Valgus osteotomy in delayed presentation of femoral neck fractures using fixed angle simple dynamic hip screw and plate.

PURPOSE: Reduction and fixation in femoral neck fracture in young patients have a problem of nonunion requiring additional procedure like valgus osteotomy but fixation devices are technically difficult for inexperienced surgeons. We aims to assess the results of valgus osteotomy in femoral neck fracture in our setup. METHODS: We report a series of 20 patients of higher Pauwel's angled fracture of femoral neck fracture presenting late wherein for valgus osteotomy was added to reduction fixation secured with a commonly available 135° dynamic hip screw and plate. RESULTS: Femoral neck fractures united in 16 patients (80%). Excellent to good results (Harris hip score >80) were seen in 70% patients. Angle of correction of preoperative Pauwels has been changed from 68.3 to 34.3. CONCLUSION: 135° dynamic hip screw and plate provides rigid internal fixation after valgus osteotomy and being a more familiar fixation device simplifies the procedure with good results.

Tuberculosis Challenging Pathognomicity of Atraumatic Avulsion of the Lesser Trochanter for Malignancy: A Rare Case Report.

CASE: A 40-year-old man presented with spontaneous, atraumatic right groin pain and inability to bear weight secondary to an isolated avulsion of the right lesser trochanter. Magnetic resonance imaging of the affected hip was suggestive of an infection, and a computed tomography-guided biopsy was remarkable for Mycobacterium tuberculosis, which was successfully managed with antitubercular therapy and activity modification. CONCLUSION: Although an isolated spontaneous avulsion of the lesser trochanter is typically pathognomonic for malignancy, an infectious etiology, such as tuberculosis, should also be considered in the differential diagnosis.

Use of INFIX for managing unstable anterior pelvic ring injuries: A systematic review.

INTRODUCTION: Subcutaneous screw rod system which is popularly known as Pelvic internal fixator (INFIX) has emerged as an alternative to external fixators in management of unstable pelvic injuries. INFIX has shown various advantages over external fixation such as reduced infection rate and patient morbidity. However, it has its own set of complications such as lateral femoral cutaneous nerve injury, heterotopic ossification, femoral nerve palsy etc. We intended to conduct a systematic review of the current literature to assess outcomes and complications with INFIX technique of fixation. METHODS: A comprehensive search of literature was performed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and online database of EMBASE, PubMed, Medline and Scopus was searched for all studies in English language till March 2020. Included studies were reviewed for demographic data, fracture type/classification, radiological outcome and functional outcomes. The inclusion criteria were: 1. Studies in English language 2. Clinical studies reporting use of INFIX technique in pelvis fracture where clinical and radiological outcomes were reported. RESULTS: Twenty-two studies fulfilling inclusion and exclusion criteria were included in this systematic review with total of 619 patients. Radiographic parameters and outcome measures were infrequently reported. Fixation with INFIX in these fractures leads to 87% excellent to good radiological results and 84% excellent to good functional results. Complications include lateral femoral cutaneous nerve irritation (25.3%), heterotopic ossification (24.7%), infection (3%), and femoral nerve palsy (1.6%); which is likely related to placing the bar and screws too deep. CONCLUSION: This analysis supports the use of INFIX in management of unstable pelvis fractures where anterior fixation is required.

Delayed femoral artey thrombosis after hemi arthroplasty of hip- a case report.

Vascular complications following hip-arthroplasty (HA) are rare. Delayed vascular complications are exceptional with handful of reports. We report a case of femoral artery thrombosis following hemi arthroplasty with delayed presentation after a bone fragment left in situ penetrated and injured the vessel. This report is a revelation for surgeons who need to be extremely careful while operating as well as be vigilant with patients in their follow up and should assess for vascular status at each visit.

Distal Locked versus Unlocked Intramedullary Nailing in Intertrochanteric Fracture; A Systematic Review and Meta-Analysis of Randomized and Non-Randomized Trials.

OBJECTIVE: To compare the outcome of distal locked and unlocked intramedullary nailing in patients with intertrochanteric fractures through systematic review and meta-analysis of randomized and non-randomized clinical trials. METHODS: Randomized or non-randomized controlled studies comparing the effects of unlocked and locked nails for treatment of intertrochanteric fractures were searched using the search strategy of Cochrane collaboration up to April 2019. Four eligible studies involving 691 patients were included. Their methodological quality was assessed, and data were extracted independently for meta-analysis. RESULTS: The results showed that the unlocked group has significantly less operative time (MD: -8.08; 95%CI -11.36 to -4.79; P< 0.00001), fluoroscopy time (MD: -7.09, 95%CI -7.09 to -4.79; p<0.00001), length of incision (MD: -2.50, 95%CI 2.85 to -2.14; p< 0.00001) than the locked group. The complication rate was significantly higher in the locking group (OR: 0.55, 95%CI 0.26 to 1.15; p=0.03). No significant differences were found in the Harris hip score between the two groups (MD: 0.68, 95% CI -0.83 to 2.19, p<0.08). CONCLUSION: The present meta-analysis suggests that intramedullary nailing without distal locking is reliable and acceptable option for treating intertrochanteric fracture. The advantages are reduced operative time, decreased fluoroscopy time, smaller size of incision and decreased complication rate. However, owing to the low-quality evidence currently available, additional high quality Randomized controlled trials are needed to confirm these findings.

