Practical Orthopedics—Biological Options and Simpler Techniques for Common Disorders SM Tuli
Page numbers followed by b refer to box; f refer to figure and t refer to table.
Abscess 30
palpable 30
Acetabulum 160
failed 80f
Achondroplasia 117
Acquired torticollis 115
Acromioclavicular arthritis 120
Adhesive capsulitis 121
Adolescent coxa vara 158
Allografts 12
Allupurinol 189
Amyoplasia 107
treatment 107
Androgens 58
Aneurysmal bone cyst 92, 93f
atypical location 197f
treatment 93
Ankle 20, 187
and foot 187
Ankylosing spondylitis 39, 63, 144, 154, 208f
advanced stage of 40f
treatment 39
Ankylosis, angle of 161
Annular ligament 130
Anomalies 75
Anticyclic citrullinated peptide, presence of 37
Antiinflammatory drugs 187
Antimetabolic agents 67
Antimitotic agents 67
Antirheumatic drugs 36, 38
Antitubercular chemotherapy
continuation phase 28
intensive phase 28
prophylactic phase 28
Antitubercular drugs 30
Antitumor necrosis factor 43
Aorta, calcification of 63
Arachnoid cyst 200f
Arthrogryposis multiplex congenita 83f, 107, 179
Arthroplasty, low friction 31
Arthroscopic techniques 123
Arthrotomy 20
cartilage 62
tuberculosis, classification of 28
Aseptic technique 22
Autogenous fibular graft 70f
Auto-immune systemic disorder 36
Avascular necrosis of
bilateral femoral heads 53f
bone 50-57
femoral head 52f, 55f, 153
stage of 156
Baclofen 109
Ball and socket 9
Bankart procedure 123
Bence Jones protein 90
bone tumors 93
lesion 88
tumor-like lesions 91
Benzodiazepine 109
Biopsy 90
Bisphosphonates 64, 154
effect of 196f
prolonged use of 65f
use of 51
Bleeding disorder 43
Blount's disease 180
Body resistance 24
Bones 3
biological cascade of repair 5f
cement 12
congenital, absence of 209f
grafting 11, 14, 54f
grafts substitutes 11t, 12
growth of 62
healing of 8t
infections of 17
layer of 6f
mineral density 63
morphogenetic proteins 13
normal age-related changes in 58
of left pelvis 80f
regeneration of 5f
transport techniques 11
Bony ankylosis 36, 154f
bilateral 154f
Botulinum toxin injections 72
Bow legs 179
deformity, progressive 180
Bowel sphincter disturbances 148
Brachialgia 115
Brachialgic pains, common causes of 116
Breast cancer 102
Bristow-Latarjet operation 123
Brodie's abscess in upper femur 22f
Broom stick like splint 78
Bryant's triangle 152
Burns and compartment syndrome 191
inflammation 130
tuberculosis 200f
Café-au-lait patches, large 69f
Caffey's disease 202f
Calcific tendinitis 121f
Calcitonin 58
Calcium 58, 62
and phosphorus, essential role of 58
homeostasis 58
intake of dietary 64
consolidation 6
mineralization of 5
remodeling 6
Capital femoral epiphysis 77
Carcinomatosis 63
Carpal tunnel release 136
Carpal tunnel syndrome 135, 136
injection for 136
symptoms of 135
Cartilage space 47
Cartilaginous deposits, multiple 95f
Cauda equina 148
Cauda equina syndrome 66, 148, 150f, 191
Caudal migration 150
Cavitary lesion 11, 29f
Cell-mediated immunity 109
Central chondrosarcoma 99
Central prolapse 148
Cerebral palsy 107
clinical features 107
lengthening of contracted tendons 109
medical treatment 109
partial neurectomy 109
stabilization of joints 109
tendon transfer operations 109
topographic distribution 107
treatment 108
with child 108f
Cervical canal stenosis 117
Cervical spine 198f
disc prolapse, treatment of 116
Cervical spondylotic myelopathy, case of 117f
Cervical vertebrae 115
arthropathy 187f
condition 187
joint 153, 188, 207f
neuroarthropathy 187
Charnley's, principles of 182
Chiari's osteotomy 157, 169, 170
Chondrodiastasis 62
Chondrogenesis 3
Chondro-osteodystrophies 70, 155
Chondrosarcoma 88, 99, 99f
Clavicles and ribs 59f
Claw hand 134, 135f
treatment of 135
Club foot
congenital 80
deformity 83f
resistant 84
Cold abscesses 199f
Colle's fracture 135
Complex regional pain syndrome 121, 139, 139f
Compound palmar ganglion 138
Connective tissue disorders, congenital 68
Connective tissue rheumatoid like diseases 42
Constrictive tenosynovitis 137
Cord involvement, prognosis 33t
Core decompression 55
Cortical bone of proximal fragment 185
Cortical bone-grafts 196f
Corticosteroids 63
Corticotomy 10
Costochondral junctions 60
Coxa magna, developed 160f
Coxa valga 106
Coxa vara 106, 155
congenital 155, 166f
early cases of 153
Coxa-magna, massive 195f
Crohn's disease 41
Cubitus valgus 127, 127f
Cubitus varus deformity 128, 129f
Curvilinear osteotomy 174
Cushing syndrome 42, 42f
Cushing's disease 63
Cyclophosphamides 67
areas, multiple 91
cavity 29, 91
lesion, presence of 88
De Quervain's disease 137
treatment of 138
Deep infections in adults 168f
Defects, congenital 84
congenital 67, 75
correction 61, 83
basic principles of 70
manipulations 70
operative 72
turn-buckle method 72
under anesthesia 72
wedging 72
in wrist and hand 137
of knee 176
seldom 181
Dega's pelvic osteotomy 79, 174
Demineralization 12
Derotation osteotomy 157
Diabetes mellitus 188
Diabetic foot 188
treatment of 188
Diaphyseal fractures 8
Diffuse idiopathic skeletal hyperostosis 43
instillation 43
intra-articular aspiration 43
Diffuse ill-defined borders 88
Disc space 116
Dislocation of
left hip, congenital 170f
patella, recurrent 179
Disorders related to neck 115
Distal humeral osteotomy 128
Distal interphalangeal joints 137
Distal metaphyseal 29
Distal osteotomy cuts 185
Distal radius osteochondral fractures 135
Dog tapeworm 201
Dorsal spine tuberculosis 66
Dorsal wrist ganglion 137f
Dorsalis pedis 188
Dorsolumbar junction 63
Duchenne muscular dystrophy 106
Dupuytren's contracture, treatment 138
Dyplasias 68
Dyschondroplasia 95f, 73
Dysplasia of
hip, development 77, 80f, 163
left hip, development 79
right hip 173f
Dysplastic hip 78
Dysraphism 84
Dysthesia 127
Echinococcus granulosus 201
Effusion 30
Elbow 20
and forearm 126
causes of stiffness 130
excision-arthroplasty of 131
joint 44, 131f
movements of 126
pulled 130
Electrone microscopy 154
En bloc resection 96
Enchondroma 73
Enchondromatosis 73, 94, 95f
