A Novel Method of Treatment of Small Osteolabral Avulsions Associated with Posterior Fracture dislocation of the Hip.

Small osteolabral avulsions of the hip can be easily missed, and postreduction stress testing and a computed tomography (CT) scan of the hip should be done to look for these injuries. The usual modality of treatment of these unstable osteolabral avulsions is suture anchors, Herbert screws or spring plates. But when the bony avulsion is small, the use of these implants becomes a tedious job. We present a novel technique of fixing small osteochondral avulsion fractures not amenable to fixation using screws or spring plates. We performed a retrospective analysis of 57 cases of patients who underwent open reduction and internal fixation for posterior fracture dislocation of the acetabulum, and we identified 6 cases of small posterior labral osteochondral fragments leading to instability. These injuries were fixed using a novelmethod. Themean Harris Hip Score at the final follow-up was of 92.5. Fixation of osteochondral avulsions associated with posterior hip fracture dislocation can be a difficult task if the bony fragment is small. Our technique is a simple, cost-effective and reliable way of fixing such avulsions with satisfactory outcomes.

A Randomized Controlled Trial Comparing the Analgesic Efficacy of Programmed Intermittent Bolus vs. Continuous Infusion of Ropivacaine and Fentanyl in Ultrasound-Guided Infraclavicular Brachial Plexus Block for Upper Limb Surgery.

BACKGROUND: Programmed intermittent bolus (PIB) is a novel method of intermittent drug delivery commonly employed in labor epidural analgesia. This study aimed to evaluate the potential benefits of PIB over continuous infusion (CI) for postoperative analgesia following upper limb surgeries distal to the mid-humerus level using ultrasound-guided infraclavicular brachial plexus block (USG-IBPB). METHODS: The USG-IBPB was performed on a total of 30 patients scheduled for upper limb surgery distal to the mid-humerus level. The patient-controlled regional analgesia pump delivered a combination of 6 mL of 0.2% ropivacaine and 2 µg/mL fentanyl via a perineural catheter as PIB in group I and as a CI in group II. The primary outcome measure was overall drug consumption, and secondary outcomes included pain scores, patient satisfaction, sensory and motor blockade, and adverse effects. RESULTS: The PIB group exhibited significantly lower overall drug consumption (306.20 ± 13.07 mL vs. 323.73 ± 11.79 mL; P = 0.001), a reduced need for patient-controlled analgesia boluses (3.87 ± 2.67 vs. 7.13 ± 2.36; P = 0.001), and higher patient satisfaction (91.93 ± 10.09 vs. 78.67 ± 17.57; P = 0.017) compared to the CI group. Pain scores at rest were significantly lower at the 24-hour mark (P = 0.007), and on movement, lower scores were observed after 1, 24, and 36 hours (P = 0.031, P = 0.031, and P = 0.011, respectively). Sensory block, motor block, and adverse effects were similar between the two groups. CONCLUSION: PIB demonstrated superior efficacy in postoperative analgesia compared to the CI technique for upper limb surgeries distal to the mid-humerus level. Therefore, PIB may be considered an effective alternative to CI for optimal postoperative pain management.

Long-Term Outcome of Valgus Osteotomy and Fixation with Double Angled Dynamic Hip Screw for Nonunion Fracture of the Neck of the Femur in Young Adults.

Objective To evaluate the long-term results of valgus intertrochanteric osteotomy fixed with double angled dynamic hip screw for nonunion fracture of the neck of the femur in young adults. This implant allows more freedom of fixation in the sagittal plane. Very few studies have evaluated the long-term outcome for treatment of nonunion in fractures of the neck of the femur. Methods This is a prospective interventional study that included 20 patients with nonunion of the fracture of the neck of the femur aged < 60 years old without avascular necrosis of the head and significant resorption of the neck of the femur. A lateral closing wedge osteotomy was performed just above the lesser trochanter after inserting the Richard screw across the nonunion site, and it was fixed with a double-angle 120° barrel plate. The outcome was evaluated using union rate and the Harris Hip Score for functional outcome. Results The average postoperative decrease in the Pauwels angle was of 28.9°. A total of 80% of the cases progressed to union within a mean duration of 7.53 months. The mean Harris Hip Score at the final follow-up was 86.45. Conclusion Valgus intertrochanteric osteotomy and fixation with a double angled dynamic hip screw is a reliable and effective method for preservation of head and promoting union in an ununited fractured neck of the femur in young patients.

