Non-surgical correction of knee flexion deformity in persons with haemophilia: A staged multidisciplinary approach.

INTRODUCTION: Flexion deformity of the knee is a common complication following recurrent haemarthrosis in persons with haemophilia (PWH) on episodic factor replacement therapy, restricting independent mobility. There is limited literature on the comprehensive management of this condition. This report provides the outcome of a staged multidisciplinary approach for the correction of knee flexion deformity (KFD) even in limited resource settings. PATIENTS AND METHODS: The data of 49 consecutive PWH who were treated for KFD were analysed. The approach included graded physical therapy (PT), followed by serial casting and/or mobilisation under anaesthesia (MUA). MUA was done in carefully selected knees. Surgical correction was opted when non-surgical methods failed. RESULTS: Of the 49 patients (55 knees), with a median KFD of 40 degrees (range: 10-90), 26/55 (47%) were corrected by graded PT. With serial casting, 9/19 (47%) knees had their KFD corrected. MUA was done for 11 knees of which five achieved correction (45%). Surgical correction was required for only seven knees (12.7%). Following this approach, KFD improved from 40 degrees (range: 10-90) to 15 degrees (range: 0-40), with only minor loss of flexion from 105 (range: 60-155) to 90 degrees (range: 30-150). Out of 55 KFD, 46 (83.6%) KFD were corrected; non-surgical, 39 (70.9%) and surgery, seven (12.7%). The remaining patients (nine KFD; 16.4%) were able to achieve their functional goal despite not meeting the correction criteria. CONCLUSION: This study shows that in PWH, functionally significant KFD correction can be achieved in about 71%, through non-surgical methods, even without prophylactic factor replacement.

Incidence and predictors of radial nerve palsy with the anterolateral brachialis splitting approach to the humeral shaft.

PURPOSE: Fractures of the humeral shaft are common and account for 3%-5% of all orthopedic injuries. This study aims to estimate the incidence of radial nerve palsy and its outcome when the anterior approach is employed and to analyze the predictive factors. METHODS: The study was performed in the department of orthopaedics unit of a tertiary care trauma referral center. Patients who underwent surgery for acute fractures and nonunions of humerus shaft through an anterior approach from January 2007 to December 2012 were included. We retrospectively analyzed medical records, including radiographs and discharge summaries, demographic data, surgical procedures prior to our index surgery, AO fracture type and level of fracture or nonunion, experience of the operating surgeon, time of the day when surgery was performed, and radial nerve palsy with its recovery condition. The level of humerus shaft fracture or nonunion was divided into upper third, middle third and lower third. Irrespective of prior surgeries done elsewhere, the first surgery done in our institute through an anterior approach was considered as the index surgery and subsequent surgical exposures were considered as secondary procedures. RESULTS: Of 85 patients included, 19 had preoperative radial nerve palsy. Eleven (16%) patients developed radial nerve palsy after our index procedure. Surgeons who have two or less than two years of surgical experience were 9.2 times more likely to induce radial nerve palsy (p=0.002). Patients who had surgery between 8 p.m. and 8 a.m. were about 8 times more likely to have palsy (p=0.004). The rest risk factor is AO type A fractures, whose incidence of radial nerve palsy was 1.3 times as compared with type B fractures (p =0.338). For all the 11 patients, one was lost to follow-up and the others recovered within 6 months. CONCLUSION: Contrary to our expectations, secondary procedures and prior multiple surgeries with failed implants and poor soft tissue were not predictive factors of postoperative deficit. From our study, we also conclude that radial nerve recovery can be reasonably expected in all patients with a postoperative palsy following the anterolateral approach.

Case of pseudoaneurysm mimicking a soft tissue sarcoma: a diagnostic pitfall.

Pseudoaneurysms represent a pulsating encapsulated hematoma in communication with the lumen of a ruptured vessel. We present a 33-year-old male with a pseudoaneurysm of the profunda femoris artery. At presentation and on further evaluation, he was diagnosed with a possible soft tissue sarcoma of the distal thigh. Catastrophic haemorrhage occurred at the time of a planned, elective open biopsy. This case report emphasises the importance of considering pseudoaneurysm as a crucial differential diagnosis in atypical swellings and scrutinising all suspected soft tissue tumours with a contrast study or a Doppler ultrasound.

The radial nerve at revision/redo surgery - using the lower lateral cutaneous nerve to prevent a postoperative radial nerve deficit.

