A comparative study of operative and conservative treatment of intraarticular displaced calcaneal fractures.

The treatment of intra-articular displaced calcaneal fracture is debatable. We conducted a prospective study to compare operative and non-operative treatment for intra-articular displaced calcaneal fractures. Patients were assigned to two groups based on the treatment given (operative and nonoperative) and were regularly followed for a period of 1 year. The outcome measures were assessed by Modified Rowe's Score (MRS), Visual Analogue e Scale (VAS) and The American Orthopaedic Foot and Ankle Society (AOFAS) scale. The outcome related to patient's job was noted after one year and compared with pre-injury status. Fifty five patients with 61 calcaneal fractures were studied. Thirty of them were operated and 31 were treated conservatively. Out of 30 operated cases, Bohler's angle was restored in 25 cases and these had good results with all three outcome scores at 1 year follow up and remaining 5 cases showed fair results (Mean MRS: 74.783, VAS: 3.348, AOFAS: 78.783). Thirty one cases treated with cast also showed fair results (Mean MRS: 57.368, VAS: 4.944, AOFAS: 71.211). The overall outcome of operated cases were better than non-operated cases (unpaired T test MRS: 5.807 p < 0.001, VAS: 4.387 p < 0.001, AOFAS: 2.728 p = 0.008) . Operative treatment of displaced intra-articular calcaneal fractures gave good results at one year follow up, provided Bohler's angle was restored to normal range. Non operative treatment gave fair results. Complications were seen both with operative and non-operative treatment.

The Results of Unstable Intertrochanteric Femur Fracture Treated with Proximal Femoral Nail Antirotation-2 with respect to Different Greater Trochanteric Entry Points.

BACKGROUND: Proximal femoral nail antirotation-2 (PFNA-2) has been widely used to treat intertrochanteric fractures with varied outcomes in the previous studies. The entry point of the nail plays an important role in achieving acceptable reduction, stable fixation, and avoiding implant related complications. This study was proposed to determine the optimal greater trochanteric entry point for PFNA-2 in unstable intertrochanteric femur fractures. METHODS: We conducted an observational study on 40 patients with unstable intertrochanteric fracture treated with PFNA-2 implant in a tertiary care hospital. The patients were grouped into two based on the entry point: group L for lateral and group M for medial entry. Randomization was carried out by assigning the patients to the group by alternate allocation. The quality of reduction, tip apex distance, Cleveland index, and all the complications were noted. The final follow-up was conducted at six months. The functional outcome was evaluated using modified Harris hip score. The data analysis was performed using Student's t-test, chi square test, and Mann-Whitney test. A P value below 0.05 was considered significant. RESULTS: Forty patients with 20 patients treated with medial entry point were included in group M and 20 patients in group L with lateral entry point. The group L had an average tip apex distance of 20.53 and group M had 20.02 (P=0.8). The complication of screw back out was seen in 3 out of 4 patients with poor reduction in group L. As per the Cleveland index, 6 patients in each group had suboptimal position and 4 out of 6 patients in group L with suboptimal position had screw back out. The lateral cortex impingement was seen in 14 patients of group L and 6 patients in group M with significant comparison (P=0.01). Three patients in group L had varus collapse with screw back out. Also, none in group M (0.05). The average modified Harris hip score in group L at six months follow-up was 71.94 and 76.8 in group M (P=0.84). CONCLUSION: Overall, to achieve good quality of fixation and reducing damage to gluteus medius entry point for PFNA-2 should be 5 mm medial to the greater trochanter tip.

Comparative study of the efficacy of gentamicin-coated intramedullary interlocking nail versus regular intramedullary interlocking nail in Gustilo type I and II open tibia fractures.

