Peroneal Artery Pseudoaneurysm after Surgery for Non-union of Tibia: A Case Report with Review of Literature.

Introduction: Arterial pseudoaneurysm is a hematoma that is formed after damage to the arterial wall. We report a rare case of peroneal artery pseudoaneurysm after open reduction and internal fixation with interlocking nailing and partial fibulectomy for non-union for the right tibia in a 31-year-old male. The patient presented with a bleeding sinus over the leg swelling, and it was managed with an exploration of the pseudoaneurysm and ligation of the peroneal artery. Case Report: A 30-year-old male patient presented with a non-union tibia on the right side and had undergone plating of the tibia at another institute for a fracture of both bone legs approximately 18 months ago. The revision surgery was performed in which a previously inserted implant was removed and an interlocking nail was inserted, along with a partial fibulectomy. The post-operative period was uneventful. At 8 weeks after the second surgery, the patient came with a complaint of swelling at the outer aspect of the right leg. Computed tomography and angiography confirmed a peroneal artery pseudoaneurysm of 3.2 × 2.8 × 3.8 cm. Pseudoaneurysm was explored, and the artery was overrun with a Figure-8 stitches using a monofilamentous, and non-absorbable suture. Conclusion: This case report highlights the occurrence of pseudoaneurysm after an orthoapedic procedure such as a partial fibulectomy. A high level of clinical suspicion, proper imaging, and early endovascular or surgical intervention is recommended to prevent complications.

Extra Articular Supracondylar Femur Fractures Managed with Locked Distal Femoral Plate or Supracondylar Nailing: A Comparative Outcome Study.

INTRODUCTION: Despite recent evolution in the operating techniques and surgical implants, debate continues around the choice of implant for management of distal femur fractures. High rates of complications and union difficulties continues to make them a momentous therapeutic challenge. AIM: To compare the outcome of locked compressive plating versus retrograde nailing in the management of extra articular supracondylar femur fractures. MATERIALS AND METHODS: In this randomized prospective study, 42 patients with extra-articular distal femur fractures were segregated into two groups based on internal fixation with distal femoral locking plate (n=22) and retrograde nail (n=20). Clinical and radiological parameters were studied and functional evaluation was done at 18 months with KSS score. RESULTS: A significant difference in terms of mean duration of surgery and intraoperative blood loss was discerned in favour of plating group although complication rates were equivalent between the groups. Mean duration until union was 26.5 weeks (SD=12.9; range 12 to 64 weeks) in the locked plating and 22.6 weeks (SD=13.1: range 12 to 60 weeks) in the retrograde nail group. The difference came out to be statistically insignificant. Fractures in nailed patients united earlier but the difference was not statistically significant with similar overall union rates. Functional scores too were comparable between them. We deduce that surgical planning and expertise rather than the choice of implant are more crucial for optimal results. CONCLUSION: Nailing proved more cumbersome intraoperatively due to escalated operating time and blood loss and successive anterior knee pain necessitating implant removal but this detriment may be offset by an inclination towards earlier union. With Less Invasive Stabilization System (LISS), technical errors are more common and less forgiving and must be overcome with proper preoperative planning and intraoperative attention to detail.

Epidemiology of knee osteoarthritis in India and related factors.

BACKGROUND: Among the chronic rheumatic diseases, hip and knee osteoarthritis (OA) is the most prevalent and is a leading cause of pain and disability in most countries worldwide. Its prevalence increases with age and generally affects women more frequently than men. OA is strongly associated with aging and heavy physical occupational activity, a required livelihood for many people living in rural communities in developing countries. Determining region-specific OA prevalence and risk factor profiles will provide important information for planning future cost effective preventive strategies and health care services. MATERIALS AND METHODS: The study was a community based cross sectional study to find out the prevalence of primary knee OA in India which has a population of 1.252 billion. The study was done across five sites in India. Each site was further divided into big city, small city, town, and village. The total sample size was 5000 subjects. Tools consisted of a structured questionnaire and plain skiagrams for confirmation of OA. Diagnosis was done using Kellgren and Lawrence scale for osteoarthritis. RESULTS: Overall prevalence of knee OA was found to be 28.7%. The associated factors were found to be female gender (prevalence of 31.6%) (P = 0.007), obesity (P = 0.04), age (P = 0.001) and sedentary work (P = 0.001). CONCLUSIONS: There is scarcity of studies done in India which has varied socio geographical background and communities. We conducted this study for analyzing the current prevalence of OA in different locations. This study has evidenced a large percentage of population as borderline OA; therefore, it depends mainly on the prevention of modifiable risk factors to preserve at ease movement in elderly population through awareness programs.

Evaluation of Vacuum Assisted Closure Therapy for Soft Tissue Injury in Open Musculoskeletal Trauma.

