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Nonunion distal radius fracture – Case series of 6 cases with Review of Literature

Vol 1 | Issue 1 | July – Sep 2015 | page: 31-35 | Dilip D Tanna[1], Ashok K Shyam[2] Author: Dilip D Tanna[1*], Ashok K Shyam [2]. [1] Private Clinic, 3A new queens road back bay view , mama parmanand marg. Mumbai 400004, India. [2] Indian Orthopaedic Research Group, Thane & Sancheti Institute of Orthopaedics and […]

Dr DD Tanna – Story of a Legend

July 25, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page:3-6| Dr. Dilip D Tanna, Dr. Ashok Shyam Author: Dr. Dilip D Tanna [1], Dr. Ashok Shyam [2, 3] [1] Lotus Clinic, Charni Road, Mumbai, India. [2] Indian Orthopaedic Research Group, Thane, India [3] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India Address of Correspondence Dr. […]

Nonunion distal radius fracture – Case series of 6 cases with Review of Literature

Dr DD Tanna – Story of a Legend

July 25, 2015/in July Sep | Volume 1 | Issue 1

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Nonunion distal radius fracture – Case series of 6 cases with Review of Literature

Vol 1 | Issue 1 | July – Sep 2015 | page: 31-35 | Dilip D Tanna[1], Ashok K Shyam[2]

Author: Dilip D Tanna[1*], Ashok K Shyam [2].

[1] Private Clinic, 3A new queens road back bay view , mama parmanand marg. Mumbai 400004, India.
[2] Indian Orthopaedic Research Group, Thane & Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India.

Address of Correspondence
Dr D D Tanna
Private practitioner, 3A new queens road back bay view , mama parmanand marg. Mumbai 400004
Email: ddtanna@me.com

Abstract

Background: Distal radius nonunions are rare but complex problems. They can present with severe disability and functional limitation, however clear guidelines do exist due to sparse literature. We present our experience of 6 cases with review of literature
Material and Methods: Retrospective review of 6 cases (4 males and 2 females) was done. Two cases were primarily treated with closed reduction and cast while others underwent surgical procedures ranging from single to 4 procedures. All were treated with open reduction, strut bone grafting using iliac crest bone graft and internal plate fixation. Darrach’s procedure was done in 4 cases and Sauvé-Kapandji in 2 patients after distal radius reconstruction. Supplementary wrist splint or below elbow plaster cast, was given in all cases for 3 wks with gradual mobilization.
Results: All patients showed, radiological union at mean 4 months (range 3 to 6 months). Range of flexion extension at wrist and supination and pronation improved over 4 months period in all cases. Grip strength was 30 % weak compared with opposite side in 5 patients. There were no subsequent complications in our series and all patients reported satisfaction with the functional results
Conclusions: Nonunion distal radius are rare but respond well to principles of open reduction, strut bone grafting and stable fixation. Distal radio ulna joint requires management in form of either a Sauvé Kapandji procedure (in young patient) or Darrach’s procedure (in older patients)
Keywords: nonunion distal radius fracture, open reduction internal fixation, bone grafting, Sauvé Kapandji, Darrach’s procedure.

Introduction

Distal radius fractures are one of the commonest fractures encountered in orthopaedic practice. Due to metaphyseal location, most fractures unite and nonunion is an unfortunate occurrence that poses a difficult scenario to treat [1,2]. Treatment of nonunion distal radius fracture depends on the size of the distal fragment, bone quality, amount of radial shortening, condition on distal radioulnar joint (DRUJ) and patients demands [1,2,3]. In cases with thin distal fragments, wrist fusion is suggested while with a sizable distal fragment a reconstruction is reported to be successful in maintaining the wrist range of motion [2,3]. In cases of distal ulna instability or incongruity procedures like Sauvé Kapandji procedure or Darrach’s procedures are combined with stabilization of distal radius [2,4,5,6]. However literature is still sparse and guidelines are still unclear. The current series adds our experience of 6 patients of nonunion distal radius treated surgically and is accompanied with detailed literature review to propose a guideline for treatment of such nonunions.

