A New Classification System for Acetabular Bone Defect Evaluation in Posttraumatic Acetabular Nonunion and Malunion.

Introduction: There is no distinct classification system to evaluate the bone defect in previously managed acetabular fractures. We propose a new classification system for bone defect evaluation in a previously managed acetabular fracture that will be helpful for total hip arthroplasty (THA). Materials and Methods: The preoperative pelvis radiographs of 99 THA patients with previous acetabular fractures with at least 2 years of follow-up were evaluated by 10 experienced surgeons (Paprosky and new classification systems). As per the new classification system, the five types of bone defects are circumferential, posterior wall, posterior column, both column defect, and anterior column. The interobserver and intraobserver reliability was calculated, and a consensus management plan based on the recommendation of the observers was formulated. Results: There was fair interobserver reliability for Paprosky classification (alpha coefficient 0.39) and substantial interobserver reliability for the new classification (alpha co-efficient 0.71). There was a substantial intraobserver agreement for the new classification (kappa value 0.80) and moderate intraobserver agreement for Paprosky classification (kappa value 0.55). Sixty-nine patients who were treated as per the management plan of the observers reported significant improvement in modified Harris hip score (improved from 25 to 85.88, p < 0.001). 89.7% of patients reported good to excellent outcomes. Overall best health as per EQ-5D VAS was obtained in THA following anterior column fracture (EQ-5D VAS 97.5), and relatively poor health was obtained after THA of posterior column nonunion (EQ-FD VAS 80). Conclusions:  The new classification system for bone defect evaluation in previously treated acetabular fractures is valid and reliable. The proposed surgical plan for the management of bone defects in THA provided good to excellent outcomes.

Safety and efficacy of perioperative tranexamic acid infusion in acetabular fracture fixation: A randomized placebo-controlled double-blind prospective study.

INTRODUCTION: Open reduction and internal fixation of acetabular fracture is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial. MATERIAL AND METHODS: Sixty-three patients undergoing open reduction and internal fixation of acetabular fracture were randomized into either TXA (n = 36) or placebo (n = 27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 min prior to incision, followed by another similar dose after 3 h of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a single pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated. RESULTS: Both groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 ± 1.36 gm% in TXA group and 9.74 ± 1.98 gm% in placebo group (p-value 0.158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups. CONCLUSION: There is no significant reduction in blood loss and blood transfusion with the use of intravenous Tranexamic acid in open reduction and internal fixation of acetabular fractures.

Satisfaction and Health-Related Quality of Life Following Hip and Knee Arthroplasty Surgeries in Indian Patients: A Cross-Sectional Study.

Introduction: Recently, the patient-reported outcome measures (PROMs) have been considered as the most important assessment tool for surgical outcome evaluation in arthroplasty. However, no study from the Indian subcontinent has evaluated the PROM in the total hip (THA) and knee (TKA) arthroplasties. Materials and Methods: This cross-sectional study evaluated the health-related quality of life (HRQoL) of 1244 North Indian patients following primary THA and TKA who had at least one-year follow-up. This study included 617 patients with 664 THA and 627 patients with 1152 TKA. The patients were asked to answer the EQ-5D-5L questionnaires and EQ-VAS in their own languages. The EQ-5D-5L values were used to derive level frequency scores (LFS) with validated Indian norms of EuroQoL. Results: Ninety percent of THA and 82% of TKA patients rated excellent HRQoL using EQ-VAS. The regression analysis revealed age, gender, etiology and brand of prosthesis had a significant impact on EQ-5D-5L following THA. However, gender and simultaneous bilateral surgery were found to be important predictors of outcome in TKA. The mean value of LFS for THA was 0.95 ± 0.12 and TKA was 0.88 + 0.24 (p < 0.001). However, There was no difference in LFS between THA and TKA when only elderly patients (> 60 years) were considered (p = 0.168). Conclusion: THA patients reported better HRQoL than TKA in the Indian subcontinent. One of the factors for a better outcome in hip arthroplasty was the relatively younger age of the patients. Patients above 60 years of age reported similar levels of statisfactior in both THA and TKA. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00589-x.

Anatomical quadrilateral plate for acetabulum fractures involving quadrilateral surface: A review.

