Reconstruction of Massive Segmental Distal Femoral Metaphyseal Bone Defects After Open Injury: A Study of 20 Patients Managed with Intercalary Gamma-Irradiated Structural Allografts and Autologous Cancellous Grafts.

BACKGROUND: Our aim was to examine the outcome of gamma-irradiated intercalary structural allografts combined with autologous cancellous grafts in treating large metaphyseal bone defects of the distal femur following open injuries. METHODS: We prospectively included 20 consecutive patients with large metaphyseal bone defects of >4 cm located in the region of the distal femur following open injuries treated between 2010 and 2018, with a mean follow-up of 2 years (range, 2 to 10 years). Of these patients,18 were men and 2 were women. The mean age was 39 years (range, 22 to 72 years). The mean length of the bone defects was 10.1 cm (range, 5.5 to 14.5 cm), and all were in the metaphysis of the distal femur. The surgical technique included initial early debridement and external fixation followed by reconstruction of the bone defect using structural allograft combined with autologous cancellous bone graft harvested from the iliac crest and locking plate fixation. Definitive fixation was performed at an average period of 22.5 days (range, 3 to 84 days) after injury. Osseous union, rate of infection, complications, need for secondary procedures, and functional outcome using the Lower Extremity Functional Scale (LEFS) at the final follow-up were assessed. RESULTS: After excluding 1 patient who was lost to follow-up, 19 patients with complete follow-up were available for analysis. Of those, 13 patients (68%) achieved complete union at both ends of the allograft with host bone without any further intervention. Three patients (16%) developed aseptic nonunion of the proximal end of the allograft requiring 1 additional procedure each to achieve union. Four patients (21%) developed a deep surgical site infection. Of those, 1 elderly patient required above-the-knee amputation following uncontrolled diabetes and infection. A second patient required 2 additional procedures, and a third patient needed 4 additional procedures to achieve union. The fourth patient developed infection after achieving union, and the infection subsided after debridement and implant removal. The mean LEFS score for all 19 patients was 55 (range, 41 to 75). CONCLUSIONS: Use of allograft was a reasonable single-stage alternative solution for massive distal femoral bone defects, which united without additional surgery in two-thirds of the patients and without limb-length discrepancy. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical management of peripheral artery pseudoaneurysm following orthopedic trauma: a report of 14 cases.

PURPOSE: Purpose of this study was to report the etiology, diagnosis, surgical management, and outcome of pseudoaneurysm associated with orthopedic trauma. METHODS: A retrospective review was conducted of all patients presenting to a Level 1 trauma center between 2013 and 2019. Clinical records were reviewed for the mechanism of primary injury, associated fracture pattern, time of presentation, site of involvement, etiology of the pseudoaneurysm, diagnosis, management, and complications. We identified 14 patients with pseudoaneurysm of peripheral arteries following orthopedic trauma. RESULTS: The mean interval between primary injury and the manifestation of clinical symptoms was 88.5 days (range, 16-304 days). There were 3 upper limb injuries and 11 lower limb injuries. The presenting symptoms were pain associated with excessive extremity swelling in most of the patients. A significant drop in hemoglobin (mean fall- 2.9 g/dL) was noted in nine patients. Most common artery involved was the superficial branch of femoral artery and posterior tibial artery followed by the brachial artery. Fractured bone spike was the cause of injury in eight patients and iatrogenic injury in six patients. Diagnosis was confirmed by CT angiography with duplex scan in eight patients, duplex scan alone in one patient, MRI along with duplex scan in one patient. The remaining four patients were diagnosed intraoperatively. Excision of the pseudoaneurysm and ligation of the involved minor arteries was done in eight patients. Surgical repair of the major artery with critical vascular injury was done in six patients. One patient underwent secondary amputation following the anastomotic blowout. CONCLUSION: Early diagnosis of pseudoaneurysm requires knowledge and a high index of suspicion. Surgical reconstruction of major arteries should always be done and ligation of major vessels can lead to catastrophes. Excision of pseudoaneurysm can be done when minor arteries are involved with the presence of good collateral circulation. LEVEL OF STUDY: Level IV Study.

