1 | P a g e
“PROXIMAL FIBULAR OSTEOTOMY WITH LATERAL TIBIAL CORTICAL DRILLING FOR MEDIAL
COMPARTMENT OSTEOARTHRITIS OF KNEE AND ITS FUNCTIONAL & RADIOLOGICAL OUTCOME
”Dissertation submitted to
THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY in partial fulfilment of the requirements for
the award of the degree of
“M.S. ORTHOPAEDICS”
DR.GOPINATH K.R.
EXAMINATION NUMBER: 221812602
KAPV GOVERNMENT MEDICAL COLLEGE AND MAHATMA GANDHI MEMORIAL GENERAL HOSPITAL, TRICHY 620 001
THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI, INDIA
APRIL 2020 EXAMINATIONS
2 | P a g e
K.A.P.V. GOVERNMENT MEDICAL COLLEGE, TRICHY
DECLARATION
I, Dr. GOPINATH K.R, solemnly declare that this dissertation entitled
“PROXIMAL FIBULAR OSTEOTOMY WITH LATERAL TIBIAL CORTICAL DRILLING FOR MEDIAL COMPARTMENT
OSTEOARTHRITIS OF KNEE AND ITS FUNCTIONAL & RADIOLOGICAL OUTCOME”is abonafide work done by me at the department of Orthopedics, KAPV Government Medical College and Mahatma Gandhi Memorial General Hospital, Trichy during the period 2018 – 2019 under the guidance and supervision of the Professor and Head of the department of Orthopaedics of KAPV Government Medical College and Mahathma Gandhi Memorial General Hospital, Trichy,
Professor Prof.P.Mathivanan M.S.Ortho., D.Ortho., .This dissertation is submitted to The Tamil Nadu Dr.M.G.R Medical University, towards partial fulfillment of requirement for the award of M.S.ORTHOPAEDICS.
Place: TRICHY Date
DR.GOPINATH K.R
3 | P a g e
K.A.P.V. GOVERNMENT MEDICAL COLLEGE, TRICHY
CERTIFICATE
This is to certify that the dissertation titled “PROXIMAL FIBULAR OSTEOTOMY WITH LATERAL TIBIAL CORTICAL DRILLING FOR MEDIAL COMPARTMENT OSTEOARTHRITIS OF KNEE AND ITS FUNCTIONAL & RADIOLOGICAL
OUTCOME” is the bonafide original work of my student Dr.
GOPINATH K.R,in partial fulfilment of the requirements for M.S.ORTHOPAEDICS examination of THE TAMILNADU
DR.M.G.R. MEDICAL UNIVERSITY to be held in APRIL 2020.The study and period of postgraduate training was from DECEMBER 2018- SEPTEMBER 2019.
Prof.P.Mathivanan M.S.Ortho., D.Ortho., Professor and Head of the Department
Department of Orthopaedics Date: KAPV Government Medical College And Place: Mahathma Gandhi GH,Trichy 620001
4 | P a g e
K.A.P.V. GOVERNMENT MEDICAL COLLEGE, TRICHY
AUTHORISATION BY THE HEAD OF THE INSTITUTION
This is to certify that the dissertation titled “PROXIMAL FIBULAR OSTEOTOMY WITH LATERAL TIBIAL CORTICAL DRILLING FOR MEDIAL COMPARTMENT OSTEOARTHRITIS OF KNEE AND ITS FUNCTIONAL & RADIOLOGICAL OUTCOME” is the bonafide original work of our candidateDr.
GOPINATH K.R,in partial fulfilment of the requirements for M.S.ORTHOPAEDICS examination of THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY to be held in APRIL 2020.The study and period of postgraduate training was from DECEMBER 2018- SEPTEMBER 2019.
Signature of the head of Institution/Dean Date:
Place:
5 | P a g e
K.A.P.V. GOVERNMENT MEDICAL COLLEGE, TRICHY
COPYRIGHT
I, herewith solemnly pronounce that the KAPV Govt. medical college and attached A.G.M.General Hospital, Tiruchirapalli, Tamil Nadu, India; shall hold the rights to preserve, utilize and
disseminate this dissertation /research work in print format or electronic form for educational / research activities.
Date: Signature of the Candidate
Place: Dr.GOPINATH K.R
6 | P a g e
ACKNOWLEDGEMENTS
A great many people made this work possible. I thank my Dean for allowing me to conduct this study.
My sincere respect and honest gratitude to our beloved Prof P.Mathivanan M.S.ORTHO.,D.ORTHO., Professor and Head of the Department of ORTHOPAEDICS, Mahathma Gandhi Government General Hospital, Trichy who was the driving force behind this research. But, for his relentless guidance, this research would not have been possible.
I am grateful to Prof. K.Kalyanasundaram M.S. Ortho., and
Prof.R.Vasantharaman M.S. Ortho., without whom, considerable amount of this work would not havebeen possible so nicely.
I acknowledge t Dr.K.Kishore M.S.Ortho., for the many worthwhile criticisms he made during this research.
I am also thankful to Dr.S.Kumaresapathy, Dr.G.Rameshprabhu, Dr.Subramaniyan, Dr.B.Ramesh, Dr.R.Devendran,Dr.Sasikumar, for theirmodestsupport and expert guidance.
I also thank all my subjects /patients for their noble minds and utmost cooperation.
Finally, I thank all my professional contemporaries for their support and their valued criticism.
7 | P a g e
PLAGIARISM CERTIFICATE
This is to certify that this dissertation work titled “PROXIMAL
FIBULAR OSTEOTOMY WITH LATERAL TIBIAL CORTICAL
DRILLING FOR MEDIAL COMPARTMENT OSTEOARTHRITIS OF KNEE AND ITS FUNCTIONAL & RADIOLOGICAL OUTCOME” of the candidate Dr.Gopinath K.R with registration Number ...for the award of degree of M.S.ORTHOPAEDICS .I personally verified the urkund.com website for the purpose of plagiarism Check. I found that the uploaded thesis file
contains from introduction to conclusion pages and result showsge of plagiarism
16 %
in the dissertation.Guide sign with Seal.
8 | P a g e
9 | P a g e
CONTENTS
I
CERTIFICATE II
DECLARATION III
10 | P a g e
INTRODUCTION
Osteoarthritis of the knee is a progressive disease of the joint associated with degeneration of the articular carticular cartilage leading to pain, deformity, disability and decrease in the range of motion of the affected joint. It is most
ACKNOWLEDGEMENT
S.NO TITLE PAGE NO.