Long-Term Outcome of Valgus Osteotomy and Fixation with Double Angled Dynamic Hip Screw for Nonunion Fracture of the Neck of the Femur in Young Adults / Desfecho a longo prazo da osteotomia valgizante e fixação com parafuso dinâmico de quadril de ângulo duplo de fratura não consolidada do colo femoral em adultos jovens

Abstract Objective To evaluate the long-term results of valgus intertrochanteric osteotomy fixed with double angled dynamic hip screw for nonunion fracture of the neck of the femur in young adults. This implant allows more freedom of fixation in the sagittal plane. Very few studies have evaluated the long-term outcome for treatment of nonunion in fractures of the neck of the femur. Methods This is a prospective interventional study that included 20 patients with nonunion of the fracture of the neck of the femur aged < 60 years old without avascular necrosis of the head and significant resorption of the neck of the femur. A lateral closing wedge osteotomy was performed just above the lesser trochanter after inserting the Richard screw across the nonunion site, and it was fixed with a double-angle 120° barrel plate. The outcome was evaluated using union rate and the Harris Hip Score for functional outcome. Results The average postoperative decrease in the Pauwels angle was of 28.9°. A total of 80% of the cases progressed to union within a mean duration of 7.53 months. The mean Harris Hip Score at the final follow-up was 86.45. Conclusion Valgus intertrochanteric osteotomy and fixation with a double angled dynamic hip screw is a reliable and effective method for preservation of head and promoting union in an ununited fractured neck of the femur in young patients.

Resumo Objetivo Avaliar os resultados a longo prazo da osteotomia intertrocantérica valgizante, fixada com parafuso dinâmico de quadril (DHS, na sigla em inglês) de ângulo duplo, em fraturas não consolidadas do colo femoral em adultos jovens. Este implante permite uma liberdade maior de fixação no plano sagital. Muito poucos estudos avaliaram o desfecho do tratamento a longo prazo da fratura não consolidada do colo femoral. Métodos Trata-se de um estudo prospectivo de intervenção que incluiu 20 pacientes com fratura não consolidada do colo femoral com idade < 60 anos, sem necrose avascular da cabeça femoral e significativa reabsorção do colo femoral. Foi realizada uma osteotomia em cunha de fechamento lateral logo acima do trocânter menor após a inserção do parafuso tipo Richard no sítio do retardo da consolidação óssea, sendo fixada com uma placa cilíndrica de ângulo duplo de 120°. O resultado foi avaliado com o uso da taxa de consolidação e da escala Harris Hip Score quanto ao desfecho funcional. Resultados Foi obtida uma redução pós-operatória média de 28,9° do ângulo de Pauwels. Os casos que evoluíram para a consolidação alcançaram 80%, em um período médio de 7,53 meses. A média da escala Harris Hip Score foi de 86,45 no acompanhamento final. Conclusão A osteotomia intertrocantérica valgizante e a fixação com DHS de ângulo duplo é um método confiável e eficaz para a preservação da cabeça do fêmur, promovendo a consolidação de uma fratura não consolidada do colo femoral em pacientes jovens.

Epidemiologic characteristics and pre-hospital care of traumatic injuries during the COVID-19 pandemic in an emerging and developing country: A single tertiary centre experience.

BACKGROUND: Pre-hospital care has been shown to reduce the mortality in trauma patients. The present study is an attempt to identify the status of pre-hospital orthopaedic trauma care in developing countries during COVID-19 pandemic. METHODS: This was a prospective observational study carried out in a tertiary care setup from March 25th, 2020 to January 31st, 2021. All the data pertaining to the traumatic injuries including demographic details and epidemiologic characteristics were recorded in an electronic database. RESULTS: A total of 1044 patients were included in the study for evaluation. The mean age was 35.24 ± 19.84 years. There were 873 males and 171 females. A total of 748 presented from nearby states, with 401 being the referrals and 347 cases coming directly to hospital. A total of 141 open fractures presented directly and 269 were referred from nearby states. Out of 269 cases of open fractures, only 67 and 139 were given intravenous antibiotics and had wound dressing done respectively at the periphery site. A total of 125, 112, 92 and 84 patients were received without traction/splintage, intravenous fluids, dose of analgesics and recording of vitals respectively. Delay from injury to presentation in emergency/administration of antibiotic (Hours) was 7.06. Road side accidents were main cause comprising of 52.58% cases. Gustilo Anderson classification grade-2 comprised of majority of the open fractures (51.63%). Lower limb fractures comprised of majority of the injuries (70.59%). Majority were adults and conservative management was the most common mode of treatment. A total of 197 and 265 patients had associated head injuries and blunt trauma chest/blunt trauma abdomen respectively. CONCLUSION: Emphasizing on pre-hospital care measures, with special focus on co-ordination between primary, secondary and tertiary health care facilities is the need of the hour and can prevent additional morbidities, avoiding overburden of the already compromised healthcare centres.