INTRODUCTION: The management of acetabulum fractures in osteoporotic elderly, as well as comminuted fractures in younger patients is likely to be difficult. These fractures need specific fixation techniques especially when the quadrilateral plate is involved. Standard implants may not be able to adequately support the fixation, so newer pre-shaped fixation plates have been proposed with some of these already in use. The concept of anatomic plates has come up for many fracture locations for providing a better buttress effect to the comminuted fragments. There has been a need to look for an anatomic buttress plates being developed for acetabulum fractures involving the quadrilateral surface. MATERIALS AND METHODS: The literature has been reviewed to find the various newer designs that have been used for buttressing the quadrilateral surface in comminuted acetabular fractures. An attempt has been made to study their design characteristics and clinical outcomes. The review also includes the analysis of Anatomic Quadrilateral plate (AQP) used in fixation of acetabulum fracture involving quadrilateral surface in a series of 33 patients. RESULTS: There has been few anatomical plates developed for the stabilization of acetabular quadrilateral surface fractures. Some of these plates have been successfully used in management of acetabular fractures primarily in young patients. Issues however remain in their application and outcomes in osteoporotic fractures of the acetabulum, as these plates support the pelvic brim fragments either from superior or medial surface. The newer development i.e. 'Anatomical Quadrilateral Plate' is optimized to counter the displacement forces due to its positioning on the pelvic brim rather than its superior or medial surface. Other special features include the possibility of longer screws across bone due to oblique position of holes, the typical location of a locking hole on the plate beam which permits dual cortical compression fixation either by using a bigger screw or a specially designed screw in screw construct across the supra-acetabular corridor. The option of using hybrid fixation of both locking and unlocked screws in AQP allows proper stress distribution on the underlying bone, aiding both primary as well as secondary stability. The minimum of one year post surgery outcome of patients having acetabular fixation using this Anatomic quadrilateral plate has been analyzed in 33 patients. Twenty three of these were aged more than 50 years and 28 out of total 33 were males. Associated injuries included Ipsilateral lower limb injury in 2 patients and distal radius fracture in 5 patients. The fracture pattern included 'Anterior column posterior hemi-transverse' in 10 patients,' Associated Both Column' injury in 9 and 'T type' acetabular fractures in 8 patients. Isolated 'Anterior column' was fractured in 6 patients. The surgical approach was 'Anterior Intra-pelvic' (AIP) in 23 patients and 'Modified Ileo-femoral' in other 10 patients. One patient had additional K L approach. Among the implants, the AQP plate was used without its pubic arm in 6 patients. The post-operative x rays showed anatomical reduction in 28 patients, while other 5 had gaps and/or steps up to 2 mm size. In subsequent car, one of these patients needed hip arthroplasty for problem arising due to collapse in fixation within six months. EQ 5D 5L telephonic score was used to know the outcome at minimum of one year follow up in 33 patients. As per this score, only 3 patients had an issue with mobility, with only one having problem in self-care activity. Six patients complained of minor limitations in carrying out their usual activities and only one patient had anxiety affecting him. In their self-assessment of overall health status, 22 patients marked it 100, 7 made it 90, 3 as 80 and 1 had marked it as 70 in a score range of 0-100. Considering the predominant elderly profile in this series of patients, the acetabular reconstruction using 'Anatomic quadrilateral plate' has shown encouraging results. CONCLUSION: For stabilization of acetabular fractures involving quadrilateral surface area and pelvic brim, various new implants have been used. The Anatomic quadrilateral plate due to its anatomical shape, the various options in fracture fixation is best optimized for management of comminuted acetabulum fractures especially in poor quality bones. It has been successful in achieving good outcome in elderly group of patients having these complex injuries.

Common hip conditions requiring primary total hip arthroplasty and comparison of their post-operative functional outcomes.