Materials and Methods
A retrospective review of database was conducted and six cases of nonunion distal radius presenting to us during last 10 years [between 1997 to 2010] were included in the study. There were 4 males and 2 females with mean age of 47.8 (range 22 to 91) (Table 1). Out of 6 patients 5 were AO Type A and 1 was AO type C. Five cases were closed while one was grade 1 compound primarily. Four cases were fall on outstretched hands while two cases were fall from height. However since all cases were treated at other centres, direct assessment of soft tissue injury was not available to us. One patient was diabetic and one was hypertensive. One patient was chronic smoker while rest had no other significant co-morbidities. Cases 1 and 2 were elderly and were treated primarily with a cast but continued to have pain and deformity after cast removal. The remaining four were treated operatively with ORIF using simple non-locking distal radius plates. Two were multiply operated with same procedure and presented with implant failure. One case had primary open reduction internal fixation with non locking distal radius plate. The repeat surgery involved implant removal and re-application of cast. The second case was primarily treated with distal end radius non locking plate. Second surgery was only local bone grafting. Third surgery was implant removal and re-application of same implant with bone graft. Fourth surgery was implant removal after which wrist was simply immobilized in a below elbow cast at which time the patient presented to us. There were no infected nonunions. Only one case was atrophic nonunion while the others were oligotrphic. All patients complained to pain, deformity with functional limitation in carrying out daily activities comfortably.
All patients were operated with strut bone graft and internal fixation as described below
Surgical procedure.
Under general anesthesia, scar tissue was excised and adjacent bone surfaces were freshened. Tri cortical cortico-cancellous bone graft was obtained from iliac crest along with extra cancellous bone graft. This strut graft was trimmed to fit in the gap at the fracture site, and was wedged in the non-union giving it good stability. Further cancellous graft was put in the remaining, bone gap. Volar locking plate was applied with divergent screws engaging in the styloid process and in medial end of the radius. One patient operated many years back before the era of volar locking plates was treated with ordinary dorsal plate. This fixation was supplemented by K wires. Darrach’s procedure was done in 4 cases and Sauvé-Kapandji in 2 patients after distal radius reconstruction. We preferred Darrach’s procedure in elderly patients in our series and did Sauvé Kapandji for younger patients. Supplementary wrist splint or below elbow plaster cast, was given in all cases for 3 wks. Period. Gradual mobilization was started after 3 weeks with intermittent splint use. At 6 wks. External support was discarded and further mobilization continued. Figure 1 and 2 show two typical cases of our series. The key to the procedure is the iliac crest block graft that offered stability and restored length (Fig 3).

Results
All patients showed, radiological union at mean 4 months (range 3 to 6 months). Range of flexion extension at wrist and supination and pronation improved over 4 months period in all cases. Grip strength was 30 % weak compared with opposite side in 5 patients. In one patient of 91 yrs old who was operated after 6 months of non-union had wrist drop pre operatively, (Fig 4) showed improvement in the wrist strength, and other functions, but grip strength, improved only by about 50%. He had tendon rupture after first surgery and hand function improved after tendon grafting was done. Whether additional k wires and external support was mandatory, is difficult to establish. But in this unstable situation, it did not result in decreased movements. One medical student who had compound fracture (Fig 5), which was treated with 3 surgical procedures before he ended up in non-union had with radio carpal radiological involvement, was offered, wrist fusion. He being a medical student and desiring orthopedic surgical carrier was reassessed carefully. He demonstrated inter carpal movements, and requested, to preserve that movement. He was treated by volar long dynamic compression plate without wrist fusion. He preserved his decent inter carpal movements with fracture union. How long he will remain painless is uncertain. There were no subsequent complications in our series and all patients reported satisfaction with their final functional results

Discussion
Nonunion of distal radius fractures are rare and no definite guidelines are available. We operated 6 of such cases using principles of strut graft, internal fixation and a DRUJ procedure. Union was achieved in all cases with good functional results.