An Unusual Occurrence of Scaphoid Fracture Fragment in the Volar Compartment of the Forearm: A Case Report with Review of Literature.

Introduction: Scaphoid fractures are common wrist injuries and are commonly missed. Patients present with radial-sided wrist pain. Computed Tomography and Magnetic Resonance Imaging help in better planning, with analysis of comminution, torn ligaments, timely diagnosis, and intricate fixation prevent avascular necrosis, non-union, and carpal collapse. Case Presentation: We present a rare scenario of right hand dominant 42 years male with scaphoid waist fracture, where the fracture fragment was unusually displaced 4 cm proximal to the wrist in the volar compartment of the forearm. Urgent open reduction and internal fixation with a Herbert screw was done. At 1 year follow-up, fracture united, with satisfactory range of motion and functional outcomes of the wrist. Conclusion: Timely diagnosis and urgent operative intervention for unstable displaced scaphoid fractures with rigid fixation provides long-term satisfactory outcomes and prevents complications.

Iatrogenic median nerve injury as a result of venous cut down procedure: A rare case report.

INTRODUCTION: Venous cut down is an emergency procedure done to get vascular access in trauma patients where peripheral cannulation/central venous catheter is challenging or causes delays. PRESENTATION OF CASE: We present a rare case of iatrogenic injury of right median nerve which occurred during basilic vein cut down. The injury came to notice when the patient presented with complaints of paraesthesia and weakness in his right hand for the past 6 weeks. On examination, tests for median nerve function were indicative of median nerve injury. Median nerve palsy was subsequently confirmed on electrodiagnostic studies. Upon exploration, it was noted that the median nerve was tightly tied circumferentially with a suture forming a constriction band which was released and neurolysis done. At 4 months follow up, patient showed complete recovery in terms of motor and sensory function of median nerve. DISCUSSION: The anatomical variations in the pattern of cubital veins have been reported in literature. These anatomical variations and close proximity of nerves should be kept in mind and anticipated for while performing venesection. Moreover, these procedures are done by junior doctors in emergency settings, under stressful circumstances and suboptimal conditions, especially in developing countries, which increase the risk of an iatrogenic injury. CONCLUSION: With good anatomical knowledge and high caution during the procedure, such complication could have been avoided.

An Initial Study into the Role of Teriparatide in Absent or Delayed Regenerate Formation during Distraction Osteogenesis: A Case Series.

Purpose: Distraction osteogenesis has been used for post-traumatic segmental bone defects. Absent or delayed callus formation in the distraction gap can lead to significant morbidity and affect the clinical outcome. Experimental evidence in animal models has demonstrated that teriparatide enhances the consolidation of regenerate and also strengthens it. This study aimed to report our experience with recombinant teriparatide therapy for patients with regenerate insufficiency. Materials and methods: Nine out of 43 patients undergoing limb lengthening using the limb reconstruction system (LRS) fixator were diagnosed with regenerate insufficiency. With informed consent, these patients received a therapeutic regime of 20 µg of teriparatide administered subcutaneously once daily for a period of 3 months. Results: The mean age in the sample was 40.22 years (SD 17.87). Regenerate insufficiency was diagnosed at a mean of 4.94 months (range 2.5-9 months) from surgery. Teriparatide injections were started at a mean of 6.94 months (range 4.5-11 months) from surgery. The sites of regenerate insufficiency were tibia (n = 5) and femur (n = 4). Favourable radiographic progress in visibility of callus was seen at a mean duration of 9.4 weeks (range 8-12 weeks) from the initiation of teriparatide therapy. No systemic complications were encountered. Conclusion: The initiation of teriparatide treatment as described in this study may be successful in triggering the osteogenic potential within poor regenerate and help in consolidation and avoid more invasive surgical procedures. How to cite this article: Patil B, Kansay R, Gupta S, et al. An Initial Study into the Role of Teriparatide in Absent or Delayed Regenerate Formation during Distraction Osteogenesis: A Case Series. Strategies Trauma Limb Reconstr 2020;15(2):117-120.

