Novel Technique for the Management of Fibrous Dysplasia of Radius Shaft with Fibular Strut Autograft without Internal Fixation: A Case Report.

Introduction: Fibrous dysplasia (FD) is a developmental disorder in which the normal bone marrow is distorted and replaced by dense fibrous stroma containing a disorganized matrix. The disorder can be localized to a single bone or affect multiple bones. Although any bone can be affected, the bones of the upper extremity are the rare site of involvement. The disease process results in deformity of the bones and is often complicated by pathological fractures. Case Report: Here, we present a case of a 14-year-old girl, who presented with FD of the radius bone with the progressive deformity with terminal restriction of supination and pronation. Radiographs showed revealed an expansile lytic lesion with ground glass appearance involving the proximal meta-diaphysis of the right radius, with its resultant bowin. Using Henry's approach, we treated with an innovative surgical approach envisioned with the non-vascularized cortical fibular bone graft without an internal fixation. Conclusion: For the management of FD of radius bone, non-vascularized cortical fibular bone grafting provided if tightly fitted gives good radiological and functional outcome without any recurrence with complete osseointegration.

Fibrous Dysplasia of Radius Bone-excision and Fibula Graft: A Case Report.

Introduction: Fibrous dysplasia (FD) is a congenital disorder in which the bone is distorted and replaced by poorly organized and structurally unsound fibrous tissue. The disorder can be localized to a single bone or affects multiple bones. Although any bone can be affected, the bones of the upper extremity are less commonly involved by the disease. The disease process results in deformity of the bones and is often complicated by pathological fractures. Case Report: A 14-year-old girl presented with gradually progressive deformity of the right forearm for the past 1 year associated with mild pain. Skeletal radiographs of the right forearm revealed an expansile lytic lesion with ground glass appearance involving the proximal meta-diaphysis of the right radius, with its resultant bowing. The zone of transition was narrow and there was no evidence of matrix calcification. The lesion was causing thinning of the bony cortex. With this radiographic appearance in mind, a diagnosis of FD of the radius was put forth. The lesion was managed surgically. The proximal three-fourth of the radius bone was exposed and the lesion was excised along with 1 cm of normal bone on the distal side. Proximally, a thin shell of the cortex was preserved after curettage of the proximal end of the radius. Fibular cortical strut graft was harvested from the leg of same side. Graft length was kept 2 cm more than the excised bone to avoid shortening of the forearm. The graft was beveled on the distal end and jammed into the shaft of the distal radius such that 1 cm of graft was inside the original bone. A long arm or above elbow splint was applied keeping the elbow at 90 degrees of flexion and the forearm in supination for a total of 6 months. The patient was being followed up regularly. Follow-up radiographs obtained at 7 months revealed complete incorporation of the cortical bone graft with reformation of the intramedullary bone canal and restoration of hand and elbow function. Conclusion: Non-vascularized fibular cortical strut grafting is an effective treatment modality for FD of radius bone. External or internal fixation is not necessary if a tightly fitting cortical graft is jammed into the defect caused by lesion excision.

Treatment of atrophic nonunion of middle phalanx in a nine-year-old boy with external distraction and bone grafting.

Nonunion of phalangeal fractures is uncommon and even rarer in the paediatric age group. There is paucity of literature relating to the treatment of atrophic non-union of phalangeal fractures in the paediatric age group. We present a case of five years old atrophic non-union of the middle phalanx of the index finger of the dominant hand in a nine-year-old male child, managed with a staged treatment protocol of initial fracture site distraction with a threaded external fixator followed by delayed bone grafting. This treatment was successful in attaining length and bony union in case of atrophic non-union of the middle phalanx with a good pinch strength and gaining a good range of motion at the proximal interphalangeal joint with little soft tissue dissection.

Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases.

