted with the help of a fine elevator and interposed
tissues were removed. After the reduction of all major
fragments, multiple Kirschner wires (K-wires) were used for
provisional fixation (Fig. 3). The coronal articular fragments
were found to be severely comminuted with a lack of bone
stock. The articular fragments were too small and thin for
Herbert screws and had minimal subarticular bone for any 2.5
mm screws through the plate. Subarticular K-wires were
inserted just below the articular cartilage in parallel cantilever
pattern (Fig. 4) and along the para-articular curvature of the
articularsurfaceofcapitellumandthentheendswerecoalesced
and buried under a lateral pillar plate to provide a stable and
rigid interface with the lateral column. Final tightening of the
screws was done after engaging all the K-wires behind the plate.
K-wires were used for fixation as the articular fragments were
A 30-year-old male presented to us in the outpatient
department with the complaints of pain and deformity of the
right elbow with a non-healing wound for 5 weeks. The patient
had a history of a road traffic accident while driving a two-
wheeler, following which he had pain, swelling, and deformity
of the right elbow with a wound over the olecranon. He had
sought treatment from a local hospital and was tested positive
for COVID-19 and was managed conservatively with posterior
above elbow slab. After getting treatment for COVID-19, the
patient visited our hospital for the persistent deformity and
stiffnessoftherightelbow.
Case Report
23
Journal of Orthopaedic Case Reports Volume 12 Issue 1 January 2022 Page 22-25
| | | |
DharSetal
Figure1:(a)Pre-operativeclinicalpictureoftherightelbow.(b)Pre-operativeX-
raysoftherightelbow(anteroposteriorandlateralview). Figure2:Pre-operative3Dcomputedtomographyscanoftherightelbow.
Figure3:Intraoperativepictures–(aandb)lateralcondylefixation;(candd)medialepicondylefixation.
Figure4:Aschematic diagramillustratingtheplacementof
multiple cantilever K-wires in (a) lateral and (b)
anteroposteriorviewofthedistalhumerus.

Conclusion
Theassociatedcomminutedfractureofthelateralcondylewasa
big challenge in our case which was further complicated by
delayed intervention and the presence of minimal subarticular
bone.K-wiresareofgreathelpwhenitisdifficulttouseheadless
screws for extremely comminuted fragments of bone [10, 11].
The inability to fix the articular comminuted fragments with
standard fixation methods due to lack of good bone stock made
usapplytheunconventionalstepofusingmultiplecantileverK-
wires and peculiarly coalescing them to provide good stability
totheconstruct.Theoverallreductionachievedwiththehelpof
this method was equivalent to other standard methods and
providesagoodalternativeinsimilarconditions.
too thin to get hold with screws. With lack of bone stock and
thin subarticular bone, cancellous screws could not be used for
thesame.
Discussion
Acute anterior elbow dislocations of the elbow joint, though
comparativelyrare,havebeendescribedintheliterature[6,7,8,
9]. An associated fracture of olecranon and condyles has been
reported [6, 7, 8]. The clinical features of the case described
here are similar to previously described cases with flexion
deformity,pain,swelling,andrestrictedrangeofmotion[1,2,3,
4, 5, 6]. The delay in seeking treatment due to associated
COVID-19infectionposedachallengeforboththepatientand
the surgeons. We had to face various challenges while
determining the surgical approach, mode of fixation, implants
to be used, soft-tissue release, and post-operative
immobilization and care in our case. We planned an open
reduction of the elbow by utilizing a paratricipital approach as
there was an associated fracture of the lateral condyle and
medial epicondyle. The triceps sparing approach helped to
maintaintheextensionpowerandpreserveelbowstrength.
The medial epicondyle was cartilaginous and quite small,
makingitunsuitableforscrewfixationwithoutasubstantialrisk
of comminution. The ulnar collateral ligament was visualized
and no frank tear was found. The fracture was stabilized with
help of K-wire and was then fixed with the help of suture
anchors and FiberWire sutures but satisfactory fixation was not
achieved.Themedialepicondylewasthenfixedwiththehelpof
K-wires and tension band wiring. At the end of the procedure,
we confirmed the stability of the elbow by testing the range of
motion in all planes and found it satisfactory. The wound was
then closed in layers after anterior transposition of the ulnar
nerveandputtingasuctiondrain.Thenecroticskintissueswere
excised along with the non-healing wound and skin edges were
freshened which left a fresh wound of (4*3 cm) without skin
coverage. The rest of the wound was sutured with staples. A
posterior above-elbow slab was applied after proper antiseptic
dressing of the wound. The drain was in situ for 24 h and later
removed. The patient was started on Indomethacin 25 mg 8
hourly for 2 weeks post-surgery. After proper wound care and
inspection,thepatientwasdischargedonthe6thpost-operative
day and was advised for wound management follow-up weekly.
Active-assisted mobilization of the elbow joint wasstarted after
3 weeks of surgery. The patient was advised to attend the
rehabilitationdepartmentforphysiotherapyfor6weeksandhis
progress was monitored throughout. At 8 months post-
operative period, the patient had a painless range of motion of
the flexion-extension with flexion of 110° and extension lag of
20°. The radiographic review at 8 months also showed good
bony union (Fig. 5). The range of supination was 80° and
pronation was at 5° (Fig. 6). The post-operative wound was
completelyhealedwithnocomplications.
To synopsize, anterior dislocation of the elbow joint when
associated with fractures and delayed presentation can be a
challenging problem. A good outcome can be expected by
With COVID-19 being declared a global pandemic and halt of
surgeries in infected patients, orthopedic surgeons were forced
to delay surgeries to reduce the spread and prevent shortages of
essential equipment. Only, urgent surgeries, such as life- or
limb-threatening related cases, were being operated on by most
surgeons. This has led to an increase in the number of
conservatively managed conditions that required early
operative intervention. Most of the earlier studies have
recommendedtreatmentofelbowdislocationin<3weekspost-
injury [3]. There are more chances of the development of soft-
tissue contracture and osteoporosis after 3 weeks which makes
the management more difficult and may lead to articular
damagetoo[3,4,5].
24
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| | | |
DharSetal
Figure 5: (a) Immediate post-operative X-rays (anteroposterior and lateral views); (b) post-
operative8monthsX-rays(anteroposteriorandlateralviews).
Figure6:Clinicalpicturesatthepost-operativeperiodof8months.

