Does augmentation of intramedullary nails by a buttress plate effectively restore lateral wall integrity in intertrochanteric fractures.

BACKGROUND: Recent studies have proved the importance of intact lateral trochanteric wall, thus buttressing/fixing the broken lateral trochanteric wall irrespective of the implant, is likely to improve the alignment and outcome. We compared the outcome of lateral wall buttressing by trochanteric buttress plate (TBP) supplemented to proximal femoral nailing versus proximal femoral nailing alone in patients of broken lateral wall intertrochanteric fractures. MATERIAL AND METHOD: Sixty patients of intertrochanteric factures (IT) of femur with broken lateral wall were randomized into group A or B and were treated with either proximal femoral nail (PFN) alone or proximal femoral nail augmented with trochanteric buttress plate (PFN + TBP), respectively. The TBP plate used was primarily fixed to proximal femur via 8 mm hip screw and 6.4 mm antirotation screw of the PFN. Operative time, blood loss, radiation exposure, quality of reduction, functional outcome, union time, and complications were compared. RESULT: The mean age was 60.03 + 7.60 (range 42 to 70 years), with male to female ratio of 4:1 and left to right ratio of approximately 1:1. The mean follow up in the series was 16.2 months (range 13 to 36 months). Mean duration of surgery, mean intra-operative blood loss, and mean number of exposures in group A (PFN alone) were 64.88 + 12.24 min (48 to 88), 93 + 1.18 ml (60 to 120), and 32.13 (24 to 46) and in group B (PFN with TBP plate) were 91.86 + 12.78 min (70 to 122 min), 144.8 + 3.6 ml (116 to 208 ml), and 56.6 (38 to 112), respectively. Twenty-five patients and 28 patients in groups A and B respectively achieved score of 4 Chang quality reduction. Mean union time was 13.4 weeks in group A whereas in group B was 11.6 weeks. Mean HHS score in group A was 87.86 with 90% patients in comparison to 94.13 and 97% cases having excellent to good results in group B. In group A, 24 patients, while 29 patients in group B, had excellent to good results. Four patients had hip pain, four had impingement of screws, two had screw migration, three had Z/reverse effect, and four patients had shortening of more than 1 cm in group A. In group B, only one patient had impingement and none of the patient had hip pain, infection, implant failure, Z effect, or shortening. CONCLUSION: The lateral trochanteric wall in IT fractures is significantly important, and when the lateral wall is broken, it can lead to poor results. TBP plate which is applied laterally on femur along with nail and fixing the plate with hip screw and antirotational screw provides faster union, early weight bearing, better reduction, and so better hip functions. TBP can be used successfully to augment, fix, or buttress the lateral trochanteric wall giving excellent to good results but at the cost of surgical time, blood loss, and radiation exposure.

Simultaneous lateral column shortening along with differential distraction by Joshi's external stabilization system for rigid neglected clubfoot correction.

Correction of rigid clubfoot in an older child by gradual differential distraction using the Ilizarov's device or Joshi's external stabilization system (JESS) is a time-consuming procedure. We simultaneously combined the lateral column shortening by cuboid wedge resection along with the differential distraction by application of JESS fixator for the treatment of severe, rigid, neglected, or relapsed congenital talipes equinovarus (CTEV) foot deformity in 30 feet in 18 children with mean age of 5.3 years and mean follow-up of 27.6 months. The mean pretreatment Pirani score was 5.3 which improved to mean Pirani score after treatment of 1.4. Excellent results were obtained in 22 (71.33%) feet, good results in four (13.33%) feet, and poor results in four (13.33%) feet. The average period for distraction in our series was 6.3 weeks, and total average period of fixator in place was 11.2 weeks. To conclude, lateral column shortening with JESS application simultaneously gives early good to excellent short-term results, and the combination of techniques permits rapid correction of deformity, and thus reducing the time for which the fixator is in place and hence has better acceptance by the patient.

Interobserver variability in Pirani clubfoot severity scoring system between the orthopedic surgeons.

BACKGROUND: Congenital talipes equinovarus (clubfoot) is one of the most common congenital pediatric orthopedic foot deformity, which varies in severity and clinical course. Assessment of severity of the club foot deformity is essential to assess the initial severity of deformity, to monitor the progress of treatment, to prognosticate, and to identify early relapse. Pirani's scoring system is most acceptable and popular for club foot deformity assessment because it is simple, quick, cost effective, and easy. Since the scoring system is subjective in nature it has inter- and intra-observer variability, it is widely used. Hence, the interobserver variability between orthopedic surgeons in assessing the club foot severity by Pirani scoring system. MATERIALS AND METHODS: We assessed the interobserver variability between five orthopedic surgeons of comparable skills, in assessing the club foot severity by Pirani scoring system in 80 feet of 60 children (20 bilateral and 40 unilateral) with club foot deformity. All the five different orthopedic surgeons were familiar with Pirani clubfoot severity scoring and Ponseti cast manipulation, as they had already worked in CTEV clinics for at least 2 months. Each of them independently scored, each foot as per the Pirani clubfoot scoring system and recorded total score (TS), Midfoot score (MFS), Hind foot score (HFS), posterior crease (PC), emptiness of heel (EH), rigidity of equnius (RE), medial crease (MC), curvature of lateral border (CLB), and lateral head of talus (LHT). Interobserver variability was calculated using kappa statistic for each of these signs and was judged as poor (0.00-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), or almost perfect (0.81-1.00). RESULTS: The mean age was 137 days (range 21-335) days. The mean Pirani score was 3.86. We found the overall consistency to be substantial for overall score (total score kappa - 0.71) and also for midfoot (0.68) and hindfoot (0.66) separately. The consistency was least for the emptiness of heel (kappa - 0.39), and best for rigidity of equnius (kappa - 0.68) and rest of the parameters were moderate (kappa between 0.40 and 0.60). CONCLUSION: The Pirani scoring system had got substantial reliability in assessing the clubfoot deformity even when the reliability test was extended to five different orthopedic surgeons simultaneously.

Outcome of limb reconstruction system in open tibial diaphyseal fractures.

BACKGROUND: Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously. MATERIALS AND METHODS: Thirty open fractures of tibial diaphysis with bone loss of at least 4 cm or more with a mean age 32.5 years were treated by using the LRS after debridement. Distraction osteogenesis at rate of 1 mm/day was done away from the fracture site to maintain the limb length. On the approximation of fracture ends, the dynamized LRS was left for further 15-20 weeks and patient was mobilized with weight bearing to achieve union. Functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. RESULTS: Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal. CONCLUSION: Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.

Haemangioma of knee joint: a case report.

BACKGROUND: Hemagioma arising in the knee is a rare cause of knee swelling. The diagnosis frequently is delayed for long. METHODS: We are presenting the case report of a 12 year old male child who had a swelling on anteromedial knee which remained undiagnosed for more than 1 year. Patient had all baseline blood investigations and plain radiograph of knee which were normal. He also had got his knee aspirated which yielded only blood. CONCLUSION: The aim of presenting this case report is to create awareness about the possibility of a hemangioma arising from a joint which although rare should be kept as a differential diagnosis. KEY WORDS: Haemangioma,knee joint,Swelling.