Endochondral ossification 3
Endocrine disorders 63
Endoscopic tunnel release 135
Enteropathic arthropathy 41
Epicondyle, medial 127
Epicondylitis, lateral 126
Epidural abscess 145
Estrogens 58
Ewing's sarcoma 100, 101f
Exostosis 93
multiple 93
solitary 93
Extracorporeal shock therapy 54
Extrapleural approach, anterolateral 34
Familial aggregation 39
Fanconi syndrome 61
Fascioscapulohumeral muscular dystrophy 106
Femoral head 160, 163, 197
containment 157
in situ 167
neck junction 44
preservation techniques 53
Femoral neck fracture 152
Femoral osteotomy, upper 162, 164f, 167
Femoral shaft, distal half of 24
Femur, distal half of 21f
Fiber bone 3
Fibroma 88
Fibro-osseous tunnel 135
Fibrosarcoma 88
Fibrous cortical defect 91
Fibrous dysplasia 68, 91f, 155
Fibrous tissue 3, 39
bone graft 13
tibialization of 14
Fibular deficiency, congenital 84
flexion of 135f
trigger 138
Flat feet 190, 191f
Fluoroquinolones 28
Folic acid, consumption of 85
Foot 188
abduction brace 81
dorsum of 192f
drop 191
fragments 7
healing of 3
natural 4
hematoma 3, 5
line 7
of femur 23f
stabilization 7
union, timetable of 6
Fragility fracture 63
Fragmentation 156
Frank pus 22
Free bone graft 22
Frozen shoulder 120, 121
Ganglion 136
Genetic disorder 69f
Gentle tissue handling procedure 22
Genu recurvatum 179
treatment of 179
Genu valgum 47, 62, 176
deformity 60f
treatment of 178
Genu varum 60, 62, 47, 179, 183f
Giant cell tumor 13, 96, 96f, 97f
of bone 95, 208f
of distal radius 97f
Giant osteoid osteoma 95
Girdleston's 31
like excisional arthroplasty 168, 169
arthritis 120
joint 44
Glenoplasty 124f
Glomus tumor 202f
Golfer's elbow 126
Gorham syndrome 194f
Goucher's disease 50
attacks, acute 189
incidence of 188
investigation 189
tophus 189f
treatment 189
Graft substitutes 11
Greater trochanter, part of 44
Growth plate modulations 62
Gun-stock 128
Hairy tuft 86f
Hallux valgus 76, 192
in left foot 192f
Hallux varus in right foot 192f
Hand-shoulder syndrome 120, 121, 140
Hansen's disease 109
Harmon's reconstructive procedure 164
Harrington rod fixation 151
natural 3
stage of 156
Hemangioma 202f
multiple 149f
of sacrum 202f
Hematogenous osteomyelitis, acute 17
clinical presentation 18
pathology 17
radiological features 18
treatment 19
Hemoglobinopathies 50
Hemolytic disorders 189
Heparin 63
Herring's grouping 157
Heterotopic ossification 133, 205f
phases of evolution 133
High tibial osteotomy 183, 184f
medial open-wedge 185f, 186f
High-arched feet 191
Hip 19, 44, 152
deformities 105
bilateral 77
clinical features 77
pathology-adaptive changes 78
radiological features 77
treatment 78
ultrasonography 77
subluxations 77
excisional arthroplasty for 31
frog position of 77
joints 79, 159
congenital dislocation of 77
movements of 152
MRI of 51f
subluxation of 152
open operative technique for 56
painful 152
Hormone replacement therapy 64
Hubbard tanks 104
Humerus, lateral condyle of 127
Hydatid-cyst 201f
Hydatid disease 201f
Hyperbaric oxygen 54
Hyperparathyroidism 193f
Hyperuricemia 189
Hypophosphatemic osteomalacia 194f
Iatrogenic 7
diagnosis 25
in orthopedics 24
infections therapeutic options 25
Idiopathic massive osteolysis 194f
Iliac spines, anterior superior 153
Iliacus muscle 170
principles 11, 82
corticotomy 10
deformity correction 10
for neohistogenesis 10f
cortical hyperostosis 202f
scoliosis 141
Infection, diagnosis early stage of 25
Infective lesions 187
Inflammatory rheumatoid disorders 42
diagnosis, early stage 37
fifth-line treatment 43
first-line treatment 42
fourth-line treatment 43
second-line treatment 42
third-line treatment 42
Inflammatory swelling, chronic 181
Innominate osteotomy 157, 168, 171, 174f
operative procedure for 170
Intermuscular septum, medial 127
Interspinous ligaments 141
Interspinous structures, retention of 148
fracture 46
injections 44
Intracapsular fractures 7
Intralesional curettage 96f
Intramedullary nails 8
Involucrum 22
behavior of 22
Ipsilateral fibula 15f
Ipsilateral pelvis 153
Irritable bowel symptoms 36
Isoniazid 28
Isotope bone scan 89
Ivory osteoma 95
cartilage and bone 36
cartilage space 55f
debris 44
disorders 120
effusion, large 30
functional, position of 19
infection of 17
stiffness 158
tuberculosis, functional treatment for 29
Joshi's external stabilization system 82
Juvenile rheumatoid arthritis 41
fracture 46, 50
osteotomy 9, 38, 43
Kidney, chronic diseases of 63
Kienböck's disease 56f
Kirschner's wires 9, 20, 170
using 174
Knee 20
and leg operative techniques 184
flexion deformities of 72
joint 44
left 182f
X-rays of 182f
pathologies 176
right, diffuse swelling of 177f
synovial chondromatosis 182
Knock knees 176
Kyphoscoliosis 69, 71f
Kyphoscoliotic tibia, congenital 206f
Kyphosis 63, 141, 142
Kyphotic deformity 32, 33, 143f
deterioration of 150f
Lamellar bone 3
Laminectomy 34
Leflunomide 67
Legg-Calvé-Perthes disease 155, 171f, 172f
Lepromatous 109
Leprosy 109
drug therapy 110
foot drop 110
operative interventions 110
total claw hand 111
transfer for opponens palsy 111
trophic ulcers 110
wrist drop 111
patellae 179
teres 156
Limb girdle muscular dystrophy 106
Lipoma 136
Little's disease 107
Looser's lines 60
Looser's zones 59, 59f
in left femur 61f
in pubic rami 61f
Lumbar canal stenosis 145, 146, 151f
developmental 148f
Lumbar disc herniation
acute 149
resolution of 149
Lumbar intervertebral disc prolpse 147
Lunate, complete collapse of 56f
Lymph nodes, calcified 196f
Lytic cystic lesion 96f
Macrodactyly 207f
Maffucci's syndrome 73
Malformations, congenital 67
bone tumors 98
diseases 63
transformation, incidence of 94
tumor 87
Maltracking patella 179, 180f
treatment 180
Malunion 47
March fracture 203f
Marfan's syndrome 68
McMurray osteotomy 162f, 167f
McMurray's upper femoral osteotomy 166
Mesenchymal cells 4f
Metabolic bone disorders 58, 90
Metabolic defects with vitamin D 62
Metacarpophalangeal joints 135f
Metal fatigue, accumulation of 14f