Forequarter Replantation.

Traumatic forequarter amputations are rare injuries in which the arm, clavicle, scapula, and proximal shoulder muscles are avulsed from the body. Historically, forequarter amputation has been treated with hemorrhage control, wound debridement, and soft tissue coverage. To our knowledge, successful forequarter replantation has not been previously reported. We present a rare case of forequarter amputation treated successfully with replantation. At the 4.5-year follow-up after replantation, the patient had antigravity elbow flexion, modest shoulder elevation, modest extrinsic finger function, and crude sensation. We discuss relevant technical considerations that indicate that, despite challenges, forequarter replantation can be achieved with success.

Current updates in management of extremity injuries in polytrauma.

Injury-related morbidity and mortality have been one of the most common causes of loss in productivity across all geographic distributions. It remains to be a global concern despite a continual improvement in regional and national safety policies. The establishment of trauma care systems and advancements in diagnostics and management have improved the overall survival of severely injured. A better understanding of the physiopathological and immunological responses to injury led to a significant shift in trauma care from "Early Total Care" to "Damage Control Orthopedics." While most of these algorithms were tailored to the philosophy of "life before limb," the impact of improper fracture management on disability and societal loss is increasingly being recognized. Recently, "Early Appropriate Care" of extremities has gained importance; however, its implementation is influenced by regional health care policies, available resources, and expertise and varies between low and high-income countries. A review of the literature was performed using PubMed, Embase, Web of Science, and Scopus databases on articles published from 1990 to 2020 using the Mesh terms "Polytrauma," "Multiple Trauma," and "Fractures." This review aims to consolidate on guidelines and available evidence in the management of extremity injuries in a polytraumatized patient to achieve better clinical outcomes of these severely injured.

Management of Tibial Shaft Fractures Distal to TKA Prosthesis by Intramedullary Nail: A Report of Three Cases.

INTRODUCTION: Diaphyseal tibial fractures distal to a well-fixed tibial component although rare present a significant challenge and optimal treatment remains controversial. Displaced periprosthetic tibial shaft fractures are ideally treated with open reduction internal fixation with plate osteosynthesis. However, this treatment method is associated with weight-bearing restrictions, which can be difficult for elderly patients with multiple comorbidities and balance impairment. We present our experience of internal fixation with an intramedullary nail that uses an inferior entry point, standard intramedullary tibial nail, and conventional instrumentation. MATERIALS AND METHODS: Between 2017 and 2018, three patients with acute tibial shaft fractures distal to a TKA (Felix Type 3A) were treated with an intramedullary nail. Preoperative planning involved assessing proximal tibia to ensure adequate room for implant and instrumentation. The average patient age was 66.3 years (range 59-72 years) and all patients were males. All the patients sustained fractures of distal tibial and fibula diaphysis, after a road traffic accident. There were no complications intraoperatively, and all procedures were completed uneventfully. One patient underwent additional fixation of the fibula. RESULTS: All patients achieved a radiological fracture union after an average of 20.6 weeks. There were no fixation failures, or nonunions postoperatively. There were no new symptoms relative to the TKA that could be attributed to the tibial nailing procedure. CONCLUSION: We recommend that this technique can be used primarily for this fracture pattern distal to a TKA, provided there is adequate space to accommodate the nail and instrumentation proximally anterior to the tibial tray.

Floating Shoulder Injury Resulting in Delayed Onset of Infraclavicular Brachial Plexus Palsy.

As the brachial plexus traverses the costoclavicular space, it is susceptible to compression by pathologies affecting the clavicle. Clavicle nonunions with hypertrophic callus may cause a delayed onset of brachial plexus palsy. We present a rare case of a floating shoulder injury causing medial and posterior cord brachial plexus palsy two months after initial injury. After the diagnosis was established, the patient was treated successfully with expeditious brachial plexus decompression, callus excision, and rigid osteosynthesis, with healing of the clavicle nonunion and scapular fracture, and recovery of sensory and motor deficits.