1 INTRODUCTION
10
2 AIMS & OBJECTIVES
13
3 LITERATURE REVIEW
14
4 MATERIALS & METHODS
21
5 RESULTS
32
6 DISCUSSION
49
7 CONCLUSION
53
8 BIBLIOGRAPHY
54
9 APPENDIX
10 GLOSSARY OF ABBREVIATIONS AND ACRONYMS
60
11 PATIENT INFORMATION SHEET PROFORMA
62
12 PROFORMA
66
13 PATIENT CONSENT FORM
68
14
ETHICAL COMMITTEE APPROVAL LETTER
70
15 X RAY ATLAS OF CASES
73
16 MASTER CHART 89
11 | P a g e
commonly seen in males less than 45 years and in females older than 45 years.
Factors associated with osteoarthritis of the knee are increasing age, obesity, sedentary lifestyle or changes in lifestyle and also work related activities.
The non operative management for arthritis of the knee include analgesic drugs, physical therapy, intra-articular visco-supplementation agents and intra articular administration of corticosteroids or platelet rich plasma. The ideal treatment for elderly patients of tric-compartmental osteoarthritis of knee will be a Total knee replacement. Whereas comparatively in younger population with only medial compartment osteoarthritis of the knee-joint together with a varus deformity, the treatment options remaining for managing are restricted to HTO-High tibial osteotomy and Unicondylar knee replacement.
These procedures are associated with their own set of
complications as well as being associated with a longer postoperative recovery period and also restriction of activities or weight bearing.
Hence, there is a necessity for a technique that is modest to do, easily reproducible, provides decent functional outcomes and associated with a smaller recovery period and develops the quality of life for the affected patients.
In this set-up, PFO with lateral cortical drilling is a relatively new and novel procedure which according to previously published and ongoing studies has been proven to be very effective in the management of medial compartment arthritis of the knee.
12 | P a g e
The hypothesis now is that the medial aspect of knee has only one
cortical support in an otherwise fully cancellous bone. This sustenance tends to be inadequate over a period of years with mild collapse as the patient ages. The lateral aspect of the knee is being buttressed by 3 cortices. One cortex is
contributed by tibia and other two from fibular strut,providing it strong, rigid and comparatively less collapsible. Hence, this might lead on to worsening varus with increasing age and would cause medial compartment Osteoarthritis of knee with a gradually reducing medial joint-space [15].
With this theory in mind, we developed the technique of transecting a 20 millimeters of fibular shaft 7cms- 8cmsexactly below the fibular head.This is done in order to relieve much concentrated medial compartment pressure and eventually realign the axis of the weight bearning on knee.
13 | P a g e
AIMS AND OBJECTIVES
14 | P a g e
The aim/objective of the present study was
1) To Assess The Role Of Proximal Fibular Osteotomy With
Proximal Lateral Tibial Cortical Drilling in the treatment of early
stages of medial compartment Osteoarthritis of knee joint
2) To assess its(PFO) functional and radiological outcome in medial
compartmental OA knee.
REVIEW OF LITERATURE
15 | P a g e
The probability of development of OA substantially increases every 10 years after the age of 45 years.[A1] The development and progression of knee OA comprises genetic ,mechanical, environmental ,structural, and social factors. While at the time of growth and
development, the tibial and femoral cartilage undergo adaptation then gradually to cyclic loading when the person starts walking; [A2] .
The hyaline cartilage lining the femoral condyle of knee gets thick in the particular zones of maximum loading in both the dimensions of anterior-to-posterior and medial-to-lateral areas .[A2] The tibiofemoral working mechanism and stocking patterns at the time of walking, thus, tend to have a noteworthy impact on the regional rather than sectoral enlargement of the hyaline cartilage.
Interruption of usual gait mechanics with trivial slips,falls,
ligament lax states, obesity and high or low velocity injuries and ill fitting shoes may shift the loading mechanisms to the alternate, while weight- bearing on the pressurised chondrogenic areas those are not well suited to acclimatise loads. [A2], Eventhough normal hale cartilage retorts
positively to loading and rises regional thickness, unhealthy or minimally injured cartilage degenerates and shrinkages the regional bluffed
thickness.[A2]
16 | P a g e
Although, there are plentifulimpending biomechanical adjustments which might influence the onset and progression of knee OA, increased internal femurotibial rotation and peak knee adduction moment (Madd) while load bearing may be the coupling factors which are of noteworthy attention.
The Madd is accepted as a clinically significant measure to study medial compartment knee OA,[A6],[A7] and is a substitute for medial contact force,[A8] disease worsening and progression, [A9],[A10] and pain severity. [A11]
Normal tibiofemoral loading may be changed in knees with either anterior cruciate ligament (ACL) tear or OA, and might transfer the weight bearing stressors to cartilagenous areas that were not previously suited for load bearing.[A3]
The stacking of these un-adapted regions paves way for
cartilaginous tissues to undergo fibrillation and focal degeneration.[A2], [A3], [A4], [A5] Correction of the irregularities of tibio-femoral rotation and/ or reducing the Madd are clinically suitable for mitigating of OA symptoms and advancement.
17 | P a g e
This research would render substantiation concerning the probable roles of the isolated and combined roles of tibio-femoral rotation and the
[Madd] in the development and evolution of knee OA.
Developing measures that satisfactorily renovates these two parameters and thus OA symptoms will be presented.
