Prospective Evaluation of Role of Limb Reconstruction System (Rail External Fixator) in Open Fractures and Infected Non-union of Femur.

INTRODUCTION: Severe open fractures continue to be a nightmare for orthopedicians even with use of more accepted line of treatment. Open fractures and infected non-union of femur bone are not infrequently seen in orthopedic wards as femur is the most common long bone injured. We present a case series of 14 such patients treated successfully with limb reconstruction system enabling recovery to pre-injury status and activities. CASE SERIES: The present study was done to access the role of limb reconstruction system in the management of open femur fractures and in infected non-union with modifications to meet the requirements of each case. We viewed the results of treatment of 14 cases of late presentation with complicated open femur fractures and infected non-unions. Average time of fixator removal was 4 months-24 months. Average follow-up duration was 18 months (range 6-36 months). Evaluation of results was based on ASAMI criteria. The excellent bone results were obtained in 85.72% of cases while 7.14% showed good and 7.14% were poor results. Excellent functional results were observed in 71.43% of cases and 28.57% of cases shows good and fair results. CONCLUSION: The use of limb reconstruction system is based on compression and distraction technique. It was found to be a simple and effective modality for open injuries in terms of enhanced union rate, rapid rehabilitation, and easy care of soft-tissue injury along with bone loss, thus avoiding multiple surgeries.

Neglected posterior dislocation of elbow: A review.

Untreated traumatic posterior dislocation of the elbow joint, 3 weeks or older, is defined as "neglected posterior dislocation of the elbow". Around 90% of these are of posterolateral type. These are much more common in the developing and underdeveloped countries. Patients presents with a deformed, stiff and painful elbow with difficulty to perform activities of daily living. The clinical picture looks quite similar to malunited supracondylar fracture of the elbow. Diagnosis is usually confirmed radiographically. CT and MRI scan give additional information and are recommended before embarking on surgery. Treatment is quite challenging due to the significant soft tissue contractures, ligamentous insufficiencies and fibrosis, with possible associated nerve injuries, myositis ossificans, non-compliant patients and the need for long-term postoperative physiotherapy. Goal of surgical treatment is to achieve a painless, stable and mobile elbow with a congruent joint space. We have reviewed the literature and present our view on the prognosis and recommended surgical technique to treat this condition.

Outcome of limb reconstruction system in tibial infected non-union and open tibial diaphysial fracture with bone loss.

INTRODUCTION: Incidence of open fractures of the long bones is increasing due to the increase in road traffic accidents (RTA) which leads to an increased incidence of complex non-unions of long bones. Patients are usually operated many times for fracture fixation (and healing) or to eradicate infection, which causes soft tissue scarring and devitalization of any surviving bone. OBJECTIVE: In this study, we assess the outcome of the Limb reconstruction system in tibial infected non-union and open tibial diaphyseal fracture with bone loss. METHOD: It is a prospective study conducted on 15 patients and patients included in this study having compound fractures of shaft tibia with bone loss classified by Gustilo-Anderson open fracture classification. With the defect in the distal tibia, proximal corticotomy 1.5 cm distal to the last screw in the proximal clamp and proximal to distal transports were done and vice versa. All patients were evaluated with the ASAMI scoring system into bone results and functional results. RESULTS: In the majority of patients, the injury was caused by road traffic accidents 80% of cases. Out of 15 cases, 2 belong to the upper 3rd, 9 cases belong to the middle 3rd and 4 cases belong to the lower 3rd of shaft tibia. The union time ranges from 4 to 11 months but the maximum union was achieved in 7-9 months in 8 (53.33%). Pin tract infection was reported in two (13.33%) patients who became better with regular dressing. Ankle stiffness was present in one case (6.67%), most probably due to improper physiotherapy.According to ASAMI Criteria excellent radiological results were present in 11 (73.33%) cases, good results were found in 4 (26.67) cases and excellent functional results were observed in 7 cases (46.67%) and good results were found in 8 (53.33%) cases. Infection was cured in all patients and did not recur till the last follow-up. CONCLUSIONS: Advantages of rail fixator include less invasive surgery, early weight-bearing, less infection, less blood loss, prevention of diffuse osteoporosis and atrophy, preservation of limb function, no need for bone grafting, correction of deformity during the process of healing, thus no need for a second surgery. Non-union, bone defect, and deformity can be corrected simultaneously. Hence, we recommend the use of this system (rail fixator) especially for infected non-union of long bones and compound fractures with bone loss.

Recurrence of Giant Cell Tumor in Fibular Graft Used for Treatment in Primary Giant Cell Tumor of Distal End Radius: A Case Report and Surgical Treatment with Excision of Tumor with Proximal Row Carpectomy with Ulnocarpal Fusion.

INTRODUCTION: Giant cell tumor (GCT) at Distal End Radius (DER) have relatively aggressive nature and higher recurrence rate and malignant transformation than their other counterparts. There is no case reported till now of GCT recurrence in grafted fibula used for reconstruction in managing primary DER-GCT. The purpose of the study is to report the recurrence of GCTin fibular graft used for treatment in primary GCT of DER. CASE REPORT: A 40-year-old female was diagnosed with Campanacci Type 3 GCT-DER 7-year back. The patient was operated and treated by excision of tumor and reconstruction with contralateral fibular grafting with K-wire fixation of DER7-year back and biopsy of growth was sent. After 7 years, the patient again developed swelling over the right wrist and radiological diagnosis of GCT Campanacci Grade 3 is made. She is managed by resection of tumor tissue by volar approach to DER with proximal row carpectomy with ulnocarpal fusion with retrograde K-wire fixation of the 3rd metacarpal resulting in centralization of ulna. CONCLUSION: Recurrence in GCT also occurs at donor fibula used in reconstruction for primary treatment and could be safely managed by wide excision and centralization of ulna with good results.

