Does “Recent advances mean Hi-Tech management” ?

A perspective from the management of deformities in orthopaedics

BY Dr.Landge D.K Coordinator Dr. Panse sir

WHAT IS RECENT Practiced in US ?

COSTLY ?

Market driven ????

That which is debatable in Conferences ???

Which fills up pages in journals??

Topics that makes the difference , the way we practice

FIVE ANGLES OF INTEREST

CLINICAL ACADEMIC INDUSTRIAL SOCIAL RESEARCH

DISCLAIMER

The speaker did not receive any outside/inside funding

or grants in support of this presentation.

Every attempt has been done to make statements in

this presentation with reference to standard

internationally / nationally accepted journals and

textbooks, audience requested to exercise their

discrimination at individual level for best practices in

the interest of profession.

INTRODUCTION

published the first book on orthopedic surgery, in 1741=L’orthopédie

two Greek Words, Orthos= signifies straight free

from Deformity and Pais = a Child. “Out of these two Words ,I have

compounded that of Orthopaedia, to express in one Term the Design I propose, which is to teach the different Methods of preventing and correction the Deformities of Children”

Nicolas ANDRY1658–1742

Andry :

“That Tendon which goes from the Calf of the leg to theHeel, is sometimes so short, that the Person is obligedto walk upon the fore part of his Foot, without beingable to set the Heel to the Ground . . . Children aresometimes born with this Defect, and sometimes theycome by it afterwards. In either Case it may be cured,provided this Shortness does not proceed from anyviolent Cause, which has absolutely maimed theTendon, such as a Burning after Birth, for example, orany other Accident that is capable of rendering thisShortness incurable.”

When a new gadget/product comes in the market a hype is created and the gadgets are used to treat a wide variety of clinical situations. People are excited about new technology. Later on the excitement weans off .

Should not we be using technology conceptually with rationale indication instead of subjecting the populations for surgery due to excitement of new technology…

Ref. IJO 2007 ; Editorial

WHY DEFORMITY AS RECENT

Why not ACI Why not Newer

approaches(MIS) Why not BMP’s Why not Gene

therapy Why not transplant Why not fMRI

Common Can be Prevented Rewarding

Surgical results Tender age

(Pediatric)

DEFORMITIES IN CHILDREN

COMMON CHILDHOOD FOOT CONDITIONS =CTEV, ROTATIONAL PROBLEMS, FLAT FEET- CVT / TARSAL COALITION

COMMON CHILDHOOD KNEE DE. = Genu vara / valgus

HIP = COXA VARA, COXA PLANA

SPINE = Idiopathic scoliosis

Cerebral palsy

PPRP

LLD

CONGENITAL LL DEFORMITIES(Prevalence wise)

ROTATIONAL

FLAT FEET

CTEV

MET.ADDUCTUS

CPT / ANGULAR

CVT

FIBULAR HEMIMELIA LLD

TIBIAL HEMIMELIA

PFFD

CONGENITAL VERTICAL TALUS

X-RAYS IN CVT

CLUB FOOT CHILD ON Rx

REVIEW OF LITERATURE

ARE OP S REQUIRED IN CTEV 1905=MACKENZIE

Shortcut to J Bone Joint Surg Am. 1905;s2-2288-302.lnk

Dr. Ponsetti says

About Development of the techniqueIn the mid 1940s, I examined 22 patients with clubfoot that had been surgically

treated in the 1920s by Arthur Steindler, a good surgeon. The feet had become rigid, weak, and painful.

About Delayed acceptance of the techniqueIt was disappointing that my first article on congenital clubfoot, published in the

The Journal of Bone and Joint Surgery in March 1963, was disregarded. It was not carefully read and, therefore, not understood. My article on congenital metatarsus adductus, published in the same journal in June 1966, was easily understood, perhaps because the deformity occurs in one plane. The approach was immediately accepted, and the illustrations were copied in most textbooks.

A few orthopaedic surgeons studied my technique and began to apply it only after the publication of our long-term follow-up article in 1995, the publication of my book a year later, and the posting of Internet support group web sites by parents of babies whose clubfoot I had treated. I have been reprimanded for not pushing the method more forcefully from the beginning .

KITE’S ERRORKite’s method of manipulationKite believed that the heel varus would correct simply by everting the calcaneus. He did not realize that the calcaneus can evert only when it is abducted (i.e., laterally rotated), under the talus.

Thou shall not pronate

ORIGINAL LANDMARK ARTICLE

Manipulation as described by Ponseti. The thumb is positioned over the lateral aspect of the head of the talus, and the index finger is positioned behind the lateral malleolus. No counterpressure should be applied at the calcaneocuboid joint. The cavus and the adduction are corrected by slight supination and abduction of the forefoot. The forefoot is never pronated

Shortcut to PONSETTI IN J. PAEDIATRICS.lnk

Shortcut to Current Concepts Review=PONSETI=1992.lnk

Pirani Severity Scoring Clinical ( not radiological)

. Scores six clinical signs 0 normal 0.5 moderately abnormal 1 severely abnormal Midfoot score Three signs comprise the Midfoot Score (MS),

grading the amount of midfoot deformity between 0 and 3.

Curved lateral border [A] Medial crease [B] Talar head coverage [C] Hindfoot score Three signs comprise the Hindfoot Score (HS),

grading the amount of hindfood deformity between between 0 and 3.