18 | P a g e
Osteoarthritis in the knee joint is a progressive pathology comprising the intra-articular tibia-femoral and patella-femoral cartilage degeneration. It might disturb any joint articulation within the body causing chronic aches, functional restriction, and
emotional discomfort and may lead to disability and will even adversely affect quality of life.[A12, 13]
Biomechanical analysis has shown that in single-leg stance the ground reaction vector (GRV) is positioned medial to the knee joint center and results in
64%–77% of the load passes through the medial compartment of the knee and
23%–36% through the lateral compartment[A1 4] , which is suggested as a predisposing factor for osteoarthritis [A15]
19 | P a g e
Knee varus deformities categorized by a mechanical femorotibial axis of <180 degrees in scannogram standing AP radiographs and a narrowed medial joint space are usual finding in patients with knee OA and affect 64% of patients with idiopathic OA.[A14]
High tibial osteotomy is usually recognized method for the
treatment of knee varus deformities subsequent from medial femorotibial
20 | P a g e
OA in young and energetic patients.Post high tibial osteotomy in many researches, most of the patients resumed to work with the same strength, and vast number of them had resumption to their playing
activities.[A16,A17]
However, since this is a technically demanding operation, complications are common and comprise nonunion, neuronal injury vessel injury, instrument irritation, and infection .[A18]
The knee joint will start load bearing with initiation of stance phase of gait and other activities might impact the natural pace of disease
progression and can influence operative and non-operative treatment results.[A19].Of unease, is the point that reduction in discomfort where related with a raise in knee joint force with weight bearing.[A20][A21]
The abnormal loading environment in knee osteoarthritis can be portrayed by the knee adduction moment. While knee osteoarthritis gait research relies much on this inconstant variable, evolving proofs supports anunwarranted role for knee kinematics, muscle activation patterns and the kinematics and kinetics of other lower limb joints in the genesis and progression of this disease. Nonetheless, knee loading is not the only factor responsible for articular cartilage degeneration.
21 | P a g e
Excessive and repetitive wear and tear with loading generates a complete exposure to loading, thereby acting as critical deciding mechanism in the process of development of OA. To evaluate the constant load bearing, collective load concept of determining this is a novel bio-mechanical move that combines loading exposure to portray the accumulated load that knee tissues endure during physical
activity.[A22]
Recognition of mechanical aspect in progression of osteoarthritis has resulted innewer strategies that demands to decrease physiological loads on the weight bearing knee, and thereby, hypothetically, to alleviate pain and reduce OA progression.[A23]
22 | P a g e
MATERIALS AND METHODS
This was Randomized controlled prospective study done between December 2018-september 2019 at the Department of Orthopaedics, Mahathma Gandhi Government General Hospital,Trichy. The study cohort comprises of 30 patients, who had medial compartmental osteoarthritis of the knee joint, who attended the outpatient clinic of our department for follow-up. All the patients belonged to the age group of more than 40 years . Informed, written consent was obtained from all the patients and their attenders. The study protocol was evaluated and approval was obtained from the Institutional Ethics Committee.
Then,proforma was used to evaluate and entry made based on observations preoperatively,intra operatively and post operatively at prescribed intervals.
23 | P a g e
THE INCLUSION CRITERIA : 1. Age of patients more than 40years
2. Medial compartment arthritis, at least 2 mm medial joint space present on weight bearing x rays,
3. Varus less than 15 degrees
4. Fixed flexion deformity <15 degrees
THE EXCLUSION CRITERIA
1. Age less than 40years
2. Tri-compartmental osteoarthritis 3. Varus angle> 15 degrees
Fixed flexion deformity >15 degrees
24 | P a g e
STUDY PROCEDURE
Patient evaluation:
All of the 30 patients were subjected to the following assessment:
1. Detailed history taking
2. Thorough clinical examination
3. Standard weight bearing Plain Radiographs of the affected knee joint in two orthogonal planes of Antero-posterior and lateral views
4. Routine Pre anaesthetic evaluation
5. Pain scale assessment using Visual analogue scale
6. Functional status of the involved patients assessed using modified Oxford Knee scoring system.
Knee pain was assessed using a visual analogue scale. Knee ambulation activities were recorded using oxford knee score
preoperatively and 0,1,3,6 months postoperatively. Preoperative and postoperative weightbearing and whole lower extremity radiographs were
25 | P a g e
obtained in all patients to analyse the alignment of the lower extremity and the ratio of knee joint space (medial/ lateral compartment).
Momentarily, the medial joint space was determined by one vertical line [-A-]between 2 horizontal lines (-C-&–D-) that is drawn from the lowest pt. of the medial condyle of involved side femur and medial condylar plateau of ipsilateral tibia. The lateral joint space was ascertained by one vertical line [-B- ] between 2 horizontal lines [-E- &-F-] which is marked from the lowest point
26 | P a g e
of the lateral condyle of the involved side femur and lateral condylar plateau of the ipsilateral tibia.
The proportion of the knee joint space (medial/lateral) can be ascertained by the division of [A]/[B].The hip to knee ;knee to ankle angle will be
calculatedtaking in reference of the involved side lowerlimb scannogram (full- limb x ray). The line A must be drawn from the midpoint of head of the femur to the centre of the knee joint, and the other line B will be marked from the midpoint of the kneejoint to the midpoint of the ankle-joint. The H-K-A angle will be given by the angle subtended in between linesA and B.
27 | P a g e
VAS SCORING SYSTEM
28 | P a g e
OXFORD KNEE SCORING SYSTEM:
29 | P a g e
OPERATIVE PROCEDURE
Patient placed in supine with knee flexed 45 degrees and the level of osteotomy is pre-determined and measurements marked.
Skin incision of length made 6-7 cm with fibular head as a landmark and using the previously marked points.
30 | P a g e
The soleus and peroneus muscles are carefully retracted and blunt dissection carried out using fingers.
31 | P a g e
The periosteum is scraped off from the shaft.
The osteotomy level is marked using drill holes and further osteotomy can be done.
The oscillating saw is used to make osteotomy
32 | P a g e
The osteotomised fragment being removed and ends smoothed.
The wound closed using nylon interrupted sutures and compressive dressing applied .
33 | P a g e
RESULTS
This study done between December 2018 to October 2019 a sum of 31 patients (32 knee joints) with medial compartment OA were operated by proximal fibular osteotomy in Department of Orthpaedics.Of the total 32 patients, 28 patients were followed up completely during the immediate postop,1 month,3 months,6 months .while,two patient lost followup after the first month visit,one patient didn’t turn up after surgery,one patient died after third month followup due to medical reasons(?Myocardial
infarction).The average BMI of the study population was 28.9.The average age of the patient was 57 years and of which 19
males(59.37%)and 13 females(40.62%).
The modified oxford knee score(OKS),Visual Analogue Scale(VAS),Tibiofemoral angle(TFA),Range of
Movements(ROM),Medial Joint space (MJS) were assessed during all visits and their findings were recorded in the respondent
sheet.The outcomes were analysed under functional and
radiological parameters.The radiological improvement was seen in 8 cases( 25%).radiological worsening was noted in 5
34 | P a g e
patients(15.6%), whilst the remaining (59.4%) had no improvement demonstrable radiologically.
