The Influence of Static Load and Sideways Impact Fall on Extramedullary Bone Plates Used to Treat Intertrochanteric Femoral Fracture: A Preclinical Strength Assessment.

Hip fracture accounts for a large number of hospitalizations, thereby causing substantial economic burden. Majority (> 90%) of all hip fractures are associated to sideways fall. Studies on sideways fall usually involve loading at quasi-static or at constant displacement rate, which neglects the physics of actual fall. Understanding femur resonance frequency and associated mode shapes excited by dynamic loads is also critical. Two commercial extramedullary implants, proximal femoral locking plate (PFLP) and variable angle dynamic hip screw (VA-DHS), were chosen to carry out the preclinical assessments on a simulated Evans-I type intertrochanteric fracture. In this study, we hypothesized that the behavior of the implant depends on the loading types-axial static and transverse impact-and a rigid implanted construct will absorb less impact energy for sideways fall. The in silico models were validated using experimental measurements of full-field strain data obtained from a 2D digital image correlation (DIC) study. Under peak axial load of 3 kN, PFLP construct predicted greater axial stiffness (1.07 kN/mm) as opposed to VA-DHS (0.85 kN/mm), although the former predicted slightly higher proximal stress shielding. Further, with greater mode 2 frequency, PFLP predicted improved performance in resisting bending due to sideways fall as compared to the other implant. Overall, the PFLP implanted femur predicted the least propensity to adverse stress intensities, suggesting better structural rigidity and higher capacity in protecting the fractured femur against fall.

Novel Design of Minimal Incision Double Oblique Device for Osteosynthesis (DODO) of Hip: Results of an In-silico Study Based on the Femur Morphometrics of the Northeast (NE) Indian population.

BACKGROUND: Hip fractures account for a large proportion of hospitalization among the trauma cases. Low cost, simple technique, easy removal, and high rate of the bone union makes extramedullary (EM) fixation techniques a preferred choice. A close-fit bone and plate are essential for the success of such implantation. Various studies have found femur morphometry being related to regional features and social differences. Most of the available commercial implants are developed based on the data of the Caucasian population. METHODS: In the herein study, a novel design, Double Oblique Device for Osteosynthesis of hip (DODO), is proposed while considering the regional morphometry of the Northeast (NE) population of India. This study employs finite element (FE) analysis to compare the biomechanical outcome of the new device with that of proximal femoral locking plate (PFLP) and variable angle dynamic hip screw (VA-DHS) on a femur having an Evans type-I intertrochanteric fracture. RESULTS: The stress shielding was substantially high for the PFLP and VA-DHS in the distal bone fragment (lateral aspect) and for DODO in the femoral head. The difference in axial displacement between the post-implanted DODO-fixed femur and its respective intact femur was predicted to be almost the same as that of PFLP-fixed femur and its respective intact femur. CONCLUSION: The computational results found the new device to be a viable alternative to the conventional plating techniques, especially for the NE population of India, and predicted better to comparable biomechanical characteristics.

Rehabilitation evaluation of the newly developed polymeric based passive polycentric knee joint.

Objective: The lower limb amputation is one of the major concerns for the amputee's daily life and the trans-femoral (TF) amputation is being paid a lot of attention because of its functional requirement in flexion-extension motion. Though significant progress has been made for the development of high end prosthetic knee joint, the affordability of the same is still a great concern. Thus, a passive polycentric knee joint was developed and the health related quality of life (HRQL) before and after the fixation of the prosthesis, and performance of the same were studied.Design: After 6 months of fixation, the HRQL and performance of the prosthetic device were evaluated.Results: The HRQL after the fixation was found to be increased, where the improvement on the physical and mental score was found to be 49 and 46%, respectively, in comparison with pre-fixation stage. The global score (G) for the prosthetic function was found to be 63, which confirmed the increased performance of the prosthesis.Conclusions: The improved HRQL and G of prosthetic performance confirmed the enhanced performance of the prosthesis. It is concluded that the developed passive polycentric knee joint could be explored in large scale for the TF amputees.Implications for rehabilitationThe above knee (AK) amputation is a surgical interference that severs the thigh segment between the knee and hip joints.The above knee prosthesis consists of a socket, knee joint, pylon and foot.The artificial prosthetic knee joint imitates the functions of human knee to achieve the flexion-extension motion of the above knee amputee.The satisfaction of the amputees with the usage of the existing artificial prosthetic knee joint is still a concern. Hence, a passive prosthetic knee joint was developed and its effect on the quality of life of trans-femoral amputee was evaluated using health related quality of life (HRQL) before and after the fixation of the prosthesisThe HRQL after the fixation was found to be increased in comparison with pre-fixation stage.The global score for the prosthetic function was also found to be increased which confirmed the increased performance of the prosthesis.It is anticipated that the developed knee joint is expected to make huge impact due to its function, performance and affordability.

Proximal tibiofibular joint: Rendezvous with a forgotten articulation.