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.

Is it necessary to use chemoprophylaxis in Indian patients after hip surgery?

AIM: To know the incidence of postoperative deep vein thrombosis after hip surgery in Indian patients. METHOD: Our study comprises 108 patients undergoing major lower limb orthopaedic surgery. Evaluation by colour Doppler ultrasonography to detect DVT was performed on both lower limbs between seventh and 14th postoperative day. There were 15 total hip replacements (THR), 50 bipolar hemiarthroplasties and 43 proximal femoral fixations by intra-/extra-medullary implant. Only 17 (15.74%) patients showed Colour Doppler evidence of DVT without any complication. RESULTS: In THR patients, incidence of DVT is 20%; in bipolar hemiarthoplasty, it is 16%; and in the proximal femoral fixation, it is 13.95%. No case developed pulmonary embolism, and the current figure for the incidence of DVT is 15.74%. CONCLUSIONS: From our study, it appears to be the difference in incidence of DVT in our country and in western countries, but incidence is not rare. Hence, chemoprophylaxis is necessary in Indian patients.

Tubercular osteomyelitis of the lateral-third of the clavicle.

An elderly women with a chronic history of pain and swelling of the right clavicle was investigated. She also had constitutional symptoms. Clinical examination showed mild inflammatory signs over the lateral one-third of the clavicle and the swelling was hard. Clavicle X-ray showed a lytic lesion in the lateral-third of the clavicle and MRI revealed a focal hyperintense area with cortical breach involving the superior cortex of the clavicle. The diagnosis was confirmed as tubercular osteomyelitis after the biopsy, which showed chronic granulomatous inflammation, and the culture was positive for Mycobacterium tuberculosis. Pain resolved by 6 weeks, swelling by 4 months and complete radiological resolution was seen at 15 months after the initiation of antitubercular therapy. No deficit in function was seen. No relapse was noted at 1-year follow-up.

Comparative study of the results of compound tibial shaft fractures treated by Ilizarov ring fixators and limb reconstruction system fixators.

PURPOSE: Ilizarov ring fixator and limb reconstruction system (LRS) fixators have been used in the management of complex tibial fractures with severe soft tissue injuries, compound tibial fractures, and infected tibial nonunion for which conventional internal fixation cannot be contemplated. Fracture union and distraction osteogenesis can be done simultaneously with these external fixators, allowing early weight bearing. Several previous studies have shown almost equal results of rail and ring fixators for the compound tibial shaft fractures. Thus we performed a prospective study to evaluate the union rate, functional outcome and amount of limb lengthening after the treatment of compound tibial shaft fractures with or without infected nonunion by ring or LRS fixators. METHODS: This prospective study was done at Sarojini Naidu Medical College and Hospital, Agra, India and included 32 patients of compound tibial shaft fractures with or without infected nonunion. There were 26 males and 6 females and the average age was 40 years. Patients were randomly divided into two groups (n=16 for each): one underwent Ilizarov fixation and the other received LRS fixation. Cases were followed up for 3-24 months, 6 months on average from September 2012 to October 2014. Functional and radiological outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria for both rail and ring fixators. RESULTS: Union was achieved in all cases. Radiological outcome was found excellent in 68.75%, good in 18.75% and fair in 12.50% of cases treated by rail fixators whereas it was excellent in 56.25%, good in 18.75%, fair in 12.50% and poor in 12.50% of cases treated by ring fixators. Functional result was satis- factory in 75.00% of cases treated by rail fixator and 68.75% of cases treated by ring fixators whereas the corresponding rate of unsatisfactory was 25.00% vs. 31.25%. CONCLUSION: In our short-term assessment, LRS fixators show a better result than Ilizarov fixators in terms of fracture union and functional outcome with soft tissue care and limb length.

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.

Neglected Posterior Dislocation of Hip in Children - A Case Report.

INTRODUCTION: Traumatic dislocation of the hip in children is a rare injury. We report the outcome of 2 patients of neglected hip dislocation which were treated by open reduction and internal fixation by k-wires. CASE REPORT: We treat 2 children both girls (one was of 4 years and other was 7 years of age). In both cases dislocation was unilateral and was not associated with any facture. Both cases were of posterior dislocation. in both cases open reduction and internal fixation was done by k wires. Hip spica was applied post operatively in both cases. The k wire was removed at 3 to 4 weeks. Patients were allowed to bear weight from gradual to full weight bearing after 6 weeks. CONCLUSION: We conclude that open reduction is a satisfactory treatment for neglected hip dislocation. It prevents not only deformity but also maintains limb length.

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.

Fat Embolism Syndrome in Fracture Tibia Treated By Unreamed Interlocking Nail.

Incidence of Fat embolism syndrome (FES) in fractures is about 16.3 but sometimes it is as high as 50% to 62%. The fat embolism is common in fatty bed ridden patients and in whom reamed interlocking is performed under tourniquet with prolonged injury-surgery interval. However in the case discussed here FES occurred under the exact opposite circumstances. In this 23 year lean and thin female with closed tibia fracture unreamed interlocking was performed without tourniquet & the operative procedure was done within 4 hours after trauma. Her pre-operative investigation were within normal limit. We want to discuss by this case report to highlight that even when risk factors are absent outlier events of FES can occur in any case and symptoms should not be discounted.

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.