On the functional aspect,4 patients (12.5%)who showed radiological improvement also had good finctional scores and one (3.12%) patient had good functional results without any
demonstrable radiological improvement. Three (9.37%) patients shown to have worsening radiologicalparameters.
The maximum medial joint space improvement was 0.3 mm ( at the end of 6 months).At 3 months ,only two cases (6.25%) showed radiological improvement,all being statisticallysignificant (P < .001).
The average Medial joint space preoperatively measured was 2.73 mmWhich was same in the postoperative period and at month it was 2.63 mm.At the 3 rd month visit ,it was 2.40 mm and at the six month follow up it was 2.43 mm. The average pre op varus angulation was 10.18 degrees and the same when measured at 6 months was 8.62 degrees. The average preop VAS score was 5.93 and it remained the same in the immediate post operative period and was 5.81 in the 1 month follow up,5.21 in both the third and the sixth month.
35 | P a g e
Complications encountered:
There were no major complications except for immediate post procedure neuropraxia involving the common peroneal nerve in one patient showing full recovery at first month followup and one case had superficial wound infection during the post op stay which was effectively managed with antibiotics and wound settled.
36 | P a g e
ANALYSIS OF DATA
The analysis is a practice of forming and making the data in such a way that the research questions can be responded and the hypotheses are verified.
This part concerns with the analysis and interpretation of the data collected from 32 medial compartment osteoarthritis patients to evaluate the results both functionally and radiologically by perfoming a proximal fibular osteotomy and lateral tibial cortical drilling . The data was
collected,scrutinized, tabulation done and analyzed in accordance to the aims and objectives. Statistical analysis allows the researcher to organize the data and to scrutinize the volume of information and inferential
statistics tells us about the correlation between two comparable factors.
ARRANGEMENT OF THE DATA
Data collected are put under the following section heads.
Section head A: Description of the demographic characteristics of osteoarthritis patients
Section head B: Assessment of thefunctional scoring system components all through follow-up visits.
Section head C: Assessment of the problems encountered.
Section head D: correllating the functional and radiological outcome of the procedure done and establishing the end result.
37 | P a g e
Section A: Description of the demographic characteristics of osteoarthritis patients.
AGE
The Mean age of patients who participated in the study was 43.97 years with a standard deviation of 15.43 years. Table 1 shows age distribution of patients in the study. Majority of patients were between 45-59 years 11 (36.7%).
Table 1: Age group distribution of patients (N=32)
Age group (years) Frequency (N) Percentage (%)
40-50 5 15.625
51-59 13 40.625
60-70 13 40.625
>70 1 3.125
15.625, 15%
40.625, 41%
40.625, 41%
3.125, 3%
AGE DISTRIBUTION IN YEARS
40-50 yrs 51-59yrs 60-70yrs
>70
38 | P a g e
SEX DISTRIBUTION:
Table number 2 portrays sex distribution of patients in the research. Most of patients were male patients 20 (66.7%)
Table 2: Sex distribution of patients (N=32) Gender Frequency (N) Percentage (%)
Male 19 59.375
Female 13 40.625
59.38%
40.63%
MALE FEMALE
SEX DISTRIBUTION
39 | P a g e
Section B: Assessment of thefunctional scoring system components all through follow- up visits.
KELLEGREN LAWRENCE GRADE
Before all parameters,using x rays grading of OA done
Table 3 portrays KL type distribution of OA patients in the study. Majority of patients were MEDIAL COMPARTMENT OA patients with grade 2
Table 3: KL grade distribution of patients (N=32)
KL grade Frequency (N) Percentage (%)
Grade I 6 18.75
Grade II 24 75
Grade III 2 6.25
Grade IV 0 0
18.75
75
6.25 0
Grade I Grade II Grade III Grade IV
KELLEGREN LAWRENCE
GRADING
40 | P a g e
VISUAL ANALOGUE SCALE :
The Mean VAS SCORE of patients who took part in the research was 5.93 preoperatively with a standard deviation of 1.04. Table 4 shows PRE
OPERATIVE VAS SCORE distribution of patients in the research. Most of patients were having pain scale of 6 ( 46.87%)
Table 4: VISUAL ANALOGUE SCALE distribution of patients preoperatively (N=32)
VAS SCORE Frequency
(N)
Percentage (%)
1 0 0
2 0 0
3 0 0
4 3 9.375
5 6 18.75
6 15 46.87
7 6 18.75
8 2 6.25
9 0 0
10 0 0
41 | P a g e
Table 5: VISUAL ANALOGUE SCALE distribution of patients 6 MONTHS postoperative follow up (N=32)
VAS SCORE Frequency (N) Percentage (%)
1 0 0
2 0 0
3 0 0
4 3 9.375
5 6 18.75
6 12 37.5
7 3 9.375
8 4 12.5
9 0 0
10 0 0
4 patients lost follow up till end of the study.There was a increase in pain scale in further two patients “( for a pain scale value of 8 from 6.25% to significant increase of 12.5 % which lietrally had doubled indicating worsening of the disease after surgery also.
42 | P a g e
MEASUREMENT OF MEDIAL JOINT SPACE NARROWING : The mean medial joint space of patients who participated in the research preoperatively was 2.73 mm.
There was no significant improvement after analysing all post op x rays at 6 months
2.25 2.3 2.35 2.4 2.45 2.5 2.55 2.6 2.65 2.7 2.75 2.8
PRE OP 6 MONTHS
AVERAGE MEDIAL JOINT SPACE IN mm
43 | P a g e
MEASUREMENT OF VARUS ANGULATION:
The average varus angle at 6 months follow up actually worsened to 10.18 degress from 8 degrees.
Hence,the benefit of procedure is questionable.
8.62
10.18
7.5 8 8.5 9 9.5 10 10.5
ANGLE IN DEGREES
6 MONTHS PRE OP
44 | P a g e
MODIFIED OXFORD KNEE SCORE
The figure shows average distribution of the modified oxford knee score assessed at the pre operative and immediate,1 month,3 month and 6 months followup
0 5 10 15 20 25 30 35
Category 1 Category 2 Category 3 Category 4
MOKS SCORE
PRE OP IMMEDIATE POST OP 1 MONTH 3 MONTH 6 MONTH
45 | P a g e
RANGE OF MOVEMENT DISTRIBUTION :
The figure shows average distribution of the range of motion of knee evaluated at the pre operative and immediate,1 month,3 month and 6 months followup
There is decrease in the range of motion when compared to pre op ( 101degrees to 92 degrees!)