Correlation of radiological parameters to functional outcome in complex proximal humerus fracture fixation: A study of 127 cases.

OBJECTIVE: The purpose of this study is to analyze the radiological and functional outcome of complex proximal humerus fractures treated by open reduction and plate fixation, and how radiological parameters correlate with functional outcome. DESIGN: Retrospective study. SETTING: Level-1 trauma center. PATIENTS/METHODS: One hundred twenty-seven patients were analyzed, with a mean follow-up of 5 (3-7) years. OUTCOME MEASUREMENTS: Radiological parameters studied were neck-shaft angle (NSA), greater tuberosity (GT) to articular surface (AS) distance, medial hinge reduction, and presence (or absence) of calcar screw. Functional outcome evaluated by DASH and Constant-Murley (C-M) score. RESULTS: The mean age is 53.8 years. All patients had a union in 14 (12-18) weeks. The mean NSA is 135° (112-155°). One hundred and thirteen patients with an NSA of >120° had a good functional outcome. Fourteen patients with NSA ≤120° had shoulder abduction <90°. The mean GT to AS distance is 7.2 mm (-2 to 16). The superior displacement of GT above AS is associated with abduction of <90° (16 patients). The mean medial gap is 3 mm (0-17). In 14 patients with a medial gap of >4 mm and without calcar screw, varus collapse is observed. All patients had a good outcome on DASH score and 122 patients had good to excellent outcome on C-M score. Five patients with poor outcome on C-M score had NSA <120° and displacement of GT above AS. CONCLUSION: Radiographic indicators for poor outcome are varus angulation with NSA <120°, superior displacement of GT above AS, the presence of medial gap >4 mm, and absence of calcar specific screw. This "terrible triad" of proximal humerus fracture should be avoided during operative fixation.

Bipolar Hemiarthroplasty in a Patient with above-knee Amputation: Surgical Technique.

INTRODUCTION: Femoral neck fractures are a common occurrence in lower limb amputees. Good post-operative results of hip hemiarthroplasty have been described in below-knee amputees. However, to our knowledge, very few such cases have been reported in above-knee amputees. CASE REPORT: We present a case of a 75-year-old male patient who underwent above-knee amputation of the right lower limb for severe crush injury right leg and a bipolar hemiarthroplasty for an ipsilateral fracture neck of femur sustained in the same road traffic accident. The treatment of neck of femur fracture in above-knee amputee patients is always a challenge for the orthopedic surgeon. We described the surgical technique in an attempt to overcome the challenges encountered in such a setting. CONCLUSION: While performing a hemiarthroplasty in an above-knee amputee, we recommend the use of two perpendicularly placed Schanz pins distally in the subtrochanteric area for control and also as a guide for verifying the version during prosthesis placement.

Ganga hospital open injury score in management of open injuries.

