Use of Paley Classification and SUPERankle Procedure in the Management of Fibular Hemimelia.

BACKGROUND: Fibular hemimelia is the most common deficiency involving the long bones. Paley classification is based on the ankle joint morphology, identifies the basic pathology, and helps in planning the surgical management. Reconstruction surgery encompasses foot deformity correction and limb length equalization. The SUPERankle procedure is a combination of bone and soft tissue procedures that stabilizes the foot and addresses all deformities. METHODS: We retrospectively reviewed 29 consecutive patients (29 limb segments), surgically treated between December 2000 and December 2014. Among the 29 patients, 27 were treated with reconstructive procedures. Type 1 (8 patients) cases were treated with only limb lengthening, and correction of tibial deformities. Type 2 (7 patients) cases were treated by distal tibial medial hemiepiphysiodesis or supramalleolar varus osteotomy. In type 3 (10 patients) cases, the foot deformity was corrected using the SUPERankle procedure. Type 4 (2 patients) cases were treated with supramalleolar osteotomy along with posteromedial release and lateral column shortening. In a second stage, limb lengthening was performed, using the Ilizarov technique. In the remaining 2 patients (type 3A and type 3C), amputation was performed using Syme technique as a first choice of treatment. RESULTS: The results were evaluated using Association for the Study and Application of Methods of Ilizarov scoring. Excellent results were obtained in 15 of 27 (55%) patients. Six (22%) patients had good results, 4 (14.8%) had fair results, and 2 (7%) had poor results. Mean limb length discrepancy at initial presentation was 3.55 cm (range: 2 to 5.5 cm) which significantly improved to 1.01 cm (range: 0 to 3 cm) after treatment (P=0.015). CONCLUSIONS: Our results and a review of the literature clearly suggest that limb reconstruction according to Paley classification, is an excellent option in the management of fibular hemimelia. Our 2-staged procedure (SUPERankle procedure followed by limb lengthening) helps in reducing the complications of limb lengthening and incidence of ankle stiffness. Performing the first surgery at an earlier age (below 5 y) plays a significant role in preventing recurrent foot deformities. LEVEL OF EVIDENCE: Level IV.

Accuracy of valgus osteotomy using dynamic hip screw.

BACKGROUND: Non-union of neck femur is a common but difficult situation to manage especially in young adults. There are two main options of arthroplasty or osteotomy. The aim of this study was to assess the results of intertrochanteric valgus osteotomy in non-union femoral neck fractures. PATIENTS AND METHODS: We present a study of 44 cases of neck femur non-union including untreated fractures, late presentations (more than 3 weeks), treated with compression screw, DHS. From 2006-2016, 44 patients presented to our institute and we analyzed them prospectively on the following criteria: Pauwel's angle, Garden classification, union at fracture site, union at osteotomy site, osteoporosis and AVN changes. Inclusion criteria were age<65, neck not reabsorbed, no AVN. Powel's angle was calculated using the anatomic axis of femur. Wedge angle is equal to Powel's angle minus 30 degree. Entry point of DHS was at the base of greater trochanter and tip of the screw was in the inferior quadrant. Y osteotomy was done in the distal half of the lesser trochanter with a proximal straight cut. RESULTS: Complete union was noted in 93% of the cases. One patient with uncontrolled diabetes developed severe infection and was treated with excision arthoplasty. AVN occurred in 3 cases. The Powell's angle was reduced to mean 30 (22-39). The neck shaft angle was increased to mean 140 (130-150). Limp was noted in almost all patients but they were able to walk full weight bearing with or without the support of a stick. CONCLUSION: Valgus intertrochanteric osteotomy achieved good union rates and good functional outcome with minimal complications.

Use of a raft construct through a locking plate without bone grafting for split-depression tibial plateau fractures.

PURPOSE: To review the outcome after open reduction and internal fixation using a periarticular raft construct through a locking plate without bone grafting for split-depression tibial plateau fractures. METHODS: Records of 38 knees in 31 men and 7 women aged 25 to 75 (mean, 42.7) years who underwent open reduction and internal fixation using a periarticular raft construct through a locking plate without use of a bone graft or bone substitute for split-depression (>5 mm) proximal tibial plateau fractures (Schatzker type II or AO/OTA type 4.1 B3) were reviewed. The integrity of the articular surface was assessed using radiographs. The Rasmussen radiological score and clinical score, the Lysholm knee score, and the Tegner activity score were also assessed. RESULTS: The mean follow-up period was 22.8 (range, 6-36) months. All patients achieved bone union after a mean of 13.2 (range, 8-26) weeks. The mean range of motion was 118º (range, 100º-130º). The Rasmussen radiological score was excellent in 27 patients, good in 9, and fair in 2. The Rasmussen clinical score was excellent in 15 patients, good in 21, and fair in 2. The Lysholm knee score was excellent in 26 patients, good in 8, and fair in 4. 32 of the 38 patients recovered to their preoperative Tegner activity scores. Only one patient with severe comminution had loss of reduction after full weightbearing. CONCLUSION: Fixation using a periarticular raft construct through a locking plate without use of a bone graft or bone substitute for split-depression proximal tibial plateau fractures is a viable option.

