A prospective randomized control trial comparing outcomes of casting, pinning, and plating for distal end of radius fractures (AO type A2, A3, C1, or C2) in the elderly population.

PURPOSE: With this prospective randomized control trial (RCT), we aim to provide the outcome analyses of the three most used treatment modalities for distal end of radius (DER) fracture management in the elderly. METHODS: A prospective randomized control trial was performed. Fifty-two patients with DER fractures (AO A2, A3, C1, or C2) were randomized to the casting (n = 17), percutaneous pinning (n = 18), and the volar plating group (n = 17). Radiological measurements measured were radial inclination (RI), radial height (RH), volar tilt (VT), and ulnar variance (UV). The outcome was measured based on range-of-motion, grip strength, Patient-Related-Wrist-Evaluation (PRWE) score, and the Quick-Disabilities-of-the-Arm-Shoulder-Hand (QDASH) score. RESULTS: Immediate post-operative and 1-year-follow-up X-rays showed a significant difference measurement between the groups (p < 0.05). Pairwise comparisons of the casting and pinning groups (p < 0.05) and the casting and plating groups (p < 0.05) revealed significant differences at the 1-year follow-up, but not the pinning and plating groups (p > 0.05). The analysis found significant differences in clinical outcomes after 1 month of follow-up, with the plating group outperforming the other two (p > 0.05). However, after a year of follow-up, all groups had comparable outcomes; however, the plating group showed improved palmar flexion (p < 0.001), radial deviation (p < 0.001), and a lower PRWE score (p < 0.05), indicating better wrist function. Complications were more in casting group. CONCLUSION: The study found a radiologically significant difference between groups throughout the follow-up, but it did not affect functional results. Clinical outcomes were similar across the groups, with plating showing better palmar flexion and radial deviation. Grip strength was also better in the plating group, but statistically insignificant. The study suggests plating should be chosen over other treatments for high-demand patients.

Role of impaction bone grafting of allografts in the management of benign lesions of the proximal femur.

Purpose of study: The use of allografts to reconstruct benign lesions of the proximal femur after curettage has seldom been reported. We report our experience of impaction bone grafting of only allografts combined with osteosynthesis to manage benign lesions involving the proximal femur. Materials and methods: Between 2013 and 2019, 35 patients of a mean age of 23.8 years (14-41) who had a biopsy proven benign pathology and a median pre-operative Mirels' score of 9 (8-11) were managed using extended curettage, impaction bone grafting of allografts combined with osteosynthesis through a lateral approach. Radiographs were assessed to see for any recurrence at follow-ups, and functional outcomes were assessed using Musculoskeletal Tumour Society (MSTS) score and Harris hip score (HHS). Results: At a mean follow-up was 41.5 months (23-80), patients demonstrated favorable functional outcomes with a mean MSTS of 28.3 (18-30) and a mean HHS of 94.3 (66-100) at the last follow-up. Two cases (GCT = 1; fibrous dysplasia = 1) had a recurrence of disease. Allografts demonstrated a particular integration pattern on radiographs that involved an intermediate period of lucency followed by consolidation and integration with the parent bone. Conclusion: Impaction grafting of allografts in benign lesions of the proximal femur allows adequate bony consolidation of the cavity after extended curettage and can be effectively used as a permanent solution to manage such lesions in most cases. The intermediate period of lucency seen on radiographs must not be confused for recurrence, and patients must be followed up continuously. Study design: Retrospective Case Series. Level of evidence: Level IV.

Pin Leverage Technique: A Simple Percutaneous Technique for Elevation of Posterolateral Tibial Plateau Fractures.

Depressed lateral tibial plateau fractures with a large central or posterior fragment can be seen in isolation or association with complex proximal tibia fractures. Conventionally elevation of the large depressed fragment is done by bone tamp through a medial metaphyseal window in isolated fractures, or the fractured window in associated complex fracture scenarios. Though various instruments have been devised for this purpose, reaching the posterior aspect of lateral condyle through the medial metaphyseal window is not always easy, considering the difficulty in aiming and trajectory. Excessive maneuvering can result in the widening of the medial metaphyseal window, leaves a large metaphyseal void, intraarticular penetration of elevating device, and comminution of the depressed fragment. Described herein is an alternate percutaneous technique for effective reduction of selected lateral tibial plateau depression fractures using Steinmann pin. Twenty- one patients with at least 1-year follow-up with successful outcomes have benefitted from this reduction technical tip thus far.

