Proximal Femoral Non-unions with Implant In Situ Treated by Revision Osteosynthesis: A Real Challenge.

INTRODUCTION: Proximal femur fractures non-union with implant failure creates a nightmare for both the surgeon and the patient. Meticulous surgical planning and the correct choice of the implant are essential to achieve success in the revision surgery. MATERIALS AND METHODS: Eleven patients with ununited proximal femur fractures including both intertrochanteric and subtrochanteric fractures who had a failed previous implant were included in the study. Femoral neck nonunions and infected nonunions were excluded from the study. One patient was lost to follow-up. RESULTS: One patient was lost to follow-up and out of the remaining ten patients, six were males and four were females. Mean age was 62.2 years (35-74). Union was achieved with mean union time of 10.1 months (9-14). Mean surgical time was 105 min (90-125) and mean blood loss during surgery was 600 ml (350-850). Mean time of revision surgery after the primary index surgery was 20 months (15-30). Mean duration of follow-up was 12.9 months (12-16). CONCLUSION: Revision osteosynthesis in proximal femoral nonunions with implant failure is a real test of surgeons expertise because of the many factors going against like osteoporosis, distorted proximal femur anatomy due to the already present implant resulting in poor bone stock availability. Judicious and appropriate selection of implants is an impeccable factor for fracture union and positive outcome.

Wound healing of open fractures: comparison of vaccum assisted dressing versus traditonal dressing.

PURPOSE: For permanent wound coverage of compound fractures, the wound surface should have 100% granulation tissue without any discharge or necrotic slough. Negative pressure wound therapy (NPWT) is a well known modality in the management of open fractures, and post-operative wound problems. This study was conducted to compare the outcome of NPWT and traditional dressing in wound healing of open fractures. MATERIAL AND METHODS: A prospective study of 100 cases was conducted to compare the wound healing outcomes of open fracture following vacuum assisted closure (VAC) dressing (50 cases) and traditional wound dressing (50 cases). Patients included in the study underwent initial debridement to remove necrotic slough and tissue when indicated. Foam dressings were used to cover the wounds using aseptic conditions in the VAC group. Dressings were changed daily for patients in traditional dressing group using hydrogen peroxide, normal saline and povidone iodine in a sequential manner and every 3-4 days in the VAC dressing group. Patients were evaluated clinically for appearance of granulation tissue, duration of hospital stay and reduction in wound surface area using appropriate statistical methods. RESULT: There was a significant difference between the rate of wound healing in the group NPWT/VAC group compared to the traditional wound dressings group in terms of appearance of granulation tissue, reduction in wound surface area and duration of hospital stay. CONCLUSION: Vacuum assisted dressing is more effective than traditional wound dressing in wound healing of open fractures.

Implant-associated Hoffa's Fracture in a Floating Knee: A Case Report and Review of Literature.

INTRODUCTION: Complex floating knee in the presence of a previous implant creates an unusual fracture pattern which is a rare entity and poses a unique challenge in management and subsequent rehabilitation. CASE REPORT: A 56-year-old psychiatric patient who jumped from height had a polytrauma and a floating knee injury. Following the primary care and damage control surgery with knee-spanning fixator at some other centers, he was shifted to us on ventilator care and was directly admitted to intensive care unit for further management. On presentation, it was a floating knee injury with gross comminution of both femur and tibia with associated Hoffa with bent implant in situ. It was managed by plating of both lower end femur and tibia and at the end of 6 months, showed a satisfactory outcome. CONCLUSION: Floating knee injuries further complicated by the presence of the previous implant in a polytrauma situation poses a unique challenge which requires meticulous surgical planning and prolonged rehabilitation to achieve satisfactory outcome.

Ipsilateral Radial Head Dislocation And Proximal One-Third Radial Shaft Fracture In An Adult: A Case Report.

INTRODUCTION: Dislocation of the radial head in adults is quite uncommon. A simultaneous dislocation of the radial head with a fracture of ipsilateral shaft radius without any other associated injury is even rare. CASE PRESENTATION: We are reporting a case of a young adult male who was operated for proximal one-third radial shaft fracture at some peripheral centre by Open Reduction and Internal Fixation (ORIF), but came to our centre on the fourth post-operative day with complaints of painful restricted movements of the elbow joint. On careful look at the postoperative x-ray, radial head was found to be dislocated. Radial head dislocation was reduced under general anesthesia and at 2 years follow up, patient fracture has fully united having good functional outcome. CONCLUSION: Traumatic dislocation of radial head with ipsilateral fracture shaft radius is a rare injury in adults and it is very important to timely diagnose it and manage it appropriately in order to give good functional outcome to the patient.

Resistant Non-union of Humerus After Intramedullary Nailing Treated with Locking Compression Plate with Bone Grafting With Nail in Situ and Shoulder Spica: A Case Report.

INTRODUCTION: Humerus non-union is a challenging situation for the surgeon and devastating and morbid situation for the patient. Surgical approach to the humerus is demanding because of the complex neurovascular anatomy and especially when previous surgeries have been attempted. CASE REPORT: We report a case of a young adult male who sustained a compound fracture of humerus shaft treated with intramedullary nailing followed by subsequent bone grafting and eventually landed up in non-union and was treated at our center by locking compression plate application with nail in situ with iliac crest autogenous bone graft followed by shoulder spica application. CONCLUSION: Although humerus nailing is a valid therapeutic option for humeral shaft fractures, compression plating is considered the gold standard and non-union secondary to failed interlocking nailing is a challenging situation.

Giant cell tumour of clavicle: Occurrence of a common tumour in a rare location.

INTRODUCTION: The clavicle is rare site of bone tumours. Majority of the tumours of clavicle are malignant and are often misdiagnosed due to low index of suspicion. The oncological patterns of clavicle resemble that of flat bones. CASE PRESENTATION: A 60year old man presented to our centre with pain and swelling over lateral end of left clavicle. After thorough investigation a provisional diagnosis of giant cell tumor was made which was treated with partial claviculectomy. At one year follow up, there was no shoulder disability or any incidence of recurrence. CONCLUSION: Since majority of clavicular tumors are malignant so any selling occurring in this area should be seen with high index of suspicion and should be investigated thoroughly.

Broken Pieces of Circlage Wire Lying in Soft Tissue Envelope Around Knee Joint: A Case Report and Review of Literature.

INTRODUCTION: The migration of circlage wires used in tension band wiring construct of patella fractures in the posterior soft tissue envelope surrounding the knee joint has been rarely reported. CASE PRESENTATION: A 60-year-old woman presented to us with pain over medial aspect of right knee joint. She underwent open reduction and internal fixation for a patellar fracture which she sustained 4 years back and subsequently underwent kirschner wire(k wire) removal for the same around 2 years back. X-rays of the knee joint shows that the circlage wire used in tension band construct which was left in place had broken into multiple pieces and was lying in the soft tissue envelope surrounding the knee joint and one piece migrate to the popliteal fossa. On examination patient did not had distal neuro-vascular deficit. The pain of the patient was due to the osteo-arthritic changes in her medial side of knee joint rather than broken wire pieces. Patient was advised to undergo total knee replacement along with subsequent removal of broken wires but patient refused for any type of surgery and is kept on regular follow up. CONCLUSION: This case report summarizes a rare complication resulting from hardware failure used for fixing patella fractures and throws a light on potential unwarned complications due to broken wires along with early recogonition and removal of broken hardware by surgeons.