PRESENTER :- DR. MALKESH SHAH (M.S. ORTHO 2 ND YEAR RESIDENT) Contact no.- +919662023475 111 CASES FROM SINGLE INSTITUTE FOR DISABLED Abstract no.- 1135 CO-AUTHER :- DR. NEEL PATEL (2 ND 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.
RANGE OF MOTION OF KNEE
QUADRICEPS PARALYSIS SEQUEALI UNSTABLE KNEE (KNEE CAN NOT BE FULLY EXTENDED AND LOCKED IN EXTENSION ON LOADING) OF KNEE BUCKLE OUT REPEATED FALL QUADRICEPS Q GAIT (1) HAND TO KNEE (2) EXTREME INTERNAL ROTATION PARALYSIS (3) EXTREME EXTRERNAL ROTATION (4) PELVIC TILTING (5) HYPER LORDTIC GAIT (6) BILATERAL PARALYSIS CRAWLING
TO OVERCOME QUADRICEPS WEEKNESS PATIENT TRIES TO LOCK KNEE WITH SEQUEALI GASTROCNEMIUS CONTRACTING FROM DOWN TA TIGHTNESS WHICH LEADS TO SECONDARY EQIUNUS OF HELPS IN PUSHING KNEE INTO EXTENSION QUADRICEPS ULIMATELY MILD RECURVATUM PARALYSIS PATIENT ABLE TO WALK WHENEVER SEVERE PARALYSIS, PATIENT CAN NOT WALK.
MATERIAL AND METHODS 66 2 TO 3 YEAR F/U FEMALE 150 67 3 TO 5 YRAR F/U 100 MALE 117 MORE THEN 5 YEAR 267 TOTAL CASES 17 LOST TO THE FOLLOW UP 250 TOTAL FOLLOWED UP 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
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 3 RD INCISION TO 1 ST 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 3 RD TO 2 ND INCISION TO BRING SEMITENDINOSU S TENDON OVER THE PATELLA
MY TECHNIQUE OF TENDON ANCHORING IN OSTEO PEROSTEAL FLAP (DIAGRAMETIC EXPLAINATION) (4) (2) (3) (1) (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) AS PER DIAGRAMETIC EXPLAINATION , THESE ARE ON TABLE OPERATIVE STEPS. (4) (3)
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 3 rd 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 5 th 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 RESTRICTED UP TO 20 KNEE EXTENSION DEGREE 20 - 40 DEGREE >40 DEGREE HANDS TO KNEE DISAPPEARED OCCASIONAL PERSISTANT COMPLICATION NIL 1 TO 3 >3 PERSONAL FEELING FULLY SATISFIED SATISFIED UNSATISFIED 20%(50 OUR RESULT 65%(162 CASES) 15%(38 CASES) 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 LAT. POPLITEAL NERVE PALSY UNSTABLE KNEE l
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
CLINICAL EXPERIENCE 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
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 of 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.
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