INTRODUCTION: Open injuries of the limbs offer challenges in management as there are still many grey zones in decision making regarding salvage, timing and type of reconstruction. As a result, there is still an unacceptable rate of secondary amputations which lead to tremendous waste of resources and psychological devastation of the patient and his family. Gustilo Anderson's classification was a major milestone in grading the severity of injury but however suffers from the disadvantages of imprecise definition, a poor interobserver correlation, inability to address the issue of salvage and inclusion of a wide spectrum of injuries in Type IIIb category. Numerous scores such as Mangled Extremity Severity Score, the Predictive Salvage Index, the Limb Salvage Index, Hannover Fracture Scale-97 etc have been proposed but all have the disadvantage of retrospective evaluation, inadequate sample sizes and poor sensitivity and specificity to amputation, especially in IIIb injuries. METHODS: The Ganga Hospital Open Injury Score (GHOIS) was proposed in 2004 and is designed to specifically address the outcome in IIIb injuries of the tibia without vascular deficit. It evaluates the severity of injury to the three components of the limb--the skin, the bone and the musculotendinous structures separately on a grade from 0 to 5. Seven comorbid factors which influence the treatment and the outcome are included in the score with two marks each. The application of the total score and the individual tissue scores in management of IIIB injuries is discussed. RESULTS: The total score was shown to predict salvage when the value was 14 or less; amputation when the score was 17 and more. A grey zone of 15 and 16 is provided where the decision making had to be made on a case to case basis. The additional value of GHOIS was its ability to guide the timing and type of reconstruction. A skin score of more than 3 always required a flap and hence it indicated the need for an orthoplastic approach from the index procedure. Bone score of 4 and 5 will require complex reconstruction procedures like bone transport, extensive bone grafting or free fibular graft. Regarding the timing of reconstruction, injuries with a score of 9 or less indicated a low violence trauma and were amenable for early soft tissue reconstruction whereas injuries with a score of 10 or more indicated high violence injuries where a staged reconstruction policy must be followed. CONCLUSIONS: Ganga Hospital Open Injury Score was found to be highly useful in decision making regarding salvage in IIIB injuries. The individual tissue scores were also useful to provide guidance regarding the timing and type of bone and soft tissue reconstruction.

Incongruent reduction following post-traumatic hip dislocations as an indicator of intra-articular loose bodies: A prospective study of 117 dislocations.

BACKGROUND: Intra-articular loose bodies following simple dislocations can lead to early degeneration. Nonconcentric reduction may indicate retained loose bodies and offer a method to identify patients requiring exploration so that this undesirable outcome can be avoided. MATERIALS AND METHODS: One hundred and seventeen consecutive simple dislocations of the hip presenting to the hospital from January 2000 to June 2006 were assessed for congruency after reduction by fluoroscopic assessment of passive motion in the operating room as well as with good quality radiographs. Computerized tomography (CT) scan with 2-mm cuts was done for confirmation of reduction and to identify the anatomy of loose bodies. Patients with nonconcentric reduction underwent open exploration to identify the etiology of the dislocation and for removal of loose bodies. Thomson and Epstein clinical and radiological criteria were used to assess the outcome. RESULTS: Twelve of the one hundred and seventeen (10%) dislocations had incongruent reduction, which was identified by the break in Shenton's line and increase in medial joint space in seven patients, increase in the superior joint space in three patients, or increase in the joint space as a whole in two patients. CT scan identified the origin of the osteocartilaginous fragment as being from the acetabulum in six patients, the femoral head in four, and from both in one. One patient had an inverted posterior labrum. Following debridement, congruent reduction was achieved in all patients. At an average follow-up of 5 years (range: 2 years 5 months to 8 years), the outcome as evaluated by Thompson and Epstein clinical criteria was excellent in eleven cases and good in one case; the radiological outcome was excellent in eight cases and good in four cases. CONCLUSIONS: Intra-articular loose bodies were identified by nonconcentric reduction in 12 out of 117 patients with simple hip dislocation. Careful evaluation by fluoroscopy and good quality radiographs are indicated following reduction of hip dislocations.

Immediate primary skin closure in type-III A and B open fractures: results after a minimum of five years.

Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded. At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion. Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.

Technical considerations and functional outcome of 22 major replantations (The BSSH Douglas Lamb Lecture, 2005).

Twenty-two consecutive major replantations carried out over a 5-year period were assessed with a minimum follow-up of 2 years. Only two patients suffered guillotine amputations. The remainders were either crush, or crush avulsion amputation. Replantation was successful in 20 cases. When analysed by Chen's criteria, there were three Grade I, nine Grade II, six Grade III and two Grade IV results. Most patients with successful replants put the hand to greater use with time and replantation greatly added to the overall well-being of the patient. We consider major replantation as a worthwhile procedure. Radical debridement, bone shortening and well laid out protocols to reduce the ischaemia time are important for success. The technical details which we believe to be important for success are outlined. With decreasing numbers of such injuries in most countries, this paper may help surgeons faced with an occasional patient with a major amputation to make the right decisions.