Correction of coronal plane deformities around the knee using a tension band plate in children younger than 10 years.

BACKGROUND: Guided growth through temporary hemiepiphysiodesis has gained acceptance as the preferred primary treatment in treating pediatric lower limb deformities as it is minimally invasive with a lesser morbidity than the traditional osteotomy. The tension band plate is the most recent development in implants used for temporary hemiepiphysiodesis. Our aim was to determine its safety and efficacy in correcting coronal plane deformities around the knee in children younger than 10 years. MATERIALS AND METHODS: A total of 24 children under the age of 10 were operated for coronal plane deformities around the knee with a single extra periosteal tension band plate and two nonlocking screws. All the children had a pathological deformity for which a detailed preoperative work-up was carried out to ascertain the cause of the deformity and rule out physiological ones. The average age at hemiepiphysiodesis was 5 years 3 months (range: 2 years to 9 years 1 month). RESULTS: The plates were inserted for an average of 15.625 months (range: 7 months to 29 months). All the patients showed improvement in the mechanical axis. Two patients showed partial correction. Two cases of screw loosening were observed. In the genu valgum group, the tibiofemoral angle improved from a preoperative mean of 19.89° valgus (range: 10° valgus to 40° valgus) to 5.72° valgus (range: 2° varus to 10° valgus). In patients with genu varum the tibiofemoral angle improved from a mean of 28.27° varus (range: 13° varus to 41° varus) to 1.59° valgus (range: 0-8° valgus). CONCLUSION: Temporary hemiepiphysiodesis through the application of the tension band plate is an effective method to correct coronal plane deformities around the knee with minimal complications. Its ease and accuracy of insertion has extended the indication of temporary hemiepiphysiodesis to patients younger than 10 years and across a wide variety of diagnosis including pathological physis, which were traditionally out of the purview of guided growth.

Antegrade interlocking nailing versus dynamic compression plating for humeral shaft fractures.

PURPOSE: To compare antegrade interlocking nailing with dynamic compression plating for humeral shaft fractures in terms of functional outcomes, union and complication rates. METHODS: 34 men and 22 women aged >18 years with fresh humeral shaft fractures (up to grade IIIa) with or without neurological deficits underwent either antegrade interlocking nailing (n=31) or dynamic compression plating (n=25). Functional outcome of the upper limbs (according to the American Shoulder and Elbow Surgeons [ASES] score), pain, rates of union, and complications in the 2 groups were compared. RESULTS: Respectively in the nailing and plating groups, mean operating times were 65 and 112 minutes (p<0.001), mean blood loss volumes were 20 and 232 ml (p<0.001), mean ASES scores were 31.4 and 29.0 (p=0.448), complication rates were 20% (6/31) and 24% (6/25) [p=0.900], non-union rates were 13% (4/31) and 8% (2/25) [p=0.625], and delayed union rates were 7% (2/31) and 4% (1/25) [p=0.787]. CONCLUSION: Both techniques were appropriate for treating humeral shaft fractures.

Intramedullary nailing supplemented with Poller screws for proximal tibial fractures.

PURPOSE: To evaluate outcome of intramedullary nailing supplemented with Poller screws for proximal tibial fractures using small diameter nails. METHODS: 50 men and 20 women (75 fractures) aged 18 to 65 (mean, 33) years underwent intramedullary nailing supplemented with Poller screws for acutely displaced fractures (n=60) or for delayed union (n=10) or mal-union (n=5) of the proximal metadiaphyseal tibia. 88% of the fractures were caused by road traffic accidents. 54 cases had closed fractures and 21 had grade I or II compound fractures. Clinical and radiological outcome was evaluated. RESULTS: In 69 cases, healing occurred after a mean of 4.2 (range, 3-9) months. In 5 cases, there was non-union, which was resolved by bone grafting. One case was mal-united. 63 patients recovered a full range of knee motion (0º-130º), and the remaining 7 attained flexion of 0º to 90º. According to the knee rating scale of the Hospital for Special Surgery, outcome was excellent in 50 patients, good in 14, poor in 3, and failed in 3 at month 12, and remained so after a mean follow-up of 30.8 months. Postoperatively, 74 cases had <5º of varus or valgus malalignment, and only one developed varus of +7º. 65 cases exhibited no deformity, 7 had a deformity of <3º, and 3 had a deformity of 4º to 9º. CONCLUSION: Poller screws help maintain fixation of intramedullary nailing and alignment of fractures.