INTRODUCTION: The application of controlled levels of negative or sub atmospheric pressure for a prolonged period of time on a wound had shown to accelerate removal of excess fluid and promote hyperaemia, which eventually promote wound healing. AIM: The study was conducted with the aim to evaluate the effectiveness of Vacuum Assisted Closure (VAC) therapy for soft tissue injury in open musculoskeletal trauma. MATERIALS AND METHODS: Twenty cases of complex musculoskeletal wound involving different parts of body were included in this progressive randomized study. In patients, aggressive debridement was done before the application of VAC therapy. Controlled negative pressure was uniformly applied to the wound. Dressings were changed after every 4 to 5 days. The evaluation of results included healing rate of the wound, eradication of infection, complication rate, and number of secondary procedures. RESULTS: VAC therapy over the wound was administered for an average of 20.4 days ±6.72 days (range 14 to 42 days). There was decrease in wound size attained by VAC therapy ranged from 2.6 to 24.4cm(2), with an average reduction of 10.55 cm(2). Three wounds were infected at the start of VAC therapy. However, all patients were cleared of bacterial infection by the end of VAC therapy. CONCLUSION: VAC therapy using negative pressure promote Wound healing by increasing local capillary perfusion and increased rate of granulation tissue formation, decreases the duration of wound healing and requires fewer painful dressing change.

Early Conversion of External Fixation to Interlocked Nailing in Open Fractures of Both Bone Leg Assisted with Vacuum Closure (VAC) - Final Outcome.

INTRODUCTION: Management of compound grade III fractures of both bone leg includes external stabilization for long period, followed by various soft tissue coverage procedures. Primary interlocking of tibia had been also done with variable results. External fixation for long time without any bone loss often leads to infected nonunion, loss of reduction, pin tract infection and failure of fixation, primary interlocking in compound grade III fractures had shown high medullary infection rate. We managed all cases of compound grade III A/B fractures with primary external fixation, simultaneous wound management using vacuum assisted closure (VAC) followed by early conversion to interlocking within 2 weeks of fixator application. AIM: To determine the effectiveness of vacuum assisted closure (VAC) for the early conversion of external fixator to definitive interlocking in open fractures of the both bone leg. MATERIALS AND METHODS: In current study we selected 84 cases of compound grade IIIA/B diaphyseal fractures of both bone leg during period of May 2010 to September 2013. We managed these cases by immediate debridement and application of external fixation followed by repeated debridement, application of vacuum assisted closure (VAC) and conversion to interlocking within two weeks. RESULTS: Out of 84 cases union was achieved in 80(95%) of cases with definitive tibial interlocking. Excellent to good result were obtained in 77(91.8%) of cases and fair to poor result seen in rest of 7(8.2%) of cases according to modified Ketenjian's criteria. 5 out of these 7 poor result group cases were from Compound Grade III B group to start with. Deep infection rate in our series were 7% i.e. total 6 cases and 4 out of these were from compound Grade III B group to start with. CONCLUSION: Vacuum assisted closure (VAC) give a good help for rapid closure of the wound and help in early conversion to definitive intramedullary nailing. Reamed nail could well be used in compound grade IIIA/B fractures without increasing the risk of infection. It gives better stability to fracture site and lessen the risk of implant failure.

Fixation with cancellous screws and fibular strut grafts for neglected femoral neck fractures.

PURPOSE: To review the outcomes of fixation with cancellous screws and fibular strut grafts for neglected femoral neck fractures. METHODS: 44 men and 28 women aged 17 to 50 years with neglected femoral neck fractures of the subcapital (n=12), transcervical (n=57), or basal (n=3) types underwent closed (n=39) or open (n=33) reduction and fixation with a single cancellous screw with double fibular strut grafts (n=24) or fixation with double cancellous screws with a single fibular strut graft (n=48). The mean time from injury to surgery was 10 weeks; the delay was 22 to 35 days in 43 patients and >35 days in 29 patients. Double fibular strut grafts were used for 18 patients with longer delay and resorption of the femoral neck, and 18 patients with posterior comminution of the femoral neck. The outcome was assessed using the Harris hip score. RESULTS: Patients were followed up for a mean of 3 years. The time to bone union was 3 to 4 months in 48 patients, 4 to 5 months in 15, and 5 to 6 months in 5; nonunion was noted in 4 patients. In 18 patients with resorption of the femoral neck, bone union took a longer time. The Harris hip score was excellent (90-100) in 30 patients, good (80-89) in 20, fair (70-79) in 15, and poor (<70) in 7. Of the latter, 4 had nonunion and 3 developed avascular necrosis of the femoral head; they had persistent pain and restriction of hip joint movement. CONCLUSION: Fixation with cancellous screws and fibular strut grafts for neglected femoral neck fractures is cost-effective and technically less demanding, and associated with good outcomes.