A detailed literature review revealed 20 publication on distal radius fracture nonunion with total of 77 cases reported (Table 2) [1-4, 7-22]. Variety of factors were considered while making a clinical decision in these articles. Wrist fusion was reported by early articles and may be needed in cases with severe collapse, poor bone quality and as salvage procedure after repeated surgery [1, 19]. Earlier the size of distal radius fragment was considered to be very critical. Segalman and Clarke suggested that in cases with less than 5 mm distal fragment size, reconstruction will fails and thus primary wrist fusion should be attempted [6]. Four years later, Prommersberger et al suggested that in cases with less than 5 mm distal fragment can still be reconstructed if bone stock is good and stable fixation can be achieved [12]. The main surgical procedure for nonunion distal radius is open reduction, freshening of nonunion, iliac crest bone grafting to achieve as much radius length as possible and stable internal fixation using a plate construct. Stability is one of the key elements in treatment of distal radius nonunion. In present series a combination of techniques are used to archive stable fixation. Corticocancellous graft not only provides a biological stimulation but also behaves as a mechanical support to maintain the radial length. Volar plating and additional K wires were used to achieve stable fixation and good results were achieved in all our cases. Two studies have reported use of biplanar fixation of distal radius by using two plates at right angle to each other [15,16], however in our series we could achieve good results with single volar locking plates.
Procedures on DRUJ are needed in cases with arthrosis, instability and incongruity of DRUJ or where there is severe shortening of radius [2]. There are two procedures that have been used, the Darrach’s procedure and Sauvé Kapandji procedure. The indications and preference of one procedure over other is still debatable. Advantage of Sauvé Kapandji is that it provides a broad support to carpus bones and thus may prevent deformities or subluxation of the carpus and maintains good load transmission [7]. Again it is reported older patients with less demands will do well with a simpler Darrach’s procedure while Sauvé Kapandji is preferred in younger individuals. We preferred Darrach’s procedure in elderly patients in our series and did Sauvé Kapandji for younger patients. One specific disadvantage of Sauve Kapandji procedure was mentioned by Karuppiah and Johnson [7]. They recommended against use of this procedure in cases where severe radial collapse has occurred but length was restored by surgery. They hypothesized that due to restoration of length there will be significant amount of tension on the ulna soft tissue sleeve which may lead to restricted forearm rotation. They also pointed on importance of maintaining adequate tension in this soft tissue sleeve to prevent ulna stump instability. Justin and Sheung-tung reported a case where mid-shaft ulnar shortening osteotomy was done to reduce the DRUJ [20]. They fixed the ulna osteotomy with additional plate and reported good result. Probably this procedure can be used in cases with no DRUJ arthrosis. Failure to address issues of DRUJ have led to persistent pain even in cases with good radius union [5] and thus DRUJ should always be considered while treating distal radius nonunion.
Various factors have been proposed as cause of these nonunions. Tobacco and alcoholism are linked with increased incidence of distal radius nonunion [12], however none of our patients was a smoker or alcoholic. Diabetes, obesity, open fractures with soft tissue injuries are all implicated as compounding factors [3,12]. Presence of combined distal radius with distal ulna fracture [2,5], use of external fixation and used of pins and plasters [5,20] are also indicated to add to occurrence of nonunion. We feel the main reason for nonunion is unstable fixation or inadequate immobilization [2]. In one of our case primary fracture was compound and may have contributed to nonunion. In all stability was the main issue and when a stable fixation with bone grafting was done it could achieve good results in all our cases. Although over good union rates are reported, complications like plate breakage, persistent nonunion and graft donor site infection are reported with revision surgeries. In our series we had one case which presented as failure of revised fixation and bone grafting. However repeat revision with same procedure finally achieved union. No other complications were noted.
Our series has the inbuilt shortcomings of a retrospective study. However the event of distal radius nonunion is rare and hence difficult to plan large size prospective study. Different in patient profile and also available implants confound the surgical choice, however the principles of surgery remained the same and thus provide valuable inferences.
Conclusion

In conclusion, as brief guideline, we can say that in cases of distal radius nonunion, the nonunion should be treated with open reduction, strut bone graft and stable fixation. If DRUJ procedure is needed, Sauvé Kapandji procedure should be preferred in young patients while in old patients a Darrach’s procedure will give good results. Wrist fusion should be the last resort as a salvage procedure. Most nonunions will respond well to this approach with good clinical and functional results.