Metaphyseal osteoporosis, severe 157
bone deposits 101
diagnosis of 90t
radiological features 102
malignancy, clinical features of 102
Metatarsophalangeal joint 76
Methotrexate 67
Minimally invasive techniques 150
Monoarticular presentation 37
Mosaic fashion 64
Movements 152
gross limitation of 153
in elderly or middle age 153
to improve arc of 161
with acute pain 153
with chronic pain 153
without much pain 153
Multicentric disease 89
Multilayered onion-peal 203f
pedicle-based bone grafts 14
power, recovery of 104
Muscular dystrophies 106
Mycetomal infections 17
Mycobacterium leprae 109
Mycobacterium tuberculosis 17, 145
Myeloma 88, 147
cells 100
deposit 102
multiple 99
treatment of 100
Myelomalacia 99f, 117f
Myeloproliferative disorders 50
Myofascial structures 141
Myositis ossificans 133, 205f
progressive 204f
stages of 133f
traumatica 205f
Navicular bone, dorsal dislocation of 191f
Necrotic bone 24
Nelaton's line 152
Neoangiogenesis 5, 10
Neoplasms 103
in lumbar spine 147
complications 65, 100
deficit 88
Neuroarthropathy 207f
changes 188
Neurofibroma 136
Neurofibromatosis, generalized 68, 68f, 69f
claudication 145
inflammation 140
Neurological symptoms 88
Neuromuscular disorders 104
non-Hodgkin's lymphoma 101
Nonossifying fibroma 91
Nonsteroidal anti-inflammatory drugs 38, 115, 120
Nonunions 7
Numbness 88
Olecranon bursitis 130
Ollier's disease 73
Oncogenic osteoporosis 64
Open bone grafting 22
Open reduction and internal fixation 7
journey in 193
tumors 87
clinical features 88
investigations 88
Osseous lesions 120
Osseous tissues, repair of 3
Ossification of posterior longitidunal ligament 116f, 117
Osteoarthritis 46, 115
Osteoarthrosis 137f
advanced 48f
early 47f
of spine 144
primary 46, 121
progressive 118f
secondary 46, 46f
early stage 47
intermediate stage 47
late stage 48
Osteoarticular fractures 182
Osteoarticular system 187
pathology of 187
Osteoblast activity 198f
Osteoblastic cells, clump of 4
Osteoblastoma 95
skeletal deformities 68
structures 177f
Osteochondroma 94f
Osteochondromatosis, multiple 93, 94
treatment 94
Osteoclastoma 95, 96f
treatment 96
Osteogenesis imperfecta 69
Osteogenicity 11
Osteoid osteoma 95, 89f
Osteoinductive potential 12
Osteomalacia 154
in adults 59
radiological features of 59f
acute 19
operative intervention for 19
chronic 20
curing 24
dry 24
wet 24
of femur 21f, 24f
Osteon 6
classification 52t
diagnosis 50
femoral head 52t, 56
pathology 50
suspected risk factors of 50b
treatment 52
nonoperative treatment 53
operative treatment 54
Osteopoikilosis 196f
Osteoporosis 63
bisphosphonates 64
diagnosis 63
of spine 64f
operative intervention 65
secondary common causes of 63t
treatment 64
unusual degree of 139f
Osteosarcoma 98
in orthopedics 9
radiological features 98
treatment 98
variants of 99
Osteotomy 9, 163, 185
dome 162f
Paget's disease 64, 99, 154, 155f, 198f
Pain 88
heel 189, 190
treatment 190
low back 141
source of 141
spine 141
Painful arc syndrome 121
Palmar cutaneous 135
Papineau's procedure 22, 24
Paradiscal edema 146f
Paralysis 88, 152
Paralytic condition 179
Paraplegia, severity of 32
Parathormones 58
Para-typhoid bacilli 17
Paresthesias 127
Parosteal sarcoma 99
Pavlik harness 78
Pelvic support osteotomy 165f, 168
MRI of 40f
reflect general health 193
X-ray of 36f
Pemberton's acetabuloplasty 174
Periosteal osteosarcoma 99
Peripheral chondrosarcoma 99
Peripheral vascular disease 187
Periscapular muscles 105
Perivertebral cold abscess 32
Perthes disease 153, 155, 163
case of 157
classification of 156
treatment 157
Pes cavus 191
Pes equinus 191
PET scan 89
Phocomelia 209f
Phosphorus 62
Pinnae of ears 189
Plano-valgus feet 191f
Plantar arthrodesis 192f
Plantar-wards tilting 191f
Plasmacytoma 100
Plasmacytosis 100
Poliomyelitis 104
acute stage 104
elbow 105
foot 105
forearm and hand 105
hip 105
knee 105
recovery 104
shoulder 105
stage of
convalescence 104
residual paralysis 104
triple arthrodesis of foot 105
Polyarticular rheumatoid arthritis, case of 37f
Polydactylism 76
Polymyositis 42
Polyostotic fibrous dysplasia 70f, 91
treatment 91
Polyostotic skeletal dysplasia 154
Ponseti cast 81
Ponseti's technique 81
Popliteal bursa 181
Porous bones 63
Postoperative compartment syndrome, risk of 181
Postpolio syndrome 104
Pott's disease
cold abscess 32
diagnosis 32
neurological complications 32
treatment 33
Prepregnancy folic acid deficiency 67
Prostate malignancy 102f
Prostatic carcinoma 102
Proximal distal border 136
Proximal femoral osteotomy 163
osteotomies of 160
Proximal humeral metaphysis 94f
Proximal tibia 13
Pseudarthrosis of tibia, congenital 84, 84f, 85f, 206f
Psoriatic arthritis 41
treatment of 41
Pterygia syndrome 107
Pubic rami 60
Pulmonary complications 142
Putti-Platt's operation 123
arthritis 182
infection 168
and tuberculosis 159
osteitis 145
Pyrazinamide 28
Quadratus femoris 15, 56
Quadriceps muscles, weak 105
border of median nerve 135
deficiency 75
treatment of 76
deviation 37f
diaphysis 197
head 130
hemimelia, congenital 132f
nerve explorations 131
Radioulnar synostosis, congenital 75, 131
congenital, absence of 75f, 131
large segment of 132f
Reactive arthritis 41
Reflex sympathetic dystrophy 120
Reiter's syndrome 41
treatment of 41
osteodystrophy 50
rickets 60
Reticulum-cell sarcoma of bone 101
Retinacular capsule 156
Rheumatoid arthritis 154
advanced case of 137f
Rheumatoid disease 47, 63
Rheumatoid disorders 36, 38, 187
prognosis 38
role of operative intervention 38
subgroup of 39
treatment 38
Rheumatoid factor 36
Rheumatoid inflammation 120
Rheumatoid spondylitis 144
Rhomboideus 105
Rickets 155
different types of 62t
in children 59, 61f
Rickety rosary, producing 60
Rifampicin 28
Rigid deformities 83
Rigid internal fixation 8
Rotator cuff disorders 120, 122
Sacral tuberculosis 199f
Sacroiliac joints 40f
bilateral 36f
Salicylates, use of 88
in children 79
innominate osteotomy 79
osteotomy 170
procedures 174f
