A new technique to reattach an extended trochanteric osteotomy in revision THA using suture cord.

UNLABELLED: The extended trochanteric osteotomy (ETO) is widely used for revision total hip arthroplasty (THA). We describe a novel technique to reattach the extended trochanteric osteotomy using a suture cord. We retrospectively reviewed 20 patients who underwent revision by this technique with a minimum followup of 2 years (mean, 2.2 years; range, 2-4 years). Bony union of the osteotomy occurred in 19 patients and fibrous union in one patient who remained asymptomatic. We observed proximal migration of the osteotomy fragment in one patient (5 mm) who had bony union of the osteotomy. This technique of anchoring the osteotomy fragment directly onto the prosthetic stem using a suture cord provides a secure fixation and does not endanger the blood supply of the osteotomy. It also has the advantage of avoiding the morbidity associated with cerclage wires and the costs associated with cabling systems. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Results of ring (Ilizarov) fixator in high energy Schatzker type VI fractures of proximal tibia.

BACKGROUND: High-energy fractures of proximal tibia (Schatzker VI) are associated with severe articular depression, separation of both condyles, diaphyseal comminution & dissociation with loss of integrity of the soft-tissue envelope. Complications of plating are well known since last 50years in these difficult fractures. An alternative method was proposed by Ilizarov (ring fixator) and was adopted for the treatment of these complex injuries. AIM OF STUDY: To analyse the results of patients who had ring fixator for the management of high-energy fractures (Schatzker VI) of the proximal tibia.Material & Methods: Fifteen patients (mean age of 36years) with high-energy fractures of the proximal tibia (Schatzker VI) by the Ilizarov fixator and transfixion wires. Nine fractures were open and six patients had severe soft tissue injuries. Thirteen were treated by ligamentotaxis and percutaneous fixation. All were followed for a mean of 19.4 months. Using the criteria established by Honkonen & Jarvinen (1992), the outcome was analysed. RESULTS: Fourteen fractures united, with an average time to healing of 14.6 weeks and one took six months. 12 patients achieved full extension and 8 patients regained more than 110° of flexion. All knees were stable with one patient uniting in mild varus deformity. Normal walking was observed in nine patients and four had a mild limp. All but one knee had an articular step-off of less than 4 mm and all had normal axial alignment except one. The outcome suggested that seven knees were excellent, seven good and one as fair. There were no cases of postoperative skin infection or septic arthritis, but three cases had pin tract infection who were treated successfully. CONCLUSION: The technique is well suited for the management of complex fractures of the proximal tibia (Schatzker VI) when extensive comminution at the fracture site and compromise of the soft tissue is present.

Spinal Deformity Correction in Duchenne Muscular Dystrophy (DMD): Comparing the Outcome of Two Instrumentation Techniques.

STUDY DESIGN: A retrospective matched cohort study. PURPOSE: To compare the results of combined Luque rod-sublaminar wiring (thoracic) and pedicle (lower lumbar) instrumentation (SLW) versus those with pedicle screw fixation (PS) for scoliosis correction in Duchenne muscular dystrophy (DMD). OVERVIEW OF LITERATURE: PS fixation is gaining popularity. Two instrumentation systems were not compared before in a matched cohort of patients. METHODS: Two groups of patients with DMD were matched according to the age at surgery, magnitude of deformity and vital capacity. Indications for surgery included loss of sitting balance, rapid decline of vital capacity and curve progression. In group 1 (22 patients) SLW fixation was used from T2/3 to pelvis or sacrum. In group 2 (18 patients) PS fixation was used from T2/3 to L5. Five patients had all level segmental PS fixations. Minimum follow-up was 2 years (range, 2 to 13 years). Radiographs, lung function tests and subjective/objective assessment were performed at standardized intervals. RESULTS: Mean Cobb angle in group 1 improved from 45.3° (range, 26 to 75°) to 17.7°(range, 0 to 37°) and mean pelvic obliquity improved from 14.5° (range, 8 to 28°) to 5.6° (range, 0 to 15°). Mean Cobb angle in group 2 improved from 42.8° (range, 28 to 80°) to 7.3° (range, 0 to 20°) and mean pelvic obliquity improved from 11.2° (range, 7 to 30°) to 2.0° (range, 0 to 5°) (p < 0.05). Mean operating time and blood loss were less in group 2 (p < 0.05). In group 1, the infection rate and instrumentation failure was higher, and subjective/objective outcomes showed no significant difference between the groups. CONCLUSIONS: PS fixation had superior correction and controlled pelvic obliquity without the need for pelvic fixation.

Radiolucent lines below the tibial component of a total knee replacement (TKR)--a comparison between single-and two-stage cementation techniques.

