A CASE REPORT ON SALVAGE OF FAILED INTERNAL FIXATION OF PROXIMAL HUMRUS FRACTURE USING FIBULAR STRUT GRAFT.

Proximal humerus fractures are common problems plaguing in geriatric population. Approximately half of all proximal humeral fractures occur due to fall usually at ground level. (Low velocity trauma). In younger individuals fractures occurring because of higher-energy trauma such as a fall from a height, motor vehicle accidents, sports, or assaults. The proximal humerus fracture because of three loading modes: compressive loading of the glenoid onto the humeral head, bending forces at the surgical neck, and tension forces of the rotator cuff at the greater and lesser tuberosities. Most proximal humeral fractures are treated nonoperatively. However, surgical treatment is becoming more popular, with development of modern implant (PHILOS plate). Implant failure is common complication occur due to improper fixation, osteoporotic bone, early mobilization, non-union and varus malalignment. Various modality available for its management i.e., Hemiarthroplasty, reverse shoulder arthroplasty and ORIF + bone graft. IN this case report 60-year male patient with right side proximal humerus fracture treated with PHILOS plating. At 6 week follow up radiograph suggest implant failure. Patient was posted for revision surgery ORIF + platting and fibular strut graft was done.

Artroplastia de resección de hombro como salvamento para infecciones recalcitrantes: estado actual de la técnica a propósito de dos casos / Shoulder resection arthroplasty as a salvage procedure for recalcitrant infections: current state of the art regarding two cases

INTRODUCCIÓN Y OBJETIVOS La artroplastia de resección de hombro (ARH) se presenta como una técnica obsoleta y una opción no válida en la actualidad, debido a la evolución de las técnicas quirúrgicas y de los implantes. Pero, como consecuencia del aumento exponencial del uso de artroplastias de hombro, están aumentando en paralelo el número de fracasos e infecciones, con necesidad de revisión y rescate. Es por ello que, en determinadas situaciones y pacientes, esa técnica vuelve a ser una opción necesaria como salvataje, aunque tiene un alto coste funcional. El objetivo de nuestro trabajo, es presentar dos casos de artroplastia de resección de hombro como una opción válida de tratamiento en la actualidad y la revisión de la literatura. CASOS Se presentan dos casos de ARH como tratamiento de rescate, en un caso de osteomielitis crónica de cabeza humeral y un caso de infección de hemiartroplastia de hombro. Ambos pacientes se encontraban sin dolor y libres de infección con un seguimiento de más de 30 meses. En un caso la funcionalidad fue limitada con un Constant de 45 pero el otro caso la funcionalidad fue aceptable con un Constant de 67. CONCLUSIONES La ARH sigue siendo una técnica útil tras el fracaso de procedimientos de revisión, para resolver infecciones protésicas recalcitrantes u osteomielitis. Los resultados funcionales son pobres, por lo que debe reservarse para pacientes con baja demanda funcional y como salvataje, tras agotar otras opciones.

INTRODUCTION AND OBJECTIVES shoulder resection arthroplasty (SRA) is currently considered as an outdated technique, due to the advances in surgical techniques and new prosthesis designs. However, with the exponential increase in the use of shoulder arthroplasties, the number of failures and infections is equally increasing, as well as the revisions and salvage procedures. In certain situations, SRA is therefore a necessary solution, although it grossly compromise shoulder function. The aim of our study is to present two cases who underwent SRA as a valid treatment option nowadays and a literature review. CASES We present two cases of SRA as salvatage treatment. First case in a chronic humeral head osteomyelitis and second in a partial shoulder prosthesis recalcitrant infection. Both patients had complete pain relief and infection was solved with a follow-up over 30 months. In the first case, postoperative shoulder function was limited with a Constant­Murley score of 45. In the second case, function was fairly good with a Constant of 67. CONCLUSIONS SRA remains a valuable technique after the failure of revision procedures, as a salvage for recalcitrant prosthetic infections or osteomyelitis. The functional results are poor, so it should be reserved for patients with low functional demand and as salvatage procedure, after assess other options.

Application of pasteurized tumor-bearing bone replantation for primary malignant bone tumor of extremities / 中国修复重建外科杂志

Objective: To assess the effectiveness of the pasteurized tumor-bearing bone replantation in treatment of primary malignant bone tumor of extremities. Methods: Between February 2012 and June 2016, 13 patients with primary malignant bone tumor of extremities were treated with pasteurized tumor-bearing bone replantation after extensive excision. There were 8 males and 5 females, aged from 11 to 27 years, with an average of 17.4 years. Tumors were located at the mid-upper humerus in 2 cases, the mid-upper femur in 2 cases, the mid-lower femur in 6 cases, the mid-upper tibia in 2 cases, and the middle tibia in 1 case. According to Enneking staging system, 3 patients were classified as stage ⅠB, 5 patients as stage ⅡA, and 5 patients as stage ⅡB. There were 11 cases of osteosarcoma and 2 cases of chondrosarcoma. The disease duration ranged from 3 to 8 months, with an average of 4.8 months. The length of the tumor-bearing bone ranged from 8 to 16 cm, with an average of 12.5 cm. Postoperative follow-up was conducted regularly to evaluate the status of inactivated bone and complications. The limb function was assessed by the Musculoskeletal Tumor Society 93 (MSTS-93) scoring system. Results: All 13 patients were followed up 26-79 months, with an average of 50.5 months. Eleven patients survived without tumors. Two patients had local soft tissue recurrence and underwent amputation, 1 had lung metastasis after amputation and died. All patients had no complications of bone resorption, shortening, and internal fixation disorder. The nonunion of osteotomy occurred in 4 cases. Among them, 3 cases were successfully healed after autologous iliac bone grafting, and 1 case was treated conservatively. The healing time of metaphyseal osteotomy end was 10-15 months (mean, 12.6 months), the healing rate was 90.9% (10/11); the healing time of diaphyseal osteotomy end was 12-21 months (mean, 17.0 months), the healing rate was 72.7% (8/11); and the total healing rate of osteotomy end was 81.8% (18/22). One case had inactivated bone fracture and 1 case had incision dehiscence and infection after operation. At last follow-up, the MSTS-93 score of affected limb ranged from 21 to 28, with an average of 25.3. Conclusion: The procedure of the pasteurized tumor-bearing bone replantation is an effective, simple, and economic way in repair of massive segmental bone defect to save limb function for primary malignant bone tumor of extremities.