re-directional osteotomy 157
Scapulae, axillary borders of 60
Scapular neck near 124
Scheuermann's disorder 142
Sciatic scoliosis 147
Sciatica 115
Scleroderma 42
Sclerosis of articular margins 121f
Scoliosis 88, 141
adolescent 142
juvenile 142
Research Society 141
young boy 142f
Scoliotic deformities 141
Scurvy 63
Seizures 109
Selective estrogen receptor modulator 64
cartilages 177
fat deposition in bone 144f
bursitis 181
tendon 181
Sensory deficit 143
Septic arthritis 20
surgical management 20
Sequestrectomy 22
Sequestrum 22
fate of 22
Seronegative spondyloarthropathies 39
Serratus anterior 105
Serum alkaline phosphatase 102
Serum electrophoresis for myeloma protein 90
Shenton's line 160
Shoulder 20, 44, 120
active infection of 122
instability of 122
painful, common pathologies 120
recurrent, anterior dislocation of 124f
tubercular arthritis of 122f
Sickle-cell disease 50
Simple bone cyst 92
Sinuses, cases of 30
Sjögren's syndrome 37
Sjögren's-sicca syndrome 42
dysplasias 67, 68
maturity, age of 71f
tuberculosis 200f
cases of 32
tumors, common primary 87t
Skeleton 193
Slipped capital femoral epiphysis 155, 158
complications 158
radiological grading 158
treatment 158
Soft callus 5
Soft tissue
damage 14
procedures 73
severe damage 7
swelling 25f
Solitary osteochondroma 93, 94f
Spasmodic torticollis 115
Spina bifida 84, 143
Spinal cord, segment of 199f
Spinal decompression 150
Spinal dysraphism 86f, 142
Spinal fusion 150
posterior 34
Spinal hyperextension, anterior 39
Spinal infection 145
cases of 145
Spinal instrumentation 150
Spinal tuberculosis
appearance of 146f
treated for 28f
Spinoplasty 148
Spinous processes 151
Spondyloepiphyseal dysplasia 71f
Spondylolisthesis 142, 205f
appearance of 143f
Spondylolysis 142
Spondylosis 115
Spotted bone disease 196f
Staphylococcus 17
Steel's triple osteotomy 170
Sternocleidomastoid 118
muscle 117, 119f
Streptococcus 17
Subchondral fracture 52
atrophy 121
complex regional pain syndrome 64
dystrophy 121, 139, 139f
treatment 140
Sulphinpyrazone 189
Supraspinatous tendinitis 121
Swelling 88
Syndactylism 76
effusion 177f
fluids 136
membrane 182
Synovioma 37
Synovitis, stage of 156
Systemic lupus erythematosus 37, 42
Talo-calcaneal joint 82
hip joint 153
test, measurements of 153
Temporomandibular joints 81
Tendinous ruptures 120
Tendo-Achilles 39
lengthening 109
Tennis elbow 126
treatment 126
Tetracycline fluorescence 5f, f6
Thyroid hormones 58
Thyrotoxicosis 63
Tibia 85f
absence of 210f
bowing of 84
pseudarthrosis of 84
distal fragment of 185
large defect 15f
Tibia varum deformity 181f
Tibial osteotomy, high 178
Tibial pseudarthrosis, location of 206f
Tibiofibular articulation, superior 185
Tibiofibular joint, inferor, diastasis of 210f
Toes 76
Tom-Smith hip 153
Torn glenoid labrum 123
Torticollis: congenital 115, 117
pathology of 118
treatment 118
Total knee arthroplasty 182
Total knee replacement 182
Trabecular bones 58
Transcutaneous nerve stimulation 140
Transiliac osteotomy 170
Transilluminant swelling 181
Trendelenburg gait 152
Tricortical bone 11
Trigger thumb, congenital 138
Trihexy-phenadryl 109
Tubercular arthritis of elbow 28f
Tuberculoid 109
arthritis of wrist 139f
bones and joints 26
antitubercular chemotherapy 28
biopsy 27
blood 27
clinical picture 26
diagnosis 26
modern imaging techniques 27
prognosis and course 28
roentgenograms 26
type of surgery 31
elbow 130f
frontal bone 201f
infection 27f
common site for 178f
joints, staging of 30, 30t
left hip joint 196
lesions 27f
osteomyelitis 29f
paraplegia, classification of 33
principles of management 29
right hip joint 29f, 160
spine 32
surgery in bones and joints 31
Tubular bones 11
fractures of 74
Tubular plates 9
Tumor necrosis factor inhibitors 39
Tumor syndrome 34
Tumor-like conditions 87
Tumor-like lesions 87f
Tumors 87
benign 87
malignant 87
source of 87
spread, assessment of 89
Typhoid 17
Ulnar nerve
congenital slipping of 126
transposition 127
operative steps 127
Ulnar neuritis 127
Unicameral bone cyst 88, 92, 92f
treatment 92
Upper femoral osteotomy 160
Upper motor neuron 32
Urist's technique 14f
Uterine cancer 64
Valgus deformity 127
claudication 145
invasion, stage of 156
tree 3
Vertebra plana in mid-dorsal spine 147f
body hemangioma 149f
disease 33
fractures 65, 142
pigmented synovitis 37
synovitis 43
Visceral disorders 141
Vitamin D 58, 64
resistant rickets 61
Walking and standing 152
Weakness 152
Wedge correction by “turn-buckle” method 72
Weight bearing 77, 78
bones 154
to improve 161
Wolff's law 97f
Wrist 20
and hand 134
drop 134
Wry neck 115
Xenogenous 11
Chapter Notes

Save Clear

Section Outline
  1. Regeneration and Repair of Osseous Tissues
  2. Infections of Bones and Joints
  3. Inflammatory Rheumatoid Disorders
  4. Osteoarthrosis
  5. Avascular Necrosis of Bone or Osteonecrosis
  6. Common Metabolic Bone Disorders
  7. Common Generalized Congenital Deformities and Dysplasias in Orthopedics
  8. Localized Congenital Deformities (Anomalies) of Limbs
  9. Common Orthopedic Tumors
  10. Common Neuromuscular Disorders

Regeneration and Repair of Osseous TissuesCHAPTER 1

Most of the fractures would unite whether splinted or not due to an in-built mechanism of healing. Land-animals afterall have been walking after such fractures.
In clinical practice, fractures require stable immobilization to alleviate pain, ensuring adequate contact of fracture ends in near anatomical position, preventing excessive movements at fracture site, however, permitting early axial loading of the limb. Axial physiological loading permits healing by natural way by formation of external callus. Visible external callus will not form if the fracture is fixed rigidly. The progress of healing process by rigid fixation cannot be easily appreciated. The bones under rigid implants due to stress shielding become osteoporotic, fracture at the weakened bone is not uncommon after the implant removal.