www.jocr.co.in
DharSetal
References
11.CarrollMJ,AthwalGS,KingGJ,FaberKJ.Capitellarandtrochlear
fractures.HandClin2015;31:S0749071215000803.
2. Kazakos CJ, Galanis VG, Verettas DA, Dimitrakopoulou A,
Polychronidis A, Simopoulos C. Unusual patterns of monteggia
fracture-dislocation.JOrthopSurgRes2006;1:12.
4. Freeman BL 3rd. Old unreduced dislocations. In: Crenshaw AH,
editor. Campbell’s Operative Orthopedics. 9th ed., Vol. 1. St
Louis:Mosby;1998.p.2673-4.
6. Guitton TG, Albers RG, Ring D. Anterior olecranon fracture-
dislocations of the elbow in children. A report of four cases. J
BoneJointSurgAm2009;91:1487-90.
8. Gyawali GP, Pokharel B, Pokharel RK. Irreducible anterior
dislocationoftheelbowwithoutassociatedfracture.JNepalMed
Assoc2013;52:398-401.
10.DubberleyJH.Outcomeafteropenreductionandinternalfixation
of Capitellar and trochlear fractures. J Bone Joint Surg Am
2006;88:46-54.
1. Robinson PM, Griffiths E, Watts AC. Simple elbow dislocation.
ShoulderElbow2017;9:195-204.
3. Arafiles RP. Neglected posterior dislocation of the elbow. A
reconstruction operation. J Bone Joint Surg Br 1987;69:199-
202.
5.RockwoodCA,editor.RockwoodandGreen’sfractureinadults.In:
TreatmentofoldUnreducedPosteriorDislocationofElbow.4th
ed.,Vol.1.Philadelphia,PA:Lippincot-Raven;1996.p.975-6.
7. Venkatram N, Wurm V, Houshian S. Anterior dislocation of the
ulnar-humeral joint in a so-called ‘pulled elbow’. Emerg Med J
2006;23:e37.
9. Kumar R, Sekhawat V, Sankhala SS, Bijarnia I. Anterior dislocation
of elbow joint-case report of a rare injury. J Orthop Case Rep
2014;4:16-8.
making use of multiple cantilever K-wires for the fixation of
comminutedarticularfragments.
Clinical Message
This case introduces a novel technique of multiple cantilever
K-wires for fixation of severely comminuted fracture in distal
humerus, especially when other standard methods of fixation
arenon-viable.
Declarationofpatientconsent:Theauthorscertifythattheyhaveobtainedallappropriatepatientconsentforms.Intheform,thepatient'sparentshavegiventheirconsentforpatientimagesandotherclinical
informationtobereportedinthejournal.Thepatient'sparentsunderstandthathisnamesandinitialswillnotbepublishedanddueeffortswillbemadetoconcealtheiridentity,butanonymitycannotbeguaranteed.
Conflictofinterest:Nil Sourceofsupport:None
25
| | | |
Source of Support: Nil
______________________________________________
Consent: The authors confirm that informed consent was obtained
from the patient for publication of this case report
Conflict of Interest: Nil How to Cite this Article
Dhar S, Kale SY, Singh S, Gunjotikar AR, Koli V, Sharma S. Multiple
Cantilever K-wiring Technique for Severely Comminuted Articular
Fragments in Neglected Distal Humerus Fracture with Anterior Elbow
Dislocation: A Case Report. Journal of Orthopaedic Case Reports 2022
January;12(1):22-25.
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Financial Ignorance among Orthopedic Surgeons: A Survey In COVID-19 Era
Article · January 2022
DOI: 10.13107/jcorth.2021.v06i02.442
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Financial Ignorance among Orthopedic Surgeons: A Survey
In COVID-19 Era
Introduction
The COVID-19 pandemic has impacted
orthopedic surgeons globally, especially
during the initial phases of lockdown.
There were guidelines to delay or
postpone elective surgeries in all major
private and government hospitals from
the Ministry of Health and Family
Welfare, Government of India. Due to a
reduction in the number of elective
surgeries, there has been a significant
reduction in the income of the
orthopedic surgeons who are involved in
private practice. There were no definite
timelines predicted for the end of
lockdown in India as the number of
C O V I D - 1 9 c a s e s w a s r i s i n g
exponentiallyduringthefirst3monthsof
lockdown. As there was the uncertainty
ofthetimeframesfortherestartingofthe
work, everyone had thought of another
source of income, which included
orthopedicsurgeonsaswell.
Methods
This study was performed to analyze the
effect of the COVID-19 pandemic
situation on the income of orthopedic
surgeons and their willingness to make
the stock market the second source of
income. A total of 28 questions that had
multiple choices were asked. The
questions covered the demographics of
surgeons and were based on the
individual profile, current knowledge on
insurance,basicsofthestockmarket,and
mutual funds. The survey also enquired
about their knowledge of compounding,
inflation, and their willingness to gain
moreknowledgeinpersonalfinance.
The survey was distributed online
through a Google Forms link through e-
mail and WhatsApp to orthopedic
surgeons of Maharashtra, India. The
responseswere collected over a period of
1 month. All survey results were
calculated as percentages out of the total
responsesandanalyzedaccordingly.
Results
A total of 457 orthopedic surgeons
responded to the survey and gave their
inputs. Eighty-two (45.3%) of the
respondents had experience of 5–15
years of orthopedic practice. Forty-seven
(26%) had 15–30 years, 31 (17%) were
Original Article
1 1 1 1 1
Sachin Kale , Ajit Chalak , Sanjay Dhar , Prasad Chaudhari , Sushmit Singh ,
1
Aditya Gunjotikar
Journal of Clinical Orthopaedics | Available on www.jcorth.com | DOI:10.13107/jcorth.2021.v06i02.442 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-
Commercial-Share Alike 4.0 License (http://creativecommons.org/licenses/by-nc-sa/4.0) which allows others to remix, tweak, and build upon the work non-commercially as long as appropriate credit is given and
the new creation are licensed under the identical terms.
1
Department of Orthopaedics, Dr. D. Y. Patil Medical College and Hospital, Nerul, Navi Mumbai, India
Address of Correspondence
Dr. Sushmit Singh,
Department of Orthopaedics, Dr. D Y Patil Medical College and Hospital, Nerul, Navi Mumbai, India.
E-mail: drsushmits@gmail.com
JournalofClinicalOrthopaedics2021 July-Dec;6(2):-8-11
Background: COVID-19 pandemic has severely affected the finances of orthopedic surgeons around the globe due to recurring
lockdowns and fewer elective surgeries. It has forced surgeons to reflect on their wealth management status and look for a second
sourceofincomeaswell.
Objectives: The objectives of the study were to determine the effect of the COVID-19 pandemic on the personal finances of
orthopedicsurgeonsandgaugetheirknowledgeregardingthestockmarketasasecondsourceofincome.
Methods:AnonlinesurveywasconductedamongtheorthopedicsurgeonspracticinginMaharashtra,India.Thesurveyincluded
assessmentofdemographicdata,financialknowledge,knowledgeofthestockmarket,andwealthmanagementstatus.
Results: Most respondents (75.6%) were forced to think about the second source of income after the COVID-19 pandemic.
Seventy-ninepercentofsurgeonsfelttheneedfortrainingforinvestmentinstockmarkets.
Conclusion: Most of the respondents lack proper knowledge about funds management and retirement planning. This study
indicates a strong need for formal education of orthopedic surgeons in the field of personal finance, stock markets, and retirement
planning.
Keywords:COVID-19,orthopedicsurgeons,personalfinance.
Abstract
Submitted Date: 23 Nov 2021, Review Date: 25 Nov 2021, Accepted Date: 26 Nov 2021 & Published Date: 31 Dec 2021
Journal of Clinical Orthopaedics Published by Orthopaedic Research Group Volume 6 Issue 2 July-dec 2021 Page 08
© | | | | |
|

trainees with 0–5 years of experience,
and10(5.5%)hadanexperienceofmore
than 30 years. Eleven (6%) were
postgraduate students. The majority of
the respondents (45%) were in the
beginning phase of their orthopedic
careers(Figure1).
When asked if the COVID-19 pandemic
has forced them to think about another
source of income, a majority (75.6%) of
respondents agreed at the time of the
survey. A majority (55.5%) of the
surgeons in the survey are investing in <5
years and almost 50.7% of the
respondents are ready to save 11–30% of
theirincome.
Themajorityoftherespondentssaidthat
the stock market was a good source of
income, while 11.4% of the surgeons
considered it as gambling (Figure 2).
About 54% of the surgeons thought of
the stock market for investment
purposes. About 79.3% of the surgeons
feel the need for training for investment
in the stocks markets which show a
majority of the surgeons plan to manage
theirfinancesthemselvesandwillingness
to get trained. About 4.2% of the
respondents plan to hire a fund manager
ortheirwealthmanagement.
In this survey, the majority (64.4%) of
orthopedic surgeons think that the stock
market is a better option for investment
as compared to fixed deposits. The
majority (40.3%) said that the stock
market is a better option for investment
while 17.4% said it’s no better than
mutual funds. About 64.4% of
orthopedic surgeons considered the
market inflation while planning their
investment portfolio while 24.6% of the
participants did not. Only 11% of the
participants planned their retirement
adequately (Figure 4). The rest of the
orthopedic surgeons were taking
insufficientactionsfortheirretirement.A
majority (65.1%) of the respondents
understand the power of compounding
but have less knowledge of using it to
their advantage. About 46.9% of
orthopedic surgeons do not find
themselves good in their wealth
management while 22.6% never thought
of it (Figure 3). About 27.6% consider
themselves good while only 2.9% of
or thopedic surgeons consider
themselvesanexpert.
Discussion
The extent of financial knowledge is
quite limited among orthopedic
surgeons. Orthopedic surgeons carry a
vast amount of debt because of several
sourcessuchaseducationalloans,carand
home loans, hospital loans, instrument
loans, and credit card payments which
are comparable to other fields of
medicine as well [1, 2]. The idea of this
survey was to gauge the financial
www.jcorth.com
Kale S et al
© | | | | |
|
Figure 1: Demographic information of respondents of the survey
highlightingtheirageandyearsinpractice Figure2:Thoughtsofrespondentsaboutthestockmarket
Figure3:Proportionofsurveyrespondent’sthoughtsontheirwealth
managementstatus
Figure 4: Survey responses regarding wealth management, power of
computing,andretirementplanning

knowledge and status of orthopedic
surgeons.
During the COVID-19 pandemic, 54%
of the respondents thought about the
stock market which explains that there
was a reduction in income through
orthopedic practice in the initialphaseof
lockdownwhichdemandedthesurgeons
tothinkofthesecondsourceofincome.
Most of the respondents were ready to
save a significant amount of their income
and if it is invested in the stock market
through proper planning and at regular
intervals, a huge corpus can be made
available for retirement and recreational
purpose. Despite the knowledge of
compounding as a big factor for
investment, most of the respondents do
not consider it during their investment.
T i m e b e i n g a b i g f a c t o r f o r
compounding, most of the respondents
failed to reap the benefit as they started
saving late in their career because of lack
offinancialtraining.
Fixed deposits have an average interest
rateof3–6%whilethestockmarketgives
much higher returns as compared to
them. However, due to a lack of
knowledge and time, many surgeons end
up taking the route of fixed deposits
rather than other lucrative options. The
majority of orthopedic surgeons do not
know the difference between regular and
direct mutual funds. If they are made to
understand the difference, there will be
an increase in the returns by about 1% in
direct mutual funds which will make a
significant difference in the long-term
corpus creation. However, the fact is
mutual fund managers ultimately invest
the assets in the stock market for good
returns. Hence, if an investment is done
directly in the stock markets, one can
expect good returns provided, they have
theknowledgeofthesame.
There is no clear idea among surgeons
about insurance and investment and
many respondents have misinterpreted
insurance as an investment option. The
fact that Life Insurance Company gives
only6%long-termreturnswithoutmuch
liquidity in the invested amount as
compared to stock markets is unknown
to many respondents as they consider it
asagoodinvestment.
Most orthopedic surgeons have their
practice as the only source of income
which hardly covers the substantial debt
and prospects of future endeavors.
COV I D - 1 9 pan d em i c an d t h e
su b seq u ent l o c kd ow n f u r t h er
deteriorated this condition and forced a
lotoforthopedicsurgeonstorelyontheir
savingsandfallbackontheirrepayments.
The stock market has always been an
option for investment and earning but
many surgeons still consider it as
gambling because of a lack of proper
knowledge.
Even if the participants were not aware of
managing their wealth themselves, the
majority of them were aware of the term
inflation. The basis of investment and
returns is to beat the inflation of the
market. This lack of financial literacy is
further affecting their ability to manage
personal finances and worsens their
condition in such difficult times. Many
surgeons and trainees suffer due to a lack
of proper personal finance education
during their formative years, and
therefore, the majorit y of the
respondents feel the need for such
training.
The majority of them were aware of the
terms such as inflation, compounding,
and portfolio diversification but very few
of them are managing their portfolio
themselves.
According to the study, many orthopedic
surgeons are not receiving adequate
education in the field of finance due to
the lack of such medical training.
Orthopedic surgeons are already heavily
burdened and the effects of that burden
reach far beyond and affect not only
short-term stress and fatigue but also
future decisions regarding savings, loan
repayment, and retirement planning.
Initial education in financial planning
and a second source of future funding
contributes to better thinking and
financial stability in the first phase of
orthopedics [3, 4, 5, 6, 7]. Therefore, it is
necessary for an hour to schedule a
financial education drive among
orthopedic surgeons. The medical
curriculum should include other courses
aimed at increasing the financial
knowledge of surgeons so that they can
manage their finances effectively. The
importance of complex interest should
be taught as soon as possible to new
surgeons so that they can benefit and
improve their financial situation
significantly. Various decisions regarding
health insurance and long-term life
insurance should be made in the early
days of a person’s work and surgeons
should be informed of this during their
studies. Information on inflation,
cofinancing, liquid investments,
insurance, stock market, and real estate
investments can go a long way in
balancing the financial burden of new
graduates and motivating them to have a
secure and successful future as an
orthopedicsurgeon.
Conclusion
In a statewide survey of orthopedic
surgeons,wefoundthatsurgeonsdohave
interest in stock markets as a second
source of income and this need has
increased in the global pandemic
scenario.Duetoalackofproperfinancial
education, many orthopedic surgeons
are not being able to take advantage of
these alternative sources of income. In
conclusion, providing basic financial
educationtoorthopedicsurgeonsduring
theirearlyyearsisimportantandcangoa
long way in reducing their financial
burden and eventually making them
bettersurgeons.
www.jcorth.com
Kale S et al
© | | | | |
|

