Mid-term results of impaction bone grafting in tibial bone defects in complex primary knee arthroplasty for severe varus deformity.

INTRODUCTION: Bone defects are a challenging problem encountered occasionally during primary knee arthroplasty. These defects should be meticulously addressed so as to avoid malalignment and premature loosening and failure. Out of the many options available to deal with these defects, impaction bone grafting provides a more biological solution, which is especially important in case of primary knees. MATERIALS AND METHODS: A retrospective analysis was done and patients with severe varus deformity of more than 20 degrees who had undergone primary knee arthroplasty with impaction bone grafting of the tibial condyle defect were followed up. RESULTS: Between 2008 and 2014, out of the 1124 patients who underwent primary total knee arthroplasty, only 26 knees in 23 patients met the inclusion criteria. The amount of varus deformity ranged from 20 to 35 degrees. Follow-up ranged from 3 to 8 years with an average of 6 years. The average pre-operative Knee Society Score (KSS) and Western Ontario McMaster Universities (WOMAC) score were 24.2 and 78, respectively. There were significant improvements in the post-op scores, with the average KSS being 90.2 and the WOMAC being 38. CONCLUSION: Impaction bone grafting provides an invaluable option to the orthopedic surgeon for managing bone defects, especially in case of primary knee arthroplasty as it reconstitutes the bone stock.

Desmoplastic Fibroma of Bone: a Case Series and Review of Literature.

Desmoplastic fibroma is an uncommon locally aggressive benign tumor of the bone. Patients usually present with a long-standing history of pain and swelling. Radiologically and histologically, it can mimic a variety of tumors. This article presents a report on three cases of desmoplastic fibroma in the proximal humerus, distal femur, and neck femur region. The varied radiographic features and the management of the three cases are described in detail. All the three patients were treated by extended curettage. Follow-up ranged from 2 to 5 years. There were no local or systemic recurrence until the last follow-up. Tumor resection with adequate margins is the preferred treatment, although extended curettage can be an acceptable alternative treatment modality when resection is not possible or acceptable.

Extensive Re-ossification and Reformation of the Proximal Femur After External Beam Radiotherapy in Metastatic Carcinoma Breast.

Management of metastatic bone disease is still evolving and is dependent upon many factors including the primary tumour type, expected life expectancy, site and size of lesion, character of the lesion, lytic or blastic, and the number of lesions. Active orthopaedic surgical intervention is usually required at the time of pathological fracture either impending or actual. Management options are either in situ fixation or replacement/arthroplasty. The role of post-operative radiotherapy is still not clearly defined and its biological effect on healing of pathological fracture is unclear. In this report, we describe a case of breast carcinoma with a large metastatic lytic lesion in the proximal femur, which was treated by in situ fixation followed by hormonal therapy and external beam radiotherapy. In the post-operative period, rapid and dramatic ossification and reformation of the proximal femur was observed.

Retrospective analysis of open reduction and internal fixation of coronal plane fractures of the capitellum and trochlea using the anterolateral approach.

INTRODUCTION: Coronal plane distal humeral injuries are relatively rare. Numerous classification systems have been proposed as the complexity of these fractures has been realized. We in the present series of ten patients describe the surgical technique of Open Reduction and Internal Fixation of Coronal plane fractures of the distal humerus with headless compression screws performed using the anterolateral approach. MATERIAL AND METHOD: It was a retrospective study, the data collected from March 2010 to 2015 was analysed and the final outcome was assessed using the DASH score. Out of a total of 13 patients with distal humerus coronal plane fractures, 10 patients were available for follow up. The X-rays and CT scans were reviewed and the fractures were classified according to Dubberley and Bryan and Morrey classification. Radiographic were evaluated for presence of union or nonunion, avascular necrosis, joint line step-off (none/1-mm/>1-mm), hardware failure and instability. RESULTS: The average age was 41 years. The average DASH score in our study was around 24. The time to union ranged between 8-12 weeks with the average time being around 10 weeks. One patient had post traumatic Arthritis radiologically classified as Broberg and Morrey Type 2 and one patient had Heterotrophic ossification Brooker Grade 1. CONCLUSION: Open reduction and internal fixation of coronal shear fractures of capitellum and trochlea using headless screw compression via the antero-lateral approach is a reliable treatment modality and results in stable fixation with restoration of a functional arc of motion. LEVEL OF EVIDENCE: IV.

Retrospective analysis of extra-articular distal humerus shaft fractures treated with the use of pre-contoured lateral column metaphyseal LCP by triceps-sparing posterolateral approach.