An outline of “natural healing” of a fracture is described below. All the structures, periosteum, endosteum, cells contained within the broken bones and muscles and soft tissues contribute to the process of fracture healing. The injury itself triggers the cascade of healing process. The cascade of fracture or bone healing starts after traumatic fracture, osteotomies (controlled fractures), pathological fractures (except due to malignancies), or any operation on bone.
Throughout the process of fracture healing (from fracture hematoma (Fig. 1.1) till the end of remodeling), many growth factors like bone morphogenic proteins, cytokines and other growth factors continuously play a role in cascadal fashion. The cellular and molecular responses are practically uniform up to the stage of soft callus formation, further behavior of growth factors and cellular response would, however, depend upon the environments provided for the healing process. The pluripotent reparative mesenchymal cells under variable conditions may induce woven bone (fiber bone), chondrogenesis, endochondral ossification, lamellar bone; or fibrous tissue when environments are unfavorable (Figs. 1.2 and 1.3).
zoom view
Fig. 1.1: Bone is essentially a vascular tree surrounded by mineralized tissue. This is the appearance of ‘bone’ after removal of all mineralized tissues.
Immediately after a fracture, in addition to the formation of fracture hematoma, there is intense vascular response in the injured area (not unlike in the Ilizarov's process). 4The vascularity increases at every level, medullary vessels, periosteal vessels, from capillaries to nutrient artries. With healing, the continuity of endosteal, periosteal and extra-osseous vasculature is re-established across the site of fractured area.
zoom view
Fig. 1.2: Reparative mesenchymal cells can be induced to form any mesenchymal tissue depending upon the environments.
zoom view
Figs. 1.3A to C: Cellular response in early stages of repair. (A) During first week—non-specific inflammatory cells; (B) Between 2nd to 4th week—osteoclasts and osteoblasts; (C) Between 3rd to 5th week—clump of osteoblastic cells.
The fractures heal by various biological stages in a cascadal fashion. The stages generally described are for convenience 5and possible understanding. Fracture or any injury to the bone triggers following biological cascade of repair (Fig. 1.4).
Stage I: Fracture Hematoma: Blood collects around the broken bones, because there is rupture of endosteal and periosteal blood vessels and the vessels in the disrupted soft tissues around the site of broken bones. At the fracture ends, one to 2 millimeter of bone dies because of disruption of its blood supply.
Stage II: Soft Callus: Within about 8 hours of the fracture, the hematoma gets organized (formation of granulation tissues) and invaded by neocapillaries accompanied by endothelial and perithelial cells under the influence of many growth factors and cytokines (Figs. 1.5A and B).
Stage III: Mineralization of Callus: Calcium starts getting deposited around the neocapillaries (neo-osteogenesis), peripheral parts earlier than deeper parts.
The pluripotent mesenchymal cells of the granulation tissue, under the influence of bone morphogenetic agents and growth factors, differentiate into osteogenic, chondrogenic and osteoclastic cells. Osteoclasts remove the dead bone and dead tissues, thus, creating channels (cutter heads) for neocapillaries to spread across the fracture site.
zoom view
Fig. 1.4: Biological cascade of repair and regeneration of bone. Adapted from literature.
zoom view
Figs. 1.5A and B: (A) Abundant neocapillaries formed at early stages of repair; (B) Neo-osteogenesis seen by tetracycline fluorescence around neoangiogenesis.
Earliest neo-osteogenosis is observed around the neocapillaries and vascular spaces (Figs. 1.5 and 1.6). Mineralization of callus is a diffuse process, external callus is radiologically visible, however, internal callus (medullary callus) is not easily discernable.
Stage IV: Callus Consolidation: The whole of callus is now mineralized spreading astride the fractured site. The fracture lines do not remain visible in the X-rays. The outer surface of callus is irregular (rough).
Stage V: Callus Remodeling: The bone laid down in the initial stages is as woven bone (fiber bone) or as endochondral bone. The restoration of the normal architecture occurs by the process of remodeling according to the Wolff's law (function determines the form of bone). The geometry, thickness and trabecular pattern of callus and bone are dependent upon the functional loading (probably the most important factor) and muscular action of the limb. Ultimately the trabeculae are laid (reorganized) in the direction of functional loading, woven bone or endochondral bone gets replaced by trabecular lamellar bone, the external callus gets resorbed (decreases in size), the medullary canal and medullary vessels get re-established. Radiologically the callus has normal mineralization and there is smoothening of the external surfaces.
How long does a fracture take to unite and consolidate? No precise answer is possible because age, general health, status of soft tissue cover, blood supply, nature of fracture (closed or compound), the site of fracture and type of treatment, all influence the time taken. Approximate prediction may be possible for fractures of major bones in an adult (with optimum health) according to Perkin's timetable. A spiral fracture in the upper limb unites in three weeks, for consolidation (time to permit all activities without protection) multiply by 2; for lower limb, multiply all figures by 2; for transverse fractures, multiply all figures again by 2.
With optimum health and nutrition of the patient, having been offered a biologically sound treatment most of the fractures heal with optimum biological process. However, 5 to 10 percent of fractures undergo delayed union and non-union, many due to poorly understood causes. Optimization or enhancement of the healing process of such patients is being debated and tried.
zoom view
Figs. 1.6A and B: Outer most layer of bone was laid about one month before harvesting this tissue, around a large vascular space. Successive layers of bone formed (as seen by tetracycline-fluorescence) in one month's time reducing the size of the vascular space to form an osteon.
We may not understand methods for enhancement of the process of fracture healing, however, causes of non-union or delayed unions are fairly well known.
If a fracture does not unite in double the expected time of union for that fracture, it is accepted to be called non-union. Common causes of non-union are:
  1. Distraction of fracture fragments, either as a result of interposition of soft tissues, or failure of soft tissues to hold the fragments in contact, or as a result of fixation of fragments in distraction (bipolar interlocking, plating).
  2. Excessive movements at fracture site.
  3. Severe damage to soft tissues (extent of trauma or iatrogenic).
  4. Poor local blood supply of bone.
  5. Infection (infected non-unions are most difficult to treat).
  6. Iatrogenic: Surgical intervention leading to excessive soft tissue stripping (damage), fixing the fracture with a gap between the fragments.
  7. Intracapsular fractures: Fracture line within the synovial fluid (fractures of femoral neck, scaphoid, talus).
Fracture line remains visible in X-rays after many months of treatment. Some operative intervention is indicated when a particular fracture is not expected to unite: The X-rays may show a gap of more than … mm, the bone ends are sclerosed, there is thinning of bone ends or the medullary canal is closed. Non-unions are classified as hypertrophic or atrophic or a mixed variety. In cases of difficulty or when the fragments are already fixed with implants, “stress X-rays” in various planes may help to reach the decision. Some non-unions especially in the elderly and located in upper limb may be managed by a suitable orthosis, which permits the patient function and ambulation without much pain. However, in general, the principles of open reduction, freshening of edges, internal fixation and barrel-stieve like copious autogenous bone grafting is mandatory. Post-operatively encourage active exercises and loading of the operated limb. When in doubt about the stability provided by the implant do not hesitate to use additional cast or orthosis. A few cm of shortening to achieve union is not much of a price to ensure union.
