Early mobilisation after pain relief for conservative management for intertrochanteric fractures: a pandemic enforced innovation and its results.

BACKGROUND: The COVID pandemic challenged the orthopaedic mind on several fronts. 1 of them was in the management of intertrochanteric fractures. A subset of these patients refused surgical intervention during the pandemic for related reasons. Faced with the goal of early verticalisation, the senior author used pain relief as a method to facilitate early mobilisation in 23 patients with peritrochanteric fractures. METHODS: 23 patients with stable intertrochanteric fractures received a ß 6 distal sodium channel block (DSCB) and were allowed to walk from day 1 without surgery, traction or spica. The goal was to prevent complications of recumbency in this subset of patients. The basic idea of immediate mobilisation from the time of fracture was based on Sarmiento's sausage theory. RESULTS: All the fractures united. There were no major complications. No shortening was seen in more than 50% cases and the shortening did not exceed 2 cm in any case. All patients were satisfied with the outcome and had good to excellent Harris Hip Scores. CONCLUSIONS: The block and walk method is a surprisingly satisfactory method of treatment for stable intertrochanteric fractures. It circumvents the risks of surgery whilst allowing immediate mobilisation preventing complications associated with the other modalities of fracture management.

Non operative management of fractures of the humerus Evaluation of a new extension casting method.

Fractures of the humeral shaft represent 2-4% of all fractures and functional bracing is the gold standard in conservative management. Complications like restricted shoulder range of motion and malunion of the proximal shaft fractures have however been reported. We conducted a retrospective chart re- view of patients treated with the extension casting method over a period of 16 years. Topographically, Garnavos P, M, D, PM and MD fractures and morphologically Simple, Complex and Intermediate fractures were included. Between 2003 and 2019, 74 patients were treated with extension casting. The fractures united at a mean of 10 weeks and there was no case of non-union. Humerus is one of the bones where conservative methodology is still very pertinent. Extension casting gives reproducible and good results. It also addresses patient comfort issues to a considerable extent by allowing shoulder motion and easier maintenance of personal hygiene.

Management of Infected Nonunion of the Forearm by the Masquelet Technique.

PURPOSE: Infected nonunion of the forearm bones is a challenge for the orthopedic surgeon on several fronts. The forearm itself is unique as the difficulties include the relation between restoration of shaft length with the anatomy and long-term functional outcome of adjacent joints, and the risk of elbow and wrist stiffness related to prolonged immobilization. The problem of infection is complex due to the presence of bone necrosis, segmental bone loss, sinus tract formation, fracture instability, and scar adhesion of the soft tissues. The ideal management method for these situations is still debated. MATERIALS AND METHODS: We used the two-stage-induced membrane technique devised by Alain Masquelet for the management of these infected nonunion of 12 forearm bones. RESULTS: All 12 bones united uneventfully. The bones united in a period ranging from 6 to 12 months with a mean of 7.8 months. CONCLUSION: Our results show that this technique addresses several of the challenges pertinent to the forearm nonunion simultaneously and results are uniformly predictable. HOW TO CITE THIS ARTICLE: Dhar SA, Dar TA, Mir NA. Management of Infected Nonunion of the Forearm by the Masquelet Technique. Strategies Trauma Limb Reconstr 2019;14(1):1-5.

Antibiotic Impregnated Cement Coated Ilizarov Rod For The Management Of Infected Non Union Of Long Bone.

The infected non union of the long bones in the presence of the intramedullary nail is a dreaded complication of fracture management. Around 7% patients may develop an infected non union of the long bones in intramedullary nailing. Amongst the various grades of infection, grade three infection is the most difficult to cure and manage as it involves an osteomyelitic bone. Amongst an array of therapeutic modalities, the two stage methods are commonly used with the first stage aimed at controlling the infection and the second stage at inducing union. This increases the number of surgical procedures. We used an Ilizarov threaded rod coated with antibiotic impregnated cement to replace the intramedullary nail with the idea of delivering higher concentration of antibiotic locally as well as provide stability. We achieved a union rate of 91% in a relatively small number of patients with this single procedure. The antibiotic impregnated cement coated Ilizarov rod that we used in our study achieves both infection control and union simultaneously and does not allow cement debonding at removal.