www.jcorth.com
Kale S et al
© | | | | |
|
References
Declarationofpatientconsent:Theauthorscertifythattheyhaveobtainedallappropriatepatientconsentforms.Intheform,thepatienthas
given his consent for his images and other clinical information to be reported in the Journal. The patient understands that his name and initials
willnotbepublished,anddueeffortswillbemadetoconcealhisidentity,butanonymitycannotbeguaranteed.
ConflictofInterest:NIL;SourceofSupport:NIL
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educational debt, and medical knowledge among internal
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2. Finney B, Mattu G. National family medicine resident survey.
Part 1: Learning environment, debt, and practice location. Can
Fam Physician 2001;47:117, 120, 126-8.
3. Jennings JD, Quinn C, Ly JA, Rehman S. Orthopaedic surgery
resident financial literacy:An assessment of knowledge in debt,
investment, and retirement savings.Am Surg 2019;85:353-8.
4. McKillip R, Ernst M, Ahn J, Tekian A, Shappell E. Toward a
resident personal finance curriculum: Quantifying resident
financial circumstances, needs, and interests. Cureus
2018;10:e2540.
5. Ramme AJ, Patel M, Patel KA, Montag WH, Schau AJ, Sabo SI,
et al. Personal finance primer for the future orthopaedic
surgeon: A starting point. JB JS Open Access
2021;6:e20.00006.
6. Cull WL, Katakam SK, Starmer AJ, Gottschlich EA, Miller AA,
Frintner MP. A study of pediatricians’ debt repayment a decade
after completing residency.Acad Med 2017;92:1595-600.
7. Connelly P, List C. The effect of understanding issues of personal
finance on the well-being of physicians in training. WMJ
2018;117:164-6.
Kale S, Chalak A, Dhar S, Chaudhari P, Singh S, Gunjotikar A. Financial
IgnoranceamongOrthopedicSurgeons:ASurveyInCOVID-19Era.Journalof
ClinicalOrthopaedicsJuly-Dec2021;6(2):08-11.
Conflict of Interest: NIL
Source of Support: NIL
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JOURNAL OF RESEARCH AND PRACTICE
ON THE MUSCULOSKELETAL SYSTEM
Journal of Research and Practice
on the Musculoskeletal System
Case Report
Primary Multi Drug Resistant Tuberculosis (MDR TB)
Osteomyelitis in Sternum associated with Xeroderma
Pigmentosa: A Case Report
Arvind Vatkar1
, Sachin Y. Kale1
, Shivam Mehra1
, Pramod Bhor2
, Aditya Gunjotikar1
, Nikhil R. Isaacs1
1
Department of Orthopaedics, Padmashree Dr. D. Y. Patil School of Medicine, Nerul, Navi Mumbai;
2
Terna Medical College, Nerul, Navi Mumbai
Introduction
A rare autosomal recessive genetic disease, Xeroderma
Pigmentosum (XP) starts in the childhood. Clinically, it
develops as cutaneous photosensitivity and pigmentary
changes in UV exposed areas of the body1
. DNA damage that
is unrepaired and unresolved by the mutated XP genes leads
to an increased risk of development of cancer2
. Continued
exposure to UV radiation may lead to development of skin
cancer1
. In 30% of XP patients, there is also development
of neurological disorders with more chances for CNS
neoplasms3,4
. Patients with XP have reduced interferon IFN-γ
production, lower natural killer (NK) cell activation, and less
circulating T cell numbers. These NK cells and T cells are
important in preventing infection and neoplasm5-8
. The ratio
of CD3+ to CD4+ circulating lymphocyte is reduced in XP8
.
Studies have shown the role of an inhibitory serum factor
to Phytohemagglutinin (PHA) stimulation in XP patients
which might cause a serious hampering of the delayed
hypersensitivity response6
.
Activated macrophages are the main effector cells
involved in the elimination of M. tuberculosis. This activation
of macrophages is clearly led by lymphocyte products,
mainly IFN-γ, and proinflammatory cytokines like TNF-α10
.
Delayed hypersensitivity is a major mechanism of defense
against many intracellular pathogenic organisms. These
include mycobacteria, fungi, and certain parasites11
.
Immunodeficiency in XP patients is not only associated
with increased chances of neoplasms, but also increased
susceptibility to infections like tuberculosis.
Case Presentation
A ten-year-old child suffering from XP (Figure 1), started
having pain in sternum. Patient had constitutional symptoms
of weight loss and loss of appetite. Patient got excoriation
on skin near sternal notch. This developed into a non-healing
ulcer.Laterhestartedhavingswellinginrightpectoralregion
Abstract
Xeroderma Pigmentosa (XP) is an autosomal recessive genetic disorder which causes defective gene repair. This
makes XP patients cancer-prone and immunodeficient. A 10-year-old male child with XP was infected with MDR
Tubercular Osteomyelitis of sternum. He had constitutional symptoms of TB like weight loss and loss of appetite.
He had also developed an abscess in his right pectoral muscles. MRI was done to find out exact location and spread
of infection. The abscess was aspirated by Z technique and sent for a Gene Xpert test. Patient was started on
second line of anti-tubercular therapy. MDR TB is a growing challenge to treat with anti-tubercular therapy. The
link of genetic disorders like XP and infections like TB (which increase in immuno-deficient subjects) needs to be
studied further.
Keywords: Immunodeficiency, Multidrug resistant Tuberculosis, Pectoral muscle cold abscess, Xeroderma Pigmentosa
The authors have no conflict of interest.
Corresponding author: Shivam Mehra, Department of
Orthopaedics, Padmashree Dr. D. Y. Patil School of
Medicine, Nerul, Navi Mumbai
E-mail: drshivammehra@gmail.com
Edited by: Konstantinos Stathopoulos
Accepted 6 December 2021
Published
under
Creative
Common
License
CC
BY-NC-SA
4.0
(Attribution-Non
Commercial-ShareAlike)
10.22540/JRPMS-06-014 14
JRPMS | March 2022 | Vol. 6, No. 1 | 14-19

15
MDR TB Osteomyelitis with Xeroderma Pigmentosa: A Case Report
JRPMS
which gradually increased in size in 5 months’ time. (Figure
2). He was investigated with blood tests, chest X-ray (Figure
3), CT scan (Figure 4) and Ultrasound scan (Figure 5).
The swelling in pectoral region was fluctuant and no local
warmth or gross tenderness on swelling was appreciated.
The nodes were non tender, painless, matted and adherent
to the underlying structures. No other lymphadenopathy was
found on examination.
The patient was found to be anemic with hemoglobin of
8.9 gm/dl and total leucocyte count was 7900/mm3
. His
ESR (Erythrocyte sedimentation rate) had raised to 110
mm/hr. HIV ELISA test was negative (Table 1). Ultrasound
showed a large abscess of 57 cc which extended from the
sinus in suprasternal region to right anterior chest wall. A
plain and post contrast CT scan showed 8 cm x 6.2 cm x 2
cm in sternal region. The abscess extended into the right
pectoralis muscle. There was destruction of manubrium with
sclerosis. Serum Albumin was deficient with level of 2.5
gm%. Rest all liver function tests and renal function tests
were normal.
The patient was aspirated by a 16-gauge needle by
Z-track technique (to prevent sinus tract formation). 6
ml of thick pus was aspirated. The pus was sent for MGIT
(Mycobacteria growth indicator tube) test and Gene Xpert
test along with culture and sensitivity. All methods detected
Multi drug resistant TB with low grade rifampicin resistance.
No surgery was performed on the patient. Patient was
started on second line of anti-tubercular therapy based on
protocols set by RNTCP in India (Table 2). The drug regimen
for the patient was as follows:
Intensive Phase: Km Eto Cs Z Lfx E (6 months)
Figure 1. Skin manifestations of Xeroderma Pigmentosa (XP).
Figure 2. Non-healing ulcer on sternal end and large pectoral cold
abscess swelling.

JRPMS
16
A. Vatkar et al.
Continuous Phase: Lfx Eto Cs E (18 months)
The patient healed in 11 months with no side effects of the
medications.
Discussion
Our case is the first case of Primary extrapulmonary
multi-drug resistant tuberculosis in a patient suffering from
XP. Xeroderma pigmentosum (XP) has some typical clinical
features. Those include sensitivity to the sun (extreme
sunburn with blistering, constant erythema on mild sun
exposure) with marked freckle-like pigmentation of the
face before two years of age in most affected individuals.
These patients suffer from sunlight-induced ocular problems
including photophobia, keratitis, and atrophy of the skin of
Figure 3. X-Ray AP and Lateral view of Chest.
Figure 4. CT scan images showing a collection in sternal region extending up to right pectoral region.

17
JRPMS
the lids (Figure 1). Due to defective DNA repair mechanisms,
there is enhanced risk of sunlight-caused cutaneous
neoplasms (squamous cell carcinoma, basal cell carcinoma,
and melanoma) in XP patients. Eight different gene
mutations are involved in XP. The clinical symptoms usually
vary depending on the specific gene involved3,4
. Defect in
Nucleotide Excision Repair (NER) is a result of mutation of
seven genes (XPA-XPG). The eighth gene mutation (XPV)
results in defective DNA polymerase η. This failure to repair
DNA damage caused by UV radiations causes a higher
risk for developing cancer4
. The diagnosis of XP should be
suspected in patients who have immune abnormalities and
history of persistent sunburn to mild exposure of sunlight or
UV radiation. Patients of XP who suffer from repeated viral
or bacterial infections should be evaluated for cellular and
humoral immune deficiencies5
.
Xeroderma Pigmentosa is a rare condition. Its prevalence
is of 1 in million in USA and 2.3 in million in Western
Europe. In Japan, the prevalence is as high as up to 45 per
million13
. A high incidence of XP has been seen in the Middle
East and North Africa. The plausible cause is wide-spread
consanguinity in certain communities and the recessive
Figure 5. USG of the chest wall showing collection on 57 cc pus collection in right anterior chest wall.
Serological markers investigated Patient’s Values
HIV Negative
HCV Negative
HBsAg Negative
ESR 110 MM/hrs
CRP 22 mg/L
HIV: Human Immunodeficiency virus; HCV: Hepatitis C virus; HBsAg:
Hepatitis B surface Antigen; ESR: Erythrocyte sedimentation rate;
CRP: C-reactive protein.
Table 1. Patient serological markers at the time of presentation.