Complete Traumatic Separation of Proximal Femoral Epiphysis in A 2 Year Old Child.

INTRODUCTION: Hip fractures are very common in adults, but are rare in children, comprising less than 1% of all pediatric fractures. Separation of the proximal femoral epiphysis can occur in a child with a traumatic hip dislocation and an open epiphysis. Regardless of the mechanism of proximal femoral epiphyseal separation, the prognosis is poor secondary to the development of osteonecrosis. CASE REPORT: Here we are reporting a case of complete separation of the proximal epiphysis of the femur in a 2 year old female child. She was treated by open reduction and internal fixation by a single k-wire of proximal femoral epiphysis. Regular follow up showed fusion of proximal femoral epiphysis at about 3 months of post operative period. After 8 months of follow up she can stand and walk without support. Long term outcome is awaited. CONCLUSION: Traumatic separation of the proximal femoral epiphysis is a rare but devastating injury because osteonecrosis occurs in most cases. In our study we found fusion of the proximal femoral epiphysis to the neck after 3 months of postoperative period. But to comment upon the final outcome a long follow up is awaited.

Periprosthetic Femoral Fracture With Broken Implant Insitu: - A Treatment Prospect.

INTRODUCTION: Fractures involving bones containing a component of a prosthetic joint are becoming more common. The causation is multifactorial but most of these injuries are associated with trivial trauma. The options available for operative management of these fractures include internal fixation of the fracture alone, fixation of the fracture with revision of the prosthesis, and reconstruction of proximal femur with either modified impaction bone grafting or proximal femoral replacement. CASE REPORT: We present here a case of periprosthetic fracture Vancouver type B1 with a broken cemented bipolar prosthesis insitu, in which the broken implant was firmly fixed in the proximal fragment and could not be removed following which the whole of the proximal fragment along with the broken implant was removed and replaced by a customized steel long stem cemented mega prosthesis. CONCLUSION: This case is being presented on account of its unusual presentation and fracture pattern. A broken prosthesis along with a periprosthetic fracture is not a common incident. Thus the treatment had to be individualized. Since the prosthesis was well fixed, its broken stem could not be removed from the proximal fragment and so the whole of the proximal fragment along with stem was removed and replaced with a long stem custom made bipolar prosthesis.

Flatfoot in Indian population.

PURPOSE: To compare outcomes of different conservative treatments for flatfoot using the foot print index and valgus index. METHODS: 150 symptomatic flatfoot patients and 50 controls (without any flatfoot or lower limb deformity) aged older than 8 years were evaluated. The diagnosis was based on pain during walking a distance, the great toe extension test, the valgus index, the foot print index (FPI), as well as eversion/ inversion and dorsiflexion at the ankle. The patients were unequally randomised into 4 treatment groups: (1) foot exercises (n=60), (2) use of the Thomas crooked and elongated heel with or without arch support (n=45), (3) use of the Rose Schwartz insoles (n=18), and (4) foot exercises combined with both footwear modifications (n=27). RESULTS: Of the 150 symptomatic flatfoot patients, 96 had severe flatfoot (FPI, >75) and 54 had incipient flatfoot (FPI, 45-74). The great toe extension test was positive in all 50 controls and 144 patients, and negative in 6 patients (p=0.1734, one-tailed test), which yielded a sensitivity of 96% and a positive predictive value of 74%. Symptoms correlated with the FPI (Chi squared=9.7, p=0.0213). Combining foot exercises and foot wear modifications achieved best outcome in terms of pain relief, gait improvement, and decrease in the FPI and valgus index. CONCLUSION: The great toe extension test was the best screening tool. The FPI was a good tool for diagnosing and grading of flatfoot and evaluating treatment progress. Combining foot exercises and foot wear modifications achieved the best outcome.

Metastatic adenocarcinoma of Proximal Femur treated by Custom made Hip Prosthesis.

INTRODUCTION: Bone is the third most common site of metastatic disease. Treatment of metastatic tumours of proximal femur usually used to be either palliative in the form of radiotherapy and chemotherapy or a very radical in form of hemipelvectomy and hip disarticulation. Both forms of treatment were associated with dismal outcomes. Now with the technological advancement and refinement in surgeries a custom made hip prosthesis offers a much better treatment option to the surgeon and a good quality life to the patient. CASE PRESENTATION: We are presenting a case of metastatic adenocarcinoma of upper end of left femur with pathological fracture with a small primary in right lung treated with custom made hip prosthesis. Patient received chemotherapy for primary lesion and is doing well at 11 months of follow up. CONCLUSION: This case is being presented on account of its unusual presentation and to give emphasis that in spite of metastatic disease, patient can be considered for limb salvage and megaprosthesis to improve his/her quality of life. This can be considered provided patient's general condition permits and if only a single solitary metastasis is present.