Prosthetic replacement of elbow in postburn bony ankylosis: long-term results.

Fifteen patients with 17 post-burn bony ankylosed elbows (two bilateral) fixed at a mean of 72.5 degrees +/- 27.5 degrees flexion were treated with Baksi sloppy hinge elbow arthroplasty. All patients agreed to avoid strenuous use of their replaced elbows. There were four males and 11 females whose ages varied from 21 to 48 years (average 31.6 years). One of the five patients who had severe anterior skin contracture required release. One patient died during the early follow-up period. During the follow-up studies which ranged from 11 to 23 years (average 14.1), eleven patients (68.7%) regained painless stable motion with mean recovery of arc of flexion from 20 degrees +/-10 degrees to 107.5 degrees +/-17.5 degrees with mean range of flexion 90 degrees +/-20 degrees . Good forearm motion was retained in all cases. According to the assessment score (Morrey BF, The elbow and it's disorder, 2nd edn. W.B. Saunders, Philadelphia, 1993), nine (56.2%) patients were recorded as excellent, two (12.5%) as good, and five (31.5%) as poor who were considered as failures. The five failures required removal of the prosthesis but retained acceptable elbow function due to periprosthetic fibrosis connecting the adjacent bone ends.

Sloppy Hinge Prosthetic Replacement in Old Healed Side Swipe Injuries of Elbow - Long term Results.

BACKGROUND: Sideswipe injuries of elbow often poses significant functional loss resulting from devastating injuries involving osseoligamentous structures as well as multilevel soft tissue injuries around the elbow. Inspite of treatment, no conscientious treatment opinion is available in the literature to provide optimum functional outcome. The objective of this study is to evaluate the results of prosthetic replacement of old healed sideswipe injuries of elbow with gross dysfunctional disabilities resulting from loss of bones and muscles around the joint. MATERIALS AND METHODS: Fourteen patients of 2-3 years old healed sideswipe injuries of the elbow, treated by Baksi sloppy hinge (original version in seven and recent version in seven) prosthetic replacement were evaluated. All had normal neurovascular status except two; one having ulnar nerve deficit the other median nerve in another. The mean age was 42.7 years (range 32-61 years). RESULTS: The average followup period was 13.5 years (range 5.11-23.11 years). Ten patients regained stable 0° to 130° elbow flexion, and four had restricted terminal flexion with arc 10°-115° following V-Y plasty of contracted triceps. Mean supination was 22° and mean pronation was 35°. According to Mayo Elbow Performance Score (MEPS), excellent results were in five (35.7%), good in six (42.8%), and fair in one (7.1%). Two patients (14.2%) needed removal of prosthesis due to intractable delayed infection and considered failure. Following removal, the resected elbow retained relatively stable motions due to mature fibrous tissues connecting the adjacent bone ends and reorientation of muscle balance. Postoperative improvement of MEPS (mean 84) was significant (P = 0.0037) compared to preoperative value (mean 41.7). Two patients had superficial wound infection and five aseptic loosening of which one was symptomatic. CONCLUSION: Prosthetic replacement of elbow is an effective salvage procedure in old healed sideswipe injuries.

Osteosynthesis of ununited femoral neck fracture by internal fixation combined with iliac crest bone chips and muscle pedicle bone grafting.