Management of extra-articular distal humerus fractures presents a challenge to the treating surgeon due to the complex anatomy of the distal part of the humerus and complicated fracture morphology. Although surgical treatment has shown to provide a more stable reduction and alignment and predictable return to function, it has been associated with complications like iatrogenic radial nerve palsy, infection, non-union and Implant failure. We in the present series retrospectively analysed 20 patients with extra-articular distal humerus shaft fractures surgically treated using the extra-articular distal humeral locking plate approached by the triceps-sparing posterolateral approach. The outcome was assessed using the DASH score, range of motion at the elbow and the time to union. The mean time to radiographic fracture union was 12 weeks.

A Closed Lateral Subtalar Dislocation With Checkrein Deformity of Great Toe due to Entrapment of Flexor Hallucis Longus: A Case Report.

UNLABELLED: Closed lateral subtalar dislocation is a very rare injury. We report a case of closed lateral subtalar dislocation with entrapment of flexor hallucis longus tendon producing a checkrein deformity. The patient was managed immediately with closed reduction under regional anesthesia and fixated with percutaneous Kirschner wires. Early mobilization and weightbearing was started and there were no complications till the last follow-up visit. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case study.

Autograft reconstructions for bone defects in primary total knee replacement in severe varus knees.

BACKGROUND: Large posteromedial defects encountered in severe varus knees during primary total knee arthroplasty can be treated by cementoplasty, structural bone grafts or metallic wedges. The option is selected depending upon the size of the defect. We studied the outcome of autograft (structural and impaction bone grafting) reconstruction of medial tibial bone defects encountered during primary total knee replacement in severe varus knees. MATERIALS AND METHODS: Out of 675 primary varus knees operated, bone defects in proximal tibia were encountered in 54 knees. Posteromedial defects involving 25-40% of the tibial condyle cut surface and measuring more than 5 mm in depth were grafted using a structural graft obtained from cut distal femur or proximal tibia in 48 knees. For larger, peripheral uncontained vertical defects in six cases, measuring >25 mm in depth and involving >40% cut surface of proximal tibial condyle, impaction bone grafting with a mesh support was used. RESULTS: Bone grafts incorporated in 54 knees in 6 months. There was no graft collapse or stress fractures, loosening or nonunion. The average followup period was 7.8 years (range 5-10 years). We observed an average postoperative increase in the Knee Society Score from 40 to 90 points. There was improvement in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in terms of pain, stiffness and physical function during activities of daily living. CONCLUSION: Bone grafting for defects in primary total knee is justified as it is biological, available then and is cost effective besides preserving bone stock for future revisions. Structural grafts should be used in defects >5 mm deep and involving 25-40% of the cut proximal tibial condyle surface. For larger peripheral vertical defects, impaction bone grafting contained in a mesh should be done.

Sideswipe injuries around the elbow: Management and functional evaluation.

INTRODUCTION: Sideswipe injuries constitute a subgroup of complex elbow trauma. Almost all of these are high energy open injuries. There is no fixed protocol that is followed in the earlier studies. The injury pattern is grotesque and ill managed with poor functional outcome. We report the functional outcome in our series of patients who sustained sideswipe injuries. MATERIALS AND METHODS: Thirty four patients presenting with sideswipe injuries around the elbow were managed and functional results evaluated. The patients were followed for 15-94 months (mean 74 months). 32 of these were males and two were females. The injuries were sustained between 8 years and 48 years age group (mean 30 years). The right side was affected in 20 and left side was injured in 14 patients. Road traffic accident was the cause in all patients. Principles of management followed were (1) debridement and stabilization of fractures, (2) vascular repair, (3) redebridement, (4) nerve repair and (5) soft tissue cover. An external fixator was used for fracture stabilization in 20 patients with open fractures. Internal fixation was used as a stabilization modality in 12 patients. Primary nerve repair was carried out in 4 cases. In case of segmental loss, tendon transfers or nerve grafting was carried out at a later date once softtissue healing was complete. Soft tissue coverage was provided within 24-48 h of injury. Results were evaluated using the Mayo elbow performance score. RESULTS: The average Mayo elbow performance score was 70. Excellent results (score > 90) in accordance with Mayo elbow score were seen in 30% of the patients. Good results (score 75-89) were seen in 33% of the patients. CONCLUSION: Sideswipe injuries should be managed timely, aggressively and an algorithmic protocol should be followed to achieve best results. The injury pattern is distinct for which a multispecialty approach is needed and an orthopedic, vascular and plastic surgeon must be involved. Limb salvage is possible in most cases.