Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study.

INTRODUCTION: Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment. MATERIAL AND METHODS: Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes. RESULTS: Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor. CONCLUSION: "Fix and Flap" in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

The effect of excision of the posterior arch of C1 on C1/C2 fusion using transarticular screws.

Transarticular screw fixation with autograft is an established procedure for the surgical treatment of atlantoaxial instability. Removal of the posterior arch of C1 may affect the rate of fusion. This study assessed the rate of atlantoaxial fusion using transarticular screws with or without removal of the posterior arch of C1. We reviewed 30 consecutive patients who underwent atlantoaxial fusion with a minimum follow-up of two years. In 25 patients (group A) the posterior arch of C1 was not excised (group A) and in five it was (group B). Fusion was assessed on static and dynamic radiographs. In selected patients CT imaging was also used to assess fusion and the position of the screws. There were 15 men and 15 women with a mean age of 51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6). Stable union with a solid fusion or a stable fibrous union was achieved in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid fusion, four (16%) a stable fibrous union and one (4%) a nonunion. In Group B, stable union was achieved in all patients, three having a solid fusion and two a stable fibrous union. There was no statistically significant difference between the status of fusion in the two groups. Complications were noted in 12 patients (40%); these were mainly related to the screws, and included malpositioning and breakage. The presence of an intact or removed posterior arch of C1 did not affect the rate of fusion in patients with atlantoaxial instability undergoing C1/C2 fusion using transarticular screws and autograft.

Modified resection technique for proximal fibular osteochondromas.

Osteochondroma is one of the most common tumors arising from the proximal fibula. Surgical treatment of proximal fibula osteochondromas may vary from debulking to resection of proximal fibula. We describe a modified surgical technique for excision of proximal fibular osteochondromas which preserves the proximal tibio-fibular joint (PTFJ). We present a series of six cases of symptomatic proximal fibular osteochondroma. Four cases were solitary osteochondromas while two were a manifestation of a hereditary multiple exostoses. Indication for surgery was peroneal nerve symptoms in three, cosmesis in one, restricted knee motion in one, and pain in one case. All these cases were operated by a modified resection technique where the head of fibula was preserved. The PTFJ was preserved. Lateral stabilizing structures of the knee were left undisturbed, and hence did not need repair. Complications occurred in two patients, one had marginal wound necrosis and one had persistent weakness of extensor haullicis longus. At a minimum follow-up of 2 years, none had recurrence or late disruption of PTFJ.