Posterior crease [D] Rigid equinus [E] Empty heel [F]

AFTER CORRECTION

SURGICAL SCAR

LATE PRESENTATION CTEV

JESS

PRINCIPLE OF JESS

Residual Clubfoot Problems

supination hindfoot

varus cavus forefoot

adductus

LLD

PFFD FIBULAR HEMIMELIA TIBIAL HEMIMELIA CP -HIP DISLOCATION

CONGENITAL DEFICIENCIES OF THE LONG BONES(Swanson classification =only taxonomical advantage)

CONGENITAL DEFICIENCIES OF THE LONG BONES

Prognosis in Fibular hemimelia Severity

LLD

FOOT DEFORMITY

No. of rays ( less than two=poor prognosis0

Ankle fusion =Plantigrade foot

Syme’s amputation= In severe deformities gives more

functional results than deformity corrections

CONGENITAL PSEUDARTHROSIS OF THE TIBIA

RADIAL CLUB HAND

ILLIZARROV FOR CLUB HAND

CP

PRE-OP POST-OP

General Principles of managing patients Communication Counseling

Likely outcome of Sx of relatives in case of severe deformities like

arthogryposis/ muscular dystrophy

Correction of deformities Club foot Club hand Coxa vara Scoliosis Genu Valgus CPT

Joint reconstruction Time buy osteotomies PAO, HTO // Joint Replacements

TITANS Ignacio Ponseti

Dror Paley =living legends

John E. Herzenberg

Gavriil Ilizarov

Langenskiold

Grice - Green

PRINCIPLES OF DEFORMITY CORRECTION

Measure quantity of deformity Find plane of deformity Calculate wedge open/close Decide fixation IF …Staples/plates/IMN EXFIX---ILLIZAROV/ORTHOFIX/TSF/JESS

ORTHO RADIOGRAM

DISTRACTION OSTEOGENESIS

PRINCIPLES OF DESIGNS

Illizarov=Distraction osteogenesis

JESS=Differential distraction

TSF = Projective Geometry - similar to that used in Aircraft Simulators (Dr. J. Charles Taylor 1990)

Angulation +rotation+translation= HEXAPOD=SIX AXIS correction

A MIND THAT KNOWS THE PRINCIPLES WILL DEVICE HIS OWN METHODS

Illizarrov Important innovation in

deformity correction Foot strategies:

ligament distraction up to 8 years old, osteotomies in older children.

Disadvantages: long learning curve; difficulty in rotational correction

Computer based technology

Six-axis deformity correction

Most accurate external fixator available

Taylor Spatial

Ponseti-inspired Clubfoot Sequence

Abduct foot while holding counter pressure on neck of talus

When heel varus and internal rotation are corrected, reprogram for dorsiflexion

Talar neck wire initially attached to tibial ring, then moved to foot ring

If needed, cut foot ring at end and modify to correct adductus/cavus

SELF LENGTHENING NAILS

Problems with “Closed” corticotomy

More of a fancy than comfort

Fully implantable computer controlled intramedullary “Lengthening” device FITBONE …..Germany No reference

LENGTHENING OVER NAIL

.. High complication Rates… All series

Bost;J Bone Joint Surg

Am.1956;38:567-584

Paley,Herzenberg ; JBJS 1997

Milind Choudhary; IJO 2008

RECENT ? = LOOKING INTO FUTUREHow do we prepare for the future? How do we adequately prepare to seize the Internet

explosion and use it to our advantage? How do we continue to attract, train, and keep the

best and the brightest young students who prefer medicine but are increasingly entering the business world because of opportunity costs?

How do we engage current notions on a host of topical issues whether they be ethical, political, economic, social, or cultural — to make us wise and more informed about the people who come to us and about the forces driving their lives? Reference… JBJS 2004 (Am)

India specific problems in medical education.Lack Infrastructure in Public sector/ Lack of commitments

to medical education in private sector Reference…. IJO 2004 Sept

As medicine becomes more about profit than about health, and as physicians are given even more powerful incentives to withhold care, the interests of the doctor and the patient are being pushed out of alignment.

We find ourselves operating within a healthcare system that is almost perfectly designed, however inadvertently, to undermine the essential bond between patient and doctor.

Residents being used as Workforces JBJS 2005(Am)

Competition to maintain the integrity and value of our

profession.

 Competition each day as doctors,as an association,

and as human beings.

We experience loss. We know failure.

We seek a model for a better way.

Now, standing at the portal of a new millennium, we are the ones to whom the charge has fallen. We must accept it with humility and pledge to continue the legacy of our founders. The challenges may be great and the obstacles may be many, but the opportunities are as boundless as our creativity, as positive as our resolve, and as thoroughly enriching as our imaginations will allow.

We are leaders in the amphitheater of medicine’s future and are poised at the threshold of unimaginable technological advancements: incredible diagnostic care, molecular technology, genetic research and gene therapy, tissue engineering, new arthroscopic equipment, and minimally invasive operative techniques and state of art implant designs.

We as an association should keep a watch on technical advances and adopt them only if it is in the best interest of our patients.

Medical education is equally an important component of health services as patient care. Hence the teachers must be given due recognition for their contributions

The Associations in general and residents in particular should become a link between past practices and future projections.

We should continue to preserve the integrity of our profession and the professionalism of its members.

Build me straight, O worthy master!Staunch and strong, a goodly vessel,That shall laugh at all disaster,And with wave and whirlwind wrestle

….Longfellow

We will one day be measured by the integrity of our design of our ship called profession.

If a man’s claim to immortality is judged by the quality of life he leaves behind and the

alleviation of human suffering, then surely the long-term results of the deformity correction must be the living monument to a truly noble profession and benefactor of humanity.

Questions?

Thank You!!!

Thank You