Despite all the technological advances made in the operative treatment of fractures (open reduction and internal fixation– ORIF), surgical intervention is not free of complications, and many a time a second operation (re-operation) is indicated for implant removal. Non-operative management is a sound method of treating many fractures especially in places with moderate or compromised infrastructure available. Most of the fractures of upper end of humerus, humeral shaft, lower end of radius, fractures of forearm bones, fractures of tibia, fractures around the ankles, clavicle, carpal and tarsal bones, metacarpals and metatarsals can be effectively managed by non-operative treatment. Multiple Kirschner's wires fixation percutneously with biplanar and bicortical engagement under C-arm guidance can improve the stability around osteochondral fracture sites. Many fresh osteochondral fractures (less than 10 days duration) can be managed by closed reduction and insertion of Kirschner's wires under C-arm.
Other methods of achieving stability at the fracture site are plates, screws, external fixations, bridging plates, intra-medullary fixations. Rigid-internal fixation was advocated by AO–school in the second half of 20th century; however, at present, the preference and consensus is for stable 8fixations. Ideally one should prefer a fixation which permits early axial physiological loading, as during walking and while doing active muscle exercises.
Intramedullary nails with many of its modifications are used as a standard option for most of the diaphyseal fractures of bones. Reaming of the medullary canal for insertion of the nail is still controversial and debated. There are proponents for reaming to permit insertion of nails with larger diameter, we prefer minimal reaming to open the isthmic areas to permit a snug fitting nail, and there are some surgeons who insert nails without reaming especially while operating on a polytraumatized patient. Do not attempt extensive operations (to achieve “anatomical” reduction) which may lead to devascularization of bone. Basic goals of fracture treatment should be aimed at stable fixation (by any means) with least disruption of endosteal and periosteal circulation, respect to and restoration of soft tissue coverage with provision for relatively pain free movements of the adjacent joints. Micromotions do not impede the healing process. Prolonged non-weight-bearing can lead to local osteoporosis, soft tissue dystrophy and loss of cartilage nutrition. Some known substances that have inhibitory effect on bone healing are NSAIDs, tobacco (nicotine), diabetic state, rheumatoid disorders, malnutrition, osteoporosis, cytotoxic drugs and irradiation.
With rigid fixation, medullary circulation may get re-established early, the “cutter heads” may cross the fracture site, however, the so called “primary healing” or “osteon by osteon” healing takes place very slowly and means to accurately determine the progress (extent) of primary healing are unreliable. For early ambulation, casts or orthosis are still required to protect the limb during full weightbearing. Rigid fixation with plates results in stress shielding under the implant leading to cortical thinning, which may cause fracture at the ends of plate (site of stress concentration), or at the site of thinning of cortex. The reported incidence of such fractures is 10 to 15 percent (Table 1.1). The likelihood of refracture of bones that heal with external callus is extremely rare.
The classical diaphyseal fractures which are stable (transverse, or short oblique) can be managed by intramedullary nails without interlocking. However, unstable diaphyseal fractures, very oblique, long spiral, grossly comminuted segmental fractures, or fractures with loss of bone fragments, are candidates for interlocking (with screws). Early loading in cases of interlocking is inadvisable because the stress would be on screws, which are likely to bend or break. When one is using bipolar interlocking, dynamization must be done to avoid non-union. On an average dynamization for upper limb in recommended after 6 weeks, for the lower limb after about 9 weeks.
Table 1.1   Healing of bone.
Natural/by callus (since antiquity)—SECONDARY HEALING
“Osteonal” (1965-1985±)—PRIMARY HEALING
Stable immobilization by POP or ORIF
Rigid internal fixation (RIF) in every fracture
Micromotion and axial loading encouraged
Aim: no motion at site of fixation
Micromotion → stimulus for callus
No micromotion → No stimulus for callus
Union judged by visible callus
Judgment of union uncertain
Refracture through callus extremely rare
Refracture not uncommon at implant—Bone interface
Load/Stress sharing
Load/Stress shielding
Our ancestors in orthopedics evolved many osteotomies for a variety of orthopedic affections (conditions). These are essentially low technology but high biology procedures. If our patient selection is appropriate and the procedure is performed following the principles advocated by the exponents one can get a satisfactory result in a number of disorders for many years.
Ideally any corrective osteotomy should be done nearest to the deformity. For genu varum, select proximal tibial osteotomy; for genu valgum, select distal femoral osteotomy; for cubitus varum or cubitus valgum, select distal humeral osteotomies. Proximal femoral osteotomies are generally indicated for fixed hip deformities or certain problematic fractures. Innominate osteotomies help provide ‘shelf’ for stability of hip joint. There are many methods of obtaining correction of deformities. It can be close-wedge osteotomy, it does not need bone grafting, however, the bone-wedge which one removes may be used as a bone graft to place over the osteotomy site before wound closure. If one opts for an open wedge osteotomy, one has to secure the correction by a suitable implant, most surgeons consider filling of the open wedge with bone grafts. Another method of achieving correction is by a dome-shaped (ball and socket) osteotomy. The convexity of the dome is generally towards the joint or broader end of the bone. After completion of the ball and socket osteotomy, the correction can be achieved in any direction—abduction, adduction, external rotation and internal rotation in isolation or in combination.
Once any of the above corrective osteotomies are completed, it is wise to correct all deformities, as planned preoperatively. The contralateral normal limb should be easily accessible for comparison of the achieved correction during surgery. The site of osteotomy can be fixed by any of the methods, plaster cast only, Kirschner's wires (K-wires) and plaster cast, tubular plates, screws and wires (like French osteotomy), angled blade plates, or external fixators. Depending upon the growth potential of the bone, one may do over-correction of the deformity by 5 to 10 degrees to negate the recurrence of deformity with growth. Basic priniciples of fracture healing must be observed during operation, fixation, postoperative immobilization, loading and rehabilitation.
Osteotomy performed by a surgeon should be considered a controlled fracture. While doing osteotomy if soft tissues are respected, while achieving correction bone ends are not treated roughly, raw surfaces at the osteotomy site are held in good apposition for at least 70% of the circumference, implants when used provide a stable fixation (without distraction) to permit axial loading in the lower limbs or active exercises (in the upper limb) 3 to 6 weeks after the osteotomy, non-union at the osteotomy site should be a rare complication. While using rigid implants for fixation of osteotomy, the surgeon must ensure the best desired position on the operating table. If one is using a semirigid implant (K-wires), the correction can be improved to the best desired at the time of stitch removal and application of definitive plaster around 2 to 3 weeks after the osteotomy. Most of the corrective osteotomies for joint problems provide adequate relief of pain, maintain functional mobility, retain natural bone stock and articular cartilage, provide proprioception and permit fairly high degree of activity for 10 to 15 years. Juxta-articular osteotomies do not necessarily compromise the later arthroplasty procedure.10
Distraction osteogenesis is a form of tissue engineering founded on the principle of generation of new tissues in response to gradual increase in tension. The basis of the technique is to produce a careful fracture of bone or corticotomy, followed by a short wait (5 to 10 days) for young callus to form at the site of ‘fracture’. Distraction is now applied gradually via a circular or unilateral external fixator device (Fig. 1.7).