BACKGROUND: Ununited femoral neck fracture is seen commonly in developing countries due to delayed presentation or failure of primary internal fixation. Such fractures, commonly present with partial or total absorption of femoral neck, osteonecrosis of femoral head in 8-30% cases with upward migration of trochanter posing problem for osteosynthesis, especially in younger individuals. Several techniques for treatment of such conditions are described like osteotomies or nonvascularied cortical or cancellous bone grafting provided varying degrees of success in terms of fracture union but unsatisfactory long term results occurred due to varying incidence of avascular necrosis (AVN) of femoral head. Moreover, in presence of AVN of femoral head neither free fibular graft nor cancellous bone graft is satisfactory. The vascularied bone grafting by deep circumflex iliac artery based on iliac crest bone grafting, free vascularied fibular grafting and muscle pedicle periosteal grafting showed high incidence of success rate. Osteosynthesis is the preferred treatment of choice in ununited femoral neck fracture in younger individuals. MATERIALS AND METHODS: Of the 293 patients operated during the period from June 1977 to June 2009, 42 were lost to followup. Seven patients with gluteus medius muscle pedicle bone grafting (MPBG) were excluded. Thus, out of 244 patients, 208 (85.3%) untreated nonunion and 36 (14.7%) following failure of primary internal fixation were available for studies. Time interval between the date of injury and operation in untreated nonunion cases was mean 6.5 months and in failed internal fixation cases was mean 11.2 months. Ages of the patients varied from 16 to 55 years. Seventy patients had partial and 174 had subtotal absorption of the femoral neck. Evidence of avascular necrosis (AVN) femoral head was found histologically in 135 (54.3%) and radiologically in 48 (19.7%) patients. The patients were operated by open reduction of fracture, cannulated hip screw fixation, iliac crest bone chips and quadratus femoris MPBG. RESULTS: The mean followup is 12.5 years (range 3-35). The union of fractures occurred in 202 (82.8%), delayed union in 18 (7.3%), and established nonunion in 24 (9.8%) patients. Full weight bearing was permitted at 16-22 weeks after union of fractures. Mean Harris hip score at the longest followup was 85.5. Among the complications, superficial wound infection occurred in 20 (8.2%), deep infection in seven (2.9%), and coxa vara in 39 (16%) patients. Preoperative radiodensity of femoral head disappeared mostly after the union of fracture whereas fresh radiodensity of femoral head appeared in 20 (8%) patients; nine (45%) of them developed segmental collapse. CONCLUSION: Ununited femoral neck fractureis characterized by absorption of femoral neck, posterior cortical defect, smoothening and overriding of fracture surfaces with intervening fibrous tissues associated with or without AVN of femoral head. The above method of osteosynthesis rectified the above pathology and provided satisfactory results with union of fractures in 90.1% patients at long term followup.

Pes anserinus transposition for patellar dislocations. Long-term follow-up results.

Transposition of part of the pes anserinus was used to treat 96 knees in 78 patients with recurrent, habitual or permanent dislocations of the patella. The knees with habitual (48) and permanent (27) dislocations also had extensive release of superolateral contracture. The patients were reviewed at an average follow-up of 9 years 8 months. The medial stability of the patella had been improved in all the cases. There were no recurrences in 21 knees with recurrent dislocations. There were four recurrences (5.3%) in knees with habitual and permanent dislocations due to inadequate release of the superolateral contracture and incorrect transfer of the whole of the pes anserinus. Correction of these technical errors prevented further recurrence in all four cases.

Restoration of dynamic stability of the patella by pes anserinus transposition. A new approach.

Lateral instability of the patella was found after recurrent, habitual and permanent dislocations. Contracture of soft tissues lateral to the patella only occurred with habitual and permanent dislocations, but medial laxity was present in all cases. After adequate release of the lateral contracture, the medial stability was improved by transposition of the lower three-quarters of the pes anserinus to the medial border of the patella, and the patellar ligament. This created a relatively unstretchable physiological sling which ensured dynamic stability of the patella. Six recurrent, 21 habitual and nine permanent dislocations of the patella were treated by this method. Results were excellent in 21 patients, good in 13 and fair in two. The follow-up period varied from 21 to 84 months. There have been no recurrences to date.

Internal fixation of ununited femoral neck fractures combined with muscle-pedicle bone grafting.

Fifty-six patients with ununited intracapsular fractures of the femoral neck were treated by internal fixation and muscle-pedicle bone grafting. All had some absorption of the femoral neck, and many had avascular necrosis of the femoral head. At operation the sclerosed surfaces of the fractures were freshened, the avascular femoral head was decompressed and the muscle-pedicle graft was fixed with silk thread wrapped around pins. Satisfactory union occurred in 42 patients (75%), and delayed union in seven, of whom four (7%) eventually united without further treatment and three united after osteotomy. Non-union occurred in five patients and technical failure in two.

Treatment of osteonecrosis of the femoral head by drilling and muscle-pedicle bone grafting.

Sixty-one patients with 68 osteonecrotic femoral heads, at different stages of development, were treated surgically; their average age was 36 years. Necrosis followed a fracture in 43 hips and traumatic dislocation in three. It was idiopathic in 14, cortisone-induced in seven and associated with gout in one. The operation of multiple drilling, curettage of the necrotic bone and muscle pedicle bone grafting was performed in all. Cheilectomy of the superolateral part of the femoral head and adductor tenotomy were added in cases of advanced necrosis. Of the several types of muscle pedicle used, tensor fasciae latae anteriorly and quadratus femoris posteriorly were preferred. Full weight-bearing was not permitted for five to six months. The follow-up period varied from three to 12 years. Hip pain was regularly relieved and abduction and rotation of the joints were improved. Those with post-traumatic or idiopathic necrosis did better than those with cortisone-induced necrosis.