The proximal tibiofibular joint (PTFJ) is a plane type synovial joint. The primary function of the PTFJ is dissipation of torsional stresses applied at the ankle and the lateral tibial bending moments besides a very significant tensile, rather than compressive weight bearing. Though rare, early diagnosis and treatment of the PTFJ dislocation are essential to prevent chronic joint instability and extensive surgical intervention to restore normal PTFJ biomechanics, ankle and knee function, especially in athletes prone to such injuries. PTFJ dislocations often remain undiagnosed in polytrauma scenario with ipsilateral tibial fracture due to the absence of specific signs and symptoms of PTFJ injury. Standard orthopedic textbooks generally describe no specific tests or radiological signs for assessment of the integrity of this joint. The aim of this paper was to review the relevant clinical anatomy, biomechanics and traumatic pathology of PTFJ with its effect on the knee emphasizing the importance of early diagnosis through a high index of suspicion. Dislocation of the joint may have serious implications for the knee joint stability since fibular collateral ligament and posterolateral ligament complex is attached to the upper end of the fibula. Any high energy knee injury with peroneal nerve palsy should immediately raise the suspicion of PTFJ dislocation especially if the mechanism of injury involved knee twisting in flexion beyond 80° and in such cases a comparative radiograph of the contralateral side should be performed. Wider clinical awareness can avoid both embarrassingly extensive surgeries due to diagnostic delays or unnecessary overtreatment due to misinformation on the part of the treating surgeon.

Complete incorporation of long diaphyseal sequestrum without surgical intervention in chronic hematogenous osteomyelitis of tibia in an immunocompetent child.

Traditionally, the management of chronic osteomyelitis emphasizes the excision of necrotic and infected material (sequestrectomy/debridement) followed by prolonged administration of antibiotics. Most children with chronic osteomyelitis undergo surgery with the inherent risk of damage to their growth plate. Treatment regimen based on findings of imaging with emphasis on antibiotics to potentially reduce the rate of surgical interventions is being increasingly reported. An 8-year-old thin built Indian boy belonging to lower socio-economic group presented to the orthopedic department with the chief complaints of pain in the left upper leg for the last 3 months. Radiograph of the affected limb showed features of chronic osteomyelitis with a large diaphyseal sequestrum on the medial cortex of tibia with incomplete involucrum. No surgery was performed; not even incision and drainage. The sinuses healed completely in 6 weeks time with appropritate antibiotics alone. Gradually, over a period of 8 months, the large tibial diaphyseal sequestrum got fully incorporated into the healthy diaphyseal bone indistinguishable from normal bony architecture with complete clinical remission of sepsis. Our rare case is an example of the evolving notion that antibiotics and supportive care alone may be sufficient enough in the treatment of chronic osteomyelitis even with large diaphyseal sequestrum in paediatric cases where excellent healing potential of the immune-competent child may potentially make surgical intervention redundant.

Risks of concomitant trauma to the knee in lower limb long bone shaft fractures: A retrospective analysis from a prospective study population.

BACKGROUND: Numerous associated injuries (bony and/or soft tissue lesions) occur commonly in conjunction with fractures of the femoral shaft in young patients after high-energy injuries. Knee ligamentous injuries, historically called as the internal derangements of the knee or IDK, are mostly not visible in plain radiographs taken in the emergency and these injuries are likely to be overlooked by clinicians because first attention always goes to open wounds and radiologically visible injuries of the limb whenever a patient is received in a trauma unit. MATERIALS AND METHODS: A total of 93 cases of lower limb long bone fractures were retrospectively analyzed from materials of a prospective study conducted on consecutive patients having high-velocity injuries to lower limb long bones with a view to confirm or rule out concomitant ipsilateral IDK in cases of femoral and tibial shaft fractures, that already employed a policy of focused clinical examination followed by arthroscopy of the ipsilateral knee, immediately after operative fracture fixation under the same anesthesia. The goal was to determine the incidence of concomitant internal derangement of the ipsilateral knee and to understand any value of adding arthroscopy to detect concomitant IDK in lower limb long bone fractures besides careful intraoperative examination to propose a recommendation thereof. RESULTS: Concomitant knee injury was found in 14 femoral fractures and 1 tibial fracture. Fifteen out of 93 (16%) such cases had concomitant knee ligamentous or meniscal injures. A total of 13 anterior cruciate and 4 posterior cruciate tears, 11 collateral ligament tears, and 10 meniscal injuries were confirmed in these 15 knees. Femoral shaft fractures were associated with a high incidence of serious ligamentous, meniscal, and chondral injury. Twelve out of 41 femoral fractures had chondral injuries (contusion), especially of the patello-femoral articulation, identifiable during arthroscopy. CONCLUSION: One should have high index of suspicion about internal knee injuries and capsule-ligamentous injuries while dealing with femoral shaft fractures in particular. Arthroscopy of knee may safely enhance the diagnosis of simultaneous IDK. We propose that when MR imaging is not possible and when contraindication for arthroscopy does not exist, a careful clinical examination followed by arthroscopy of the knee may be considered a useful adjunct in femoral shaft fractures as it can readily confirm IDK by its ability to objectively look, probe, and distinguish fragile tissue from a normal one. Further study in larger number of subjects is needed to validate our findings.

