56  yr old lady with stiff knee post patellectomy 20 year ago for an infected patelar fracture  post fixation presented with fracture proximal tibia with bi compartmental arthritis. no infection. Normal ESR/ CRP and normal scar  works as a govt employee living in a women’s hostel and need to climb into a bus

Problems

(pre fracture ROM 10 to 30), 

porotic bone

 ? bugs

financially challenged

 Options

 1. Fixation first with or without cultures

     and second stage tkr

 2 one stage Arthrolysis,Replacement and fixation  

sequence of surgery

 Mid line incision perpendicular to previous transverse incision

 Supra patellar  and gutter scar release. 

 Distal femoral standard resection. cruciate ligaments removed to get tibial intra
medullary access

 Intra medullary tibial jig for  tibial  resection.

 Stemmed tibia to bypass fracture and augmentation with a l medial MIPO tibial plate. graft the   Fracture site with cancelous graft from cut  surface. immediate passive flexion tom 90 obtained  

 and NWB ROM  for 4 weeks

3 months postop

 

Slope correction for acl re-tear prevention

Much has been said about slope correcting osteotomies in ACL injury with > 10 degree tibial slope. Surek et al have found the lateral tibial slope followed by medial tibial slope and lastly differential slope ratio to be statistically significant risk factor for failure.  Therefore correcting  both condyle slope may not be be ideal. Do we need to do selective uni-condyle slope correction to correct the torsional and sagital forces on the reconstructed ACL.

Another biological solution to buy time

 Stromal vascular fraction

Adipose derived stem cell has been used for some time in Plastic surgery and Orthopedics. Its use in joint preservation is increased due to its beneficial effects and to delay or ? avoid knee replacement.  Chondro-protective effects such as chondrocyte proliferation and cartilage matrix protection due to its paracrine actions have been proved in murine models for over a decade

Y.G Koh (KSSTA 2013), on second-look arthroscopy, 87.5 % of elderly patients (14/16) improved or maintained cartilage status at least 2 years post-operatively. No one underwent total knee arthroplasty during this 2-year period.  J. Pak, Int J Mol Sci. 2018 Jul; 19(7):  were among the first to report  injection of adipose derived stem cell as a single harvest and implantation as a medical procedure where are others lab cultured the cells and implanted higher  quantity to as a pharmaceutical product.

 We have been using the same SVF  for close to an year with good functional improvement in young arthritic patients or patients who wants to  avoid or delay knee replacement. In india, at present  cultured adipocyte are not permitted  and  we harvest stems from 60 cc of liposuction, centrifuges as per standard recommendations  and mix with PRP to inject into the knees.