Role of proximal femur locking plate fixation in certain unstable trochanteric fractures.

Background: Comminution of the lateral trochanteric wall, postero-medial communition, reverse oblique fractures, fractures involving communition of greater trochanter are unstable fractures which had poor results with the regular methods of fixation. Our aim in this study is to evaluate radiological and functional outcome at the end of one year following proximal femur locking plate fixation for certain group of unstable intertrochanteric fractures. Methods: 20 patients (14 male and 6 female patients) with per trochanteric fractures underwent proximal femur locking plate fixation in Sri Ramachandra Medical College hospital. Intertrochanteric fractures were classified according to Boyd and Griffin. Mean age of the patients was 55.2 years (26-82 years). The Schatzker & Lambert Criteria used to evaluate the functional outcome at the end of one year. Minimum follow up period was six months and maximum follow up was one year. Results: The functional outcome was assessed by Schatzker and Lambert criteria and was excellent in 8 patients; good in 6, Fair in 4 and Poor in 2.The average time to bear weight fully and walk was 6.5 weeks. Conclusions: Union was achieved in unstable, comminuted trochanteric fractures without significant complications and neck shaft angle was maintained in majority of the cases following proximal femur locking plate fixation.One of the major drawbacks of using proximal femur locking plate is that weight bearing is to be controlled and done only after radiological evidence of callus formation.

Osteofibrous dysplasia of the proximal tibia: an illustrative case report.

A 5 years old girl presented 3 years back with pain and swelling over the upper right leg for 2 years duration. X-ray, CT and MRI revealed osteolytic well defined lesion 2.5 × 2 cm in the meta-diaphyseal region of the proximal tibia with pathological fracture of anterolateral cortex. Child underwent thorough curettage of the lesion and the defect was filled with allograft (iliac crest graft) from mother which was harvested in an adjacent operation theatre. The limb was protected with a plaster splint for a period of 3 months. The graft gradually consolidated and new bone formation was apparent by 6 months. Remodelling of the medullary canal occurred at 1 year follow up. Child has been followed up to 3 years (till date) and there is no evidence of recurrence. The case illustrates that osteofibrous dyplasia can be effectively treated by curettage and replacement of defect by allograft from parents.

Functional outcome of displaced tibial plateau fracture treated by Illizarov fixator.

The tibial plateau fracture is a typical example of complex periarticular trauma, which has been and continues to be a considerable clinical challenge to the orthopaedician in terms of decision-making in management. Residual functional deficits in case of complex knee trauma treated with open reduction and internal fixation even when delayed till recovery of soft tissues were found to be significant. With this knowledge, we proposed to conduct a study on the effectiveness of the Illizarov technique in management of displaced tibial plateau fractures. Methods: Prospective study of twenty two cases of complex tibial plateau fracture treated with Illizarov fixator done in Sri Ramachandra medical centre between June 2011-June 2013. The inclusion criteria were closed Schatzker type V & type VI tibial plateau fracture. The exclusion criteria were Schatzker Type I, II, III and IV tibial plateau fracture and any other associated lower limb fractures. The post op outcome was measured using the knee society score at each follow up and the final scoring was done at the final follow up. Results: The average knee society knee score was 78.09 and the average function score was 93.5. We had 95% of excellent/good result. Conclusions: Illizarov technique gives good to excellent results in high energy closed and open tibial condylar fractures. The Illizarov method offers significant advantage in the case of fracture blisters with impending compartment syndrome associated with closed high energy tibial plateau fractures. Illizarov technique provides the greatest advantage of ability to maintain the functional status of the extremity.

Analysis of SNRB in patients with lumbar radiculopathy resistant to conservative treatment.