86 88 90 92 94 96 98 100 102 104
PRE OP 6 MONTHS
ROM DISTRIBUTION
ROM
46 | P a g e
Section C: Analysis of the complications/problems.
COMPLICATIONS
Table 12 describes complications review of patients in the research. Most of patients didn’t have any complications (93.75%).
Table 12: complications encountered in the patients (N=32)
COMPLICATION Frequencies (N) Percent(%)
No complication 30 93.75
Neuropraxia 1 3.125
Wound infection 1 3.125
vascular injury 0 0
Joint infection 0 0
47 | P a g e
Section D: Correllating the functional and radiological outcome of the procedure done and establishing the end result.
Table 1: Analysing the functional and radiological outcome of the procedure done and establishing the end result . (1 month)
Months Functional outcome
Outcome variable Radiological p- value Range of
movemen t
Oxford knee score
Visual analogue
scale score
Varus Medial joint space
N % N % N % 6 Satisifactory
improvement
4 3 3 3 0.005*
worsen 2 0 3 2
Remains same
25 25 25 25
2 patients lost follow up at 1 month 1 patient didn’t turn up
**p<0.001 highly significant
48 | P a g e
Table 14: Association of thefunctional outcome during follow-up period among distal radius fractures patients with their complications. (3 months) Months Functional
outcome
Outcome variable Radiological p- value Range of
movemen t
Oxford knee score
Visual analogue
scale score
Varus Medial joint space
N % N % N % 6 Satisifactory
improvement
4 4 5 4 0.005*
worsen 2 2 2 3
Remains same
23 23 22 22
49 | P a g e
Table 15: Association of thefunctional outcome during followup visits among OA KNEE patientswith their complications. (6 months)
Months Functional outcome
Outcome variable Radiological p- value Range of
movemen t
Oxford knee score
Visual analogue
scale score
Varus Medial joint space
N % N % N % 6 Satisifactory
improvement
5 5 5 8 0.005*
worsen 3 3 3 5
Remains same
20 20 20 15
50 | P a g e
DISCUSSION
The basis of this technique is that the lateral support delivered to the osteoporotic tibia by the fibula-soft tissue multipart may lead to the un-uniform settlement and degeneration of the tibial plateau bilaterally ,so this procedure resorted to eradicate this non essential support.
Eventhough the basis of this technique looks reasonably instinctual and biomechanically appealing , the mechanism failed to create fast and
demonstrable pain relief .This is much ambiguous when considering there are substantial amount of the patients got impressively rapid pain
attenuation immmediate post surgery as compared with other surgical procedures like high tibial osteotomy and arthroscpic procedures done for early osteoarthritis.
Zhang and his contemporaries also indicated that at the end of the follow-up the mechanical axis of the affected limb was improved and the knee joint pain relief could be attributed to it,but in our study only two cases shown to have the axis improvement which has been discussed extensively in the results part. Because the process of natural settlement of knee joint is obviously time consuming, it is not likely to anticipate the re-establish of recognised imbalance settlement, realignment of the
ground reaction vectorand correction of knee joint disorientation were
51 | P a g e
caused by instant postoperative lateral plateau settlement from only fibular osteotomy. To put in other way, the deduction of lateral support influence of fibula strut is not sufficient to rebalance lateral and medial tibial plateau settlement and relieve the over-load of the medial tibial compartment soon post surgery.Hence,we also combined the lateral cortical drilling as an adjunctive procedure to enhance the results.
On careful analysis, various researches revealed that osteotomy, unicondylar arthroplasty, Total knee replacement, and arthroscopic debridement might recover the functional scores of patients with medial OA, amongst which osteotomy and unicondylar arthroplastly have shown good efficacy short term while Total knee replacement has shown good results in long-term.
Though high tibial osteotomy and unicompartmental arthroplasty have both been described for treatment of medial compartmental
arthritis, both of these are relatively major procedures [18].
There is a comparitive deficiency of described literature on the role of proximal fibular osteotomy in medial compartment osteoarthritis of the knee [19].
With increasing age ,reduction in bone mass is a common
occurrence. Just as in the spinal column where there is a dorsal collapse owing to solitary cortical support, as compared to mightier posterior
52 | P a g e
support, the same as with knee joints also, a sustained increasing varus occurs as age advances developing medial compartment arthritis [19].
Resecting a segment of fibular strut, loosens and renders weaker the lateral side allowing the upper tibia to settle into a more favourable lateral alignment, shifting the mechanical axis towards neutral or valgus [20].
The HTO is a technically demanding procedure. Several untoward complications can occur in course. In a research study by Lee., et al.
The constraints of operative error can be defined by 3 unique factors [21]:
[A].Error of Correction (-under- &-over-correcting).
[B].Exaggerated changes in the posterior slope of tibia [C].Evidence of fracture in the lateral hinge
The goal line of HTO are to reduce knee pain and delay the need for a knee replacement. To achieve these goals, apt patient
selecting,precise surgical planning, meticulous surgical techniques, and astute prevention of complications are the need of hour.
In difference, the point of concern to be cautiouswhile doing a PFO is stretching out of the common peroneal nerve.
We also detected that outcomes are reproducible. We recognize the limitations of the study. The lesser sample size , and shortterm follow-up are areas in which there is scope for Further.
53 | P a g e
Lastly, we expect that there will be more investigators to discover the efficacy and safety of different surgical treatments for patients with OA knee, thus there will be more and more references and data to be referenced, which will provide a better surgical hypothesis.
Moreover, the surgery leave knee joint morphology intact and no attempt to raise the medial plateau, there should be some hidden
mechanism leading to lower limb realignment and prompt pain alleviation in the few patients.
To the best of our awareness, there is no rationale and wide believed clarifications have been suggested that this proximal fibular osteotomy is useful in treating the medial compartment osteoarthritis and the follow up needs to be prolonged with few modifications to attain prompt results
54 | P a g e
CONCLUSIONS
With the results obtained we could conclude that the proposed technique of proximal fibular osteotomy for medial compartment osteoarthritis did not yield any satisifactory radiological and functional outcome at the end of 6 months follow up and it warrents new studies to analyse it in detail and propose newer techniques that need to be fllowed up for longer terms based on the observations of the study.
