PRESENTER :- DR. MALKESH SHAH (M.S. ORTHO 2 ND YEAR RESIDENT) - - PowerPoint PPT Presentation

111 CASES FROM SINGLE INSTITUTE FOR DISABLED Abstract no.- 1135 CO-AUTHER:- DR. NEEL PATEL (2ND YEAR RESIDENT)

• DR. PARTH PATEL

(MS ORTHO SENIOR RESIDENT) GUIDED BY:-

• PROF. DR. J. J. PATWA

(M.S. ORTHO) S.B.K.S.M.I.R.C ,PIPARIA, WAGHODIA, VADODARA, GUJATRAT, INDIA. PRESENTER:- DR. MALKESH SHAH (M.S. ORTHO 2ND YEAR RESIDENT)

Contact no.- +919662023475

RANGE OF MOTION OF KNEE

QUADRICEPS PARALYSIS

UNSTABLE KNEE

(KNEE CAN NOT BE FULLY EXTENDED AND LOCKED IN EXTENSION ON LOADING)

KNEE BUCKLE OUT REPEATED FALL

Q GAIT

(1) HAND TO KNEE (2) EXTREME INTERNAL ROTATION (3) EXTREME EXTRERNAL ROTATION (4) PELVIC TILTING (5) HYPER LORDTIC GAIT (6) BILATERAL PARALYSIS CRAWLING

SEQUEALI OF QUADRICEPS PARALYSIS

TO OVERCOME QUADRICEPS WEEKNESS PATIENT TRIES TO LOCK KNEE WITH GASTROCNEMIUS CONTRACTING FROM DOWN

TA TIGHTNESS WHICH LEADS TO SECONDARY EQIUNUS PATIENT ABLE TO WALK HELPS IN PUSHING KNEE INTO EXTENSION ULIMATELY MILD RECURVATUM

WHENEVER SEVERE PARALYSIS, PATIENT CAN NOT WALK.

SEQUEALI OF QUADRICEPS PARALYSIS

MATERIAL AND METHODS

TOTAL CASES

267

LOST TO THE FOLLOW UP

17

TOTAL FOLLOWED UP

250

FEMALE 150 MALE

100

OPERATED BETWEEN 7-10 YEARS 100 OPERATED BETWEEN 11-12 YEARS 38 OPERATED BETWEEN 13-14 YEARS 83 OPERATED BETWEEN 15-18 YEARS 17 OPERATED ABOVE 18 12

2 TO 3 YEAR F/U

66

3 TO 5 YRAR F/U

67

MORE THEN 5 YEAR

117

PRE REQUISITE FOR HAMSTRING TRANSFER

• POWER IN BICEPS AND SEMITENDINOSUS SHOULD BE GRADE 4 OR

MORE.

• HIP FLEXOR AND EXTENSOR MUST BE GOOD FOR CLEARING THE

GROUND WITHOUT DIFFICULTY.

• FLEXION DEFORMITY OF HIP AND VARUS VALGUS DEFORMITY OF

KNEE REQUIRES CORRECTION.

• KNEE FLEXORS OTHER THEN BICEPS AND SEMI TEDINOSUS MUST BE
• GOOD. GASTROCNEMIUS MUST BE ACTIVE ENOUGH TO PERFORM

KNEE FLEXION AND PREVENT RECURVATUM

• TRICEPS SURI MUST BE NORMAL TO PREVENT GENU RECURVATUM

AND REMAIN AS AN ACTIVE KNEE FLEXOR AFTER SURGERY.

• THEREFORE THE EQUINUS DEFORMITY SHOULD NOT BE CORRECTED

BY TENDO ACHILIS LENGHTHING WITH OUT SEEING RESULT OF HAMSTRING TRANSFER.

OPERATIVE TECHNIQUE

• UNDER APPROPRIATE ANAESTHESIA ENTIRE EXTREMITY WAS PREPARED AND

DRAPED AFTER THE APPLICATION OF TOURNIQUET

• BICEPS FEMORIS TENDON WAS

DISSECTED OUT TAKING CARE NOT TO INJURED LATERAL POPLITEAL NERVE WHICH LIES IMMEDIATELY BEHID TENDON AND WIND AROUND NECK FIBULA

• BICEPS TENDON WAS DIVIDED

ALONG WITH THIN CHIP OF BONE AT ITS INSERTION ON LATERAL ASPECT OF HEAD OF FIBULA TAKING CARE NOT TO DAMAGE LATERAL LIGAMENT KNEE WHICH WIND AROUND THE TENDON

• 1. POSTEROLATERAL INCISION OVER BICEPS

(2) POSTERO MEDIAL INCISION WITH SEPARATED

• SEMITENDINOSUS. IT IS ROUNDED CORD LIKE STRUCTURE

WITHOUT MUSCLE BELLY AND FANNING OUT ITS INSERTION OVER TIBIA FROM WHERE IT IS TO BE DETACHED AND MOBILIZE AS PROXIMALLY AS POSSIBLE.