JRPMS
18
A. Vatkar et al.
inheritance of the disease12,13
.
Differential diagnosis of Xeroderma Pigmentosa
includes various autosomal dominant diseases like Leopard
syndrome, Peutz-Jeghers syndrome, Cockayne syndrome,
and Carney complex14
. Wysenbeek et al. found that there
was significant decrease in the T4 positive lymphocyte
subpopulation. This kind of decrease is seen often in acute
viral infections in agammaglobulinemic patients15
, AIDS
(acquired immunodeficiency syndrome)16
, after irradiation17
and after immunosuppressive therapy18
.
The estimated incidence of Tuberculosis in India was 2.1
million cases in 2013 out of which 16 percent were new
extra-pulmonary TB cases, that is, 336,000 people with
extra-pulmonary TB19
. A meta-analysis of the prevalence of
MDR-TB in India found it to be 35 percent20
in comparison
to 11.6 percent found in the National level Survey21
. Extra-
Pulmonary TB accounts for 10-20% of global TB cases. The
incidence of Extra-Pulmonary TB and disseminated forms
of TB increases with worsening immunosuppression22,23
.
TB is more prevalent in populations with immunodeficiency
especially antigen-specific T-cell immunity. Also, Major
Histocompatibility Complex (MHC) 1 and 2 play role in
protection against TB19
.
Our case is the first reported case of Primary Extra-
pulmonary multi-Drug resistant Tuberculosis in a patient
suffering from Xeroderma Pigmentosa.
Conclusion
The prognosis of MDR TB in XP patients is not known in
detail. In many parts of the world, MDR TB is posing a serious
threat to success of antibiotic therapy. More research to
explain the intricate correlation between immunity and
infections can help us formulate better adjuvant therapies
like vaccines and gene therapy. These could be new ways to
tackle the emerging MDR TB wave.
References
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pigmentosum: an inherited disease with sun-sensitivity, multiple
cutaneous neoplasms and abnormal DNA repair. Ann Intern Med
1974;80:221–248.
2. Kraemer KH, Patronas NJ, Schiffmann R, Brooks BP, Tamura D,
DiGiovanna JJ. Xeroderma pigmentosum, trichothiodystrophy and
Cockayne syndrome: a complex genotype–phenotype relationship.
NeuroSci 2007;145(4):1388-96.
3. KraemerKH,LeeMM,ScottoJ.Xerodermapigmentosum:cutaneous,
ocular, and neurologic abnormalities in 830 published cases. Arch
Dermatol 1987;123(2):241-50.
4. Lehmann AR, McGibbon D, Stefanini M. Xeroderma pigmentosum.
Orphanet J Rare Dis 2011;6(1):1-6.
5. Goldstein B, Khilnani P, Lapey A, Cleaver JE, Rhodes AR. Combined
immunodeficiency associated with xeroderma pigmentosum.
Pediatric Dermatol 1990;7(2):132-5.
6. Wysenbeek AJ, Weiss H, Duczyminer-Kahana M, Grunwald MH, Pick
AI. Immunologic alterations in xeroderma pigmentosum patients.
Cancer 1986;58(2):219-21.
7. Gaspari AA, Fleisher TA, Kraemer KH. Impaired interferon production
and natural killer cell activation in patients with the skin cancer-prone
disorder, xeroderma pigmentosum. J Clin Invest 1993;92(3):1135-
42.
8. Mariani E, Facchini A, Honorati MC, Lalli E, Berardesca E, Ghetti P,
MarinoniS,NuzzoF,RicottiGA,StefaniniM.Immunedefectsinfamilies
and patients with xeroderma pigmentosum and trichothiodystrophy.
Clin Exp Immunol 1992;88(3):376-82.
9. Doğru D, Kiper N, Ozçelik U, Yalçin E, Tezcan I. Tuberculosis in
children with congenital immunodeficiency syndromes. Tuberk
Toraks 2010;58(1):59-63.
10. Van Crevel R, Ottenhoff TH, Van Der Meer JW. Innate immunity to
Mycobacterium tuberculosis. Clin Microbiol Rev 2002;15(2):294-
309.
11. Osita EC, Philip BD, Harrison GT, Sylvester NC, Okechukwu EC.
Effects of Lactobacillus spp. isolated from the sap of palm tree
Elaeis guineensis (palm wine) on cellular and innate immunity. Afr J
Microbiol Res 2019;13(2):33-9.
12. Kleijer WJ, Laugel V, Berneburg M, Nardo T, Fawcett H, Gratchev
A, Jaspers NG, Sarasin A, Stefanini M, Lehmann AR. Incidence of
DNA repair deficiency disorders in western Europe: Xeroderma
pigmentosum, Cockayne syndrome and trichothiodystrophy. DNA
Repair (Amst) 2008;7(5):744-50.
13. Kraemer KH, DiGiovanna JJ. Xeroderma Pigmentosum. 2003 Jun
20 (updated 2014 Feb 13). GeneReviews^{(R)} $(Internet). Seattle
(WA): University of Washington 1993;2016.
14. DiGiovanna JJ, Kraemer KH. Shining a light on xeroderma
pigmentosum. J Invest Dermatol. 2012 Mar 1;132(3):785-96.
15. Reinherz EL, Schlossman SF. The differentiation and function of
human T lymphocytes.
16. Fauci AS, Macher AM, Longo DL, Lane HC, ROOK AH, MASUR H,
GELMANNEP.Acquiredimmunodeficiencysyndrome:epidemiologic,
clinical, immunologic, and therapeutic considerations. Ann Int Med
1984;100(1):92-106.
17. Petrini BJ, Wasserman J, Blomgren H, Rotstein S. T helper/
suppressor ratios in chemotherapy and radiotherapy. Clin Exp
Immunol 1983;53(1):255.
18. DupontE,SchandenéL,DevosR,LambermontM,WybranJ.Depletion
of lymphocytes with membrane markers of helper phenotype: a
feature of acute and chronic drug-induced immunosuppression. Clin
Exp Immunol 1983;51(2):345.
19. World Health Organization. Tuberculosis control in the South-East
Asia region: annual TB report 2014.
20. Charan J, Tank N, Reljic T, Singh S, Bhardwaj P, Kaur R, Goyal JP,
Kumar A. Prevalence of multidrug resistance tuberculosis in adult
patients in India: A systematic review and meta-analysis. J Family
Antibiotics Dosage
Kanamycin; Km 250 µg OD ATD
Ethionamide; Eto 250 µg OD
Cycloserine; Cs 250 µg OD
Levofloxacin; Lfx 250 µg OD
Ethambutol; E 400 µg OD
Pyrazinamide; Z 500 µg OD
Table 2. Antibiotics and their dosage as administered to the patient.

19
JRPMS
Med Prim Care 2019;8(10):3191.
21. Central TB Division. TB India Revised National Tuberculosis Control
Programme: annual status report 2017.
22. India TB. RNTCP Status report. Central TB Division, Directorate
General of Health Services, Ministry of Health and Family Welfare,
Nirman Bhawan, New Delhi.
23. Harries A D, Hargreaves N J, Kwanjana J H, Salaniponi F M. Clinical
diagnosis of smear-negative pulmonary tuberculosis: an audit of
diagnostic practice in hospitals in Malawi. Int J Tuberc Lung Dis
2001;5(12):1143-7.

Vol.:(0123456789)
1 3
Indian Journal of Orthopaedics
https://doi.org/10.1007/s43465-022-00669-6
ORIGINAL ARTICLE
Ilizarov Ankle Arthrodesis: A Simple Salvage Solution for Failed
and Neglected Ankle Fractures
Ajit Chalak1
· Sushmit Singh1
· Ashok Ghodke2
· Sachin Kale1
· Javed Hussain1
· Ronak Mishra1
Received: 7 April 2022 / Accepted: 23 May 2022
© Indian Orthopaedics Association 2022
Abstract
Background Infection around the ankle joint after fracture fixation, or septic arthritis with active discharging sinuses is
often challenging to manage with conventional procedures of arthrodesis. The Ilizarov method of arthrodesis gives a better
alternative for salvage in such cases.
Methods This was a retrospective study including 20 patients who were subjected to tibiotalar arthrodesis with Ilizarov
method. The major pathologies included internal fixation of ankle fractures complicated by infection, posttraumatic infected
ankle arthritis, and osteomyelitis. The patients were evaluated on the basis of Association for the Study and Application of
the Method of Ilizarov (ASAMI) criteria. The aim of the surgery was to achieve plantigrade, stable, and painless foot with
no signs of infection.
Results A total of 20 patients were operated and reviewed at our institute. The study comprised of 15 male and 5 female
patients with a mean age of 43.9 years (range 33–55 years). Out of 20 patients, 4 patients had complications of pin-tract
infection and one had wire breakage of the forefoot ring. According to the ASAMI criteria, 17 patients had excellent bone
scores and 18 patients had good functional scores. Union was achieved in all patients with resolution of infection and the
mean limb length discrepancy was 1.92 cm (range 1–2.5 cm).
Conclusions The Ilizarov fixator for ankle arthrodesis provides an excellent way for strong bone fusion, infection eradication,
early weight-bearing, and the added benefits of compression at the arthrodesis site post-operatively.
Keywords Ankle arthrodesis · Ilizarov frame · Infection
Introduction
Ankle fractures with infection following fracture fixation are
difficult to manage due to the superficial nature of the joint,
poor soft-tissue cover around the ankle joint, and skin
defects following debridement. Additionally, subluxation of
the joint after implant removal further complicates the treat-
ment in patients with previous fixation of ankle fractures.
Patients with advanced age and associated comorbidities
also have wound healing complications.
Ankle arthrodesis has been recognized as one of the
standard procedures for salvaging ankle joints in advanced
cases of degeneration with associated comorbidities [1–5].
Conventional methods of internal fixation for ankle arthro-
desis are often difficult to use in the presence of infection
and the Ilizarov method serves as a good modality of treat-
ment [6].
Tibiotalar arthrodesis serves as one of the most com-
monly performed arthrodesis around the ankle joint [7–10].
Though we have made significant advances in the form of
arthroscopy, arthroplasty, and arthrodiastasis, ankle arthro-
desis still acts as the gold standard for end-stage disease
[11]. There are various indications for arthrodesis, including
post-traumatic degeneration, infection, rheumatoid arthritis,
tumors, and neuromuscular conditions [11, 12].
Ankle joint presents with numerous difficulties as the
amount of cases with joint destruction after complicated
fractures are on the rise [10, 13, 14]. Incidence of chronic
infections, bone defects, limb length discrepancy, soft-tissue
* Sushmit Singh
sushmit.singh@dypatil.edu
1
Department of Orthopaedics, Dr. D Y Patil Medical
College and Hospital, Sector 7, Nerul, Navi Mumbai,
Maharashtra 400706, India
2
Department of Orthopaedics, MGM Medical College
Hospital, Kamothe, Navi Mumbai, India