55 | P a g e
BIBLIOGRAPHY
1. Prakash L et al: A beginner’s guide to total knee replacement. CBS Publications, New Delhi, 2016. ISBN 978-93-86217-48-6
2. Tierney WM,et al. Tricompartmental knee replacement: A comparison of orthopaedic surgeons’ self reported performance rates with surgical indications, intraindications, and expected out-comes. Clinical Orthopaedics 1994;305:209–
17.
3. Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF et al.
The prevalence of knee osteoarthritis in the elderly: The Framingham Osteoarthritis Study. Arthritis Rheum. 1987; 30(8):914-918.
4. Vincent KR, Conrad BP, Fregly BJ, Vincent HK et al. The pathophysiology of osteoarthritis: a mechanical perspective on the knee joint. PM&R. 2012;
4(5):S3-S9.
5. Shiozaki H, Koga Y, Omori G, Yamamoto G, Takahashi HEet al .
Epidemiology of osteoarthritis of the knee in a rural Japanese population. Knee.
1999; 6(3):183-188.
6. Ahlbäck S et al. Osteoarthrosis of the knee: a radiographic investigation. Acta Radiol. 1968; 277(suppl):7-72.
7. Prakash L et al: Varus Scenario in the Indian Knees. Indian Academy of Orthopaedic Surgeons, Instructional course lectures 2016.
56 | P a g e
8. Wu LD, Hahne HJ, Hassenp ug T et al . A long- term follow-up study of high tibial osteotomy for medial compartment osteoarthrosis. Chinese Journal of Traumatology. 2004; 7:348-353.
9. Sprenger TR, Doerzbacher JF et al. Tibial Osteotomy for the treatment of varus gonarthrosis: survival and failure analysis to twenty-two years. Journal of Bone and Joint Surgery 2003; 85:469- 474.
10. Aglietti P, Buzzi R, Vena LM, Baldini A, Mondaini A et al. A high tibial valgus osteotomy for medial gonarthrosis: a 10- to 21-year study. Journal of Knee Surgery. 2003;16:21–26
11. Hanssen AD, Stuart MJ, Scott RD, Scudery GR et al. Surgical options for the middle aged patient with osteoarthritis of the knee joint. Journal of Joint Bone Spine. 2000;67(6):504–508.
12. Schnurr C, Jarrous M, Gudden I, Eysel P, Konig DP et al. Pre-operative arthritis severity as a predictor for total knee arthroplasty patients’ satisfaction.
International Orthopaedics. 2013; 37(7):1257-1261.
13. Prakash L et al:Orthopedics Usual and unusual. Indian Academy of Orthopaedic Surgeons, Instructional course lectures 2016.
14. Prakash L et al: Proximal Fibular Osteotomy. Indian Academy of Orthopaedic Surgeons, Instructional course lectures 2016.
15. Zhang Y, Li C, Li J, et al. The pathogenesis research of non-uniform settlement of the tibial plateau in knee degeneration and varus. Journal Hebei Medical University. 2014; 35(2): 218-219.
57 | P a g e
16. Huskisson E et al. Measurement of pain. Lancet. 1974; 304:1127-1131.
17. Prakash L et al: Knee Scoring and Outcome Prediction in developing a surgical paradigm of total knee replacement. Indian Academy of Orthopedic Surgeons, Instructional course lectures 2016.
18. Hofmann S, Lobenhoffer P, Staubli A, Van Heerwaarden R et al.
Osteotomies of the knee joint in patients with monocompartmental arthritis. Der Orthopedics. 2009; 38(8): 755-769.
19. Zong-You Yang, MD et al: Medial Compartment Decompression by Fibular Osteotomy to Treat Medial Compartment Knee Osteoarthritis: A Pilot Study . 20. Wang F, Chen B-C, Gao S et al. Influence of knee lateral thrust gait to tibiofemoral angle and lateral joint space in the knee varus patients. Chinese Journalof Orthopedics. 2005; 25(9):517-519.
21. Prakash L et al: Proximal Fibular Osteotomy in medial compartment
Osteoarthritis of the knee joint. Institute for Special Orthopedics Chennai. First edition 2018. ISBN 978-81-924355091
[A1] Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Journal of Arthritis & Rheumatism. 2008; 58(1):26–35. [PubMed: 18163497]
[A2] Andriacchi TP, Koo S, Scanlan SF et al. Gait mechanics influence healthy cartilage morphology and osteoarthritis of the knee. Journal of Bone and Joint Surgery. Feb; 2009 91( Suppl 1):95–101. [PubMed: 19182033]
58 | P a g e
[A3]Andriacchi T, Mundermann A, Smith R et al. A framework for the in vivo pathomechanics of osteoarthritis at the knee. Annals of Biomedical
Engineering. 2004; 32(3)
[A4]. Andriacchi T, Mundermann A et al. The role of ambulatory mechanics in the initiation and progression of knee osteoarthritis. Current Opinion in
Rheumatology. 2006; 18:514– 518. [PubMed: 16896293]
[A5]. Chaudhari AM, Briant PL, Bevill SL, Koo S, Andriacchi TP et al. Knee kinematics, cartilage morphology, and osteoarthritis after ACL injury. Medical Sciences Sports Exercises journal. Feb; 2008 40(2):215–222.[PubMed:
18202582]
[A6]. Cheng Y, Hootman J, Murphy L, Langmaid G, Helmick C. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2007–2009. CDC Morbidity and Mortality Weekly Report. 2010;
59(39):1261–1265.
[A7]. Andriacchi TP. Dynamics of knee malalignment. Orthopedic Clinics of North America. Jul; 1994 25(3):395–403. [PubMed: 8028883]
[A8]. Zhao D, Banks SA, Mitchell KH, D’Lima DD, Colwell CW, Fregly BJ.
Correlation between the knee adduction torque and medial contact force for a variety of gait patterns. Journal of Orthopaedic Research. 2007; 25:789–797.
[PubMed: 17343285]
[A9]. Miyazaki T, Wada M, Kawahara H, Sato M, Baba H, Shimada S.
Dynamic load at baseline can predict radiographic disease progression in medial
59 | P a g e
compartment knee osteoarthritis. Annals of the Rheumatic Diseases. 2002;
61:617–622. [PubMed: 12079903]
[A10]. Sharma L, Hurwitz DE, Thonar EJ-MA, et al. Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral
osteoarthritis. Arthritis & Rheumatism. 1998; 41:1233–1240. [PubMed:
9663481]
[A11]. Thorp LE, Sumner DR, Wimmer MA, Block JA. Relationship between pain and medial knee joint loading in mild radiographic knee osteoarthritis.