BACKGROUND: Primary osteoarthritis of hip has been widely reported to be the leading cause for total hip replacement (THR) in the world. The other common causes are avascular necrosis of hip, inflammatory diseases and trauma sequelae. We report the prevalence of these disease as studied retrospectively at a tertiary healthcare centre and discuss the common age groups and sex ratios of these patients as compared to the West. Additionally, we compare the outcomes of these surgeries based on the aetiologies for which they were done. METHODOLOGY: Patients who underwent primary THR in our institute within six years were called and retrospectively analysed. Revision cases were excluded. All the surgeries were done by a single experienced arthroplasty surgeon. On follow ups, functional scores were assessed using standard Harris hip score (HHS) and quality of life scores were assessed using the Short musculoskeletal functional assessment (SMFA) score. RESULTS: 118 hips in 99 patients (M:F- 3.2:1) with a mean age group of 43.22 years, were operated over a period of six years. Non traumatic avascular necrosis (AVN) of hip topped the list in our study with 42.4% of cases, followed by post-traumatic sequelae (30.5%). These were followed subsequently by primary osteoarthritis (OA) (14.4%) and the remaining were inflammatory pathologies (IA). The HHS of patients with non traumatic AVN hip, traumatic sequelae and primary osteoarthritis were significantly superior to inflammatory arthritis with a p value of 0.001, 0.001 and 0.016 respectively. Additionally the short musculoskeletal functional assessment score was also significantly higher in IA than AVN, OA and post trauma groups (p = 0.001, 0.037 and 0.002 respectively); where a higher score denotes inferior outcomes. CONCLUSION: In our part of the world, non traumatic AVN hip is the commonest indication for primary hip arthroplasty, followed by traumatic sequelae. The frequency of males undergoing hip arthroplasty is much more than females and at a younger age as compared to the West. Additionally, the functional outcomes in cases of inflammatory arthritis are inferior as compared to the other indications, probably because of associated contractures, deformity and spinal issues.

Amelioration of collagen antibody induced arthritis in mice by an antibody directed against the fibronectin type III repeats of tenascin-C: Targeting fibronectin type III repeats of tenascin-C in rheumatoid arthritis.

Tenascin-C (TN-C) levels are elevated in the synovial tissue and fluid, as well as cartilage of rheumatoid arthritis (RA) patients. In addition, the presence of TN-C fragments has also been documented in arthritic cartilage. We have previously shown that a single chain variable fragment antibody (TN64), directed against the fibronectin type III repeats 1-5 (TNfnIII 1-5) of TN-C, effectively inhibits fibrotic pathology. Given that fibrosis results from chronic inflammation, and the fact that increased levels of TN-C in the synovial fluid of patients with RA contributes to synovial inflammation and joint destruction, we aimed to investigate the role of TNfnIII 1-5 region of TN-C in RA pathogenesis. Using either the wild type or variants of the two integrin-binding motifs (RGD and AEIDGIEL) present within the TNfnIII 1-5 polypeptide, we demonstrate that the adhesion and migration of synovial fibroblasts is RGD-dependent. The antibody TN64 is effective in inhibiting migration of cells in response to TnfnIII 1-5, and prevents fibroblast-mediated destruction of cartilage. The TN64 antibody was further tested in collagen antibody induced arthritic (CAIA) mice. Our data shows the efficacy of TN64 in preventing induction of arthritis, with significant downregulation of RA-associated cytokines. This suggests that components of the extracellular matrix such as the TNfnIII 1-5 region of TN-C could be exploited to develop therapies to suppress inflammation seen in RA. The TN64 antibody is one such promising candidate in the development of novel treatments for RA.

Blocking osteopontin-fibronectin interactions reduce extracellular fibronectin deployment and arthritic immunopathology.

Elevated levels of a thrombin-cleaved fragment of osteopontin (OPNT) are seen in synovial fluid (SF) and tissues of rheumatoid arthritis (RA) patients. OPNT binds to integrins on cell surfaces, inducing adhesion, migration and survival of inflammatory cells in the synovial joints, where OPNT binds to fibronectin to link fibroblast-like synoviocytes (FLS) with B cells, stimulating the latter to produce inflammatory cytokines. Our aim was to block OPNT-fibronectin interactions and examine whether this reduces inflammation. A human antibody (phage displayed) library was used to select scFv antibodies cognate to OPNT, and a particular scFv antibody (scFv 31) was evaluated. Adhesion, migration and fibronectin polymerization of FLS cells derived from RA patients were monitored, in cultures incorporating scFv 31. Also, scFv 31 was used in mice with CAIA (collagen antibody-induced arthritis), subjected to clinical and histological assessment, analysis of fibronectin and cartilage damage and induction of pro-inflammatory cytokines. The scFv antibody, scFv 31, appeared to cause significantly reduced migration of synovial fibroblasts, altered cell morphology, changes in actin stress fiber arrangement, and marked reduction in fibronectin. In CAIA mice, scFv 31 appeared to prevent arthritic changes through inhibition of synovial hypertrophy and loss of articular cartilage, decrease in fibronectin polymerization and expression of pro-inflammatory cytokines implicated in arthritis. Osteopontin-fibronectin interaction(s) appear to play a role in the expression of key inflammatory molecules by B cells infiltrating the synovial joint. The scFv antibody, scFv 31, provides a potential therapeutic lead for inhibition of some processes implicated in rheumatoid arthritis.