(3) CURVILINEAR INCISION IS PUT OVER PATELLA

• THICK OSTEO- PERIOSTEAL

FLAP IS RAISED OVER THE PATELLA BY PUTTING TWO PARALLEL INCISION OVER PATELLA

• PASSAGE IS MADE WITH

SHARP OSTEOTOME

OBLIQUE SUBCUTENEOUS TUNNEL WAS MADE FROM 3RD INCISION TO 1ST INCISION TO BRING BICEPS TENDON UNDERNEATH THE FLAP. THE S.C. TUNNEL BE MADE AS WIDE AS POSSIBLE TO ALLOW FREE GLIDING OF BICEPS MUSCLE. SECOND OBLIQUE S.C. TUNNEL MADE FROM 3RD TO 2ND INCISION TO BRING SEMITENDINOSU S TENDON OVER THE PATELLA

MY TECHNIQUE OF TENDON ANCHORING IN OSTEO PEROSTEAL FLAP (DIAGRAMETIC EXPLAINATION)

(1) (2) (3) (4) (1) TENDON OF BICEPS WAS PASSED THROUGH THE OSTEO PERIOSTEAL FLAP AND SUTURED NEAR THE INFRAPATELLAR PORTION OF LIGAMENTUM PATELLAE.THEN PASS THE SLONG TENDON OF SEMITENDINOSUS THROUGH THE OSTEOPERIOSTEAL FLAP. (2) PART OF THE SEMITENDINOSUS TENDON SUTUREFD AT THE LEVEL OF LOWER PORTION OF THE OSTEO PERIOSTEAL FLAP . (3) A SLIT IS MADE IN THE PROXIMAL PORTION BICEPS PROXIMAL TO THE OSTEO PERIOSTEAL FLAP . THE SEMITENDINOSUS PASSED THOUGH THAT SLIT AND SUTURED WITH ITS PROXIMAL PORTION OF SEMITENDINOSUS (4) 2 TO 3 STITCHES TAKEN BETWEEN SEMITENDINOSUS AND BICEPS TO KEEP THE DIRECTION OF PULL IN CENTER OF THE PATELLA IN THE MIDLINE

(1) (2) (3) (4)

AS PER DIAGRAMETIC EXPLAINATION , THESE ARE ON TABLE OPERATIVE STEPS.

OPTIMUM TENSION OVER ANCHORED AREA

• AFTER ANCHORING THE TENDON KNEE

FLEXION MUST BE POSSIBLE ATLEAST UP TO 30 DEGREES, SO THERE WILL BE NO RESTRICTION OF KNEE FLEXION POST OPERATIVELY.

• All wound closed by subcutaneous stitches and skin after

negative suction drain.

• Tendon anchoring sutures must be taken with prolene for

strengthening the anchor Advantage of hamstring transfer : long lever arm of hamstring acting on short lever arm ligamentum patellae via patellar lever

Post Operative Regimen

• A long leg cast groin to toe with knee in either neutral of 15 degree

flexion without raising the limb. Initially slab which is to be given by bringing the whole leg out of table by side to side movement to avoid tension on transferred hamstring tendon

• Do not allow the patient to sit for 4 weeks
• Only foot end of cot is raised for elevation not the extremity.
• At the end of 3rd day drainage tube is removed from all wounds and

sutures are to be removed after 11 days and then complete plaster from groin to toe for 3 weeks

• Functional training of the transfer is begun on 5th post operative
• day. The Knee and Hip are slightly flexed and patient asked to extend

his hip and knee . During the movement patient is placed on his side to eliminate gravity.

• Walking only permitted when full active extension and 90 degree

knee flexion is possible.

TECHNICAL TIPS

• WE USE CONTINOUS INCISION ON THE POSTEROMEDIAL ASPECT OF THIGH

KEEPING FOUR FINGER DISTANCEE BETWEEN POSTERO LATERAL INCISION.MOBOLIZE THE TENDON FREELY UP TO ITS ADEQUATE LENGHTH AND REROOT THE TENDON IN THE DIRECT LINE BETWEEN ITS ORIGIN AND NEW INSERTION.