1 3
loss, and joint abnormalities are quite challenging and dif-
ficult to treat [13, 14]. Amputation may present as the last
resort for patients with failed arthrodesis, and therefore,
fusion procedures should be thoroughly evaluated to prevent
inadequate results.
The Ilizarov device is a flexible external fixator that per-
mits dynamic and multidirectional stresses to be applied.
The ability to alter the alignment of the hindfoot and forefoot
after the surgery by repositioning the frame as required is
a distinct benefit of the Ilizarov technique, allowing for the
rectification of intraoperative errors or early postoperative
loss of position. These advantages significantly improve the
outcome of the surgery and are quite helpful in the correc-
tion of malalignment, providing an improved level of activ-
ity, and pain management.
The aim of this study was to evaluate the outcomes of
arthrodesis of the tibiotalar joint using a relatively simple
Ilizarov ring fixator frame.
Materials and Methods
Twenty ankle (tibiotalar) arthrodesis performed at our insti-
tute between May 2017 and May 2019, and followed up on
until October 2021 utilizing the Ilizarov external fixator
were evaluated retrospectively. The study comprised 15
men and 5 women ranging in age from 33 to 55 years at
the time of arthrodesis. Fourteen individuals had their right
ankle arthrodesed, whereas 6 had their left ankle arthrodesed
(Table 1).
All patients had a history of trauma. The causal pathol-
ogy in most of the patients was post-traumatic infection with
active discharging sinus. Eighteen patients had a history of
open reduction and internal fixation for bimalleolar ankle
fractures and osteoarthritis, and the remaining two patients
took conservative treatment for bimalleolar fractures. Most
of the patients were previously operated on an average of 1.3
(range 0–4) times. The previous surgical procedures were
in the form of external fixation, open reduction and internal
fixation with implant in situ, bone grafting, revision surgery
for wound management, implant removal, and soft-tissue
defect. The primary aim of Ilizarov frame arthrodesis was to
obtain a painless and solid plantigrade foot and to eradicate
existing infection.
Operative Procedure
The medial and lateral approaches were used to open the
ankle joint. In instances where prior incision scars and dis-
charging sinuses were evident, the incision was modified.
To minimize wound problems, full-thickness subperiosteal
skin flaps were raised. If implants were present, they were
removed. Debridement was performed and joint synovium
was excised.
The distal 5 cm of the fibula was removed, exposing the
articular surface of the ankle joint. The medial malleolus
was removed at the tibial plafond level. The articular surface
of the tibia was cut perpendicular to the long axis of the tibia
with an oscillating saw. Talar dome articular cartilage was
sliced parallel to the tibial cut. In neutral flexion and 10°–15°
of external rotation, the cancellous surfaces of the tibia and
talus were opposed to each other with no varus or valgus
angulation. The opposing ends were secured in position and
two 3 mm K-wires were passed across the ankle joint.
A simple preconstructed Ilizarov frame design with two
full and one 5/8th ring connected with 4 rods between each
other was slid over the leg (Fig. 1). The desired position of
the frame over leg was maintained by keeping folded towels
between leg and ring. 2 full rings were fixed to the tibia
perpendicular to its axis using Schanz screws and wires.
The level of the 5/8th ring was adjusted at the level of the
calcaneum. Two crossing olive wires were passed in the cal-
caneum opposing each other and were tensioned up to 60 kg.
A Schanz screw was passed using a one-hole Rancho cube
from the posterior aspect of the heel into the calcaneum
pointing towards the cuboid under IITV (Image intensifying
TV system) guidance. One drop wire was passed through the
talus and connected to the calcaneal ring using male posts.
One 5/8th ring was put in the forefoot at the level of
the metatarsal neck using two olive wires. One wire from
the inferomedial aspect of the 1st metatarsal neck and the
another olive wire from the posterolateral aspect of the 5th
metatarsal neck incorporating the 3rd and 4th metatarsal.
The forefoot ring was connected to the calcaneal ring
using simple hinges and coupled washers with two rods over
medial and lateral aspect. The forefoot ring was also con-
nected to the distal tibial ring using hinges and coupled
washers with one connecting rod (Figs. 2, 3, 4).
After all the connections were put in, the K-wires which
were used to hold the arthrodesis in position were removed.
Table 1 Patient demographics
Total patients 20
Mean age (range) 44.75 (33–68) years
Gender (male:female) 15:5
No. of previous surgeries
Mean (range)
1.3 (0–4)
Duration of Ilizarov frame application
(months)
Mean (range)
22.9 (18–34) weeks
Duration of follow-up
Mean (range)
39.4 (26–52) months
Postoperative limb length discrepancy
Mean (range)
1.9 (1–2.5) cm

1 3
Fig. 1 Schematic diagram of
a ankle and hindfoot Ilizarov
frame with forefoot rings for
ankle arthrodesis. The arrows
show the direction of compres-
sion. b Hindfoot component of
the ankle frame. c Location and
direction of wires in the meta-
tarsals for forefoot extension of
the frame
Fig. 2 Case 1 Illustration. 68 Year female with history of bimalleolar fracture and four revision surgeries. a Preoperative X-rays of ankle joint. b
Preoperative clinical pictures of ankle (lateral view). c Preoperative clinical pictures of ankle (medial view)

1 3
Corticotomy for lengthening was not done in any patient
undergoing surgery as all of them were counseled preopera-
tively about shortening up to 1 inch. The goals of the surgery
were to get a plantigrade, stable, and painless foot without
any infection.
Postoperative Protocol
All patients are permitted to walk with a walker and modi-
fied footwear with weight-bearing as tolerated. The patient
and a relative were both educated on pin-tract care and
compression techniques. The fixator was used to compress
the arthrodesis site for 10 days at a pace of 1 mm/day
divided into four times. The arcing of wires in the talus
and calcaneum was used to ensure that the arthrodesis site
was adequately compressed. CRP levels were measured
every 2 weeks until the wound healed and normal values
were reached. Patients were seen as outpatients once a
month. After radiological healing was confirmed, fixators
were dynamized and patients were permitted to walk for
another 3–4 weeks. After the fixator was removed, a plaster
slab was applied for 2 weeks. After the pin tracts and skin
wounds healed, a below-knee cast was applied for 6 weeks.
Following that, a shoe raise with a rocker bottom sole was
given.
Fig. 3 Case 1 Illustration. a Immediate postoperative X-rays. b Immediate postoperative clinical picture. c Clinical picture after complete heal-
ing of wounds
Fig. 4 Case 1 Illustration. a Postoperative X-rays (1-year follow-up). b Clinical pictures after frame removal

1 3
Results
In our study, 20 patients were operated for ankle arthrode-
sis with the Ilizarov fixator frame. Patient age ranged from
33 to 68 years with an average of 44.75 years. 14 patients
out of 20 had active osteomyelitis and the average number
of previous surgeries done were 1.3 ranging from 0 to 4.
The external fixation time averaged 22.9 (range 18–34)
weeks. The average postoperative limb length discrepancy
(LLD) was 1.9 cm (range 1–2.5 cm) and all the patients
were given an appropriately sized shoe raise as none of the
patients opted for bone lengthening. The average period
of follow-up for all patients was 39.4 (26–50) months.
Bony union was achieved in all patients (100%) at the
end of the study (Fig. 5). After fusion, patients reported
either no pain or mild discomfort, all could walk indepen-
dently without assistance, and all were satisfied with the
procedure.
On the basis of ASAMI (Association for the Study and
Application of the Methods of Ilizarov) criteria, 17 patients
had excellent bone scores, 2 as good and 1 as fair. (Table 2).
18 patients had good ASAMI functional scores with
the remaining two as fair (Table 3). Because the ASAMI
functional score included ankle range of motion, the maxi-
mum attainable function score for the fusion group was
“good”.
Complications occurred in six patients, with four devel-
oping pin-tract infections which healed after oral antibiotics,
repeated dressing, and wound care, and one patient had wire
breakage of the forefoot ring.
Discussion
Ankle arthrodesis can be performed utilizing a variety
of techniques, including external fixator compression
[15, 16], internal fixation with plates or screws [17–19],
Fig. 5 Case 2 Illustration. 60 Year male with history of trauma to ankle joint 1 year back. a Preoperative X-rays of ankle joint. b Immediate post-
operative X-rays ankle joint. c Postoperative X-rays after 1-year follow-up. d Clinical pictures after 1-year follow-up
Table 2 ASAMI criteria (bone result)
LLD limb length discrepancy
Bone result Number of patients Criteria
Excellent 17 (85%) Union, no infection, deformity<7°, LLD<2.5 cm
Good 2 (10%) Union plus any two of the following: absence of infection, deformity<7°, LLD<2.5 cm
Fair 1 (5%) Union plus any one of the following: absence of infection, deformity<7°, LLD<2.5 cm
Poor 0 Nonunion/refracture/union plus infection plus deformity>7° plus LLD>2.5 cm