BACKGROUND: Soft tissue defects over the mid- and distal third tibia, heel, dorsum and plantar aspect of the foot and over the medial, lateral and posterior aspect of the ankle are a common scenario in clinical orthopaedic practice. In this article, we describe the utility of the reverse sural fasciocutaneous flap with a cutaneous pedicle in 109 clinical cases with distal lower limb soft tissue defects. MATERIALS AND METHODS: A total of 109 patients were operated on for moderate (5-15 cm) and large (more than 15 cm) soft tissue defects at various sites along the lower limb including foot, heel and sole with the reverse sural fasciocutaneous flap. The defects were secondary to trauma (61 cases), diabetic ulcers (12 cases), post-traumatic scar contracture (8 cases), venous ulcer (4 cases), wound dehiscence (10 cases), leprotic non-healing ulcer (1 case), post-infective wound (1 case), radiation-induced ulcer following radiotherapy for synovial cell sarcoma (1 case), post-fibromatosis excision (1 case), post-dermatofibrosarcoma excision (1 case), post-heel melanoma excision (1 case) and actinomycosis foot (1 case). Patients were assessed for flap uptake and healing of defects. RESULTS: Among the 102 cases analysed, 81 were male and 21 female with an average age of 32.7 years. The average size of the flaps was 148.10 ± 59.54 cm(2). The flap healed uneventfully in 89.21 % of patients. Edge necrosis occurred in 9 cases. Donor site regrafting was required in 7 patients. CONCLUSION: The reverse sural fasciocutaneous flap with a cutaneous pedicle is a quick, versatile, easy and safe soft tissue defect coverage technique to cover most of the soft tissue defects of the lower limb in common orthopaedic practice and does not require any microvascular repair, though it may be cosmetically unappealing in a few cases. LEVEL OF EVIDENCE: IV (Case series).

Antegrade joint-sparing intramedullary wiring for middle phalanx shaft fractures.

PURPOSE: To evaluate the outcome for surgical stabilization of middle phalanx shaft fractures with joint-sparing antegrade intramedullary K-wire fixation. METHODS: We treated 15 extra-articular transverse or short oblique shaft fractures of the middle phalanx in 13 patients. All fractures were treated with closed reduction internal fixation with antegrade joint-sparing intramedullary K-wires. Patients had a minimum follow-up of 1 year (range, 1-10 y). We assessed the objective outcome at 6 months by calculating total active range of motion. RESULTS: All fractures healed. Based on the total active motion score at 6 months, 10 digits showed excellent results, 3 digits were good, 1 was fair, and 1 was poor. Among 3 patients with an associated flexor tendon injury, 2 had excellent outcomes and one had a poor outcome. For 2 patients with an associated extensor tendon injury, 1 had a good outcome and the other had a fair outcome. CONCLUSIONS: Antegrade intramedullary wiring for extra-articular transverse and short oblique shaft  fracture of middle phalanx is a simple, safe, inexpensive, and joint-sparing technique that provides enough fracture stability, even in cases of associated injuries, for early rehabilitation and functional recovery with the expectation of a good to excellent outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Salvage of delayed union of a phalangeal fracture with "a hairpin wire".

The advantages of using multiple joint sparing antegrade intramedullary wiring for displaced, transverse and short oblique fractures of the small long bones of the hand has been well documented. This technique provides stable three-point fixation and permits early range of motion exercises to prevent hand stiffness. But in some revision cases where there is a breach or deficiency of subchondral bone due to previous intramedullary wiring or in old neglected juxta articular fractures of the metacarpal, proximal phalanx or middle phalanx with disuse osteopenia, there is a high chance of inadvertent joint penetration with intra medullary wiring, inspite of using blunt tipped bent K wires. This could happen intraoperatively or later in the follow up due to collapse of the fracture ends. We describe an innovative fixation technique which ensures stable fixation, no joint penetration and enables early range of motion to prevent hand stiffness.

A new technique of locked, flexible intramedullary nailing of spiral and comminuted fractures of the metacarpals: a series of 21 cases.

