Operative Orthopaedics John Ebnezar
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1Step by Step® Operative Orthopaedics
2Step by Step® Operative Orthopaedics
Editor John Ebnezar MBBS, D' Ortho, DNB (Ortho), MNAMS (Ortho), (PhD) Yoga Sports medicine (Australia), INOR fellow (UK), DSC, DMT Consulting Orthopaedician, sports specialist, spine surgeon and holistic orthopaedic expert Parimala Health Care Services (An ISO 9001:2000 Hospital), Bilekahalli, Bannerghatta Road, Bengaluru, India Ebnezar Orthopaedic Centre Bilekahalli, Bannerghatta Road, Bengaluru, India Chairman: The Physically Handicapped and Paraplegic Charitable Trust of Karnataka® Chairman: The Karnataka Orthopaedic Academy® President: The Bangalore Holistic Academy, Bengaluru Chairman: The Rakesh Cultural Academy President: Vaidya Kala Ranga, Bengaluru Secretary: SK Educational Society® Formerly Senior Specialist: Victoria Hospital, Bangalore Medical College, Bengaluru Assistant Professor of Orthopaedics: Devaraj Urs Medical College, Kolar, Karnataka
3Published by
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Step by Step® Operative Orthopaedics
© 2009, John Ebnezar
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the publisher.
This book has been published in good faith that the material provided by contributors are original. Every effort is made to ensure accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2009
9788184485349
Typeset at JPBMP typesetting unit
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4To
My mother (Late) Sampath Kumari who taught me that life is more than self and there is more joy in giving and sharing than taking
My wife Dr Parimala, my lovely children Rakesh and Priyanka who are an epitome of love, sacrifice, encouragement and inspiration
All my teachers who made me what I am today and All my students past and present
6Contributors 7Preface
Rapid strides are being made in almost all spheres of life and orthopaedic surgery is no exception. Newer techniques of treatment are being introduced like never before. Not all have stood the test of time. However, there are a few newer techniques that are proving to be quite useful and have revolutionised the field of orthopaedic surgery. I have put together a few such techniques in the form of the book. I have selected a few common advanced procedures like arthroplasty, arthroscopy, interlocking nailing and spine surgery. These are the days of subspeciality superspecialization. Hence I decided to involve those who have made a big name in their respective fields and have chosen the best team of contributors.
Dr S Venkat needs no introduction. He was one of the few orthopaedic surgeons in India who took to arthroplasty in a very big way quite early in the 90s. After a successful stint at Coimbatore he is now based in the United Kingdom and still doing a phenomenal work in the UK in joint replacement techniques. He, along with his colleague Dr Sam Morgan, has authored the section on Arthroplasty and needless to say they have done an excellent job.
Dr Kirti Moholkar is another UK-based orthopaedic surgeon who has made a landmark in the field of arthroplasty and arthroscopy alike. He is doing a lot of work in minimally invasive procedures. I had a short stint with him at Royal Orthopaedic Hospital at Birmingham in Nov 2005 and was very impressed with his work and hence I requested him to put his work in the form of a book. He has done an excellent job in the respective section of Unicondylar Knee Replacement and Arthroscopy.
Dr Vishwanath M Iyer and Dr B Shivashankar are two big names in the field of Interlocking nailing. They 8have been actively conducting CME's, Conferences, Workshops and training young orthopaedic surgeons in the interlocking nailing skills. They have invented and designed their own implants, instrumentation and technique that have proved to be of great help to our Indian orthopaedic surgeons. I could not have approached better persons to author the section on Interlocking nails. Their works speak for themselves.
Last but not the least, the Spine section is being authored by my good friend Dr JKBC Parthiban. He is a neurosurgeon of repute and has been doing phenomenal work in the field of spine surgery, particularly the minimally invasive techniques of Microscopic Lumbar Discectomy and Endoscopy Lumbar Discectomy. A protégé of another legend in spine surgery, Dr PS Ramani, Dr Parthiban is making great strides in his chosen field. He has done an excellent job as an author of the spine section and his effort is there for all to see.
I hope you will enjoy reading this book and will cherish and inculcate the knowledge and skills of these luminaries through this book. You will find this book very handy and useful as a ready reckoner. There are several books on the subjects I have chosen but probably this is the first book which gives all these techniques under one cover thereby providing ample opportunity for a practising orthopaedic surgeon to refer to it whenever desired.
Suggestions and criticisms are welcome. They help in our endeavour to propagate and spread the knowledge of orthopaedic surgery.
John Ebnezar
9Acknowledgements
I owe my gratitude to all the pioneers, Dr Venkat and his colleague Sam Morgan, Dr JKBC Parthiban, Dr Iyer, Dr Shivashankar and Dr Kirti Moholkar for consenting to be a part of this unique project. No words of thanks are enough for their efforts, despite their busy schedules they instantly agreed to contribute for this book. They have done a wonderful job and presented all their works extremely well.
I thank Shri Jitendar P Vij (Chairman and Managing Director, M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi) and his team for doing an excellent job. My association with this marvellous team is almost a decade old and I wonder at their zeal and commitment which keeps growing by the day.
I also thank all the staff of my hospital who have helped me in bringing out this book.
13Introduction to Arthroplasty
Total knee and hip arthroplasty has become the definitive treatment for end-stage osteoarthritis. This has proved to be reliable and successful allowing patients to resume normal activities. Both knee and hip arthroplasty can be performed using cement or biologic fixation.
In cement fixation there is mechanical interlock of methylmethacrylate to the interstices of bone. Biological fixation can be either a porous-coated metallic surface that provides bone ingrowth fixation or by a grit-blasted metallic surface that provides bone ongrowth fixation.
The choice of method of fixation remains controversial. In hip arthroplasty, the tendency is towards the use of uncemented prosthesis in younger active patients because cemented prosthesis have reported a higher loosening rate in long-term follow-up. In total knee arthroplasty, the cemented prosthesis has been reported good results in long-term follow-up and is more widely used than the cementless ones.
Aseptic loosening is the most common indication for revision surgery. In cemented hip, the most common reason for revision is failure of the cemented acetabular component, while in the uncemented ones the most common cause for failure is the femoral component. In knee arthroplasty, aseptic failure can be caused by many factors as component loosening, polyethylene wear, ligament instability and patellofemoral maltracking.
Articular bearing in hip arthroplasty is mainly on “hard on soft couple” which include metallic heads coupled with polyethylene cup. The other hard on soft couple is ceramic head with polyethylene cup. Titanium alloy heads should be avoided because it is liable to scratching which will 14cause rapid wear of the polyethylene surface. In knee arthroplasty, the majority of articular bearing components are metallic femoral surface (cobalt, chromium) coupled with polyethylene tibial surface.
In 1997, Birmingham hip resurfacing was introduced using metal on metal prosthesis. It is a bone conserving operation with minimal or virtually no dislocation which makes it ideal for young active people.
John Ebnezar