Novel Method for Removal of Broken Intramedullary Interlocking Nail with a Subtrochanteric Fracture: A Case Report.

CASE: A 45-year-old man with ankylosing spondylitis with bilateral ankylosed hips presented with subtrochanteric femur fracture with a broken intramedullary nail in situ. The nail was removed by making a hole in the nail using a carbide bit and putting a Steinmann pin in this hole to extract the nail. CONCLUSIONS: This novel broken intramedullary nail extraction technique is especially useful for nonunions or implant failures that occur in the proximal shaft/subtrochanteric area, and the instruments used are also readily available. There is minimal radiation exposure, and it is an effective method to remove the distal part of the broken nail.

Isolated Anterior Dislocation of the Radial Head with Atypical Presentation in an Adult: A Case Report.

Isolated anterior dislocation of the radial head is rarely reported. To date, only five cases have been reported in the world literature. In all of these cases, the patients presented with restricted supination-pronation movements of the forearm with maintained elbow flexion-extension. We report an unusual case of isolated anterior radial head dislocation in an 18-year-old male, who presented with maintained supination-pronation movements of the forearm but restricted elbow flexion-extension. Closed reduction was attempted, but it failed. Hence, an open reduction was performed. However, the reduction was unstable due to rupture of the annular ligament. Hence, the repair of the annular ligament was performed, and a radio-ulnar Kirschner wire was passed to maintain the reduction of the proximal radio-ulnar joint, thus keeping the annular ligament stress-free, facilitating its healing. At 12 months of follow-up, the patient had normal elbow function and complete range of motion.

Isolated Anterior Dislocation of the Radial Head with Atypical Presentation in an Adult: A Case Report / Luxação anterior isolada da cabeça radial com apresentação atípica em um adulto: Relato de caso

Abstract Isolated anterior dislocation of the radial head is rarely reported. To date, only five cases have been reported in the world literature. In all of these cases, the patients presented with restricted supination-pronation movements of the forearm with maintained elbow flexion-extension. We report an unusual case of isolated anterior radial head dislocation in an 18-year-old male, who presented with maintained supination-pronation movements of the forearm but restricted elbow flexion-extension. Closed reduction was attempted, but it failed. Hence, an open reduction was performed. However, the reduction was unstable due to rupture of the annular ligament. Hence, the repair of the annular ligament was performed, and a radio-ulnar Kirschner wire was passed to maintain the reduction of the proximal radio-ulnar joint, thus keeping the annular ligament stress-free, facilitating its healing. At 12 months of follow-up, the patient had normal elbow function and complete range of motion.

Resumo A literatura sobre a luxação anterior isolada da cabeça do rádio é escassa, com apenas cinco casos relatados no mundo inteiro até hoje. Em todos esses casos, os pacientes apresentaram movimentos de supinação-pronação restritos do antebraço, e manutenção da flexão-extensão do cotovelo. Os autores apresentam um caso incomum de luxação de cabeça radial anterior isolada em um paciente do sexo masculino de 18 anos, que apresentou movimentos de supinação-pronação no antebraço e restrição na flexão-extensão do cotovelo. A redução fechada foi tentada, mas sem sucesso. Assim, foi feita a redução aberta. No entanto, a redução foi instável devido à ruptura do ligamento anular. Por isso, o reparo do ligamento anular foi realizado, e um fio de Kirschner rádio-ulnar foi inserido para manter a redução da articulação rádio-ulnar proximal, evitando estresse sobre o ligamento anular, facilitando sua cicatrização. Aos 12 meses de acompanhamento, o paciente apresentava função normal do cotovelo e amplitude de movimento completa.

Mechanism of injury based classification of proximal tibia fractures.

INTRODUCTION: We treated proximal tibia fractures according to our own CT based classification in which we divided these fractures into different varus and valgus fractures. We also provide a guide for reduction of these fractures and the sequence in which different fractured fragments of proximal tibia should be fixed. MATERIALS AND METHODS: Patients were identified from the hospital records, treated according to classification based upon mechanism of injury, from August 2014 to December 2016. Patients were called for follow up in outpatient department for evaluation. Functional evaluation was done according to Rasmussen functional grading score. RESULTS: Twenty one patients of proximal tibia fracture were treated between august 2014 to December 2016 according to our method. There were 17 male and 4 female. Age ranged from 20 year to 65 year (average 35.19 year). 17 patients were turned up for latest follow up who were analysed for Rasmusssen functional grading score. 14 patients had excellent and 3 patients had good function according to Rasmussen functional grading score. CONCLUSIONS: Our classification system provides a guide for reduction of proximal tibia fractures and also tells us the sequence of different fracture fragments.

