Management of delayed vertically unstable pelvic fractures

Current treatment protocols for surgical intervention in unstable pelvic fractures recommend early fixation. For some reasons, patients are referred late after trauma, and surgery imposes difficulties to the patient and the surgeon. This study represents a case series of 16 patients with vertically unstable pelvic fractures who presented 3 weeks or more after the initial trauma to Assiut University Hospital during a period of five years. Time since injury averaged 7 weeks [range 3-32 weeks]. There were 14 males and 2 females. Age of the patients averaged 28 years. There were twelve unilateral and four bilateral type-C pelvic fractures. The posterior injury was iliac bone fracture in 5 patients, sacroiliac joint disruption in 5 and sacral fracture in 10. The anterior injury was symphyseal disruption in 9 patients, pubic rami fracture in 6, and combined pubic rami fracture and symphyseal disruption in one patient. Seven patients had neurologic injuries. Combined posterior and anterior pelvic ring fracture fixation was done in 9 patients. Posterior pelvic fixation alone was done in 7 patients. Radiographic assessment of reduction was done according to Matta and Tornetta, and functional assessment was done using Majeed score. The mean postoperative follow up was 31 months. All fractures healed. Complications included transient L5 palsy [n=1], ilio-femoral DVT [n=l], early metal failure [n=2]. Postoperative fracture displacement averaged 5 mm [range 1-19 mm]. Fracture reduction was considered excellent in 11 patients [69%], good in four patients [25%], and fair in one patient [6%]. Limb length discrepancy ranged from 0-17 mm [average 4 mm]. Functional result was excellent in 12 patients [75%], good in three patients [18.75%] and fair in one patient [6.25%]. This study supports planned surgical intervention for delayed vertically unstable pelvic fractures. Rules of inter-hospital referral should impose early transfer of patients to avoid the additional difficulties of late fixation

Transdermal nitroglycerin enhances lidocaine and neostigmine for intravenous anesthesia in patients undergoing hand surgery. a prospective randomized double blind placebo control study

In a prospective randomized blind study, we investigated the effects of adding transdermal nitroglycerine for lidocaine and neostigmine for intravenous regional anesthesia in adult patients undergoing hand surgery. Sixty patients [ASA grade I, aged 20-60 years] of both sexes were enrolled. The patients were randomly allocated to receive either 40ml of 0.5% lidocaine plus a transdermal placebo patch [control group n=15], 40ml of 0.5% lidocaine with 0.5mg of neostigmine plus a transdermal placebo patch [Neostigmine group, n=15], 40ml of 0.8% lidocaine plus a transdermal nitroglycerine patch [Nitroglycerine group, n=15] or 40ml of 0.5% lidocaine with O.smg of neostigmine plus a transdermal nitroglycerine patch [Neostigmine - Nitroglycerine group, n=15]. All routine hemodynamic parameters and O2 saturation were monitored, surgical time, sensory and motor block onset times, sensory and motor block recovery times and time to first analgesic requirement were measured. Operative conditions and quality of anesthesia were also recorded. Sensory and motor block onset times were shorter in the neostigmine - nitroglycerine group compared with all other groups [p<0.05]. Sensory block recovery time was significantly prolonged and the quality of anesthesia was better in the neostigmine - nitroglycerine group compared with all other groups [p<0.05]. We found that the addition of O.smg neostigmine to 40ml of 0.5% lidocaine for intravenous regional anesthesia with a 5mg transdermal nitroglycerine patch improved the operating conditions and quality of anesthesia and prolonged postoperative relief with no adverse effects

Valgus intertrochanteric osteotomy and dynamic hip screw fixation for trochanteric nonunion

Nonunion of intertrochanteric fractures is uncommon, but gives rise to severe disability. Nonunion is usually preceded by drifting of the fracture into a varus position and external rotation leading to mal-non-union, which presents the difficulty of mal-position, shortening and non-union, Twelve patients with trochanteric nonunion were treated at the authors' institution. They were 7 men and 5 women. Age ranged between 26 to 72 years [average 53 years]. Six patients were not treated before and six presented after failed internal fixation. All patients underwent the same treatment protocol consisting of the following surgical steps: [1] Direct fracture exposure and excision of the fibrous non-union between the fracture fragments, [2] Intertrochanteric valgus osteotomy, and [3] The use of dynamic hip screw [DHS] for internal fixation. Duration of nonunion varied from 16 weeks to 17 months [mean 28 weeks]. The average limb shortening before surgery was 3.4 cm [range 2-5 cm]. Intertrochanteric osteotomy was healed in less than 12 weeks and fracture union was achieved in all patients. Time to fracture union ranged between 12 to 20 weeks [average 14 weeks]. The average valgisation angle was 34° [range 20°-45°], and the average surgical lengthening was 2.6 cm [range 1-4 cm]. An external rotational deformity of the limb of less than 20° persisted in three patients. Avascular necrosis of the femoral head was reported only in one patient. Follow up ranged from 10 to 48 months [average 22 months]. Valgus intertrochanteric osteotomy and DHS fixation provide a good solution for nonunion of trochanteric fractures