18F-FDG PET/CT in Diagnostic and Prognostic Evaluation of Patients With Suspected Recurrence of Chondrosarcoma.

PURPOSE: The aim of the study was to analyze the diagnostic and prognostic utility of F-FDG PET/CT to predict the disease-specific survival (DSS) with FDG uptake and tumor grade in recurrent chondrosarcoma. METHODS: Retrospective analysis of FDG PET/CT findings in 31 previously treated patients (46 studies) with mean follow-up period of 40.7 ± 23.9 months (range, 3-77 months) from the date of first PET/CT study was done. Kaplan-Meier DSS analysis was made with respect to tumor grade, FDG uptake at the recurrent primary sites, and a combination of grade and FDG uptake as parameters. RESULTS: Recurrence (local and distant) was shown in 28 (60.8%) of 46 FDG PET/CT studies with sensitivity and specificity of 88.9% and 78.9%, respectively. The median SUVmax at the recurrent primary sites differed significantly (P = 0.008) among 3 tumor grade groups, with higher median SUVmax in higher grades. There was significant difference in median SUVmax among different grade groups except between grade II and grade III. Recurrent primary site SUVmax cutoff at 6.15 derived from the receiver operating characteristic curve yielded significant difference (P < 0.001) in mean DSS time. Significant difference in survival was noted between 3 different tumor grade groups (P = 0.016). The combination of SUVmax and grade improved the survival prediction than with grade alone. CONCLUSIONS: In recurrent chondrosarcoma, the recurrent primary site FDG uptake and grade were found to be reliable prognostic factors with respect to DSS. PET/CT in recurrence setting has the potential to predict tumor grade and survival and may assist in clinical management.

WHOQOL-BREF Hindi questionnaire: Quality of life assessment in acetabular fracture patients.

BACKGROUND: The incidence of acetabular fractures in India has increased over the past years but so has the operating skills of pelvi-acetabular trauma surgeons. The outcomes of surgical management need to be assessed so as to be able to devise proper treatment plan and execute the same during and after surgery, which in turn requires assessment of quality of life indices as well as functional scores. While there are studies assessing Harris Hip scores (HHS) and world health organization quality of life BREF (WHOQOL BREF) in the western population there is no study which assesses the same in Indian population. We designed this study to evaluate and define reference values for use of WHOQOL BREF Hindi scores in QOL Assessment in patients with acetabular fractures and to assess the relationship between it and HHS. MATERIALS AND METHODS: 118 patients with acetabular fractures who were treated surgically were included in this retrospective study. Assessment of reduction quality (Matta's radiological criteria), clinical outcome (HHS) and functional outcome (WHOQOL-BREF score) were done. The affect of age, gender, fracture displacement, hip dislocation, delay in surgery and associated injury on the clinical and functional outcome was evaluated. RESULTS: The mean HHS was 90.65 (42-100) which showed an overall good to excellent outcome in 78.8% cases. WHOQOL-BREF Hindi score of domain-one was 63.06 ± 20.31 (13-94), of domain-two was 58.22 ± 19.57 (13-100), of domain-three was 70.49 ± 17.92 (13-100) and of domain-four was 64.48 ± 18.46 (13-100), which showed significant functional deficit in domain-one (P = 0.0001) and domain-two (P = 0.0001) but not in domain-three (P = 0.458) and domain-four (P = 0.722) when compared to score of general healthy population. The domain scores of general population norms were achieved in 59.3%, 61.9%, 69.5% and 66.1% cases in domain one, two, three and four respectively. CONCLUSIONS: Based on these results one can conclude that WHOQOL-Hindi questionnaire is good enough for assessment of QOL in addition to clinical measures in acetabular fracture patients.