PURPOSE: Open tibia fracture is prone to infection, consequently causing significant morbidity and increasing the hospital stay, occupational loss and onset of chronic osteomyelitis. Intramedullary nailing is one choice for treating tibia shaft fractures. To improve the delivery of antibiotics at the tissue-implant interface, many methods have been proposed as a part of prophylaxis against infection. This study was conducted to study the role of gentamicin-impregnated intramedullary interlocking (IMIL) nail in the prevention of infection in Gustilo type I and II open tibia fractures and to compare the results with regular intramedullary nail. METHODS: The study included 28 patients with open tibia fractures (Gustilo type 1 or type 2); of them 14 underwent regular IMIL nailing and the other 14 were treated with gentamicin-coated nailing. Randomization was done by alternate allocation of the patients. Follow-up was done postoperatively (day 1), 1 week, 6 weeks, and 6 months for bone union, erythrocyte sedimentation rate (ESR), hemoglobin and C-reactive protein (CRP). Statistical significance was tested using unpaired t-test. A p value less than 0.05 was considered significant. RESULTS: There were 4 cases of infection in controls (regular IMIL nail) and no infection among patients treated with gentamicin-coated nail during the follow up (X2 = 4.66, p = 0.031). At 6 months postoperatively, CRP (p = 0.031), ESR (p = 0.046) and hemoglobin level (p = 0.016) showed significant difference between two groups. The bone healing rate was better with gentamicin-coated nail in comparison to regular IMIL nail at 6 months follow-up (p = 0.016). CONCLUSION: Gentamicin-coated IMIL nail has a positive role in preventing infection in Gustilo type I and II open tibia fractures.

Comparison of radiological and functional outcome of unstable intertrochanteric femur fractures treated using PFN and PFNA-2 in patients with osteoporosis.

INTRODUCTION: Presently, unstable intertrochanteric femur fractures are treated commonly with intramedullary nailing devices. Various designs of intramedullary nail are introduced. The conventional Proximal Femoral Nail has given diverse outcome. Complications have also been noted with this implant. Newer designs like Proximal Femoral Nail Antirotation-2 have been introduced for Asian population. The aim of our study was to compare the radiological and functional outcome of unstable intertrochanteric femur fracture treated with conventional Proximal Femoral Nail and Proximal Femoral Nail Antirotation-2 in osteoporotic patients. MATERIALS AND METHODS: Patients presenting with unstable intertrochanteric femur fracture (AO classification) and Singh's index ≤ 3 were included. Patients were assigned to the groups based on the implant used for treatment (PFN and PFNA2 group). Post-operative radiographs were used to assess the quality of reduction, by calculating neck shaft angle. The quality of fixation was assessed, by calculating tip apex distance and Cleveland index. The duration of surgery, blood loss, number of fluoroscopic images taken and length of hospital stay were noted. Patients were followed up for 6 months, and complications were noted. The functional outcome was compared using modified Harris hip score. The data analysis was done using Student's unpaired t test/Mann-Whitney U test and Chi-square test/Fisher's exact test. A p value less than 0.05 was considered significant. RESULTS: Seventy-eight patients with unstable intertrochanteric fractures and Singh's index < 3 were included. Thirty-seven were treated with PFNA2 and 41 with PFN. The average age in PFNA2 group was 69.51, and PFN group was 70.804. Nine patients in PFNA2 group and 10 patients in PFN group had tip apex distance more than 25 mm. Twelve patients in PFNA2 group and 14 Patients in PFN group had sub-optimal implant position as per Cleveland index. The difference in neck shaft angle between uninjured and operated side was more than 10° in four patients of PFNA2 group and seven patients of PFN group. The average Harris hip score was 74.55 for PFNA2 group and 69.88 for PFN group. Four complications were seen in PFNA2 group and 5 in PFN group. CONCLUSION: The functional outcome (p = 0.102) achieved with both the implants was similar. Good functional outcome can be achieved, when the radiological parameters are restored, i.e. TAD < 25 mm, Cleveland index in centre-centre position and neck shaft angle difference < 5°. The overall complications, in the set-up of osteoporosis, seen with both the implants were similar (p = 0.44). PFNA2 group showed better results in terms of perioperative morbidity.