1 3
intramedullary fixation [20], and arthroscopic ankle fusion
[21]. Charnley was the first to describe the use of exter-
nal fixation for ankle fusion [22]. The fixators employed
were monopolar, and there were numerous difficulties such
as motion at the fusion site, malunion, and delayed union.
This led to the development of triangular frames to improve
fixation and provide multiplanar compression [15, 23].
The Ilizarov ring fixator has distinct benefits over conven-
tional fusion methods, making it an excellent fixing tool in
patients with severe ankle pathologies [10, 16, 24]. These
include dynamic axial fixation, which keeps bone contact
without the need for additional bone grafting, excellent
bending, shear, and torsional stability, which allows for
early weight-bearing and reduces pin-tract infection, and
great modularity with circumferential mechanical control,
which allows for postoperative adjustments that are impos-
sible with nails, screws, or plates. Ilizarov wires applied per-
cutaneously can offer stable fixation in osteoporotic bones.
Furthermore, arthrodesis can be performed as a one-stage
procedure in the presence of active infection. Bony fusion
can also be improved by gradually compressing the fusion
site.
Hammerschlag achieved substantial fusion in all ten
of his patients, including two who had previously failed
arthrodesis, utilizing a basic two-ring circular frame [16].
Yanuka et al. conducted Ilizarov arthrodesis on six patients
suffering from posttraumatic arthrosis both with and without
infection. All patients had a painless fusion between 7 and
15 weeks [25].
In our study, we have fixed the arthrodesis provisionally
with thick K-wires and used a simple preconstructed frame
that was slid over the leg. The fixator rings were used as a
reference guide to put the fixation elements. The elements
were fixed to the rings without any stress on the components.
The removal of malleoli allowed us to close the skin flaps
without much tension as we got redundant skin post-removal
of malleoli. We were able to achieve gradual compression
over the fixator postoperatively till we saw arcing of talar or
calcaneal wire.
Complications are a part of every procedure and ankle
arthrodesis with an Ilizarov fixator also presents some.
Pin-tract infections and non-union are the most frequent
complications which can be reduced with proper care of pin-
tract, weight-bearing, and sufficient compression at the fusion
site. Joint infection and necrosis of the talus have been cited as
the main causes of non-union [15]. Other risk factors include
smoking, medical comorbidities, and insufficient compression
[15, 26].
Ilizarov ring fixation provides the advantage of permitting
early weight-bearing and has been indicated in situations with
severe ankle joint disease and when bone quality is impaired
to the point where adequate screw thread purchase is doubtful.
Furthermore, external ring fixation allows for post-operative
correction of bone alignment and joint compression.
Conclusion
Ilizarov fixator should be considered as an important tool for
arthrodesis in failed ankle fractures, Charcot joint, and arthri-
tis of ankle joint especially in presence of infection when the
other methods of internal fixation are difficult to consider.
Ilizarov ring fixator has an advantage over the other external
fixators for better control of axial and torsional forces, better
hold in osteoporotic bones, and hence providing stable fixation
which would aid in early healing of fusion site.
Declarations
Conflict of Interest Ajit Chalak, Sushmit Singh, Ashok Ghodke,
Sachin Kale, Javed Hussain, and Ronak Mishra declare that they have
no conflict of interest.
Ethical Standard Statement This article does not contain any studies
with human or animal subjects performed by the any of the authors.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
References
1. Fragomen, A. T., Borst, E., Schachter, L., Lyman, S., & Rozbruch,
S. R. (2012). Complex ankle arthrodesis using the Ilizarov method
yields high rate of fusion. Clinical Orthopaedics and Related
Research, 470, 2864–2873.
Table 3 ASAMI criteria (functional result)
RSD Reflex Sympathetic Dystrophy
Functional result Number of patients Criteria
Excellent 0 Active, no limp, minimum stiffness (loss of<15° knee extension/<15° ankle
dorsiflexion), no RSD, insignificant pain
Good 18 (90%) Active, with one or two of the following: limp, stiffness, RSD, significant pain
Fair 2 (10%) Active, with three or all of the following: limp, stiffness, RSD, significant pain
Poor 0 Inactive (unemployment or inability to return to daily activities because of injury)

1 3
2. Rabinovich, R. V., Haleem, A. M., & Rozbruch, S. R. (2015).
Complex ankle arthrodesis: review of the literature. World J
Orthop, 6, 602–613.
3. Siebachmeyer, M., Boddu, K., Bilal, A., Hester, T. W., Hardwick,
T., Fox, T. P., et al. (2015). Outcome of one-stage correction of
deformities of the ankle and hindfoot and fusion in Charcot neu-
roarthropathy using a retrograde intramedullary hindfoot arthro-
desis nail. Bone Jt J, 97-B, 76–82.
4. Perlman, M. H., & Thordarson, D. B. (1999). Ankle fusion in a
high risk population: an assessment of nonunion risk factors. Foot
and Ankle International, 20, 491–496.
5. Christian, C. A., & Donley, B. G. (1998). Arthrodesis of ankle,
knee, and hip. In S. T. Canale (Ed.), Campbell’s operative ortho-
paedics (9th ed., pp. 145–187). St. Louis: Mosby-Year Book.
6. Ogut, T., Glisson, R. R., Chuckpaiwong, B., Le, I. L., & Easley,
M. E. (2009). External ring fixation versus screw fixation for ankle
arthrodesis: a biomechanical comparison. Foot and Ankle Inter-
national, 30, 353–360.
7. Hagen, R. J. (1986). Ankle arthrodesis: problems and pitfalls.
Clinical Orthopaedics, 170, 184.
8. Iwata, I., & Norimassa, Y. (1980). Arthrpdesis of the ankle
joint with rheumatoid arthritis: experience with the transfibular
approach. Clinical Orthopaedics, 153, 189.
9. Lance, E. M., Paval, A., & Fries, I. (1979). Arthrodesis of the
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(1994). The Ilizarov technique in ankle fusion. Clinical Orthopae-
dics and Related Research, 303, 217–225.
11. Kalish, S., Fleming, J., & Weinstein, R. (2003). External fixators
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tions. Clinics in Podiatric Medicine and Surgery, 20, 65–96.
12. Mann, R. A., Van Manen, J. W., Wapner, K., & Martin, J. (1991).
Ankle fusion. Clinical Orthopaedics, 268, 49–55.
13. Sakurakichi, K., Tsuchiya, H., Uehara, K., et al. (2003). Ankle
arthrodesis combined with tibial lengthening using the Ilizarov
apparatus. Journal of Orthopaedic Science, 8, 20–25.
14. Yanuka, M., Krasin, E., Goldwirth, M., Cohen, Z., & Otrem-
ski, I. (2000). Ankle arthrodesis using the Ilizarov apparatus:
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297–300.
15. Berman, A. T., Bosacco, S. J., Yanicko Jr, D. R., & Raisis, L. W.
(1989). Compression arthrodesis of the ankle by triangular exter-
nal fixation: an improved technique. Orthopedics, 12, 1327–1330.
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external fixator. Techniques in Orthopaedics, 11, 263–268.
17. Braly, W. G., Baker, J. K., & Tullos, H. S. (1994). Arthrodesis of
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A Unique Case of Recurrent Osteochondroma Enclosing Brachial Artery in a 13-
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1 1 1 1 1
Sachin Yashwant Kale , Shivam Mehra , Aditya Gunjotikar , Raju Patil , Pratik Dhabalia ,
1
Sushmit Singh
Introduction ThereareuniquechallengesindiagnosisandtreatmentofOCEs
of the proximal humerus. One can be predisposed to tendinitis,
tendon ruptures, limitations of shoulder motion, and
neurovascular compression depending on their proximity to
important structures [6, 7, 8, 9]. Furthermore, additional
complicationscanoccurduetosurgicalexcisionofsymptomatic
OCEs, such as brachial artery pseudoaneurysm, constant pain,
and improper resections leading to recurrence. To avoid
recurrence, wide resection is done, and the whole cartilage cap
and bone are removed from the base, after which the whole base
is cauterized using electric cauterization [10, 11, 12]. Most data
concerning surgical treatment of proximal humerus OCE are
based on case reports or small case series, particularly in the
skeletallyimmaturepatient[10].
Osteochondromas (OCEs) are the most common benign
tumors arising on the external surface of the bone with aberrant
cartilage [1, 2, 3]. OCEs account for 20–50% of benign bone
tumorsand9%ofallbonetumors[1,2,3].Mostofthesetumors
(85%) are solitary and nonhereditary in nature, while
approximately 15% of these tumors are hereditary multiple
OCEs [1, 2, 3]. Diagnosis of OCE involves presence of a capped
cartilage and cortical and medullary continuity with the parent
bone [3, 4]. Many of the patients are asymptomatic, thoughpain
can be a clinical feature due to neural irritation, bursitis,
mechanical irritation, fractures, osseous deformities, and
malignantchanges[3,5].
Author’s Photo Gallery
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DOI:10.13107/jocr.2022.v12.i03.2726
77
Keywords:Recurrentosteochondroma,proximalhumerus,brachialartery.
Introduction: Osteochondromas (OCEs) are benign chondrogenic lesions arising on the external surface of the bone with aberrant cartilage
(exostosis) from the perichondral ring that may contain a marrow cavity also. In few cases, depending on the anatomical site affected, different
degrees of edema, redness, paresthesia, or paresis can take place due to simple contact or friction. Furthermore, depending on their closeness to
neurovascular structures, the procedure of excision becomes crucial to avoid recurrence. We report a unique case of recurrent OCE of the
proximalhumerusenclosingthebrachialarterywhichmakesforanimportantcaseandproceduretoensurethatnorelapseoccurs.
Case Report: We report a unique case of a 13-year-old female who had presented with a history of pain and recurrent swelling for 5 years. The
swellingsizewas4.4cm×3.7cm×4cmwithaprevioushistoryofswellingatthesamesiteoperatedin2018.
Conclusion:ThiscasereportdemonstratesthatwhenpresentedwithacaseofrecurrentOCEoftheproximalhumerus,doingproperexcisionof
thetumoriscrucialtopreventitsrelapse.
Abstract
Dr. Shivam Mehra Dr. Aditya Gunjotikar Dr. Raju Patil Dr. Pratik Dhabalia
Dr. Sachin Yashwant Kale
Learning Point of the Article:
Osteochondroma,ifnotexcisedproperlycanrecurinvolvingtheneurovascularbundle,andthus,itsproperexcisionbecomesverycrucial.
A Unique Case of Recurrent Osteochondroma Enclosing Brachial Artery
in a 13-Year-Old Female
Case Report Journal of Orthopaedic Case Reports 2022 March:12(3):Page 77-80
Access this article online
Website:
www.jocr.co.in
10.13107/jocr.2022.v12.i03.2726
DOI:
1
Department of Orthopaedics, Padmashree Dr. D.Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India.
Address of Correspondence:
Dr. Shivam Mehra,
Department of Orthopaedics, Padmashree Dr. D.Y. Patil School of Medicine, Navi Mumbai - 400 706, Maharashtra, India.
E-mail: drshivammehra@gmail.com
Dr. Sushmit Singh
© 2022 Journal of Orthopaedic Case Reports Published by Indian Orthopaedic Research Group
|
Submitted: 25/10/2021; Review: 18/01/2022; Accepted: February 2022; Published: March 2022