Results of open reduction and derotational femoral shortening osteotomy in the treatment of developmental dysplasia of the hip in the child younger than 3 years

Treatment of DDH after walking age is a point of controversy and raise a lot of questions. The material included 17 hips in 14 patients [10 females and 4 mails].Right hip was affected in 8 patients while the left hip was affected in 3 patients; bilateral dislocation in 3 patients. All cases were discovered late when patients started to walk and presented with limping or waddling gait. The age of our patients ranged between 1.5-3 years old. In this age group there are adaptive shortening of the extra-articular soft tissues, acetabular dysplasia, capsular constriction, and increased femoral antiversion. All cases did not receive any previous treatment. Combining derotational femoral shortening osteotomy with open reduction to reduce the incidence of redislocation and avascular necrosis [A VN] were done for all cases. K wire fixation was added between the greater trochanter and the hip bone. The average follow up was 2 years. All patients were evaluated clinically on the basis of rang of motion 9hip stability, limp and pain.Clinically,16 cases were scored excellent according to the modified Mckay criteria.One case developed avascular necrosis. We concluded that Femoral osteotomy [varus derotation and shortening] with open reduction is an effective and recommended approach for treatment of DDH in patients who had begun to walk. The use of K-wire helps maintaining the reduction during femoral osteotomy and during changing of the cast

Surgical tips and tricks for open reduction and internal fixation of intra-articular calcaneal fractures

Twenty-four intra-articular calcaneal fractures in twenty-three patients have been treated by open reduction and internal fixation. Ten were women and thirteen were men. Age ranged from 18 to 45 years. Fracture classification was based on Sanders computed tomographic classification. There were 5 type II, 15 type III, and 4 type IV fractures. All operations were performed using a standard surgical technique with an extended lateral approach, and the fractures were fixed with plates and screws with bone grafting if needed. Average follow-up was 14 months [range, 10-22 months]. The Creighton-Nebraska assessment score was used for clinical evaluation. Radiological and functional assessments were done for all patients at the latest follow-up. Excellent results were achieved in nine fractures, good in twelve, and fair in three. The average score was 93 for type II, 89.2 for type III, and 73.75 for type IV fractures. There was a clear statistically significant superiority with type II and type III fractures treated with open reduction when compared with type IV fractures [p 0.0001]. Open reduction and internal fixation is recommended for all displaced intra-articular fractures of the calcaneus. It restores hindfoot and subtalar joint anatomy so that sub talar arthritis may be avoided

Radiation independent distal aiming device versus the freehand technique in distal locking of unreamed femoral nails: a prospective clinical study

The aim of this clinical study was to compare the distal aiming device [DAD] versus the freehand technique [FHT] in distal locking of unreamed femoral nails inserted in a closed manner. Thirty cases were included in the study. FHT was applied in 15 cases and DAD was used in the other 15 cases. The radiation exposure and operative time during steps of nailing were recorded in each case. In the DAD group, the mean radiation exposure was 66 seconds, the mean radiation exposure during distal locking was 3 seconds, the mean operative time was 93 minutes and the mean time for distal locking was 18 minutes, versus 99 seconds, 33 seconds, 95 minutes and 22 minutes in FHT group, respectively. Failure of distal locking occurred in 16.6% [5 of 30 screws] of DAD group

condylar Buttress plate: an unusual indication for proximal femoral periprosthetic fractures

This study described an unusual application of the condylar buttress plate in a reversed manner to the proximal femur for the fixation of periprosthetic fractures. The plate fitted well to the trochanteric ridge without plate bending, but contouring of the posterior limb of the plate was necessary to conform to the posterolateral aspect of the trochanteric region. In this manner, a stable proximal fixation can be obtained by inserting multiple cancellous screws in the trochanteric mass and by the well-fitted limbs of the plate surrounding the trochanteric mass, both anteriorly and posteriorly. The condylar buttress plate was used with a success in four cases of proximal femoral periprosthetic fractures

Compression arthrodesis of the subtalar joint using two parallel lag screws

Thirteen subtalar fusions in 12 patients were included in this study. In situ arthrodesis was done in 11 fusions and distraction arthrodesis with bone block graft was done in two cases. Stabilization of the fusion was done by two parallel lag screws, one from the talar neck down to the calcaneus and the second from the tuberosity of the calcaneus to the talar body. They exert maximum compression on the subtalar joint, hence postoperative plaster cast was not needed. All cases reached union within 12 weeks. The results of the study showed that the use of two parallel lag screws fixation is a reliable technique for compression arthrodesis of the subtalar joint