References

1. Prommersberger KJ, Fernandez DL. Nonunion of distal radius fractures. Clin Orthop Relat Res. 2004 Feb;(419):51-6.
2. McKee MD, Waddell JP, Yoo D, Richards RR. Nonunion of distal radial fractures associated with distal ulnar shaft fractures: a report of four cases. J Orthop Trauma. 1997 Jan;11(1):49-53.
3. Segalman KA, Clark GL. Un-united fractures of the distal radius:Areport of 12 cases. J Hand Surg. 1998;23A:914–919
4. Gómez EA, Mena RV. [Treatment of distal radius non-union in a three-stage procedure. Case report]. Acta Ortop Mex. 2009 Jan-Feb;23(1):26-30
5. Prommersberger KJ, Fernandez DL, Ring D, Jupiter JB, Lanz UB. Open reduction and internal fixation of un-united fractures of the distal radius: does the size of the distal fragment affect the result? Chir Main. 2002 Mar;21(2):113-23
6. Watson-Jones R. Fractures and other bone and joint injuries. 2nd edition. Edinburgh: Livingstone; 1942.
7. Karuppiah SV, Johnstone AJ. Sauvé-Kapandji as a salvage procedure to treat a nonunion of the distal radius. J Trauma. 2010 May;68(5):E123-5
8. Hamada G. Extra-articular graft for non-union in Colles’s fracture. J Bone Joint Surg 1944;26:833-835.
9. Bacorn RW, Kurtzke JF. Colles’ fracture: a study of two thousand cases from the New York State Workmen’s Compensation Board. J Bone Joint Surg 1953;35A:643-658.
10. Harper WM, Jones JM. Non-union of Colles’ fracture: report of two cases. J Hand Surg 1990;15B:121–3.
11. Saleh M, Ribbans WJ, Meffert RH. Bundle nailing in nonunion of the distal radius: case report. Handchir Mikrochir Plast Chir 1992;24:273-275.
12. Smith VA, Wright TW. Nonunion of the distal radius. J Hand Surg Br. 1999 Oct;24(5):601-3
13. Fernandez DL, Ring D, Jupiter JB. Surgical management of delayed union and nonunion of distal radius fractures. J Hand Surg 2001;26A:201–9.
14. Grecco Marco Aurélio Sertório, Angelini Luis Carlos, Oliveira Marcelo Tavares de, Trombini Nelson, Martins Francisco Carlos, Barbosa Sônia Maria de Almeida Pacheco. Treatment of nounion in the third distal of the radio. Acta ortop. bras. 2005;13(2): 95-99.
15. Ring D. Nonunion of the distal radius. Hand Clin. 2005 Aug;21(3):443-7
16. Crow SA, Chen L, Lee JH, Rosenwasser MP. Vascularized bone grafting from the base of the second metacarpal for persistent distal radius nonunion: a case report. J Orthop Trauma. 2005 Aug;19(7):483-6
17. De Baere T, Lecouvet F, Barbier O. Breakage of a volar locking plate after delayed union of a distal radius fracture. Acta Orthop Belg. 2007 Dec;73(6):785-90.
18. Villamor A, Rios-Luna A, Villanueva-Martínez M, Fahandezh-Saddi H. Nonunion of distal radius fracture and distal radioulnar joint injury: a modified Sauvé-Kapandji procedure with a cubitus proradius transposition as autograft. Arch Orthop Trauma Surg. 2008 Dec;128(12):1407-11.
19. Cao J, Ozer K. Failure of volar locking plate fixation of an extraarticular distal radius fracture: A case report. Patient Saf Surg. 2010 Nov 25;4(1):19.
20. Koo Siu-Cheong Jeffrey Justin, Ho Sheung-Tung, Non-union of Fracture of Distal Radius: A Case Report and Literature Review, Journal of Orthopaedics, Trauma and Rehabilitation, June 2011; 1(1):21-24
21. Nusem I, Moghaddam AK. Darrach’s ulnar resection and ulna intercalary bone graft for non-union of the distal radius: two birds one shot. Eur J Ortho Surg Traumatol 2011;21:345-349
22. Rappo TB, Kanawati AJ. Non-Union Of Fractured Distal Radius Treated With A Volar Locking Plate: A Case Report. The Internet Journal of Orthopedic Surgery. 2012 Volume 19 Number 2.

How to Cite this article: Tanna DD, Shyam AK. Nonunion distal radius fracture – Case series of 6 cases with Review of Literature. Trauma International July-Sep 2015;1(1):31-35

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Dr DD Tanna – Story of a Legend

July 25, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page:3-6| Dr. Dilip D Tanna, Dr. Ashok Shyam

Author: Dr. Dilip D Tanna [1], Dr. Ashok Shyam [2, 3]

[1] Lotus Clinic, Charni Road, Mumbai, India.

[2] Indian Orthopaedic Research Group, Thane, India
[3] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India

Address of Correspondence
Dr. Dilip D Tanna
Lotus Clinic, Charni Road, Mumbai, India.
Email: ddtanna@gmail.com

Dr DD Tanna – Story of a Legend

This interview was conducted at the famous Lotus Clinic at Mumbai. Interview of Dr DD Tanna (DDT) was personally conducted by our Editor Dr Ashok Shyam (AK). It was an interesting two hours talk in late evening and we are presenting here the salient features of the interview.