Background: The posterior approach to the humeral shaft is commonly used for surgical procedures on the humeral shaft. We present our experiences using the modification of the surgical exposure described by Gerwin M. which we have found useful at the time of revision surgery. Methods: Between 2014 and 2019, six patients who underwent a revision surgical procedure for a nonunion of the humeral shaft where a prior surgical procedure was performed through a posterior incision were included. The approach used a modification of the posterior approach described by Gerwin M. where the lower lateral cutaneous nerve branch of the radial nerve is used to identify trace, mobilize, retract, and protect the radial nerve to achieve adequate exposure of the humeral shaft. Results and Discussion: None of the patients had a postoperative nerve deficit.Adequate exposure to aid hardware removal, osteosynthesis, and bone grafting was achieved in all patients. Conclusion: The modification of the posterior approach described by Gerwin M. is useful at the time of revision or redo surgery on the humeral shaft where other bony and soft tissue landmarks are altered to prevent an iatrogenic injury to the radial nerve while providing adequate exposure to treat a nonunion.

Multiple High-Energy Open Injuries in the Same Limb: Comparison of Outcomes Between Salvage and Amputation Groups.

AIM: To analyze the functional outcomes between limb salvage and amputation patients who had multiple open injuries in the same lower limb. MATERIALS AND METHODS: This observational study analyzed 21 patients who were admitted with multiple open injuries in the same lower limb between January 2012 and December 2015 in our unit. Twelve patients underwent limb salvage and nine patients underwent amputation. The total number of surgeries, duration of hospital stays, ICU admission, complications, time to return to work and costs of inpatient treatment were analyzed. The functional outcome was assessed by using the lower extremity functional scale (LEFS) in both groups, SF-12 score was done for both groups and amputation specific scoring was done by using locomotors capabilities index (LCI). RESULTS: The LEFS was lower in salvage group than amputation group. The SF-12 score was close to normal population in the amputation group and was higher than salvage group. The duration of hospital stays, total number of surgeries and the costs of inpatient admission were higher in salvage group. The time to return to work was earlier in amputation group. Sixty-seven percentage of patients in the salvage group developed complications. CONCLUSION: The functional outcome and SF-12 score was better in amputation group. Patients who had amputation returned to work earlier, had smaller number of secondary hospitalization and has less complications and incurred less expenditure for treatment. The treatment decision should be periodically reviewed when an initial choice of salvage is made. Amputation must be looked at as a treatment for early rehabilitation.

Functional outcome of knee arthrodesis with a monorail external fixator.

Several methods for obtaining knee arthrodesis have been described in the literature and world; over, the commonest cause for arthrodesis is a failed arthroplasty. Less commonly, as in this series, post-infective or traumatic causes may also require a knee fusion wherein arthroplasty may not be indicated. We present salient advantages along with the radiological and functional outcome of twenty four patients treated with a single monorail external fixator. All patients went on develop fusion at an average of 5.4 months with an average limb length discrepancy of 3 cm (1.5-6 cm). Improvements in functional outcome as assessed by the lower extremity functional score (LEFS), and the SF-36 was significant (p = 0.000). Knee arthrodesis with a single monorail external fixator is a reasonable single-staged salvage option in patients wherein arthroplasty may not be the ideal choice. The outcome, though far from ideal, is definitely positive and predictable.

A paradoxical triad: scapulothoracic dissociation with clavicle and humeral shaft fractures.

Scapulothoracic dissociation involves varying degree of discontinuity of the upper extremity from its truncal attachment. An eighteen-year-old male presented to the accident and emergency department following a motor vehicle accident where he was hit by a four wheeler while riding a two wheeler. He had tenderness and deformity over the left clavicle and the left humerus. He was unable to perform active wrist and finger dorsiflexion. A CT subsequently revealed a grade 2 splenic laceration. The splenic laceration was treated conservatively. As his general condition improved, he was gradually weaned off the ventilator and his left upper limb neurology was reassessed. He had isolated radial nerve palsy with an otherwise intact brachial plexus. He underwent internal fixation of the clavicle and the humerus. At 4 months after injury the EMG/NCV report showed signs of renervation of the radial nerve, and the fracture progressed to an uneventful union. This prior unreported triad of scapulothoracic dissociation with ipsilateral clavicular and humeral fractures may represent a parody. An apparent increase in the severity of skeletal injury was associated with a paradoxical decrease in the severity of neurovascular injury. We report this case to create awareness among orthopedic surgeons and emergency physicians about the clinical presentation of such injuries.