Arthritis & Rheumatism. Oct 15; 2007 57(7): 1254–1260. [PubMed: 17907211]
[A12] Heidari B. Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian J Intern Med 2011;2:205–12.
[A13] Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA 2013;310:1263–73.
[A14].Shiozaki H, Koga Y, Omori G, et al. Epidemiology of osteoarthritis of the knee in a rural Japanese population. Knee 1999; 6: 183–188.
[A15]. Van derSchoot DK, Den Outer AJ, Bode PJ, et al. Degenerative changes at the knee and ankle related to malunion of tibial fractures. 15-year follow-up of 88 patients. Journal of Bone and Joint Surgery B 1996;78(5):722–725
60 | P a g e
[A16]. Faschingbauer M, Nelitz M, Urlaub S, et al. Return to work and sporting activities after high tibial osteotomy. International Orthopaedics 2015; 39:
1527–1534.
[A17].Saragaglia D, Rouchy RC, Krayan A, et al. Return to sports after valgus osteotomy of the knee joint in patients with medial unicompartmental
osteoarthritis. International Orthopedics 2014; 38: 2109–2114.
[A19] C Prodromos;T Andriacchi;J Galante et al ; A relationship between gait and clinical changes following high tibial osteotomy.The Journal of Bone &
Joint Surgery. 67(8):1188–1194, OCTOBER 1985.
[A20]Schnitzer TJ1, Popovich JM et al .Effect of piroxicam on gait in patients with osteoarthritis of the knee.Arthritis Rheum. 1993 Sep;36(9):1207-13.
[A21] Hurwitz DE1, Ryals AR, Block JA et al.Knee pain and joint loading in subjects with osteoarthritis of the knee. Journal of Orthopedic Residency. 2000 Jul;18(4):572-9.
[A22] Maly MR et al.Abnormal and cumulative loading in knee osteoarthritis.Curr Opin Rheumatol. 2008 Sep;20(5):547-52.
[A23]Block JA1, Shakoor N et al.Lower limb osteoarthritis: biomechanical alterations and implications for therapy.Current Opin Rheumatology. 2010 Sep;22(5):544-50.
[A24] Guo et al.Changes in ankle joint alignment after proximal fibular osteotomy.PLoS One. 2019 Mar 22;14(3):e0214002.
61 | P a g e
ABBREVIATIONS AND ACRONYMS
OAK-OSTEO ARTHRITIS OF KNEE
PFO- PROXIMAL FIBULAR OSTEOTOMY HTO-HIGH TIBIAL OSTEOTOMY
HKA –HIP KNEE ANGLE
TFA-TIBIO FEMORAL ANGLE OKS- OXFORD KNEE SCORE
VAS SCORE- VISUAL ANALOGUE SCALE ROM- RANGE OF MOVEMENTS
TKR- TOTAL KNEE REPLACEMENT MAdd- MEDIAL ADDUCTION
VD- VARUS DEFORMITY
62 | P a g e
QSE- QUADRICEPS STRENGTHENING EXERCISES ADD- ADDUCTION DEFORMITY
MJL- MEDIAL JOINT SPACE LJL-LATERAL JOINT SPACE PFJ-PATELLO FEMORAL JOINT HC-HYALINE CARTILAGE
APE-ANKLE PUMP EXERCISES
BCM- BED TO CHAIR MOBILISATION WI-WOUND INFECTION
63 | P a g e
INFORMATION TO PARTICIPANTS
Title of the study :
“Proximal fibular osteotomy with proximal lateral tibial cortical drilling for medial compartment osteoarthritis of knee and its functional
&radiological outcome”.
Aim of the study:
The aim/objective of the present study was to evaluate the role of PROXIMAL FIBULAR OSTEOTOMY AND LATERAL CORTICAL DRILLING in the management of OA and to assess the functional and radiological outcome of medial compartment OA knee
Study procedure:
On admission, all patients were evaluated clinically and
radiologically. Standard weight bearing X rays of the affected knee taken in anteroposterior and lateral views and the radiological parameters such as tibiofemoral angle and amount of medial and lateral space will be evaluated and documented in the case records.
The patients will then be evaluated with the Visual analogue score (VAS) and the modified oxford knee score and the
64 | P a g e
preoperative values will be documented in the patient case records.
After obtaining informed consent and anaesthetic fitness, the patients will taken up for the procedure. The surgery will be performed with the patient in the supine position under spinal anaesthesia/regional anesthesia under antibiotic coverage.
The fibular head is marked and the osteotomy site is chosen to be 7 to 9 cm from the head of fibula. The basis of rationale in choosing this level of osteotomy is that an osteotomy at a higher level would be likely to traumatise the common peroneal nerve whereas if that is being done somewhat lowered down that the outcome of the osteotomy on the medial compartment arthritis would not be there. A 5-8 cm laterally oriented incision is made directly over the marked site of osteotomy and deep dissection is carried on via the skin and subcutaneous tissue. The peroneal muscles and soleus-gastrocnemius complex is then splitted to expose the periosteum of the fibula that is then stripped and a 1.5 centimeters to 2 centimeters of fibula bone is then cut with the use of an manman osscilating saw-blade following placement of some drill holes near and towards the proposed osteotomy site.
With the help of 4.5 mm drill bit,multiple drilling done in the lateral proximal tibial cortex . After ensuring heamostasis and giving wound wash, closure was done in layers and sterile dressing
65 | P a g e
and compression bandage to be applied. All patients are
encouraged to stand and walk on the same day evening of surgery and will be discharged on the third postoperative day after the first wound inspection. Intravenous antibiotics for given for 3 days followed by oral antibiotics for a period of 5 days.
The sutures will be removed on the 12th postoperative day.
Postoperative weight bearing X rays are then taken and the radiological parameters are evaluated and documented.
Quadriceps strengthening exercises will be taught to the patient and movements are begun on the the same day.
Together with that ankle pump exercises and active knee movements exercise under the supervision of trained
physiotherapist was done and The patients are reviewed at 1, 3, 6 months and at the end of the first and second year where the VAS and the Oxford knee scores were evaluated and documented.