AK: First let me thank you for this interview. Let’s begin by asking about your family and where you grew up?
DDT: I grew up in Kalbadevi area in Bombay in a typical Gujrati locality. I had four brothers so we were five of us together with my father and mother. At that time education was not something very popular in our family and when I graduated I was among the handful in 2 mile radius and when I completed post-graduation there were none in the entire area. The trend was that people used to go to college just for the stamp of collage and then join the father business. But I was a good student and so I did complete my studies

AK: Tell us something more about your childhood?
DDT: I had a very eventful childhood, we used to play many sports. I was very good at cricket and even at medical college I was captain of the cricket team. But along with cricket I played many local sports kho-kho, langadi, hoo-to-too, football, volleyball, swimming etc. Didn’t get chance to play hockey but I did play everything I came across.

AK: I understand you have seen Mahatma Gandhi and heard him speak. Please share your remembrance of that?
DDT: Once Gandhiji was holding a meeting in Bombay and my father said to me ”let’s go see Gandhiji”. I went with him and there was a huge crowd and I felt quite uncomfortable. I wanted to leave when my father said to me ‘why are you afraid of the crowd, these are all your fellow human beings, not cattle herd”. That statement touched me very much and till today, I am not afraid of any crowd. Understanding that all are my fellow human beings, took away my stage fright forever. I can speak my thoughts clearly and without fear and I can dance with the crowd with equal ease.
I have seen Mahatma Gandhi at close distance and he appeared to be a very frail man. At first I wasn’t impressed, but then I realised that this frail man can have the huge crowd following him just because of his thought process. That understanding has helped me a lot in my life.

AK: So why did you become a doctor, what was your inspiration?
DDT: I was good in studies and in those days there were only two choices either to be an engineer or to be a doctor. I had decided that I would be an engineer with no doubt in my mind. One day one of my uncles, who happened to be an engineer, visited us. When asked I told him my intention to become an engineer, to which he replied ”In that case you have to take up a government job all your life”. In those days the only scope for an engineer was to be in government job, but the idea of being a enslaved for life by an organisation was something I couldn’t accept. My freedom was very dear to me and overnight I changed my decision and pledged to become a doctor.

AK: How was your MBBS term? Why did you choose orthopaedic surgery?
DDT: I was quite casual in MBBS and was more involved in sports. I got serious in last year to get good grades. Frankly speaking there were none who influenced me in the undergraduate college. After joining medicine developed a natural liking to surgery and always wanted to become a surgeon. Doing general surgery and then super specialisation for another two years seemed to be a long time. Orthopaedic surgery was a new branch at that time and offered direct super specialisation. And so I joined orthopaedic surgery.

AK: What were your early influences in medical college?
DDT: I wasn’t a very serious student in medical college. Possibly I became a bit serious in my last year of MBBS to score marks to get the branch of my choice. After MBBS and before joining post-graduation I had some spare time at hand which I utilise in reading. That period was a period of change I my life. I read authors like Bertrand Russel who had a major influence in my life. I read ‘Altas shrugged’, ‘We the Living’, and ‘Fountainhead’ and these three books had deep impact on me. I also read The Manusmrti’s specifically for their philosophical treatise and not the religious aspect. I still like to ponder on these philosophical aspects from time to time. By the time I joined as an orthopaedic registrar, I was a pretty serious person. In first 6 months of my orthopaedic residence I was fascinated with basics specially the histopathological aspect of orthopaedics. I read all about the histiocytes, the fibroblasts etc and even today I still think in these terms when I think about orthopaedics.

AK: You joined the B Y L Nair Hospital, Mumbai in 1965. Tell us something about your life at Nair Hospital?
DDT: Well in fact I passed my MS in 1965. I joined possibly in 1954 as a medical student. I was a student, house surgeon, lecturer, honorary surgeon all at Nair hospital. I was one of the youngest consultant as I became consultant at Nair hospital at age of 28, merely 8 months after passing MS exams. Possibly God was kind to me. Nair hospital was a decent place, but it became a force once Dr KV Chaubal joined Nair. Earlier KEM hospital had big name because of Dr Talwalkar and Dr Dholakia. I was lecturer when Dr Chaubal joined. He changed Nair hospital with his modern and dynamic approach. He gave me an individual unit within 3 years. Our rounds would be more than 4 hours in Nair hospital and had great academic discussions.