Functional outcome after surgical treatment of perilunate injuries: A series of 12 cases.

PURPOSE: Perilunate injuries (PLIS) are complex injuries, which are frequently missed in the initial setting, and delayed presentation leads to poor functional outcomes. In this study, we are presenting our experience of treating these injuries by surgical treatment and the effect of neglect on their outcome. MATERIALS AND METHODS: In this retrospective study, 11 patients with 12 PLIS, which presented to our center from January 1, 2000 to December 31, 2012 were included. They were managed surgically as open reduction and internal fixation. Function was documented by using Mayo score. To ascertain the effect of the delay/neglect on the outcome, the patients were divided into two groups according to time between day of injury and final surgery (group I - operated within 6 weeks of injury and group II - treated after 6 weeks of injury). RESULTS: Average postoperative Mayo score was 76.4. Average Mayo score in group I was 93.7 (90-95). Average Mayo score in group II was 67.1 (60-75). Although functional result as Mayo score was significantly better in group I (p value <0.5) even chronic or delayed group patients also had good to fair results. CONCLUSION: Early diagnosis and treatment of such injuries should be emphasized as delay in treatment leads to progressive poor results. Well-planned surgical management gives good functional results even in delayed cases.

Neglected post burns contracture of hand in children: Analysis of contributory socio-cultural factors and the impact of neglect on outcome.

BACKGROUND: No study has ever evaluated the causes and effect of neglect on the outcome of post burns contractures of hand in children. METHODS: 66 hands in 61 children (mean age 12.22 years) with a mean neglect of 11.6 years (range 5-17 years) were assessed for the causes of neglect and the outcome of surgery. Average follow up was 6.6 years. The results were assessed in two groups of 5-10 years neglect as group I and >10 years neglect as group II. RESULTS: In a total number of 134 contracted rays in 66 hands, the surgical procedures included local Z/V-Y flap (51 rays), cross finger flap (48 rays), full thickness graft (35 rays). Additional external fixator with a distracter was used in 3 patients treated at a delay of 14, 16 and 17 years. 50 (81.96%) patients belonged to rural and slum areas. The reasons for delayed treatment included poverty - 33 patients, lack of awareness of surgical treatment - 16 patients; and indifference of parents - 12 patients. 44 (72.13%) children were illiterates. With treatment the average DASH score improved from 65.10 to 36.90 (p < .000) and from 68.14 to 45.93 (p < .000) in group I and II respectively. The results were significantly superior in group I (p < .000). CONCLUSION: The main factors for neglect in treatment of post burns contracture include poverty, lack of awareness and illiteracy. All the patients showed significant improvement in function after the surgery. Contractures with higher neglect had significantly inferior outcome.

Outcome of pedicle screw fixation and monosegmental fusion in patients with fresh thoracolumbar fractures.

STUDY DESIGN: Prospective clinical study. PURPOSE: The present prospective study aims to evaluate the clinical, radiological, and functional and quality of life outcomes in patients with fresh thoracolumbar fractures managed by posterior instrumentation of the spine, using pedicle screw fixation and monosegmental fusion. OVERVIEW OF LITERATURE: The goals of treatment in thoracolumbar fractures are restoring vertebral column stability and obtaining spinal canal decompression, leading to early mobilization of the patient. METHODS: Sixty-six patients (46 males and 20 females) of thoracolumbar fractures with neurological deficit were stabilized with pedicle screw fixation and monosegmental fusion. Clinical, radiological and functional outcomes were evaluated. RESULTS: The mean preoperative values of Sagittal index, and compression percentage of the height of the fractured vertebra were 22.75° and 46.73, respectively, improved (statistically significant) to 12.39°, and 24.91, postoperatively. The loss of correction of these values at one year follow-up was not statistically significant. The mean preoperative canal compromise (%) improved from 65.22±17.61 to 10.06±5.31 at one year follow-up. There was a mean improvement in the grade of 1.03 in neurological status from the preoperative to final follow-up at one year. Average Denis work scale index was 4.1. Average Denis pain scale index was 2.5. Average WHOQOL-BREF showed reduced quality of life in these patients. Patients of early surgery group (operated within 7 days of injury) had a greater mean improvement of neurological grade, radiological and functional outcomes than those in the late surgery group, but it was not statistically significant. CONCLUSIONS: Posterior surgical instrumentation using pedicle screws with posterolateral fusion is safe, reliable and effective method in the management of fresh thoracolumbar fractures. Fusion helps to decrease the postoperative correction loss of radiological parameters. There is no correlation between radiographic corrections achieved for deformities and functional outcome and quality of life post spinal cord injury.