In corticotomy, the bony cortex is partially divided in a circumferential manner using sharp narrow osteotomes through small skin incisions. The break is completed by gentle manual force (osteoclasis), thus, leaving endosteal and periosteal blood supply intact. Alternatively, the site of osteotomy is exposed subperiosteally. Multiple drill holes are made all around the site of bone division in the cortex without going across the medullary canal. The osteotomy is completed using a sharp narrow osteotome.
One can understand the biological principles, however, mastery of the technique has a long learning curve. The operative technique is got to be tailored to each patient. Probably this method is best indicated in patients who have concomitant complex deformities like angulation, rotation, translation and shortening. The corticotomy or osteotomy must be completed by low energy technique (sharp, narrow osteotomes) to minimize necrosis and damage to endosteal and periosteal blood supply. Distraction osteogenesis has the best potential of “regeneration” at metaphyseal or metaphysio-diaphyseal junctional areas as compared to diaphyseal sites. A nearly ten-fold spatial increase in blood flow through neoangiogenesis following corticotomy (and possibly following osteotomy) has been observed. Neoangiogenesis is the precursor to neo-osteogenesis. Distraction is recommended at 0.25 mm four times a day. Distraction at this rate causes neovascularization, neo-osteogenesis, generalized cellular proliferation almost in all the tissues (most appropriately termed distraction histogenesis) under the effect of tension distraction. Ilizarov's corticotomy can be successfully used even in the presence of moderate active infection and local scarring of soft tissues.
zoom view
Fig. 1.7: Ilizarov's technique for neohistogenesis by slow distraction (axial and transverse).
Distraction is usually applied through a circular or unilateral or bilateral external fixator. Depending upon the age of the patient and the health of the concerned bone, after 5 to 10 days of waiting period of osteotomy, graduated distraction generally forms a soft callus (regenerate) at the site of distraction in about 3 to 4 weeks. If distraction is too fast, the regenerate may be thin (poor) and has hour-glass appearance. If distraction is too slow, the regenerate shows a bulbous appearance and may undergo premature rapid consolidation defeating the purpose of the whole procedure. Ilizarov's principle of distraction histogenesis has also been used for distraction of the growth plate (chondrodiastasis), preferably in children close to the closure of the physis. Growth plate generally closes or is sealed after this procedure.11
Ilizarov's principle has also been used for correction of soft tissue contractures, like Volkmann's ischemic contracture in upper or lower limbs, and resistant club-foot deformities. Another indication for this technique is for filling of segmental defects in bone (bone-transport). Probably bone loss of more than double the diameter of tibia or femur would need the help of bone transport techniques. The gap is gradually filled by creating a “floating segment” of bone by performing a corticotomy (or osteotomy) proximal or distal (or bifocal corticotomy) to the site of bone gap. Ilizarov's technique offers a reliable method to correct complex deformities, overcome shortening, and bridge bone gaps. However, the complications in the hands of a general orthopedist remain high, therefore, for the best results, Ilizarov's technique should remain in the domain of especially trained and committed surgeons with adequately resourced infrastructure.
Bone grafts are needed in clinical orthopedics mostly for treatment of non-union of fractures, for filling large cystic lesions of bone and for reconstruction of large osteo-periosteal bone defects (Table 1.2). The best bone graft is autogenous, because it provides: (i) osteogenesis by the osteoinduction property of the graft inducing the reparative mesenchymal cells (from the host) into osteoprogenitor cells, (ii) it provides an ideal porous scaffold for penetration of vessels and cells, upon which the new bone can form, (iii) structural (mechanical) stability is provided minimally by cancellous, moderately by corticocancellous grafts and predominately by tubular bones, (iv) osteogenesis may also be brought about by a few surviving surface cells of autogenous grafts. Donor area morbidity is recorded, however, any orthopedic surgeon with moderate training would learn to obtain adequate amount of cancellous bone from the thickest part of iliac crest without serious complications. After subperiosteal exposure of the iliac crest and outer surface of the “harvest area,” one can remove adequate amount of cancellous bone as slivers. If one leaves the inner table intact and does a meticulous closure of muscles and skin, as a rule no complication is encountered. The most disturbing complication observed by us has been a sliding hernia through a major defect in the full thickness of iliac bone, this is, however, avoidable. The iliac bone provides a rich source of cancellous bone. Tricortical bone harvested from the thickest part of iliac crest constituted by the upper border, medial and lateral cortices of the bone can provide about 6 cm × 1.5 cm × 1.5 cm segment of bone for use as a structural graft. Cancellous autogenous bone grafts are best suited for non-unions, and for filling of “cavitory lesions”. For structural integrity, tricortical bone from iliac crest or a segment from distal half of fibula, or ribs when one is operating on spine would serve the purpose.
Table 1.2   Rough biological behavior of bone-grafts and substitutes.
Speed of incorporation
Graft Substitutes
One may sometimes need to use both the structural grafts combined with cancellous bone. The limitation of autogenous bone grafts is the availability of sufficient quantity required especially in children. Cortical bones provide mechanical stability, however these are very slow regarding incorporation. Part of fibular grafts may still be radiologically visible 7 to 10 years after operation. Cancellous bone grafts provide poor mechanical stability however these get completely incorporated within 2 to 5 years after implantation.
Allografts: Earlier than 1965, fresh allografts generally donated by ‘mother’ of a child were used when no other material was available. Such grafts have no surviving cells, however, these cells have illicit antigenicity and induce an inflammatory response, which may lead to failure of the grafts. Slow penetration of neocapillaries in the transplanted fresh allogenic bone did not create a sudden surge of antigen-antibody reactions. Thus, the immune reaction was mild. However, since mid-sixtees clinical use of untreated allografts is not permitted.
When adequate amount of autogenous bone graft is not available to fill or bridge large defects, one has to depend upon allogenic bone. Currently the allografts are harvested under sterile conditions, the donor is cleared for malignancy, infection, and viruses (including HIV). The harvested bones are stored or preserved by deep freezing (at −70° C), freeze-drying or ionizing radiation. Osteoinductive potential of such grafts is, however, markedly reduced.
Demineralization (according to the principles of Urist, 1965) is another way of reducing antigencity, and increasing the porosity for better osteoconduction. Decalcified bone matrix retains sufficient osteoinductive agents (BMPs, growth factors) inducing the host mesenchymal cells to osteoprogenitor cells. The author has used such allogenic grafts between 1972 and 2013 for cavitory lesions, spinal fusions (in children) and for structural defects with impressive success comparable with the grafts from more sophisticated banking facilities (Figs. 1.8A and B). Preparation and maintenance of decalbone banks is simpler, less expensive and can be practised in hospitals with moderate facilities (Figs. 1.9A and B). Allografts are ideal for conditions like polyostotic fibrous dysplasia, generalized enchondromatosis, neurofibromatosis with pseudarthrosis and osteogenesis imperfecta. In such cases, the autogenous bone per se is inherently defective.