AK: We have heard about a very famous incident when you operated Dr Chaubal? Do tell us something about that
DDT: Well Dr Chaubal was suffering from a prolapsed disc and he had taken conservative management for some time with recurrent episodes. At one point we went ahead and got a myelogram done (no MRI in those days), and a huge disc was diagnosed. He called me the next day and asked to operate on him. I was 10 years his junior and moreover he was my boss and there were many more senior surgeons who were available. It came as a shock to me that he would chose me to operate on him [and of course it was an honor to be chosen]. Dr Laud and Dr Pradhan assisted me in operating him and it was big news at that time

AK: You were pioneer in bringing C-arm to India? Tell us something about the C-arm Story?
DDT: We used to do all surgeries under X ray guidance in those days, at the most we had 2 x-rays set together by Dr Talwalkar to get orthogonal views. I used to go to USA and they would do all surgeries under C-arm. I came back and contacted Mr Kantilal Gada who used to manufacture X ray machines. He agreed to try to make a C arm if I pay him one lakh rupees [in those days]. The condition was if he succeeded, he would give the c arm to me at no profit rate and if he failed my money would be lost. He did succeed and we had India’s first C-arm at my place. It helped me at many times in clinical practice. One specific incidence about an Arab patient who had a failed implant removal surgery previously and Icould remove the implant within 30 mins because I could clearly see the distal end of the nail entrapped. This patient was a friend of The Consulate General of UAE and since then I started getting lot of patients from there. So that was a wise investment I think.

AK: You were specifically instrumental in developing trauma surgery in India. Why focus of Trauma Surgery?
DDT: Dr Chaubal the first person to start trends in everything. At first we were spine surgeons as Dr Chaubal was very interested in spine surgery. Dr Bhojraj and Dr VT Ingalhalikar were our students. I was one of the first people to do total hip and total knee surgeries very soon after Dr Dholakia did it for the first time in India. But somehow I felt these surgeries did not hold much challenge. Trauma surgeries were challenging and each case was unique and different. So I decided to stick to trauma surgery for the sake of sheer joy of intellectual and technical challenges it offers.

AK: A lot has happened in the field of Orthopaedic Trauma in and you are witness to these growth and development. What according to you are the important landmarks in History of trauma Surgery?
DDT: Interlocking is the major change. I used to go to AAOS meeting every year where people were talking about interlocking when we were doing only plates. I decided to make an interlock nail by drilling holes in standard K nail. There was no C-arm in those days and surgeries were done on X rays. We got a compound fracture tibia and I made a set of drilled K nails for this patient as per his measurements. We successfully did the static locking using K nail in this patient. We slowly developed the instrumentation and jigs for it and developed commercially available instrument nail. Interlocking spread like wild fire and I was called as the Father of Interlocking Nail in India.

AK: Your specific focus was on Intramedullary nailing and you have also designed the ‘Tanna Nail’ How did you think of designing the nail? Tell us about the process of designing the nail, the story behind it?
DDT: Like said above, I developed the nail and instrument set with one Mr Daftari in Bombay. This was sold as ‘Tanna nail’ in Bombay. Slowly implant companies from other states also copied the design and started selling it as ‘Tanna NAIL’. I had no objections to it and I didn’t have a copyright anyway. Slowly I phased away the name as the design progressed and asked them to call it simply interlocking nails.

AK: You are known for Innovation. Tell us something more about it?
DDT: I specifically remember C-arm guided biopsy which I used successfully for tumor lesions. The same principle I used for drilling osteoid osteoma under CT guidance, which avoided an open surgery. There are many more technical tips and surgical techniques that I have been doing and some of them are listed in my book named ‘Orthopaedic Tit Bits’

AK: The last two decades have seen a tremendous increase in the choices of implants available in the market. Many of these implants were sold as the next “new thing”. Do you feel these new implants offer justifiable and definite advantage over the older ones? How should a trauma surgeon go about this maze of implants and choose the best for his patients?
DDT: There is no easy way to do that, because most implants comes with a huge propaganda and body of relevant research. Many senior faculties will start talking about it and using it. For example, distal femur plates have now reported to have 30% non-union rate. Earlier I had myself been a strong supporter of distal femur plate but through my own experience I saw the complications. Now I feel the intramedullary nail is better than the distal femur plat in indicated fractures. Same with trochanteric plates or helical screws in proximal femur fracture. So we learn the hard facts over a period of time and by burning our own hands. But then you have to be progressive and balance your scepticism and enthusiasm. In my case the enthusiasm wins most of the time.