Morphological changes during growth in healed childhood spinal tuberculosis: a 15-year prospective study of 61 children treated with ambulatory chemotherapy.

STUDY DESIGN: A retrospective clinical study for prognostic purposes. OBJECTIVE: To study the morphological changes that dictate the variable progression of childhood spinal tuberculosis. SUMMARY OF BACKGROUND DATA: Posttuberculous kyphosis in children either improves or deteriorates during growth. Associated morphological changes in the kyphosis fusion mass and the uninvolved adjacent levels have not been described in literature. METHODS: The study group consisted of 61 children with 63 spinal lesions selected from a prospective multicenter clinical trial. These children were followed up for a uniform period of 15 years at regular intervals. Anterior and posterior heights of the kyphosis fusion mass were measured. Relative difference in anteroposterior growth was analyzed by calculating the anteroposterior ratio of heights. Wedge angle and height-width ratio of uninvolved adjacent vertebrae along with changes in the morphology of disk spaces above and below the lesion were also analyzed. RESULTS: An increase in the anteroposterior ratio of kyphosis fusion mass leading to a decrease in kyphosis was seen in 30 lesions. A decrease in the anteroposterior ratio leading to an increase in kyphosis was noticed in 16 lesions. Overgrowth of the kyphosis fusion mass resulting in formation of large vertebral bodies was noticed in 7 lesions. No change was noticed in 10 lesions. Interestingly, changes were also noticed in 234 adjacent vertebral bodies uninvolved by the disease process: anterior wedging (n = 53), growth alteration of ring apophysis (n = 26), decrease in anteroposterior diameter (n = 26), longitudinal overgrowth (n = 40), attrition at the point of contact resulting in irregular bodies (n = 44), and posterior wedging in the region of compensatory curve (n = 45). Changes in disk spaces were noted at 136 levels, the most common finding being an opening of the disk space anteriorly (n = 126) due to formation of compensatory lordotic curves. The secondary changes leading to an increase in deformity were observed significantly more in lesions with a deformity angle of more than 30 degrees and a vertebral body loss of more than 1, and in lesions of the thoracolumbar region. Children younger than 10 years differed from those 11 years or older by having a significantly more severe disease and more number of morphological changes with growth in both the fusion mass and the adjacent segments. CONCLUSIONS: Notable morphological changes occurred in both the kyphosis fusion mass and the uninvolved levels above and below the lesion in children with healed spinal tuberculosis. These changes occurred during growth, after complete healing of the disease was achieved, and were responsible for the variability in progression of the deformity during growth seen in these children. Our results imply that all children with spinal tuberculosis must be followed up regularly till the entire growth potential is completed.

A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures.

Limb-injury severity scores are designed to assess orthopaedic and vascular injuries. In Gustilo type-IIIA and type-IIIB injuries they have poor sensitivity and specificity to predict salvage or outcome. We have designed a trauma score to grade the severity of injury to the covering tissues, the bones and the functional tissues, grading the three components from one to five. Seven comorbid conditions known to influence the management and prognosis have been given a score of two each. The score was validated in 109 consecutive open injuries of the tibia, 42 type-IIIA and 67 type-IIIB. The total score was used to assess the possibilities of salvage and the outcome was measured by dividing the injuries into four groups according to their scores as follows: group I scored less than 5, group II 6 to 10, group III 11 to 15 and group IV 16 or more. A score of 14 to indicate amputation had the highest sensitivity and specificity. Our trauma score compared favourably with the Mangled Extremity Severity score in sensitivity (98% and 99%), specificity (100% and 17%), positive predictive value (100% and 97.5%) and negative predictive value (70% and 50%), respectively. A receiver-operating characteristic curve constructed for 67 type-IIIB injuries to assess the efficiency of the scores to predict salvage, showed that the area under the curve for this score was better (0.988 (+/- 0.013 SEM)) than the Mangled Extremity Severity score (0.938 (+/- 0.039 SEM)). All limbs in group IV and one in group III underwent amputation. Of the salvaged limbs, there was a significant difference in the three groups for the requirement of a flap for wound cover, the time to union, the number of surgical procedures required, the total days as an in-patient and the incidence of deep infection (p < 0.001 for all). The individual scores for covering and functional tissues were also found to offer specific guidelines in the management of these complex injuries. The scoring system was found to be simple in application and reliable in prognosis for both limb-salvage and outcome measures in type-IIIA and type-IIIB open injuries of the tibia.