Stable relocation of the radial head without annular ligament reconstruction using the Ilizarov technique to treat neglected Monteggia fracture: two case reports.

INTRODUCTION: A Monteggia facture dislocation is not an uncommon injury, and the diagnosis can often be missed. Long-term follow-up of untreated Monteggia fracture dislocations reveals development of premature arthritis, pain, instability, and loss of pronation and supination. Methods involving annular ligament reconstruction require post-operative immobilization and use of transcapitellar pinning for maintenance of reduction, and thus a delay in rehabilitation. The literature reports satisfactory results with methods that involve ulnar osteotomy and open reduction of the radial head without annular ligament reconstruction. We used the Ilizarov method in two cases with neglected Monteggia fracture dislocations to stably reduce the radial head without open reduction and annular ligament reconstruction. CASE PRESENTATION: We report two cases of neglected Monteggia fracture dislocation, in two Kashmiri boys aged four and six years. Using ulnar osteotomy with distraction osteogenesis, we were able to relocate the radial head gradually and maintain the reduction without a requirement for open reduction and annular ligament reconstruction. CONCLUSION: Distraction lengthening and hyperangulation in different planes by use of the Ilizarov technique effectively reduces the radial head without open reduction and annular ligament reconstruction.

Lateral invaginating peg (LIP) osteotomy for the correction of post-traumatic cubitus varus deformity.

Closing wedge osteotomies are the gold standard for the management of post-traumatic cubitus varus deformity. However, most of these osteotomies are fraught with complications such as lateral condylar prominence, instability, and difficulty in correcting internal rotation. We describe a new technique that provides a means for the management of all these problems simultaneously.

Delayed fixation of displaced femoral neck fractures in younger adults.

We report the results of 52 patients aged 20-55 years with displaced femoral neck fractures, in whom delayed closed reduction and internal fixation was performed. Seven patients developed avascular necrosis (AVN) and non-union was seen in five patients. Whereas most patients with non-union were subjected to repeat procedures, none of the patients with AVN required surgery. The follow-up averaged 40 months (range 22-64 months). Three patients were lost to follow-up. Functional outcome was defined by Judet's system. Good to excellent functional outcome was achieved in 45 cases. The study demonstrated that delayed closed reduction and internal fixation of displaced fractures in young adults which, we believe, is the prevalent form of treatment of these injuries in the developing world results in high rate of fracture union and good functional outcome. The rate of AVN, however, may be a concern if the patients are followed for a longer period.

Short segment pedicle screw instrumentation and augmentation vertebroplasty in lumbar burst fractures: an experience.

To assess the efficacy and feasibility of vertebroplasty and posterior short-segment pedicle screw fixation for the treatment of traumatic lumbar burst fractures. Short-segment pedicle screw instrumentation is a well described technique to reduce and stabilize thoracic and lumbar spine fractures. It is relatively a easy procedure but can only indirectly reduce a fractured vertebral body, and the means of augmenting the anterior column are limited. Hardware failure and a loss of reduction are recognized complications caused by insufficient anterior column support. Patients with traumatic lumbar burst fractures without neurologic deficits were included. After a short segment posterior reduction and fixation, bilateral transpedicular reduction of the endplate was performed using a balloon, and polymethyl methacrylate cement was injected. Pre-operative and post-operative central and anterior heights were assessed with radiographs and MRI. Sixteen patients underwent this procedure, and a substantial reduction of the endplates could be achieved with the technique. All patients recovered uneventfully, and the neurologic examination revealed no deficits. The post-operative radiographs and magnetic resonance images demonstrated a good fracture reduction and filling of the bone defect without unwarranted bone displacement. The central and anterior height of the vertebral body could be restored to 72 and 82% of the estimated intact height, respectively. Complications were cement leakage in three cases without clinical implications and one superficial wound infection. Posterior short-segment pedicle fixation in conjunction with balloon vertebroplasty seems to be a feasible option in the management of lumbar burst fractures, thereby addressing all the three columns through a single approach. Although cement leakage occurred but had no clinical consequences or neurological deficit.