www.jocr.co.in
We report a unique case of a 13-year-old female who had
presented with a history of pain and recurrent swelling for 5
years.Onphysicalexamination,theswellingwasofsize4.4cm×
3.7 cm × 4 cm, non-tender, non-mobile, two in number, non-
cystic without any redness or sinus discharge, no visible
pulsations,andnodilatedveins.A10cmpreviousscarmarkwas
present and the brachial artery pulsations were felt just over the
swellingwithaprevioushistoryofswellingatthesameplace,for
which she was operated in 2018 (Fig. 1). The patient provided
with discharge card and radiological investigation of previous
surgery of a tertiary hospital from which OCE was diagnosed.
CT reports were suggestive of a large well defined broad-based
exophytic diaphyseal lesion in the medial side of the proximal
humerus extending posteriorly (Fig. 2, 3). It measured
approximately 4.4 cm × 3.7 cm × 4 cm in size. Another similar
morphological lesion measuring approximately 9 mm × 7 mm
was noted involving the posterior humeral shaft (Fig. 4). The
minimaldistancebetweenthelesionandthebrachialarterywas
2mmjustanteriortotheposteriomedialgrowth.
OCE is a cartilage-capped bony exostosis on the external
surface of a bone containing a marrow cavity continuous with
that of the underlying bone. Most cases are identified in
children and adolescents which could be asymptomatic or
complicated due to fractures and other lesions. OCEs may
become malignant in approximately 1% of solitary forms and
around3–25%ofmultipleforms[13].OCEcanalsorecurpost-
excision if it has been removed imperfectly and is in close
proximitytoneurovascularstructures.Although,thismightnot
alwaysbetrue.
A cardiovascular thoracic team was involved for the dissection
and a 6 cm incision was taken on the previous scar. The tumor
was first dissected posteriorly (Fig. 5). A first interval was made
between biceps brachii muscle and triceps brachii muscle.
Then, the neurovascular bundle was identified and retracted
followed by a second interval made by splitting the biceps
brachii muscle. The anterior tumor was identified, after which
thebrachialarterywasisolatedandposteromedialexostosiswas
removedwiththehelpofanosteotomeofsize6cm×4cm×3.7
cm.Thiswasfollowedbyanteriorexostosisofsize1cm×1.2cm
and of the whole cartilage cap was excised and electrical
cauterization of the base was done to prevent further
reoccurrence and a requirement of second surgery.
Postoperatively, the patient was started on broad spectrum
antibiotics and shoulder and elbow range of motion exercises
were started post-operative day 1. The patient was discharged
on post-operative day 5 and suture removal was done on post-
operative day 14. Immediate post-operative X-Ray and post-
operative6monthsX-Rayweredone(Fig.6,7).
In a study reported by Vallance et al., they present cases of
vascular complications of OCE. In one of the cases, they report
Case Report
Here, we present a case of recurrent OCE of the proximal
humerusenclosingthebrachialartery.
Discussion
78
Journal of Orthopaedic Case Reports Volume 12 Issue 3 March 2022 Page 77-80
| | | |
KaleSYetal
Figure1:Pre-operativeX-rayandclinicalimage;(a)pre-operativeX-rayoftheanteroposteriorview
oftheproximalhumerus,(b)pre-operativeX-rayofthelateralviewoftheproximalhumerus,and(c)
pre-operativeclinicalimageoftheosteochondromaoftheproximalhumerusina13-year-oldfemale.
Figure 2: Pre-operative 2D CT scan; pre-operative two-dimensional CT scan of the proximal
humerusina13-year-oldfemale.
Figure 3: Pre-operative 3D CT scan; pre-operative three-dimensional CT scan of the proximal
humerusina13-year-oldfemale.
Figure4:Pre-operativemagneticresonanceimage(MRI);pre-operativeMRIoftheproximalhumerus
ina13-year-oldfemale.

Both these cases demonstrate that when presented with a case
of recurrent OCE, proper removal of tumor is important
keeping in view any blood vessels or nerves surrounding the
tumor.
In another case, a 24-year-old man presented with swelling in
theupperpartofhisrightarmwithpain.Theauthorsreporteda
very large calcified OCE arising from the upper humerus and
clinicalexaminationrevealedreducedbutpalpablebrachialand
radial pulses. It was observed that there was marked forward
displacement of the brachial artery which was lengthened and
narrowed by extrinsic compression. Successful resection was
donewithplacementofavascularizedgraft[14].
anOCEof6cmindiameterarisingfromtheuppermedialfibula
in a 19-year-old football player. Arteriography revealed
completeocclusionoftheproximal2–3cmoftheanteriortibial
artery. The posterior tibial artery was displaced backward and
reducedabovetheoriginoftheperonealartery[14,15].
Toconclude,OCEoftheproximalhumerusnearthebaseofthe
axilla should always be excised properly so that the chances of
reoccurrence should be very less as the neurovascular bundle is
veryneartotheshaft.
Proper curettage and excision of the tumor were done after
dissecting and removing the soft tissue, blood vessels, and
nerves so that there were very less chances of relapse. Post-
operative X-ray was done and post 6 months of follow-up, there
werenochanges,andnorelapsewasobserved.
Conclusion
79
www.jocr.co.in
| | | |
KaleSYetal
Figure 5: Intraoperative images; (a) intraoperative image of the
tumor,(b)neurovascularbundleinthemiddleofthetwopartsofthe
tumor,(c)imageshowingtwopartsofthetumor.
Figure 6: Immediate post-operative X-ray; immediate post-
operative X-ray of anteroposterior view of the shoulder in a 13-year-
oldfemale.
Figure7:Post-operative6monthsX-rayandclinicalimage;
(a) post-operative 6 months X-ray of the axial view of the
shoulder, (b) post-operative 6 months X-ray of the
anteroposterior view of the shoulder, and (c) 6 months
post-operativeclinicalimageofa13-year-oldfemale.
Clinical Message
WhenpresentedwithacaseofrecurrentOCEoftheproximal
humerus, OCE could also be in proximity to important
vasculature as in this case enclosing the brachial artery. Thus,
proper curettage and excision should be done in such cases to
avoidrecurrence.
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Conflictofinterest:Nil Sourceofsupport:None
Declarationofpatientconsent:Theauthorscertifythattheyhaveobtainedallappropriatepatientconsentforms.Intheform,thepatienthasgiventheconsentforhis/herimagesandotherclinicalinformationto
bereportedinthejournal.Thepatientunderstandsthathis/her namesandinitialswillnotbepublishedanddueeffortswillbemadetoconcealtheiridentity,butanonymitycannotbeguaranteed.

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______________________________________________
Consent: The authors confirm that informed consent was obtained
from the patient for publication of this case report
Source of Support: Nil
Conflict of Interest: Nil How to Cite this Article
KaleSY,MehraS,GunjotikarA,PatilR,DhabaliaP,SinghS.AUniqueCaseof
Recurrent Osteochondroma Enclosing Brachial Artery in a 13-Year-Old
Female.JournalofOrthopaedicCaseReports2022March;12(3):77-80.