Glenoid fossa fractures: Outcome of operative and nonoperative treatment.

BACKGROUND: Glenoid fossa fractures are rare injuries having a prevalence of 0.1%. These fractures may be managed operatively if substantially displaced. However, several fractures of glenoid fossa are managed nonoperatively, even if displaced, due to high incidence of associated injuries which may render patient unfit to undergo major orthopaedic surgery. There is a relative paucity of articles reporting on outcome of treatment of glenoid fossa fractures. We present our experience of treating these injuries over past decade with operative and nonoperative methods. MATERIALS AND METHODS: 21 patients of glenoid fossa fractures were included in this series with 14 males and 7 females. Patients with displacement of >5 mm who were fit to undergo surgery within 3 weeks of injury were operated using a posterior Judet's approach. Overall 8 patients with displaced fractures were operated (Group A) while 9 patients with displaced fractures (Group B) and 4 patients with undisplaced fractures (Group C) were managed nonoperatively. RESULTS: The mean age and followup period in this series was 29 years and 7.3 years respectively. In group A, average constant score was 87.25. The least constant score was observed for group B (58.55) while group C had an average constant score of 86. Brachial plexus injury and fracture-dislocations had poorer outcome. CONCLUSION: Operative treatment for displaced glenoid fractures is a viable option at centers equipped to handle critically ill patients and subset of patients with fracture-dislocation as opposed to fracture alone should always be treated operatively due to persistent loss of function.

Early, reliable, utilitarian predictive factors for fat embolism syndrome in polytrauma patients.

BACKGROUND: Fat embolism is one of the apocalyptic pulmonary complications following high energy trauma situations. Since delay in diagnosis may have devastating consequences, early, easily accessible and relatively inexpensive investigations for risk stratification may prove useful, especially in developing nations. MATERIALS AND METHODS: This prospective trial included a total of 67 young polytrauma patients, in whom the role of nine easily available, rapidly performable clinical or laboratory investigations (or observations noted at admission) in predicting the later occurrence of fat embolism syndrome were assessed. All the patients also underwent continuous monitoring of oxygen saturation with pulsoximetry. RESULTS: The correlation between initial serum lactate (within 12 hours of injury) and hypoxia was statistically significant. There was a trend towards correlation with FES(by Gurd's criteria) (P=0.07), Sensitivity of 24-hour monitoring of oxygen saturation in predicting later pulmonary deterioration approached 100%. CONCLUSIONS: The combination of three factors including polytrauma (with NISS >17), serum lactate >22 mmol/l at admission (within 12 hours of injury) fall in oxygen saturation (SaO2 below 90% in the initial 24 hours) predict the development of post-traumatic pulmonary complications, especially the fat embolism syndrome.

Predictors of early outcome in unstable pelvic fractures.

OBJECTIVE: To define the preoperative and intraoperative variables which may affect the immediate postoperative outcome in surgically managed patients with unstable pelvic fractures. METHODS: This study was performed prospectively from January 2009 to June 2011 on 36 consecutive patients admitted to the trauma ward of Postgraduate Institute of Medical Education and Research, Chandigarh, with unstable pelvic injuries. RESULTS: In the present study of 36 patients, 29 were managed surgically. Surgical duration was 2 hours in patients operated on within 1 week and 3.4 hours in those operated on after 1 week. The blood loss was 550 ml when surgery was done after a week, but when done within a week it was 350 ml. The average blood loss through Pfanenstial approach was 360 ml, through posterior approach was 408 ml and through combined approach was 660 ml which was significantly high. CONCLUSION: Anterior approach to the pelvis would cause significantly more amount of blood loss than posterior approach and external fixation. Surgical approaches do not have any influence on the surgical duration or the infection rate. The blood loss significantly increases when the surgical time is more than 1 h. The infection rate is not influenced by the duration of surgery. Presence or absence of associated injuries to the head, chest or abdomen is the main determinants of patient's survival and it greatly influences the duration of hospital stay.

Simple reproducible technique in treatment for osteopetrotic fractures.

