Exchange reamed nailing for tibial non union

Ninety acute tibial shaft fractures were managed by un-reamed tibial nailing. Seventeen cases in 15 patients ended in nonunion. Eight cases showed evidence of implant failure. Exchange nailing was carried out at an average of 9.5 months. After removing the original implants, the modularly canal was reamed until cortical chatter was encountered. The new nail 1-2 mm of larger diameter was introduced either unlocked or dynamically locked. Fibular osteotomy was added in one case and closed intramedullary autogenous graft was needed in three cases. Early full weight bearing was encouraged postoperatively. Follow-up interval of the 17 cases averaged 27 months from the time of injury and 17.5 months after exchange nailing. All cases united at an average of 15.5 weeks. Two wound infections were encountered at the proximal nail insertion site. Exchange nailing is a relatively simple procedure with low morbidity. It is an effective method of treatment for delayed union of closed and grades I and II open tibial shaft fractures that fail to unit after un-reamed nailing. Each case should be individually assessed for the need of adjunctive procedures at the same time, e.g. fibular osteotomy and closed intramedullary grafting. In view of the high incidence of implant failure encountered, surgical intervention should be undertaken as soon as the diagnosis of delayed union is established

Valgus intertrochanteric osteotomy after failed osteosynthesis for femoral neck fractures in young adults

Eleven patients with failed internal fixation of femoral neck fractures were treated with valgus intertrochanteric osteotomy. The patients ranged in age from 21 to 39. The interval from injury to osteotomy ranged from 7 to 18 months with an average follow-up of 11 months [range 8-16 months], the femoral neck fractures healed in all but one case. The average time to radiological union in the ten cases was 16.7 weeks [range 11-24 weeks]. Apart from one case of failure to achieve union, another case developed progressive arthritic changes and was considered a poor outcome. Otherwise, the remaining nine patients achieved good to excellent results according to the assessment criteria described by Anglen. For active patients with non-union of the femoral neck fracture, Pauwels osteotomy provides a high proportion of good results even in the presence of avascular necrosis of the head providing there has been no collapse

Correction of axial mal-alignment of lower limb in adolescents

Twenty-one patients aged between eleven and seventeen years old, having knee deformities were treated by corrective osteotomies. Surgery was done for eighteen varus limbs in thirteen patients and ten valgus limbs in eight patients. Pre-operatively, a whole limb view was needed to evaluate the tibial and femoral proportions of the deformity as well as location of the apex of the deformity. Accordingly, seven patients had combined tibial and femoral osteotomies, two had bilateral procedures done for varus deformity, two had unilateral osteotomies for varus and three for valgus deformity. Nine patients had upper tibial metaphyseal osteotomies for varus deformity [three bilateral, six unilateral]. The remaining five patients had valgus deformity [two had bilateral correction and three were unilateral]. Thus a total of thirty-seven corrective osteotomies in twenty-eight limbs were done. All osteotomies were preplanned to determine the appropriate size and site. Correction was controlled intra-operatively by aiding devices under fluoroscopy control, T plate was the common implant used and correction was achieved by the help of plate tension device. Our objectives for correction were restoration of normal limb alignment as indicated by the relation between mechanical axis and joint line and normal co-linear relation between the joint centers of the hip, knee and ankle joints as indicated by the hip, knee, ankle angle. The final results showed correction of the deformity among the varus limbs from an average of -14.4 degrees preoperatively to -2.4 degrees post-operatively. While in the valgus limbs the average pre-operative valgus deformity was +12.9 degrees and +1.2 degrees post-operatively. The average estimated preoperative mechanical axis deviation was 111% and this was reduced to an average of 8.6% post-operatively. There were six cases of mal-correction [four tibial and two femoral], and the success rate according to our criteria was 79%

Supracondylar femoral osteotomy distraction, compression technique

Seventeen distal femoral corrective osteotomies for various forms of knee deformities with and without concomitant degrees of limb shortening was conducted in this study. The osteotomies were instrumented by distraction and compression devices to exert correction of angular deformity with linear distraction whenever needed to achieve bone lengthening. Open wedge osteotomy was performed in eleven femora, four of them had concomitant bone lengthening. The average degree of angular correction was 15 degrees, an average of 1 cm bone lengthening was achieved in seven cases and 2.5 cm in four other cases. Six closing compression osteotomies were done to correct varus deformity of the distal femur. The average degree of angular correction was 14 degree in those cases. The average time to complete union after opening wedge osteotomy was 11.5 weeks, where bone lengthening was done the average healing time was prolonged to 17.75 weekes. After closing wedge osteotomy, bone union was achieved at an average of 4.8 weeks. Two cases of mild undercorrection and one case of delayed union after acute lengthening were encountered. The results of the study are encouraging to consider this technique for mild degrees of angular deformity of distal femur [less than 15 degrees] with some degree of bone shortening [less than 3 cm]

Results of surgical management of hypophosphatemic vitamin [D] resistant state

Hypophosphatemic rickets is the most common form of rickets seen in the developed communities. Intensive investigations recently had described several clinical forms of the disease in various age groups. This article presented the management results of six patients with hypophosphatemic vitamin D resistant rickets and osteomalacia. Two adolescents presented with bilateral lower limb deformities were treated with corrective osteotomies. Four adults presented with various pathological femoral fractures were managed by open reduction and internal fixation. The diagnosis was largely based on the typical biochemical profile which consistently showed hypophosphatemia with hypophosphatemia and reduced tubular re-absorption of phosphate. Other investigations were necessary to exclude similar forms of metabolic bone disease. Radiologically, non-specific ricketic changes in adolescents with looser zones in adults denoting metabolic nature of the disorder were seen in all cases. Increased bone density in axial skeleton with coarse widely spaced bone trabeculae in the pelvis were noted in adult males. All cases were started on combined regimen of vitamin D and oral phosphate supplement once the diagnosis was established. Apart from one incidence of delayed union in a pathologically fractured femur, all cases proceeded to union uneventfully