Neurological outcome following delayed fixation of unstable thoracolumbar spinal injuries with short segment posterior fixation.

OBJECTIVE: To evaluate the improvement in neurological deficit following late decompression and stabilization of the fractured thoracolumbar spine. METHODS: Between January 2001 and August 2004 neurological recovery in 120 thoracolumbar fractures was studied after posterior stabilization at the Hospital for Bone & Joint Surgery, Srinagar, India. There were 88 male and 32 female patients. Fall from a height, usually a tree, was the most common (90%) cause of injury. Seventy-six patients (63%) had neurologic deficit at the time of presentation. The unstable spine was fixed, between 4-18 days after trauma, by posterior short segment instrumentation (Steffee). Neurological recovery for the patients was recorded in the follow-up period. Frankel grade was used to assess the neurological status. The average follow-up period was 25 months (range 8-44 months), and average age was 34 years (18-54). RESULTS: There were 40 patients (30%) with an incomplete neurological deficit, namely, patients with Frankel grade B, C, and D. Two grades of improvement were found in 8 patients, and one grade improvement in 32 patients with incomplete lesion. Only one third of the patients with complete neuro deficit improved at the final follow-up. The overall result of the surgery for partial lesions was an improvement of at least one Frankel grade in all cases, but no improvement in most of the cases with complete lesion. CONCLUSION: This study demonstrates a clear relationship between the level of injury and Frankel grades, translational injuries are associated with a more severe neurologic grade, and surgical intervention appears to improve the neurological outcome, even when the intervention is inadvertently delayed (average 7.9 days).

Retrospective analysis of the occurrence of radiologically detectable surgical error in cases of failed pedicle screw implants.

Pedicle screw instrumentation is an important tool in an orthopaedic surgeon's armamentarium in the management of spinal fractures. Complications with this system have been studied extensively. Due to the exacting technique the possibility of surgical error exists while using this modality. We studied a series of 216 cases where pedicular screws had been used and isolated 34 cases of implant failure. Retrospective analyses of their radiographs showed that surgical error does contribute to the implant failure in a statistically significant manner.

Late onset neurogenic claudication in a case of metallic intradural ballistic fragment.

Metallic foreign bodies in the intradural location are rare. Even rarer is the absence of neurodeficit in such cases. We report a case where the patient came to the outdoor department of our hospital with symptoms of neurogenic claudication. From history the patient did not volunteer the information which was pertinent to his symptomatology. On examination he was asked about the small scar in his lumbar region. He attributed it to the subjectively insignificant trauma he had sustained when he had been trapped in a crossfire and had been hit by a fragment. The patient had been absolutely symptom free for 12 months after the event followed by 6 months of increasing claudication. X-ray and CT examination revealed the presence of a metallic foreign body in the lumbar spinal canal. Surgical exploration and removal correlated the presence. This case report substantiates the view that a patient with a foreign body in the spinal canal is always a potential candidate for surgery.

The Kashmir Earthquake Experience.

On October 8, 2005, a major earthquake measuring 7.6 on the Richter scale struck the Himalayan region of Kashmir. Around 90,000 people died in the mass disaster. The Bone and Joint Hospital in Kashmir found itself in a relatively unique situation of having to deal with the orthopedic morbidity generated by this quake. The hospital received 468 patients over a period of 10 days, out of which 463 were received over the initial 5 days. The admission for a single day peaked at 153 patients on the third day. Due to the unprecedented admission in terms of numbers the hospital utilized outreach methods to streamline admission by sending out specialists to the affected areas. Manpower was judiciously utilized to concentrate specialist advise where required. Besides documenting the pattern of trauma, this paper throws light on some unforeseen problems faced in dealing with a large number of patients far exceeding the normal capacity of the hospital.