The role of a trauma review system and development of intra-operative checklists in improving the quality of fracture fixations in a high volume tertiary centre.

INTRODUCTION: In high volume centres, audits are essential to ensure good surgical techniques and fracture fixations to avoid complications, revision surgeries and poor outcomes. A method to assess fixations for fractures of different regions employing different implants and surgical demands is a challenge. We present here a simple method of review and follow-up work flow of more than 6000 fixations every year that helped in improving outcomes and also provide training for residents and junior staff. MATERIALS AND METHODS: The results of 6348 fracture fixations in 2014, led to a trauma review system in January 2015 to classify all fracture fixations by senior consultants into three categories: category A (good fixations); category B (acceptable fixations; need further follow-up); category C (poor/unacceptable fixations needing revision) combined with a teaching program. A strategy was evolved that included the following practices: (1) identifying 'red flag' fractures that led to frequent failures, (2) routine senior surgeons' involvement in such fractures, (3) evolving 'intra-operative checklists', (4) requirement of senior surgeons' intervention if there was a 'fiddle time' of more than 20 min, and (5) approval of post-fixation c-arm image by a senior person before closure. The impact of these rules on the fixations for 2015, 2016 and 2017 were prospectively analysed. RESULTS: In the years 2015, 2016 and 2017 the number of fracture fixations performed were 6579, 6978 and 7012, respectively. There was a significant increase (p < 0.001) in the number of category A fixations (87.7%, 94.6% and 96.3% in 2015, 2016 and 2017, respectively) and also a decrease in the number of category C fixations (2.23%, 0.7% and 0.2% in 2015, 2016 and 2017, respectively). The quality of fixations of the 'red flag' fractures also improved. CONCLUSION: We present here a very effective, tested, simple and easily reproducible method of audit and follow-up work flow that can be used in all high turnover trauma centres to improve outcomes and can also serve as a teaching resource for junior staff. STUDY DESIGN: Prospective study. LEVEL OF EVIDENCE: Level II.

Morphology Specific Lateral Wall Reconstruction Techniques Using Cerclage Wires in Unstable Trochanteric Fractures.

Trochanteric lateral wall fracture (LWF) indicates instability and is found to be an important predictor of reoperations following trochanteric fracture fixation. A single unified technique for lateral wall reconstruction may not adequately stabilize all the fracture patterns. We have presented morphology specific lateral wall reconstruction techniques using cerclage wire around proximal femoral nails. Various LWF patterns have been simplified into three types. Type-specific lateral wall reconstruction techniques using cerclage wire were adopted in 49 consecutive unstable trochanteric fractures presented to our institute between 2016 and 2018. We analyzed the fracture pattern, fixation method used, union time, and complications. The functional outcome was analyzed using the Harris hip score (HSS). The mean follow-up period was 13 months (range 10-36 months). The mean age of the population was 66 years (range 36-91 years). There were 15 patients with type 1 LWF pattern, 26 patients with type 2, and 8 were of type 3 pattern. The mean operating time was 66 min. The mean union time was 14 weeks (10-24 weeks). HSS was excellent in 9 patients, good in 33 patients, fair in 4 patients, and poor in 5 patients. Complications include one patient with avascular necrosis (AVN) of the femoral head, varus collapse with non-union in one patient, screws back out in one patient, superficial infection in 4 patients, and distal screw breakage in one patient. Type 2 is the most common LWF type in our study. In unstable trochanteric fractures, morphology specific lateral wall reconstruction using cerclage wire loops around the proximal femoral nail is a simple technique with promising results with minimal complications.

Impaction Bone Grafting and Valgus Osteotomy: A Technical Trick for the Treatment of Femoral Neck Nonunions.