66 | P a g e
Your Rights in the Study:
Your medical records will be maintained confidential. The results of the study may be published in journals, but will not disclose the identity of the participants. Your participation in this study is voluntary and not under any compulsion and you are free to withdraw from the study without giving any reasons, without affecting the medical care which will be provided to you
normally.If in case any complication arises, you will be adequately taken care of by the medical crew.
67 | P a g e
PROFORMA
CD No:
NAME:
AGE AND SEX:
ADDRESS:
IP NO:
CHIEF COMPLAINT:
GENERAL EXAMINATION FINDINGS:
PREOPERATIVE:
I)CLINICAL EVALUATION: (FUNCTIONAL ) 1.VAS SCORE
2.MODIFIED OXFORD KNEE SCORE:
MORPHOLOGICAL:
AMOUNT OF VARUS:
AMOUNT OF FIXED FLEXION DEFORMITY:
RANGE OF MOVEMENTS:
TENDERNESS OF INDIVIDUAL COMPARTMENTS : RADIOLOGICAL EVALUATION:
68 | P a g e
AMOUNT OF MEDIAL AND LATERAL JOINT SPACE IN AP VIEW:
TIBIO FEMORAL ANGLE IN AP VIEW :
COMPARTMENTAL INVOLVEMENT AND SUPPORTIVE FINDINGS:
KELLEGREN LAWRENCE SCORE:
POST-OPERATIVE FOLLOWUP:
IMMEDIATE POST OP:
ROM
VARUS CORRECTION:
JOINT LINE TENDERNESS
MEDIAL AND LATERAL JOINT SPACE IN AP VIEW:
KELLEGREN LAWRENCE SCORE:
TIBIO FEMORAL ANGLE IN AP VIEW : COMPARTMENTAL INVOLVEMENT MONTH 1:
ROM
VARUS CORRECTION:
JOINT LINE TENDERNESS
MEDIAL AND LATERAL JOINT SPACE IN AP VIEW:
KELLEGREN LAWRENCE SCORE:
TIBIO FEMORAL ANGLE IN AP VIEW : COMPARTMENTAL INVOLVEMENT
MONTH 3 ROM
VARUS CORRECTION:
JOINT LINE TENDERNESS
MEDIAL AND LATERAL JOINT SPACE IN AP VIEW:
KELLEGREN LAWRENCE SCORE:
TIBIO FEMORAL ANGLE IN AP VIEW : COMPARTMENTAL INVOLVEMENT MONTH 6:
ROM
VARUS CORRECTION:
JOINT LINE TENDERNESS
MEDIAL AND LATERAL JOINT SPACE IN AP VIEW:
KELLEGREN LAWRENCE SCORE:
TIBIO FEMORAL ANGLE IN AP VIEW : COMPARTMENTAL INVOLVEMENT SPECIAL REMARKS:
69 | P a g e
CONSENT FORM
Title of the research:
Proximal fibular osteotomy with proximal lateral tibial cortical drilling for medial compartment osteoarthritis of knee and its functional
&radiological outcome.
Study done at : Annal Mahatma Gandhi Memorial Government Hospital, Trichy.
Patient’s name:
Age/Sex :
Parent/Guardian’s Name:
Address:
particulars of the research had been given to me in written and explained to me in my own language. I assure that I have clearly understood all the above study nature and had the chance to ask related questions about the pre-operative assessment and the anesthetic techniques to be administered to me.
70 | P a g e
and that I am free to move away from this study at any time, without providing any reasons, without hindering the medical care that will usually be given by the hospital.
in the study does not require my approval, to look after me and assess for some medical parameters
of any data or results that come from this study, provided such a usage will be only for educational purpose(s).
that If in case any complication arise of this , I will be sufficiently taken care of by the surgical team.
Signature/Thumb impression of the Patient:
DATE: Signature of the Investigator:
PLACE:TRICHY
71 | P a g e
72 | P a g e
73 | P a g e
74 | P a g e
X RAY ATLAS:
CASE 1 - 1 MONTH FOLLOWUP
CASE 1 PRE OP
75 | P a g e
CASE 1 -6 MONTHS FOLLOWUP
NO OBVIOUS MEDIAL JOINT SPACE IMPROVEMENT
CLINICALLY ALSO PATEINT COMPLAINED OF WORSENING OF SYMPTOMS
76 | P a g e
CASE 2 –PRE OP
MEDIAL JOINT SPACE NARROWING SEEN (2.8MM ) NO OBVIOUS VARUS
CLINICAL TENDERNESS IN MJL MOKS : HIGH
ROM : 90 DEG
77 | P a g e
CASE 2
6 MONTHS FOLLOWUP
SYMPTOMS WORSENED AND THERE IS ALSO JOINT SPACE FURTHER NARROWING
78 | P a g e
CASE 3
PRE OP
79 | P a g e
3 MONTHS FOLLOWUP
SYMPTOMS WORSENED AS WELL AS THERE WAS FURTHER MEDIAL JOINT SPACE NARROWING
80 | P a g e
CASE 4
PRE OP
81 | P a g e
POST OP
IMMEDIATE: NO OBVIOUS IMPROVEMENT
82 | P a g e
6 MONTH FOLLOWUP
NO IMPROVEMENT SEVERE NARROWING
OKS DECLINED
Patient had initial wound infection which was treated with
appropriate antibiotics.
83 | P a g e
CASE 5
PRE OP
84 | P a g e
IMMEDIATE POST OP
85 | P a g e
SIX MONTH FOLLOWUP
PT HAD SIGNIFICANT PAIN RELIEF AND IMPROVED FUNCTION
Surrogate outcome variable positive for the pt:
OKS-
VAS -
ROM -
86 | P a g e
CASE 6 PRE OP
MEDIAL JOINT SPACE 2 MM
87 | P a g e
6 MONTHS FOLLOWUP-
PATIENT HAD SIGNIFICANT PAIN RELIEF AND WIDENING OF MEDIAL JOINT SPACE NOTED.
88 | P a g e
CASE 7
PREOP
89 | P a g e
6 MONTHS POSTOP
PATIENT HAD SIGNIFICANT PAIN RELIEF AND IMPROVED FLEXION BUT SPACE DECREASED
90 | P a g e
MASTER CHART CASES 1-10
91 | P a g e
MASTER CHART CASES 11-23
92 | P a g e
MASTER CHART CASES 24-32