BACKGROUND: Spiral and comminuted fractures of the metacarpals are rotationally and axially unstable fractures with a tendency to shorten, which in turn causes significant extensor lag and loss of grip strength. We have designed a new, cheap and locally developed method of locked intramedullary nailing of these metacarpal fractures. We are presenting the results of our first 21 patients with 22 fractures treated by closed, fluoroscopically assisted, intramedullary K-wiring with proximal locking done by a specially designed locking pin. MATERIALS AND METHODS: This was a retrospective, observational cohort study of all patients with spiral and comminuted fractures of metacarpals with minimum of 1 year of follow-up and average follow-up of 14 months (range, 12 to 26 months). The patients were evaluated clinico-radiologically using range of motion, extensor lag, time to healing, amount of collapse, angulation and rotation and complications. RESULTS: All fractures had healed uneventfully with average time to union being 8 weeks. Average metacarpal shortening was 2.04 ± 0.95 mm, while the average post-operative angulation of the fracture was 4.81° ± 1.7. The metacarpophalangeal range-of-motion recovered almost fully with the average extensor lag being only 5.22° ± 2.42. Other than extensor tendinitis in two patients, there were no other complications. CONCLUSIONS: This method is cosmetically appealing, provides stable fixation, avoids periosteal stripping associated with open reduction and is associated with very low complication rate, and thus can be safely and effectively used for the treatment of these difficult fractures.

Multiple intramedullary nailing of proximal phalangeal fractures of hand.

BACKGROUND: Proximal phalangeal fractures are commonly encountered fractures in the hand. Majority of them are stable and can be treated by non-operative means. However, unstable fractures i.e. those with shortening, displacement, angulation, rotational deformity or segmental fractures need surgical intervention. This prospective study was undertaken to evaluate the functional outcome after surgical stabilization of these fractures with joint-sparing multiple intramedullary nailing technique. MATERIALS AND METHODS: Thirty-five patients with 35 isolated unstable proximal phalangeal shaft fractures of hand were managed by surgical stabilization with multiple intramedullary nailing technique. Fractures of the thumb were excluded. All the patients were followed up for a minimum of six months. They were assessed radiologically and clinically. The clinical evaluation was based on two criteria. 1. total active range of motion for digital functional assessment as suggested by the American Society for Surgery of Hand and 2. grip strength. RESULTS: All the patients showed radiological union at six weeks. The overall results were excellent in all the patients. Adventitious bursitis was observed at the point of insertion of nails in one patient. CONCLUSION: Joint-sparing multiple intramedullary nailing of unstable proximal phalangeal fractures of hand provides satisfactory results with good functional outcome and fewer complications.

A new technique of graft harvest for anterior cruciate ligament reconstruction with quadruple semitendinosus tendon autograft.

A new technique of graft harvesting was used in 8 cases for arthroscopic anterior cruciate ligament reconstruction with quadruple semitendinosus tendon autograft. The graft is acquired through a small incision on the posteromedial aspect of the knee at the flexor crease instead of the standard anteromedial approach through a paramedian incision. Compared with the standard technique of graft harvesting, this new method of graft harvest facilitates easier identification of the semitendinosus and avoids inadvertent amputation of the semitendinosus tendon during graft harvest, disinsertion of the pes anserinus, or injury to the infrapatellar branch of saphenous nerve. The surgical scars, in addition to the standard portal scars, include a small scar on the posteromedial aspect, which merges into the flexor crease and a 1-cm anteromedial scar. This provides improved cosmesis and better patient compliance for early rehabilitation with less pain in the immediate postoperative period. There is no compromise on the intraoperative ligament reconstruction with good postoperative results. No intraoperative or postoperative complications were encountered. It would be advisable to follow this technique of graft harvesting for all individuals undergoing arthroscopic anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon to avoid the problems encountered with the standard technique, and also to achieve an excellent cosmetic and functional outcome.