Femoral neck nonunions in young adults is among the most challenging problems to treat. This is due to their inherent problems, such as neck resorption, increase in fracture gap, sclerosis of fracture margins, and avascular necrosis. Hip salvage in these cases, although challenging, is recommended in the Asian subcontinent where social and religious activities require squatting and sitting cross-legged. Muscle pedicle grafts and other vascularized bone grafting techniques are preferred treatment options, but they are technically demanding and require advanced microsurgical skills. Valgus osteotomy, although successful in certain cases, has a high failure rate in patients with poor bone stock. We present a simple technique of valgus subtrochanteric osteotomy, impaction bone grafting, and stabilization with a sliding hip screw. Here, we describe in detail about the surgical technique and present the clinical outcomes in 44 patients, with a mean follow-up of 3.4 years and a union rate of 95.5%.

A surgical algorithm for the management of recalcitrant distal femur nonunions based on distal femoral bone stock, fracture alignment, medial void, and stability of fixation.

BACKGROUND: Recalcitrant distal femur nonunions (RDFN) are a challenge in management due to factors including poor bone stock, multiple surgeries, metaphyseal bone loss, and joint contractures. There are no specific guidelines in the management of cases of RDFN. Based on our experience, we devised an algorithm and we present the results of 62 cases of RDFN managed following it. MATERIALS AND METHODS: Our algorithm was formulated after analyzing 34 cases of RDFN and it involved four factors which were hypothesized to influence outcomes namely: distal femoral bone stock, extent of medial void, alignment of the fracture, and stability of fixation. Each factor was addressed specifically to achieve a good outcome. Between 2012 and 2015, 62 patients with RDFN at a mean age of 47.4 years (26-73) and 2.3 prior surgeries (2-6) were managed following the algorithm. INTERVENTION: 58 patients required revision osteosynthesis to improve alignment and achieve a stable fixation. 4 elderly patients with poor bone stock were managed with arthroplasty. Extent of medial void was found to significantly influence surgical decision making. Five patients without medial void required only cancellous autograft bone grafting, 47 patients with < 2 cm void were treated with an allograft fibular strut inserted in the metaphysis and 6 patients with a void > 2 cm were managed with medial plating. OUTCOMES AND RESULTS: 57 patients treated with osteosynthesis achieved union at an average of 7.4 months (6-11) and the 4 patients managed with arthroplasty also had a favourable outcome. One patient who was managed with revision osteosynthesis had a nonunion with an implant failure and needed an arthroplasty procedure. The average LEFS (lower extremity functional score) of all our patients was 67 (51-76) at an average follow-up of 18.2 months (12-33). CONCLUSION: Our stepwise surgical algorithm would help surgeons to identify the factors that need to be addressed and guide them towards the interventions that are necessary to achieve a successful outcome while managing cases of RDFN. LEVEL OF EVIDENCE: III. LEVEL OF CLINICAL CARE: Level I Tertiary trauma centre.

Modified Capanna's Technique (Vascularized Free Fibula Combined with Allograft) as a Single-Stage Procedure in Post-traumatic Long-Segment Defects of the Lower End of the Femur: Outcome Analysis of a Series of 19 Patients with an Average Gap of 14 cm.

Objectives Salvage and reconstruction of posttraumatic defects of the long bone are complex due to the multiple procedures involved and increased chances of poor outcomes. We present the outcomes of the modified Capanna's technique-a reliable single-stage procedure of combining allograft and free vascularized fibular graft-in treating large posttraumatic bone defects in the distal third of the femur. Study Design This is a retrospective analysis. Materials and Methods Between April 2012 and September 2016, 19 patients with an average age of 33.8 years (range: 18-49 years) and an average defect of 14.5 cm (range: 9.5-20 cm) in the distal femur were managed by the modified Capanna's technique. Bone union time and functional outcome using lower extremity functional score (LEFS) after union were noted. Outcomes and Results Eighteen grafts went onto achieve bony union at an average of 6.6 months (range: 5-9), with an average knee flexion of 80 degrees (range: 45-110 degrees) and an average LEFS of 63 (range: 46-72). One patient had a nonunion with graft resorption at 8 months following persistent infection and was revised with debridement and augmenting the vascularized fibula from the other leg which went on to achieve union. Three patients had superficial infection, and three patients had delayed union. Conclusion The modified Capanna's technique provided increased biology and enhanced structural stability and therefore is a good single-stage procedure in the reconstruction of posttraumatic long-segment defects of the distal femur. Level of Evidence Level 4. Level of Clinical Care Level I tertiary trauma center.

Successful reconstruction of a post-traumatic defect of 16 cm of the distal femur by modified Capanna's technique (vascularised free fibula combined with allograft) - A case report and technical note.