• INSTEAD OF CUTTING PERIOSTEUM IN AN “I” SHAPED MANNER WE RAISE

THICK PERIOSTEAL FLAP FROM PATELLA AND BOTH THE TENDON PASSED THROUGH IT SO THAT WE COULD GIVE AS MUCH TENSION AS NECESSARY FOR THAT PERTICULAR CASE AND STRENGHTHEN THE PERISTEAL FLAP WITH REMAINING PORTION OF SEMITENDINOSUS TENDON.SO THERE IS NO FEAR OF BRECKAGE OF THICK FLAP.

• BY THIS NEW INSERTION OF TENDON PATELLA WOULD ACT AS FULCRUM

DURING EXTENSION OF KNEE BY PRODUCING BOW STRING EFFECT

• IN SOME CASES MEDIAL HAMSTRING WAS SO POWERFUL, IT WAS FIXED

WITH QUADRICEPS , IT NOE ONLY ACT AS A CHECKREIN BUT ALSO HELP IN GETTING POWERFUL EXTENSION.

• TO MUCH TENSION OF ANCHORING TENDON OVER PATELLA SHOULD BE

AVOIDED WHICH OTHERWISE CAN LEAD TO RESTRICTION OF KNEE FLEXION

• BY OSTEO PERIOSTEAL FLAP WE ARE PROVIDING NEW INSERTION IN BONY

TISSUE OF THE FLAP, TENDON WHICH UNITES WITH PATELLA.

TOTAL NUMBER OF CASES 267 17 CASES LOST TO THE FOLLOW UP 250 CASES WERE FOLLOWED UP FOR 2 TO 10 YEARS AS PER FOLLOWING ASSESSMENT FOR DECIDING OUTCOME FOR SURGERY

CRITERIA E(10) G(7) P(5) KNEE FLEXION FULL UP TO 20 DEGREE >20DEGREE KNEE EXTENSION RESTRICTED UP TO 20 DEGREE 20 - 40 DEGREE >40 DEGREE HANDS TO KNEE DISAPPEARED OCCASIONAL PERSISTANT COMPLICATION NIL 1 TO 3 >3 PERSONAL FEELING FULLY SATISFIED SATISFIED UNSATISFIED OUR RESULT 65%(162 CASES) 15%(38 CASES) 20%(50 CASES)

COMPLICATIONS

GENU RECURVATUM 50 RESTRICTED FLEXION 30 EXTENSION LAG >20 DEGREES 25 EPIDERMAL EDGE NECROSIS 10 INFECTION SUPERFICIAL 1 LATERAL DISPLACEMENT OF PATELLA

NIL l

• LAT. POPLITEAL NERVE PALSY

UNSTABLE KNEE

DISADVANTAGE

• CONTINOUS MEDIAL INCISION MAY CAUSE

EDGE NECROSIS

• TOO MUCH TENSION OVER TENDON

SUTURING MAY LEAD TO RESTRICTION OF FLEXION.

CONCLUSION

• H – Q TRANSFER IN THE PRESENCE OF QUADRICEPS

PARALYSIS WITH GOOD POWER IN HAMSTRING IS A METHOD OF CHOICE BECAUSE IT IS BETTER THEN SUPRACONDYLAR OSTEOTOMY WHICH IS A STATIC CORRECTION WHILE H—Q IS A DYMANIC CORRECTION AND PRODUCES SOME DEGREE OF RECURVATUM WITH INCREASING STABILITY OF THE KNEE IN EXTENSION WHILE WALKING

• IN MODIFIED TECHNIQUE AS A PERIOSTEUM IS NOT

CUT IN I SHAPED, THE FLAP GIVES ADDITIONAL STRENGHTH TO NEW INSERTION

• PATELLA WILL ACT AS FULCRUM DURING EXTENSION

OF KNEE BY PRODUCING THE BOW STRING EFFECT

A 35 years old lady having 25 years follow up of right sided hamstring transfer with full range of movement no extension lag and able to sit cross legged and squat HAVING TWO KIDS

CLINICAL EXPERIENCE

A 12 years old male treated with hamstring transfer on right side with full extension and virtually normal flexion and patient able to sit cross legged and squat, hand to knee gait disappear and patient able to walk without support

A 14 years old girl operated for hamstring transfer on right side with fair result as patient having 10 de3gree of extension lag and 20 degree

• f restriction of knee flexion. Inspite of that patient able to lock the

knee while walking and hand to knee gait disappear because of veryfact reason we have done guarded TA lengthening to keep foot in to keep the foot in 10 degree equinous

I have operated 111 cases only at APANG MANAV MANDAL with good to excellent result and very good follow up because it is done at one single institute for disabled.