Spontaneous rapid osteolysis in Paget's disease after internal fixation of subtrochanteric femoral fracture.

Rapidly-progressive spontaneous progression of the osteolysis following internal fixation of pathological fracture in patients with Paget's disease has not been previously reported. We describe two patients, aged 59 and 65 years, respectively, who had pathological subtrochanteric fractures in Pagetic femora fixed internally using an interlocked intramedullary nail, and who developed spontaneous rapid osteolysis. Both patients responded favourably to long-term treatment with alendronate, with resultant fracture union and resolution of osteolysis.

Tuberculous lesions of the lumbosacral region. A 15-year follow-up of patients treated by ambulant chemotherapy.

STUDY DESIGN: A 15-year clinical follow-up of tuberculous lesions of the lumbosacral region. OBJECTIVES: To verify the hypothesis that the lumbar lordosis and the specific biomechanics of the lumbosacral region influence and alter the healing pattern and progress of the disease when compared with their effects in other regions of the spine. SUMMARY OF BACKGROUND DATA: An estimated 2 million or more patients have active spinal tuberculosis, and the global incidence of the disease is increasing. The involvement of the lower lumbar region and the lumbosacral junction is relatively rare, with few reports in English literature. METHODS: Of a total of 304 patients forming a part of a controlled clinical trial comparing two forms of therapy in spinal tuberculosis, 53 patients had involvement of L3 and below. The following data were studied in these patients: age at start of treatment, number of vertebra involved, vertebral body loss, progress of the angle of kyphosis, and anterior and posterior growth of the involved segment during a period of 15 years. Student's t test for independent samples was used for statistical analysis. RESULTS: The fourth lumbar vertebra was the most common vertebral segment involved, and the lumbosacral junction was affected in 12 patients. The average pretreatment kyphosis was 6.4 degrees and increased to 10.2 degrees at the end of 15 years. The average kyphotio angle per vertebral body loss was 4.9 degrees, far less than in the dorsolumbar region in which kyphotic angles of 27-30 degrees have been reported. Children younger than 10 years old differed in clinical appearance and progress compared with those older than 17 years. They not only showed more extensive involvement but also had more deformity with the same vertebral loss. Twelve patients less than 10 years old had an average involvement of 3.1 vertebral bodies and an average vertebral loss of 2.2 bodies. In comparison, the average number of vertebrae involved was 1.9 (P < 0.01) and the vertebral body loss was only 0.87 (P < 0.01) in patients older than 17 years. Also, the average kyphosis was 6.4 degrees compared with only 4.2 degrees (P < 0.01) in adults. In patients older than 17 years, there was no change after 2 years, by which time the collapse was complete. Four of 12 patients less than 10 years old, showed progressive kyphosis caused by continued growth of posterior parts of the body (i.e., sequestrated hemivertebrae). CONCLUSIONS: In tuberculosis of the lumbosacral region, the development of kyphosis is minimal in patients older than 17 years, when growth has already stopped, and deformity is expressed more as foreshortening of the trunk. Children younger than 10 years old have more severe involvement with increased tendency toward greater kyphosis. They are also prone to progressive deformity through the years when the anterior growth plates are destroyed. Surgery is indicated in this group to prevent greater deformity.