Background: The transforaminal application performed with SNRB (Selective nerve root blocks) should be more accurate. Moreover, the amount of corticosteroid and local anesthetic can be reduced compared to the amount of these agents administered with the epidural steroid. Methods: Prospective study of 72 patients with low back pain done in Sri Ramachandra medical centre, Chennai during April 2012 to April 2014. 46 patients were diagnosed to have inter vertebral disc and 26 patients with Lumbar canal stenosis. The patients were evaluated using VAS score and Oswestry disability index. The indication and determination of the therapeutic SNRB level was established by the spine surgeon after all the diagnostic test results had been obtained and after a detailed discussion with the patient. After confirming the correct placement of spinal needle with a short bevel with the help of contrast, a solution of 1ml of 0.5% sensorcaine with 1 ml of triamcinolone acetonide (Inj. kenocort) is injected. Results: Only 2 patients out of 72 had persistent pain and underwent surgery. 60 of our patients were comfortable and were able to proceed with their normal life/day to day activities following the administration of one block. Conclusion: Selective nerve root block is effective and less invasive intervention, and serves as an adjunct to non-operative treatment. The blocks give the best result in disc herniation cases, followed by favorable results in foraminal stenosis.

The MESS: is it must.

Massive lower extremity trauma presents an immediate and complex decision making challenge. Significant advancements have made in the field of reconstructive surgery over the past 30 years. Severely traumatised limbs which would have been treated by primary amputation 20 years ago are beginning to be saved. On the contrary, such extensive reconstructive procedures may not always produce the best of results in terms of functional outcomes. Thus the management of a severely crushed extremity presents a therapeutic dilemma as whether to amputate or to attempt salvage. Methods: All Prospective study of 40 patients with severe crush injury to the lower extremities treated in Sri Ramachandra Medical College, Chennai between June 2012 and June 2014. The inclusion criteria were grade IIIb and grade IIIc open fractures of the lower extremity with a Mangled extremity severity score (MESS) of 7 and above with minimum of 12 months follow up. All the fractures were classified according to the Gustilo and Anderson classification system and Mangled extremity severity score. Out of the 40 patients 18 of them had their limbs salvaged and 22 underwent primary amputation. Results: The lowest MESS in this study was 7 and highest MESS was 12. The mean score in the limb salvage group was 8 and in the amputated group was 9.7. Complication rates in salvage group were higher. The mean SF score for amputated group for physical component summary was 40.15 and mental component summary was 44.30 while for limb salvage group score for physical component summary was 30.91 and mental component summary was 36.90. Conclusions: The MESS scheme provides excellent guidelines to the treating surgeon when faced with a dilemma of whether to attempt salvage or amputate a severely injured limb. The decision of whether to amputate or salvage an injured limb must be made very early in the course of treatment. This is because immediate amputation is most often viewed by the patient as a result of injury; whereas, delayed amputation is often considered as a failure of treatment.

Functional outcome of minimally invasive posterior stabilisation in dorsal and lumbar spine fractures.

Minimally invasive spinal surgery will be a highlight of operative approaches in the twenty-first century and already has been popularized worldwide. This procedure will provide surgical options that address several pathological conditions in the spinal column without producing the types of morbidity commonly seen in open surgical procedures. The objective was to assess the outcomes of minimally invasive posterior stabilization of dorsal and lumbar spine fractures. Methods: This was a prospective study of twenty patients with dorsal or lumbar fractures who were admitted at Sri Ramachandra University. All patients having dorsal and lumbar spinal fractures with intact neurology were included in the study. All the patients underwent minimally invasive posterior stabilization by freehand technique. Functional outcomes were measured by VAS scale, ASIA scoring (neurology), and their ability to mobilize. Results: The average duration of surgery was 85.50 minutes. The average blood loss in our study group was 77 ml. The average operation to mobilization time was 2.2 days. The average post-operative Cobb’s angle was 0.6 degree of kyphosis. The average post-operative gain was 12 degree. Conclusion: Minimally invasive percutaneous stabilization of the spine helps to minimize approach related morbidity and secondary iatrogenic soft tissue trauma. It enables early mobilization, which contributes to improved outcome.