Case report and brief review of literature on sonographic detection of accidentally implanted wooden foreign body causing persistent sinus.

Despite advances in imaging techniques, the detection of vegetative foreign bodies in soft tissues remains a difficult and sometimes even a challenging task. Clinical evaluation of such patient may present several months or even years after the initial injury and clinician may fail to elicit an antecedent skin puncture. X-ray examination will miss radiolucent foreign bodies. A 15-year-old boy presented with a draining non-healing sinus at the lateral aspect of his right thigh for 9 months. Musculoskeletal ultrasonography was ordered after ruling out chronic osteomyelitis to detect possible lesions around the thigh. High-frequency linear ultrasonic probe readily detected an elongated foreign body within the vastus lateralis muscle. A long piece of wood was confirmed at surgery. Non-healing sinus with normal finding in radiograph following old trauma should raise the suspicion of implanted radiolucent foreign body/bodies. The role of diagnostic ultrasound as a valuable screening tool for the detection of foreign body is briefly reviewed.

Double parabolic Kirschner-wires as dynamic distractor for treatment of unstable intraarticular phalangeal fractures of hand.

BACKGROUND: Treatment of complex injuries of interphalangeal joints (IPJs) is difficult. The restoration of joint stability for early joint mobility till fracture union is the key for successful outcome. Although various treatment options like dynamic splinting, external fixator, closed reduction, transarticular Kirschner (K)-wire and ORIF, etc., are available in literature, a universally accepted ideal treatment for complex intraarticular fractures of IPJs is still evolving. Open reduction is difficult because fixation of volar fragment is often impractical and radical procedures like volar plate arthroplasty, arthrodesis or joint replacement, etc., may become mandatory for salvage. We describe percutaneous technique to treat unstable fractures and dorsal fracture-dislocations of the PIP joint and report short-term postoperative results. MATERIALS AND METHODS: Ten cases of unstable or potentially unstable intraarticular fractures including pilon fractures and fracture-dislocations of IP joints were treated percutaneously by double parabolic K-wire technique (DPK). The device was used as a dynamic distraction, using the principle of ligamentotaxis. The idea was to commence early postoperative continuous active and active-assisted joint motion exercises and to carry on the frame as a definitive treatment for achieving fracture union. RESULTS: In all patients of fracture-dislocation the reduction was satisfactory and early mobility was achieved. Although there is a tendency towards over-distraction, no loss of reduction occurred. Pin tract infection occurred in one with no delayed union or nonunion. The average total range of motion for each involved IP joint was 93.5 degree and the average total active range of motion was 90.8° each at the end of 4 months followup. Excellent to good results were restored in nearly all cases without further interventions. CONCLUSION: DPK technique may be a cheap and valuable definitive treatment option in the management of unstable or potentially unstable intraarticular fractures of IPJs. The technique gave satisfactory radiological union and functional outcome in our small series. This technique may be worth considering in unstable or potentially unstable intraarticular fractures of IPJs with intact collateral ligaments and when other treatment options are impractical.

Occult renal cell carcinoma with acrometastasis and ipsilateral juxta-articular knee lesions mimicking acute inflammation.

Generally, skeletal peripheral metastases below the elbow and the knee are rare. Skeletal metastases to the hand or foot are very rare; but when they do it may be a revealing clinical finding. Purely lytic lesions are commonly seen in metastases from lung, renal, and thyroid tumors, but they are also known to occur in primary myeloma, brown tumor and lymphomas. A 70-year-old man was brought to the emergency department with acute painful swelling involving his right hand and the right knee. Due to significant accompanying soft tissue swellings cellulitis, acute osteomyelitis and gouty arthropathy were included in the initial differential diagnosis. Radiographs showed pure lytic bony lesion with complete disappearance of lower two third of the second metacarpal, trapezium and trapezoid bones of the right hand along with a lytic subarticular lesion of medial condyle of ipsilateral femur. Chest X-ray (CXR) was normal but sonography of the abdomen readily demonstrated a large renal mass, later confirmed at biopsy as renal cell carcinoma (RCC). Clinicians should be cognizant of the strong association between digital acrometastases and renal cell carcinoma in male patients with normal CXR findings. In suspected hand acrometastasis associated with a soft tissue component outside the contours of normal bone, screening the abdomen by sonography should be done prior to bone biopsy and before costly or time-consuming investigations are offered. Metastatic RCC should be included in the differential diagnosis of all unilateral expansile bony lesions of the digit. It is particularly important if such lesion/lesions are accompanied by local inflammation. Screening the abdomen by sonography may be of particular value in such elderly male patient when Chest X-ray shows no abnormality.