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Sachin Kalea, Sandeep Deorea, Aditya Gunjotikara, Sushmit Singha, *, Rahul Ghodkeb,
Parth Agrawala
a Department of Orthopaedics, Dr. D Y Patil Medical College, Nerul, Navi Mumbai, India
b Department of Orthopaedics, YMT College and Hospital, Navi Mumbai, India
A R T I C L E I N F O
Article history:
Received 12 November 2021
Received in revised form 15 July 2022
Accepted 1 August 2022
Keywords:
Meniscus repair
Fibrin clot augmentation
Inside-out meniscus repair
Meniscus tear
A B S T R A C T
Introduction: This study was proposed to evaluate the efficacy of fibrin clot augmentation in meniscal tear using
inside-out meniscal repair.
Methods: A total of 35 patients with meniscus tears were operated on with inside-out meniscus repair and fib-
rin clot augmentation. Patients were evaluated preoperatively and postoperatively with clinical criteria,
Lysholm knee scoring system, and MRI.
Results: Out of the total 35 cases, 5 cases were lost to follow-up. Clinical improvement was observed in 29 out
of 30 patients (96.6%). The mean Lysholm score improved significantly from 67.63 ± 6.55 points preopera-
tively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 3 years follow-up. Follow-up MRI in all patients re-
vealed complete healing except in 1 case where the patient presented with recurrence of symptoms such as
pain and locking which resolved with partial meniscectomy. Paraesthesia in the anterior part of the knee was
observed in 2 cases. (6.6%).
Conclusion: We conclude that fibrin clot augmentation is a good cost-effective modality of treatment for re-
pairable meniscus tears to preserve the meniscus and decrease the point contact pressure on the condyles which
may prevent the early occurrence of osteoarthritis.
© 20XX
1. Introduction
The meniscus helps in load transmission and shock absorption of the
tibiofemoral joint in the human knee1,2. It also acts as a secondary an-
teroposterior stabilizer of the knee joint, which further provides propri-
oception of the knee joint, lubrication, and nutrition supply to the artic-
ular cartilage.3 (see Figs. 3–5)
Meniscal tears are one of the most common knee injuries and are
found in patients of almost all ages due to various causes: degeneration,
trauma, and discoid meniscus.4 In the long-term follow-up studies, in-
creasing degenerative changes have been noted after the excision of
torn menisci, especially after total meniscectomy.5
Most of the studies show that patients on whom meniscectomy was
performed end in long-term articular cartilage degeneration.2 In vitro
studies have shown that the excision of 16%–34% of the meniscus re-
* Corresponding author. Department of Orthopaedics, Dr. D Y Patil Medical
College and Hospital, Sector 5, Nerul, Navi Mumbai, Maharashtra 400706,
India.
E-mail address: drsushmits@gmail.com (S. Singh).
sulted in a 350% increase in contact forces.6 Also, according to the bio-
mechanical studies peak contact pressure increases by up to 235% after
total meniscectomy and by up to 165% even after partial meniscec-
tomy.7,8 In contrast to meniscectomy, the contact pressure after repair
of the meniscus decreases almost to the intact level.4,9 So it is beneficial
to preserve meniscus especially in cases of young active patients.
Many augmentation techniques have been used in past such as syn-
ovial rasping, vascular access channels, platelet-rich plasma(PRP), fib-
rin glue, fascial-sheath coverage, the rasping of the intercondylar notch
which helps to increase the success rates of meniscus repair8–.10
In our study, we tried to evaluate the clinical course of patients hav-
ing meniscal tears augmented with autologous fibrin clot in an Indian
scenario with an inside-out repair method.
2. Materials and methods
This was a prospective study that included 35 patients operated by a
single team of surgeons in a single tertiary centre.
https://doi.org/10.1016/j.jcot.2022.101969
0976-5662/© 20XX
Note: Low-resolution images were used to create this PDF. The original images will be used in the final composition.

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2 S. Kale et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) 101969
Inclusion criteria
• Physically active patients within an age limit of 60 years
• Isolated meniscus tears in the red-red zone (Miller, Warner, and
Harner classification) like radial, bucket-handle, horizontal and
longitudinal tears
• Meniscus tears with associated anterior cruciate ligament tears
• Less than 3-months after injury
• Patients willing for post-operative rehabilitation
Exclusion criteria
• Patients with inflammatory arthritis/synovitis
• Rheumatoid arthritis
• Infection
• Degenerative and complex tears
• Multi-ligament injuries
• Meniscus tears associated with any ligament injuries other than
anterior cruciate ligament.
• Meniscus root avulsion
• Abnormal alignment of the lower limb
Clinical criteria were a history of knee pain and locking symptoms,
joint line tenderness, positive McMurray's test.11 Meniscus tear was also
confirmed on MRI. The preoperative Lysholm score was calculated.
Tests for associated instability like Lachman's test, anterior drawer test,
pivot shift test were done to rule out associated ligament injuries. Pa-
tients were operated on from June 2017 to June 2018 and were fol-
lowed up until September 2021 at our Institute. Follow-up of all pa-
tients was done with similar clinical criteria at an interval of 3, 6, 9, 12,
and 24 months. Rehabilitation protocol was the same for all types of
meniscus tears and concomitant ACL reconstructions which is nil
weight-bearing for 6 weeks and full ROM for one month.
2.1. Surgical procedure
The procedure was performed under spinal anesthesia. After diag-
nostic arthroscopy, tears were identified, and associated ACL tears, if
present, were treated beforehand to create a stable knee and then
reparable meniscus tears (red-red zone according to Miller, Warner,
and Harner classification) were repaired, and irreparable degenerative
tears in the avascular zone were debrided. Fig. 1 shows the types of
reparable meniscal tears and the meniscus repair instruments.
Exposure of the posteromedial capsule: A 2 cm vertical incision
at the posteromedial joint line was taken. After identifying the saphe-
nous nerve and dissection of the sartorius fascia, an anatomic triangle
was identified made by the posteromedial joint capsule, the medial gas-
trocnemius, and the semimembranosus which bounds it anteriorly, pos-
teriorly, and inferiorly respectively [Fig. 2]. A bent tablespoon was
placed in this interval to act as a retractor, protecting the popliteal ves-
sels and receiving the outcoming needles from the joint.
Posterolateral approach: A longitudinal incision was made poste-
rior to the fibular collateral ligament. After the posterior border of the
iliotibial band down to Gerdy's tubercle, a transverse and oblique inci-
sion was taken over the lateral joint line. The common peroneal nerve
is located posteromedial to the biceps femoris tendon and should be
carefully avoided. Next, blunt dissection was performed toward the
fibular head, and an interval was created with the lateral head of the
gastrocnemius superiorly and posterolateral joint capsule anteriorly.
The gastrocnemius muscle was dissected off the capsule bluntly in a
Fig. 1. Bucket handle tear(A), Radial tear(B), Horizontal tear(C), Protector meniscus suturing set-Arthrex (D).

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S. Kale et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) 101969 3
Fig. 2. Isolation of Saphenous nerve.
similar fashion as in the medial approach. Once again, a bent table-
spoon can be used in this interval to act as a retractor for the neu-
rovascular structures.
Meniscal Repair: Viewing through anterolateral portal freshening
of the periphery with shaver and microfracture awl was done till pin-
point bleeding was seen and excision of avascular meniscus edges was
done. Pie crusting of superficial MCL was done with an 18G needle to
open up the tight medial compartment. The tear was anatomically re-
duced and inside-out sutures were passed through the zone-specific
cannula with long flexible needles. 2–0 polyester braided sutures were
placed from both the superior and inferior surfaces of the torn meniscus
to avoid eversion of the meniscal edge. Colour coding of threads with
methylene blue was done to avoid confusion while tying the knots. Pa-
tients having concomitant ACL tear underwent ACL reconstruction with
the hamstring graft. Tibial fixation was carried out after meniscal re-
pair.
The radial meniscus tears extending into the peripheral vascular
zone were selected for repair. Radial tears in the inner 1/3rd zone of the
meniscus were excluded from the study as they were trimmed till stable
rim. Precaution was taken to suture the radial tears robustly in a criss-
cross fashion and the patients were protected from weight bearing for 6
weeks. Horizontal meniscus tears which extend into the periphery and
form parameniscal cyst were selected for repair as they extend into vas-
cular outer 1/3rd zone of the meniscus. Capsular abrasion along with
abrasion of torn edges of meniscus was done to augment healing.
2.2. Fibrin clot preparation and usage
While the meniscal repair was being undertaken, 60 mL of venous
blood was drawn from the upper limb under all aseptic precautions. An
assistant stirred the blood with the reverse end of the 4.5 mm
arthroscopy reamer for approximately 15 min to assure adequate clot
formation. The clot was transferred to a sterile surgical sponge. The clot
was washed with a lot of normal saline to remove excess RBCs. After
washing, the clot was soaked in wet gauze. With the help of the scalpel
(No. 15), the clot was cut and shaped to best fit the meniscal lesion.
A long hemostat was then used to introduce the clot through the
portal for the respective injured meniscus. To fit the clot underneath the
meniscus and have the best contact with the lesion, the meniscal su-
Fig. 3. Preparation of peripheral rim(A), Needle through cannula piercing inferior surface(B), Needle through cannula piercing superior surface (C, D), Final repair
(E), Colour coding of threads (F).

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4 S. Kale et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) 101969
Fig. 4. (A) Preparation of fibrin clot, (B) Fibrin clot, (C) Horizontal meniscus tear repair with fibrin clot augmentation.
Fig. 5. 35 years old male. (A) Preoperative MRI showing bucket-handle tear of medial meniscus, (B) Follow-up MRI after 2 years showing complete healing of medial
meniscus, (C) Clinical picture of patient at 2 years follow-up.
tures were loosened. To prevent the dislodgement of the clot, water
flow was stopped and the clot was held gently with a hemostat to push
through the loosened threads into the meniscus tear and threads were
tied. The knee was then taken to 90° of flexion and the sutures were fas-
tened down and then tied with a sliding knot.
2.3. Postoperative rehabilitation for isolated meniscal repairs
Postoperatively, all patients were kept non-weight bearing for at
least 6 weeks. Physical therapy emphasized early quadriceps muscle ac-
tivation and knee flexion from 0° to 90° restricted for the first 2 weeks
and progressed thereafter. Six weeks post-operatively, weight-bearing
was initiated. After 6 months, full flexion, squatting, and return to full
activities or sports were allowed. The same rehabilitation protocol was
followed for all patients irrespective of the associated anterior cruciate
ligament injury.
3. Results
A total of 35 cases were operated and 5 were lost to follow-up. Of
the remaining 30, 9 were bucket handle tear (30%), 8 were horizontal
(26.7%), 7 were longitudinal (23.3%), 6 were radial tears (20%). Clini-
cal criteria for healing were loss of knee pain and locking symptoms,
absence of joint line tenderness, and negative McMurray's test which
was observed in 29 out of 30 patients (96.6%). The mean Lysholm score
improved significantly from 67.63 ± 6.55 points preoperatively to
92.0 ± 2.9 points postoperatively (P < 0.05) in 3 years follow-up. A
follow-up MRI done in all patients revealed complete healing. Sixteen
patients (53.3%) had associated anterior cruciate ligament tear and
fared better when compared with isolated meniscus tears. All patients
improved clinically except one who had a recurrence of knee pain and
effusion and on repeat arthroscopy revealed complex tear which was
debrided in form of partial meniscectomy. Paraesthesia in the anterior
part of the knee was observed in 2 cases (6.6%) which resolved in 6
months. Our results faired better in comparison with the previous liter-
ature in which meniscus repair without fibrin clot augmentation was
done (Table 1).
4. Discussion
Most of the studies show that patients on whom meniscectomy was
performed logged long-term articular cartilage degeneration.2 Noyes et
al. recommended the preservation of meniscal tissue whenever possible
in both of his studies reviewing patients undergoing meniscal repair in
the avascular zone with and without anterior cruciate ligament re-
pair.12 So it is beneficial to preserve meniscus, and therefore meniscal

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