AK: Share your views on role of Industry in dictating terms to trauma surgeons?
DDT: I feel it’s very difficult to bypass the industry. Also because the industry is supported by orthopods. But again like I said we learn from our own errors and something that does not have substance will not last for long. For example clavicle plating, I supported clavicle plating for some time [and it felt correct at that time], but now I do not find wisdom in plating clavicle and so I have stopped. So I believe it’s a process of constant learning and also realising and accepting mistakes. Once I was a great proponent of posterolateral interbody fusion (PLIF) in spine but after few years of using it I realised the fallacy and I presented a paper in WIROC (Western India regional orthopaedic conference) titled ‘I am retracting PLIF’ and it was highly appreciated by the audience.

AK: Tell us about your move toward joint replacement surgeries?
DDT: I was one of the first one after Dr Dholakia to start joint replacement surgeries in India and I continue to do many joint surgeries. And of course ‘cream’ comes from joint replacement surgeries (laughs heartily)

AK: You have been active in teaching and training for over 4 decades, how has the scene changes in terms of teaching methods and quality of surgeons undergoing training?
DDT: Teaching is now become more and more spoon feeding and I think it is not real teaching. Even in meetings I enjoy the format where there is small number of faculty and case based discussion on practical tips and surgical technique. The 8 minute talk pattern is something I think is not very effective. Real teaching of orthopaedics cannot be done in classroom or in clinics. In clinics we can teach students to pass exams but not orthopaedics. Dr Chaubal always used to say that real orthopaedics is taught in practical patient management and in operation theatres. I tell my fellows that I wont teach much, but they have to observe and learn. In medical colleges there is no teaching at all, its almost died off.

AK: What you feel is the ‘Way of Working’ of Dr Tanna that makes him a successful Orthopaedic Surgeon? Your Mantra?
DDT: Always do academically correct things. Like I have been practicing 3 doses of antibiotics since last 20 years. I read a lot and then distil the academic points and follow them in practice. I get up at 4 am and read everyday.

AK: What technical tips would you give for someone who has just embarked on his career as an Orthopaedic surgeon?
DDT : I have given one oration which is also on you tube, you should listen to that. Anybody who becomes an orthopaedic surgeon is actually cream of humanity and are capable of doing anything. The only thing required is a strong will to excel and passion to succeed

AK: I understand that you are a very positive person, but do you have any regrets, specifically related to orthopaedics. Something that you wished to do but couldn’t?
DDT: Honestly nothing. Today when people ask me ‘How are you’ I say ‘can’t be better’. I couldn’t have asked for a better life

AK: Any message you will like to share?
DDT: I think passion to be best is essential. Even if one patient does not do well or if we do a mistake in a surgery, it causes huge distress and misery to us. We as doctor should be truthful to your patients. Between you and your patient there can’t be any malpractice. You should treat every patient as if you are doing it on your son or daughter. Always keep patient first

AK: What degree or accolades would you like me to mention in your introduction?
DDT: Nothing just plain MS Orth, I have no other degrees. In fact after my MS I attempted to give D orth exam. My boss at that time Dr Sant, said ‘are you crazy, after passing MS you want to give KG exam?’ He actually did not allow me to appear (laughs). Never felt like having any more degrees, degrees won’t take me ahead, its only my orthopaedic skill that will be take me ahead in life.

How to Cite the article: Tanna DD, Shyam A. Dr DD Tanna – Story of a Legend. Trauma International July-Sep 2015;1(1):3-6

Dr Dilip D Tanna

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Nonunion distal radius fracture – Case series of 6 cases with Review of Literature

Dr DD Tanna – Story of a Legend

Nonunion distal radius fracture – Case series of 6 cases with Review of Literature

Dr DD Tanna – Story of a Legend

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Nonunion distal radius fracture – Case series of 6 cases with Review of Literature

Author: Dilip D Tanna[1*], Ashok K Shyam [2].

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Dr DD Tanna – Story of a Legend

Author: Dr. Dilip D Tanna [1], Dr. Ashok Shyam [2, 3]

Dr DD Tanna – Story of a Legend

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