Allografts or bone graft substitutes can also be used as autogenous bone grafts expander. The process of incorporation of allografts is similar to that of autogenous grafts but slower.
Bone Graft Substitutes (Synthetics)
Synthetically produced graft substitutes are prepared from calcium phosphate, hydroxyapatites and calcium carbonate in various combinations. These graft substitutes act as osteoconductive agents for osteoprogenitor cells (accompanying neocapillaries) to penetrate in their pores and lay down bone. Mechanical strength and rate of resorpotion (one to 2 years) vary with different combinations.
Bone cement: Cementation may be used for filling-up benign cavities in bone if bone grafts or substitutes are not available. Cementation leads to exothermal reaction on the recipient wall. Probably the reaction eliminates the reparative potential from the host-bed (Figs. 1.8A and B). Once infected the infection persists. Metal implants at best provide stability to damaged bones. If the underlying damaged bone does not stabilize in the “critical” time the implant would break due to the accumulation of “metal-fatigue” (Figs. 1.10A and B).13
zoom view
Figs. 1.8A and B: After curettage of giant-cell-tumor of proximal tibia, the cavity was filled with (A) cementation. The tumor recurred within 18 months after the operation; (B) The cement was removed, intralesional curettage of the tumor was performed and the cavity was compactly filled with allogenic bone graft. The biological activity of the host bone and the graft helped heal the osseous cavity.
Bone Morphogenetic Proteins (BMPs)
These bone inducing agents were earlier extracted from allogenic bones. The process was too complicated and the yield was too small (probably one mg from one kg of bone). At present, BMP-2 and BMP-7 are commercially prepared by recombinant techniques, these are available for clinical use, however, the cost is prohibitive (e.g. US dollars 400 for a single level disc fusion) for widespread use.
Fibula as a Bone Graft
Fibula is another source of autogenous bone graft especially for structural integrity. It provides an excellent mechanical stability, but has scanty cellular contents. The compact structure of fibula makes permeation by repairing mesenchymal cell and neocapillaries a slower process, delaying complete incorporation. The deepest part of fibular grafts may not get completely incorporated even after many years.14
zoom view
Figs. 1.9A and B: (A) Synthetic bone graft substitute; (B) Decal-bone preserved in ethanol (prepared according to Urist's technique).
One can safely harvest about 15 to 20 cm of fibula. The distal cut should be at least one cm proximal to the inferior tibio-fibular joint. If one is impelled to obtain the upper end of fibula (as for reconstruction of distal end of radius), one must ensure the safety of the common peroneal nerve winding around the neck of fibula.
Transfer of Vascularized Bone Graft (Taylor, 1975)
The commonest free vascularized bone graft used in clinical practice has been the fibula. This procedure, however, requires microvascular expertise and sound orthopedic principle with two operating teams working simultaneously at the donor-site and the recipient area. Besides the highly specialized expertise, the other limiting factors are scarring at the recipient area due to infection, soft tissue damage or radiation necrosis. This option may be considered only when simpler techniques have failed or judged to fail.
Muscle Pedicle-based Bone Grafts (Huntington, 1905)
Muscle pedicle-based bone grafts can be performed by most of the orthopedic surgeons, however, the limitation in this procedure is that the “pedicled bone” has a limited radius of excursion. The most popular (and successful) graft has been the transfer of muscle pedicled vascularized fibula to repair or replace large defects in the ipsilateral tibia.
zoom view
Figs. 1.10A and B: Any metal-implant would fail due to accumulation of metal fatigue unless the underlying bone gets stabilized before implant failure (within critical time): (A) In the femur; (B) In the humerus.
zoom view
Figs. 1.11A to C: Ipsilateral fibula is one of the most vital grafts available to reconstruct any large defect in the tibia. Distal half of tibia was lost after an open injury of this leg (A and B). Ipsilateral fibula was “tibialized” to bridge the gap with fusion of the ankle joint (C). Note hypertrophy and remodeling of the fibular graft, the proximal non-weight-bearing fibula has not hypertrophied
The author has used this technique (tibialization of fibula) successfully for repair of large tibial defects due to traumatic extrusion, extensive sequestration, oncological resection and congenital defects (Figs. 1.11A to C).
Many other muscle pedicled bone grafts have been innovated by orthopedic surgeons, a few examples are sartorius and tensor fascia lata based bone from anterior part of iliac crest, for neglected or nonunion of femoral neck fractures, and for avascular necrosis of femoral head in young patients. This would delay the need for total joint replacement by 10 to 15 years. Lumbosacral paravertebral muscle based bone from posterior part of iliac crest, for posterior or posterolateral fusion of lumbar or lumbosacral spine, and quadratus femoris based bone graft from ischeal tuberosity are other examples. Pedicled bone grafts provide the benefit of osteogenesis as of living bone, irrespective of the length of bone defect and condition of the recipient bed. These grafts are tolerant to moderate infection and are capable of hypertrophy according to the Wolff's law. For success, adherence to sound orthopedic principles for repair and regeneration of bone is mandatory.
  1. Huntington TW. Case of bone transference. Ann Surg. 1944;26:455.
  1. Urist MR. Bone formation by autoinduction. Science. 1965;150:893–99.
  1. Companacci M, Zaanoli S. Double tibio fibular synostosis (fibula pro tibia) for non-union and delayed union of the tibia: End results review of one hundred seventy-one cases. J Bone Joint Surg. 1966;48–A:44–56.
  1. Illizarav GA. The tension-stress effect on the genesis and growth of tissues. Part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res. 1989;239:263–85.
  1. Ilizarov GA. Clinical application of the tension-stress effect for limb lengthening. Clin Orthop. 1990;250:8–26.
  1. Paley D, Chaudhry M, Pirone AM, Lentz P, Kautz D. Treatment of malunions and mal-nonunions of the femur and tibia by detailed preoperative planning and the Ilizarov techniques. Orthop Clin North Am. 1990;21:667–91.

  1. 16 Perren SM, Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg. 2002;84B: 1093–110.
  1. Sarmiento A, Latta L. The evolution of functional bracing of fractures. J Bone Joint Surg. 2006;88B:141–48.
  1. De long WG Jr, Einhorn TA, Koval K, et al. Bone grafts and bone graft substitutes in trauma surgery. A critical analysis. J Bone Joint Surg. 2007;89A:649–58.
  1. Kelly MP. Savage JW, Bentzen SM, et al. Cancer Risk from Bone Morphogenetic Protein Exposure in Spinal Arthrodesis. J Bone Joint Surg. 2014;96A:1417–22.
  1. Tuli SM. Tibialization of the fibula: A viable option to salvage limbs with extensive scarring and gap nonunious of the tibia. Clin Orthop Relat Res. 2005;431:80–4.
  1. Yadav SS. The use of a free fibular strut as a “Biological Intramedullary Nail” for treatment of complex non union of long bones. J Bone Joint Surg Open Access. 2018:e0050.