Non-vascularised fibular graft as an intramedullary strut for infected non-union of the humerus.

PURPOSE. To review outcomes of 7 patients who underwent revision surgery for infected non-union of the humerus using a fibular graft as an intramedullary strut. METHODS. Records of 7 men aged 29 to 59 (mean, 40) years with humeral diaphyseal infected non-union who underwent fixation using a compression plate and a non-vascularised fibular graft as an intramedullary strut were reviewed. The mean number of previous surgeries was 2.7 (range, 2-4). Three of the patients had active draining sinuses previously. Their C-reactive protein levels were normal and tissue cultures negative. The remaining 4 patients had active draining sinuses. They first underwent implant removal and debridement. Tissue cultures confirmed infection in 3 of them. The mean duration between debridement and the index surgery was 5 (range, 3-10) months. RESULTS. The mean length of the fibulae harvested was 13 (range, 12-15) cm. All 7 non-unions healed. The mean time to healing was 5.4 (range, 4-8) months. The mean follow-up period was 15 (range, 13-24) months. All patients had weakness of the extensor hallucis longus, which improved to near normal at month 3. There was no donor-site morbidity. Three patients with active infection at presentation underwent repeat surgery. Two of them had wound washouts, and their non-unions went on to heal successfully; one underwent implant removal after union due to an active sinus. Six of the patients returned to their pre-injury activity level, and one endured a brachial plexus injury. CONCLUSION. Fixation using a compression plate and a non-vascularised fibular graft as an intramedullary strut achieved good outcome for infected non-union of the humerus despite prior multiple failed surgeries.

Preoperative embolisation in benign bone tumour excision.

PURPOSE: To assess the role of preoperative embolisation in benign bone tumour excision. METHODS: 3 men and 3 women aged 19 to 35 (mean 23) years with either a giant cell tumour or an aneurysmal bone cyst in limb girdle sites underwent preoperative embolisation a day prior to wide local excision by the same surgeon. Tumour size, blood loss, wound healing, infection, and tumour recurrence were assessed. RESULTS: The mean total blood loss was 391 (range, 100-980) ml. No blood transfusion was needed. No patient had any surgery- or embolisation-associated complication. No tumour recurred within a minimum 5-year follow-up. All patients had satisfactory limb function. CONCLUSION: Preoperative embolisation is useful in the management of vascular and aggressive bone tumours located at limb girdle sites where a tourniquet cannot be used.

Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation.

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab's criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.

Fracture neck of femur in haemophilia A - experience from a cohort of 11 patients from a tertiary centre in India.

We describe here the management of eleven patients with fracture neck of femur. Excepting one patient all had severe haemophilia A. Nine patients were less than 50 years of age. Eight out of eleven patients had fracture after trivial trauma. Nine patients had closed reduction and one patient open reduction. The patient with non union had a Valgus osteotomy. All fractures united. The average time to union was 11 weeks (range:8-16). We followed either a low dose intermittent or a low dose continuous infusion factor support protocol for the management of these patients. The median dose of factor support was 252 u/kg (range: 136-580). The average duration of factor support was 9 days (range: 7-10). Two patients had aggravation of pre existing knee stiffness following post operative immobilisation. No other major complication was observed in this cohort of patients. To conclude, management of fracture neck of femur in patients with haemophilia is no different from general population if an adequate haemostasis is achieved.

Total innominatectomy for chondrosarcoma innominate.

Internal hemipelvectomy or innominatectomy is a preferred alternative to hindquarter amputation for malignant tumours of the pelvis. Various segments of the pelvis have been removed surgically leaving the lower limb with residual segments of the pelvis in treatment of such tumours. We herewith present a case of total innominatectomy, i.e. dis-articulation at the pubic symphysis and sacroiliac joint for surgical clearance and treatment of a chondrosarcoma of the Innominate bone. The tumour extended from just in front of the sacroiliac joint to the ischium and warranted such a complete resection.