Osteopetrosis is a rare skeletal condition first described by German radiologist Heinrich Albers-Schonberg. The most important technical difficulty is drilling due to hard bone in patients with osteopetrosis; recommendations have been made to use high-speed electric drill bits. But, the unavailability of this special drill bit in most of the centres makes the job more difficult. The study was conducted from 2009 to 2012; the cases are selected from Outpatients Department of Postgraduate Institute of Medical Education and Research. The patients were in the age group of 10-50 years with a mean age of 26 years. Five cases were included in the study: four patients had subtrochanteric fractures, and one had segmental fracture of the humerus. Open reduction and internal fixation was done in all the fractures using metal-cutting drill bit. The use of metal-cutting drill bit in osteopetrosis not only made our job easy but also prevented thermal necrosis of the bone to a large extent. The union rate was 100 % in our series, and there was no infection in any of our cases. In the treatment for fractures in osteopetrosis, the use of a metal-cutting drill bit along with careful attention to drilling technique can help avoid bit breakage and thermal bone injury that may produce ring sequestrum or destroy the already scant osteogenic cells.

Buttress plating for a rare case of comminuted medial condylar Hoffa fracture associated with patellar fracture.

Hoffa fracture is an uncommon injury. In the literature, lateral condylar Hoffa fracture is mentioned as a more common injury pattern than medial condylar Hoffa fracture. The mechanism of injury and method of treatment is not very well described in the literature. We are presenting a rare case of comminuted medial condylar Hoffa fracture with ipsilateral patellar fracture. The mechanism of injury has not been described in the literature. Lag screw fixation, which is the most acceptable method of treatment, is not possible due to comminution. We explain the possible mechanism of injury and fix the fracture with L-buttress plate.

Clinical utility of intra-operative 6% hydroxyethyl starch (130 / 0.4) supplementation in hypoxemic femur injury patients: a preliminary report of twenty cases.

ABSTRACT: Posttraumatic intravasation of fat and debris can lead to a cascade of events. Hydroxyethyl starches (HES) markedly suppress neutrophil influx by decreasing pulmonary capillary permeability and facilitating tissue oxygenation by improving microcirculation. It was hypothesized that in hypoxemic femur injury patients undergoing operative stabilization, HES administration will prevent the deterioration of respiratory variables and facilitates recovery. This prospective, double-blind, randomized preliminary study, enrolled twenty posttraumatic hypoxemic patients (room air PaO2 < 70 mmHg, Schonfeld fat embolism index score (SS) > 5) scheduled for femur fracture stabilization under general anesthesia. Patients were allocated to receive either; 6% HES 130/0.42, 15 mL/kg or 0.9% normal saline (NS) to maintain their central venous pressure (CVP) 12 + 2 mm Hg. Blood was transfused according to the maximum allowable blood loss and by serial hematocrit estimations. Perioperative Glasgow Coma Scale (GCS), physiological variables, arterial oxygen saturation (SpO2), arterial blood gas (ABG), SS and P/F ratios were recorded until recovery. The partial pressure of oxygen in arterial blood / fraction of inspired oxygen ratio (PaO2/FiO2) improved from a preoperative value of 273.33 ± 13.05 to 435.70 in the 6% Hydroxyethyl starch group (HES) and from 275.24 ± 15.34 to 302.25 ± 70.35 in the NS group over a period of six days (P values =0.970, 0.791, 0.345, 0.226, 0.855, 0.083, 0.221). Time taken to achieve a P/F ratio > 300 and for persistent reduction of Murray's lung injury score (LIS) were comparable (P = 0.755 and 0.348, respectively). The number of ventilator, intensive care unit (ICU) and hospital stay days, did not differ (P value = 0.234, 1.00, 0. 301, respectively). There were no adverse sequelae or mortalities. A trend showing relatively fast improvement in the P/F ratio and an early reduction in LIS values was observed in hypoxemic, femur injury patients receiving intraoperative colloid supplementation.

Role of corticosteroid as a prophylactic measure in fat embolism syndrome: a literature review.