Treatment of post-traumatic avascular necrosis of the femoral head by multiple drilling and muscle-pedicle bone grafting. Preliminary report.

Twenty-nine patients with avascular necrosis of the femoral head after injury have been treated by operation. Multiple drilling of the femoral head was performed, necrotic bone removed and a muscle-pedicle bone graft implanted into the head and neck of the femur. In 17 of the patients the necrosis was associated with an un-united femoral neck fracture, in 11 it occurred after the fracture had united, and one case followed reduction of a dislocated hip. The hips became painless soon after operation. The patients were young (average age 35 years), and full weight-bearing was not allowed for several months. The follow-up period ranged from 22 to 64 months. The results were excellent in 20 patients, good in five, fair in three and poor in one.

Sloppy hinge prosthetic elbow replacement for post-traumatic ankylosis or instability.

From 1984 to 1995, 68 ankylosed elbows and 11 which were unstable after trauma were replaced in India by Baksi sloppy hinge prostheses. The mean age of the patients was 28.6 years (17 to 70) and the mean follow-up 9.6 years (2 to 13.5). Of the 68 ankylosed elbows, 59 (87%) regained a mean arc of painless movement of 88.5 degrees (27 to 115). The mean improvement of supination was 24 degrees and of pronation 16.5 degrees . There were 54 good results (80%), eight fair and three poor. There were two complete failures due to infection, and one due to a broken humeral stem. Of the 11 unstable elbows, the nine with good results had a mean arc of 125 degrees (15 to 140) of painless stable movement, with a mean improvement in supination of 26 degrees and of pronation of 19.5 degrees . There was one fair result and one failure due to loosening with subsequent late infection. There were significant complications in 14 cases with infection in seven and aseptic loosening in four. Patients with loosening or late removal of the prosthesis often retained reasonably stable elbow movement because periprosthetic fibrosis had connected the approximated bone ends, and muscle balance had been restored.

Palliative operations for painful old Perthes' disease.

Thirty-one adults with painful old Perthes' disease were treated by subcutaneous adductor tenotomy and cheilectomy of the femoral head with the aim of increasing abduction and rotation of the hip. In addition, multiple drilling was carried out to decompress the femoral head, and muscle-pedicle bone grafting to improve the circulation and repair the necrotic bone. Follow up was from 38 to 120 months. Pain was relieved in every case and movement improved in most. There were 14 excellent, 12 good, 4 fair and one poor result.

Sacrospinalis muscle-pedicle bone graft in posterolateral fusion for spondylolisthesis.

Twenty three patients with lumbar spondylolisthesis (6 Grade I, 14 Grade II and 3 Grade III) with low back pain, and radicular pain in 14, were treated surgically when they failed to respond to conservative treatment. Their average age was 33.2 years. Bilateral posterolateral spinal fusions with autologous iliac bone chips, supplemented by a sacrospinalis muscle-pedicle bone graft on the left side, were undertaken after laminectomy and foraminotomy in all except in two adolescents, where laminectomy and foraminotomy were avoided. The period of follow-up varied from 26 to 126 months (average 65.3 months). The results in 11 (48%) patients were excellent, 9 (39%) were good, 2 (9%) fair and one (4%) poor. There was a higher incidence (87%) of good quality of osseous fusion on the left side, where the sacrospinalis muscle-pedicle bone graft was used, compared to the right, where 70% of fusions were satisfactory. Function improved in 91% of the patients. Neither scoliosis nor weakness of the extensor muscles of the back developed due to reanchorage of the sacrospinalis muscle to the lumbosacral spines.

Modified Boytchev procedure for the treatment of recurrent anterior dislocation of the shoulder.

From January 1990 to December 1998, 48 patients with 50 recurrent anterior dislocations of the shoulder were treated using a modified Boytchev procedure. The age of the patients varied from 18 to 35 years (average 24.7 years). The follow-up period was in average 88 (26-132) months. Six patients were lost in follow-up. Forty-two shoulders showed excellent results. There was one traction injury of the musculocutaneous nerve and one patient with immediate recurrence of the dislocation. Superficial wound infection occurred in five cases, all of which were controlled by antibiotics.