Early non-progressive horizontal radiolucent lines (RLLs) (<2 mm) under the tibial component following cemented total knee replacement (TKR) are considered to result from poor cement injection into cancellous bone. These RLLs may facilitate the entry of joint fluid and wear debris into the interface, which may proceed to ballooning osteolysis. There is currently no consensus on the preferred cementing technique (single- versus two-stage cementation) in TKR. We have prospectively analysed postoperative radiographs in 50 consecutive TKRs to compare the RLLs following single- (25 TKRs) and two-stage (25 TKRs) cementation techniques. Of the TKR radiographs studied, 26 (52%) had RLLs; nine (36%) of these were single-stage TKRs, and 17 (68%) were two-stage TKRs. This study demonstrates that single-stage cementing may be superior to the two-stage technique in terms of avoiding RLLs in immediate postoperative TKRs.

Simple elbow dislocation among adults: a comparative study of two different methods of treatment.

Post-manipulation treatment of elbow dislocation includes plaster of Paris immobilisation for a mean of 2 weeks followed by physiotherapy, or sling support followed by early mobilisation. This study retrospectively reviewed 42 simple elbow dislocations. The management of 20 patients by the plaster of Paris method and 22 by the sling method was assessed after a minimum follow-up of 2 years using Mayo Elbow Performance Index (MEPI) scores, the Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and time off work. The final functional outcome in the plaster of Paris group showed 10 excellent, 2 good, 5 fair and 3 poor results, compared with 19 excellent, 1 good and 2 fair results in the sling group. The mean times to return to work in plaster of Paris group and sling group were 6.6 and 3.2 weeks, respectively (p<0.001). Early mobilisation did not result in redislocation or late instability of the elbow. Thus the final functional outcome of the sling and early mobilisation group was significantly better than in the plaster of Paris immobilisation group.

Open grade III "floating ankle" injuries: a report of eight cases with review of literature.

INTRODUCTION: "Floating ankle" injuries result from high-energy trauma and are usually associated with extensive soft tissue damage. Such rare and complex injuries in the acute phase pose therapeutic dilemma to the treating surgeon. When salvage instead of amputation is preferred, a variety of treatment options are available ranging from open reduction along with minimal internal fixation to external fixation. In this retrospective case series study we report eight patients with open "floating ankle" injuries who had been treated with external fixation with or without internal fixation. MATERIALS AND METHODS: Eight consecutive patients (7M: 1F) with mean age of 28 years (range 18-35 years) were treated. All had Grade III open fractures of the distal tibia with foot fractures and various degrees of soft tissue injuries. ISS and MESS were used to assess injury severity. Immediate radical wound debridement; skeletal stabilization and early soft tissue coverage were done by combined trauma and plastic surgical services followed by standard post-operative rehabilitation. All the patients were assessed with SF-36 questionnaire at mean follow-up of 2.5 years (range 2-4 years). RESULTS: Three patients were treated primarily with Ilizarov ring fixators, one had hybrid fixation and the other four had Hoffman frames. Four patients needed further surgeries. One patient developed metatarsal osteomyelitis, which was debrided and treated with antibiotics. The SF-36 results were compared with age matched UK norms for men and women in all categories. Only two patients returned to their previous employment. Six suffered varying degrees of disability out of which one underwent amputation. CONCLUSIONS: External fixation with or without internal fixation is an option when salvaging rare injuries like open grade III "floating ankle" injuries. Salvaged patients do suffer a cocktail of crippling disease characterized by psycho-socio-economic and physical disability and result in increased hospital costs. We recommend more prospective studies with long-term follow-up of such complex injuries to identify the indications for salvage and also the criteria for a successful salvage.

Chemonucleolysis revisited: a prospective outcome study in symptomatic lumbar disc prolapse.

OBJECTIVE: This prospective study was carried out to assess the functional outcome in patients with symptomatic lumbar disc prolapse treated by chemonucleolysis (CNL). METHODS: The Oswestry Low Back Pain Disability Index (ODI) was used to assess the pre- and postprocedure functional status of 112 patients with magnetic resonance (MR) scan-proven lumbar disc prolapse treated by CNL. Follow-up was for at least 5 years. RESULTS: Ninety-three of 112 patients (83%) had excellent/good results, whereas 11 of 112 (10%) were unchanged and 8 of 112 (7%) were worse after the CNL. The younger patients with single-level discs at L5-S1 had the most successful outcome. Seventy percent of our patients (25-45 years of age) were gainfully employed with a mean return to work at 12 weeks. CONCLUSIONS: CNL is a good procedure to bridge the gap between conservative treatment and surgery for lumbar disc prolapse. CNL is beneficial in 80% of patients with significant leg symptoms. After careful selection of candidates using MR scans, it is an effective procedure that does not compromise future open surgery, should it be necessary.