Reconstruction of large defects following trauma in the distal femur are a surgical challenge. These cases usually require multiple procedures and are associated with poor functional outcomes. We managed a post-traumatic distal femur defect of 16 cm using the modified Capanna's technique - combination of a vascularised free fibula and an allograft - and achieved a successful union at 6 months and also a good functional outcome with knee flexion of 100°. The patient received a vascularised free fibula which was pegged into an allograft which was sculptured to bridge the defect. The construct was fixed with a locking compression plate on the lateral side. With the allograft providing structural stability and the vascularised free fibula enhancing biology, our technique which involves the expertise of an orthopaedic surgeon and a plastic surgeon is a useful single stage procedure to manage large post-traumatic bone defects.

Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients.

INTRODUCTION AND PURPOSE: Challenges to the surgeon in managing cases of resistant non-union of the distal femur include poor bone stock, disuse osteopenia and joint contractures. Procedures varying from simple bone grafting to megaprosthesis revision have been described. We successfully managed such cases using our technique of combining cortical allograft struts to augment the defect in the femoral condyle coupled with autogenous iliac crest bone grafting and locking plate osteosynthesis. MATERIALS AND METHODS: Between April 2012 and May 2014, 22 patients who presented with resistant nonunions of the distal femur following initial surgery were managed using this technique. Cortical allograft struts were taken from the tissue bank of our institution. All patients were followed up post operatively and their time to union was noted. Functional outcome was calculated using LEFS (Lower extremity functional score). The average follow up of all our patients was 24 months. RESULTS: All patients went on to achieve complete bony union. The average union time was 6.2 months (5 to 8 months). One patient who was a diabetic had superficial infection post operatively which was treated successfully with IV antibiotics. Average knee flexion was 110 degrees (80 to 130 degrees). The mean LEFS score was 72 (59 to 79). CONCLUSION: Combing a locking plate fixation with the bone grafting technique of using an allograft strut to support the metaphyseal medial bone defect and autografts gives a good union and a good functional outcome in the management of resistant non-unions of the distal femur by enhancing the biology and providing a good structural support to the distal femur.

Variation in practice preferences in management of open injuries of extremities-an international survey by SICOT research academy.

PURPOSE: Open fractures are challenging injuries and there is a lot of variation in practice preferences which may reflect the wide variations in outcome in different units across the world. A survey was done amongst the international community of SICOT membership to document the practice preferences and variations. METHODS: An online questionnaire containing 23 questions which were sub-divided into three sections covering the various aspects of open injury management was sent by email to orthopaedic trauma surgeons across the world. A total of 358 responses were evaluated and presented in this manuscript. RESULTS: The SICOT study confirmed wide variation in practice protocols. About 94.7 % of orthopaedic surgeons around the world use the Gustillo Anderson scoring system for assessment of open injury and 50.6 % of surgeons prefer lavage in operation theatre. For lavage, 84.6 % of surgeons preferred normal saline and for antibiotic prophylaxis, 48.3 % used a combination of second generation cephalosporin, metronidazole and an aminoglycoside for a minimum of three to five days. In 88 % of patients, orthopaedic surgeons performed the initial debridement and 69.2 % surgeons aimed for debridement within six hours. Regarding wound management, 43.9 % units preferred and were capable of soft tissue cover within 72 hours and about 26.3 % surgeons combined definitive fixation along with plastic procedure. CONCLUSION: Our study documented wide variations in practice preferences across the world and showed that information and awareness about current guidelines and practices will help many to update themselves in terms of basic questions about open fracture care.

Successful reimplantation of extruded long bone segments in open fractures of lower limb--a report of 3 cases.

Extruded bone segments are rare complication of high energy open fractures. Routinely these fractures are treated by debridement followed by bone loss management in the form of either bone transport or free fibula transfer. There are very few reports in the literature about reimplantation of extruded segments of bone and there are no clear guidelines regarding timing of reimplantation, bone stabilisation and sterilisation techniques. Reimplantation of extruded bone is a risky procedure due to high chances of infection which determines the final outcome and can result in secondary amputations. We present two cases of successful reimplantation of extruded diaphyseal segment of femur and one case of reimplantation of extruded segment of tibia.