Chronic Instability of Distal Radioulnar Joint

Chronic instability of distal radioulnar joint (DRUJ) can develop after injury such as fractures or dislocations, to the bony structures or to the soft tissue as like ligament, capsule. If proper treatment is not performed, normal biomechanics of DRUJ would be altered, thus arthritic joint with chronic functional impairment, pain resulted in. The proper treatments included several procedures for repair of the bony structures and recovery of realignment, various methods for soft tissue repair and reconstruction in unstable condition without bony structures destruction. Several salvage methods such as Darrach procedure, hemiresectional interposition arthroplasty, Sauve-Kapandji procedure, were recommended for the advanced arthritic DRUJ. Wide ulnar resection, one-bone forearm procedure, prosthetic replacement for DRUJ were rarely indicated, but the a few long-term results were reported. Operative stabilization (repair or reconstruction) for each structure assumed as DRUJ instability, is essential and proper selection among the several salvage procedures for the advanced arthritis joint, is needed.

Central Vein Occlusion in Hemodialysis Patients

As the increasing incidence of the double lumen catheterization (Quinton catheter) for temporal hemodialysis, central vein occlusion, a serious complication which can cause arteriovenous fistula failure, occurred more frequently. Severe arm edema, pain with venous hypertension and insufficient fistula function suggest central vein obstruction and this can be confirmed by color duplex sonography or venography. This kind of occlusion should be treated promptly because it is closely related with arteriovenous fistula function. Division and ligation of fistula is one option but to salvage the fistula is more recommendable. For this purpose, thrombolysis, percutaneous transluminal balloon angioplasty (PTA) with or without stent insertion, direct surgical approach to the obstructed vein, surgical bypass using autogenous vein or artificial graft are performed according to the site and degree of the obstruction. From January 1995 through December 1997, we experienced 9 cases of subclavian vein or innominated vein occlusion which were detected by angiogram in hemodialysis patients. Four cases were treated by PTA with one case of thrombolysis at the same time. Two of them developed recurred symptoms at 3 and 6 months after PTA. The previous fistula were ligated and made a new basilic vein reposition arteriovenous fiatulas were made at opposite arm. Among the remaining 5 cases, surgical bypass was performed between internal jugular vein and subclavian vein in 2 cases, between axillary vein and opposite subclavian vein in 3 cases using 8 mm PTFE graft. One out of 5 surgical bypass group showed recurred occlusion at 16 months and that patient died soon after that occlusion. Another one showed partial occlusion of bypassed graft but the symptoms were mild so we could continue hemodialysis without problems. The remained 3 cases were patent for more than 13 months of their follow up. In summary, to salvage the failed fistula by central vein obstruction, aggressive procedure such as surgical bypass using artificial graft to opposite central vein also be considered with PTA.

Causes of Failed Internal Arteriovenous Fistula and Their Salvage Procedures

Adequate vascular access is essential for hemodialysis and Cimino type arteriovenous fistula is the solution for this purpose. But even after we made that fistula, we faced with early fistula failure in about 5~15% of these internal fistula and about 10% drop of fistula patency during the follow up each year. In order to select adequate salvage procedures after fistula failure, we analyzed the causes of failure and compared the result of salvage procedures performed in 423 re-arteriovenous fistula cases which were done between March 1983 through February 1996 in the Department of Surgery Dongsan Hospital, Keimyung University. In early failure cases, poor arterial flow(51.4%) and missed proximal obstruction of fistulated vein before fistula creation(20.9%) were two most common causes of failure but in late failure, stricture and thrombosis were leading causes(81.4%). In the case of repeated arteriovenous fistula, usage of proximal artery showed less early failure rate(5.6%) than opposite radial or ulnar artery(14.8%). This is especially true in patient with diabetes, collagen disease or obesity. Both repeat arteriovenous fistula and salvage procedure showed more early fistula rate and less mean patency compare with primary fistula. Among the salvage procedures of late onset fistula failure, patch graft and bridge graft showed less failure rate(7.1% and 8.3% each) compared with balloon angioplasty(60.0%) or thrombectomy(25.0%). Thrombosis or occlusion at around the fistula site can be managed by performing new fistula using the arterized vein and artery 1~2 cm proximal to the previous fistula. In summary, salvage procedure in the failed arteriovenous fiatula should be chosen according to their failure causes and onset time.