Role of Beta Tri-calcium Phosphate-based Composite Ceramic as Bone-Graft Expander in Masquelet's-Induced Membrane Technique.

BACKGROUND: Filling bone defect after debridement of infected nonunion is an orthopedic challenge. Since the volume of autologous bone graft available is limited, allograft, demineralized bone matrix, and calcium phosphate ceramic-based bone graft substitutes have come up as potential autograft expanders. This study was conducted to analyze the use of beta tri-calcium phosphate (B-TCP)-based composite ceramic as autologous bone-graft expander in the management of postinfective segmental gap nonunion of long bones managed with two-stage Masquelet's technique. MATERIALS AND METHODS: 42 consecutive patients with postinfective segmental long bone defects of 4-12 cm managed with Masquelet's-induced membrane technique, operated between February 2012 and June 2015, were included in this prospective case series. During the second stage bone-grafting procedure, iliac crest autograft alone or mixed with B-TCP granules (ratio not exceeding >1:1) was used along with appropriate internal-fixation. Bony union (defined clinicoradiologically as ability to painlessly bear weight on affected limb without support along with bridging of 3 cortices on X-rays) was evaluated. RESULTS: Union was achieved in 80.9% patients (34/42) with index bone grafting. 100% union rate was achieved in patients where only autograft was used (15/15) and in nonsmoker femoral nonunion patients with the use of B-TCP (13/13). The use of B-TCP was associated with higher rate of nonunion in smokers (6/8, 75%) and in tibial nonunions (4/9, 55.5%). All, but one, of 8 patients with nonunion, united after the second-bone grafting procedure. CONCLUSION: B-TCP is an efficacious and safe autologous bone graft expander in Masquelet's two-stage management of post infective segmental gap nonunion of long bones. Patients should be counseled regarding increased risk of nonunion and need for repeat grafting with its use, especially if they are smokers or site of involvement is tibia.

Greater Trochanteric Reattachment Using the Third-Generation Cable Plate System in Revision Total Hip Arthroplasty.

BACKGROUND: The purpose of the study is to evaluate the radiologic and functional results of greater trochanteric reattachment using the third-generation cable plate system in revision total hip arthroplasty (THA). METHODS: A total of 47 trochanteric fixations (27 men and 18 women; mean age of 60.2 years) using the third-generation cable plate system in revision THA were retrospectively evaluated. The mean follow-up was 80.4 months (range 27-148 months). The osteotomized greater trochanter was reattached using the Cable-Ready system (Zimmer, Warsaw, IN) and the Dall-Miles cable system (Stryker, Mahwah, NJ). The clinical results with Harris hip score, visual analog scale, and radiologic outcomes were evaluated. RESULTS: The mean Harris hip score was improved from 55.7 (range 17-72) preoperatively to 90.8 (range 68-100; P = .001) postoperatively, and the mean pain score was improved from 6.6 (range 3-10) to 2.5 (range 0-6; P = .001), respectively. Nonunion was observed in 6 hips (12.7%). Migration of the osteotomized greater trochanteric fragment (>1 cm) was seen in 8 hips (17.0%). Cable breakage occurred in 13 cases (27.6%). Although 5 cable plate systems were removed, there was no need for reattachment of the greater trochanter in this study. CONCLUSION: This study showed a relatively high incidence of radiologic failure after greater trochanteric reattachment using the cable plate system in revision THA, although reattachments were not required and clinical outcome was relatively satisfactory. Periodic and close observation for the early detection of failure is necessary.

Results of operative treatment of acetabular fractures from the Third World--how local factors affect the outcome.

The objective of this study was to assess the outcome of operations on acetabular fractures from a developing country in the presence of locally available facilities. Sixty-three acetabular fractures were assessed at an average follow up of 52.94 months after operation. Twenty-six patients operated upon in the first three years and 37 operated thereafter were separately studied to discover the effect of the learning curve. Regarding the fractures, 47 of 63 (74.6%) had excellent/good results (Harris Hip Score>80). The complications included broken drill bit in eight patients (12.69%), deep infection and heterotopic ossification in five patients (7.93%), avascular necrosis and sciatic nerve palsy in two patients (3.17%) and implant failure in one patient (1.58%). The results collected during the learning curve were inferior in the complex fractures (p value<0.001). Complications were common in patients opting for local implants and in those operated after over 2 weeks delay.