Despite a number of studies on steroid therapy as a prophylactic measure in fat embolism syndrome (FES), there is no universal agreement about its role in this critical situation. The present article attempts to search the available literature, and provides a more lucid picture to the readers on this issue. Seven articles (total 483 patients) were reviewed and analyzed. Total of 223 patients received steroid (methyl prednisolone sodium succinate), while the remaining 260 patients formed the control population. Among these subjects, 9 patients in steroid-receiving group and 60 patients in the control group developed FES (P < 0.05). The lack of uniformities in these studies, variable dose and single-center trial are the principal limitations and confuses the surgeons to have definite conclusion. Large-scale, more uniformly designed, multi-centered, randomized, prospective trials are needed to determine the correct situations and dosage in which steroids provide the maximum benefit (with the least possible risk).

Internal fixation and bone grafting for intraarticular nonunion of tibial plateau: a report of four cases.

Intraarticular nonunion of tibial plateau is rare. In the literature, only 9 patients were found to be treated for intraarticular tibial plateau nonunion and they got varying results. Internal fixation along with bone grafting was done as a standard treatment in all cases. We treated 4 different profile cases of intraarticular tibial plateau nonunion in our institution by 4 different methods. We treated these cases with plaster of paris cast, internal fixation along with bone graft, arthrodesis with K-nail and total knee replacement. Case 1 was treated with plaster of paris (POP) cast as the patient refused surgery. The fracture was united and the patient was fully satisfied with full range of motion despite valgus malalignment. Case 2 was managed with open reduction internal fixation along with bone grafting. The patient had a good union and got full range of motion at the knee joint. Case 3 was treated with total knee arthroplasty due to her old age and got satisfactory result. Case 4 was an infected nonunion. Arthrodesis was done and the patient could walk with full weight bearing independently. We conclude that internal fixation along with bone grafting may not be suitable in all cases of intraarticular nonunion of tibial plateau. Causes of nonunion, present condition and range of motion of the knee joint, as well as the age of patient should be all considered and the treatment should be individualised according to each patient's situation.

Osteochondral allograft transplantation after excision of femoral head giant cell tumour: a case report.

We report a case of Giant Cell Tumour of the femoral head in a 22-year-old man that was excised and reconstructed with an osteochondral allograft. After 3.5 years follow-up, the graft had completely united and there were no signs of recurrence or resorption; the patient had an excellent functional outcome. Osteochondral allograft transplantation may provide a viable option for joint salvage after excision of a benign or locally aggressive tumour in the femoral head in selected cases.

Use of gentamicin-loaded collagen sponge in internal fixation of open fractures.

OBJECTIVE: To assess the outcome of immediate plate osteosynthesis via application of antibiotic impregnated collagen fleeces (gentamicin-collagen and antibiotic sponge) which gradually release antibiotic locally in the surgical treatment of open fractures presented to us 6 hours after injury. METHODS: All cases were treated in our tertiary level trauma center and teaching hospital including 35 patients with open fractures who were treated by immediate open reduction and plate fixation from January 2008 to August 2010. Among them, 31 patients were available for adequate follow-up and assessment. All fractures were treated by irrigation and debridement, immediate open reduction and plate fixation along with placement of antibiotic-releasing collagen fleeces around the plate just before closure of wound. Patients were assessed to determine postoperative infection, delayed union or nonunion and development of other postoperative complications. It was hypothesized that immediate plate osteosynthesis after thorough debridement and local antibiotics would give safe and acceptable clinical results in treatment of open fractures. RESULTS: The 31 patients with adequate final follow-up were assessed at a mean time of 40 weeks (15-160 weeks). Most fractures united primarily in an acceptable time period according to area of involvement. Local wound complications (superficial infection and skin loss) were found in 3 patients (9.67%). Deep infection was noted in 2 patients (6.45%). None of these patients needed implant removal and both fractures united in due time. Delayed union was noted in 5 patients (16.13%). No patient progressed to nonunion or implant failure in long term follow-up. Excessive scarring was developed in 2 patients (6.45%). CONCLUSIONS: Immediate plate osteosynthesis after adequate debridement and placement of collagen film eluting antibiotics locally produces excellent results regarding bone union and absence of deep infections and is a safe technique in the management of open bone injuries. These sponges can be used easily with any form of internal fixation and there is no need of second surgery for the removal of these antibiotic carriers since they are bioabsorbable. Local antibiotic-impregnated collagen sponges along with systemic antibiotics for 3 to 5 days offer promising results in open fracture management.