The outcomes of surgical treatment for lateral Hoffa fracture nonunions.

INTRODUCTION: Lateral Hoffa nonunion are rare injuries. A significant percentage of these nonunions are due to missed acute lateral Hoffa fractures. Operative management of these injuries is difficult and complicated by the presence of bone loss, infection, and soft-tissue contractures. In this study, the aim was to assess clinical and functional outcome in our group of patients with lateral Hoffa nonunion who had undergone operative management and to determine whether variables such as fracture type, infection, and previous surgery affect nonunion/complication rates. MATERIALS AND METHODS: Data were analyzed for patients with lateral Hoffa nonunion who underwent surgical fixation from January 2008 to December 2020 at a tertiary-care referral center. Patients with lateral condyle Hoffa nonunion and having a minimal follow-up of 1 year were included in this study. Patients with medial Hoffa nonunion, pathological fractures, and children aged less than 16 years were excluded from the study. The fractures were classified by the AO/OTA and Letenneur classification systems. Clinical and functional outcomes were assessed by the Knee society score (KSS) and the lower extremity functional scale (LEFS). RESULTS: All the 12 patients had united in our series. One patient had reduction failure at 3 months who united after re-fixation. The union rate in our patients was 100%, with a loss of reduction rate of 7.7%, and post-traumatic arthrosis of 7.7%. The average follow-up period was 52.16 ± 27.7 months. The mean knee flexion obtained at the final follow-up was 104.5° (80°-130°). The average KSS clinical score was 80.6 (65-88). The average KSS functional score was 92 (70-100). The average LEFS score was 71 (47-79). There is a statistically significant improvement in the knee range of motion in our patients (p = 0.001). However, no correlation could be detected between variables like type of fracture, infection, and previous surgeries and outcomes. CONCLUSIONS: Lateral Hoffa nonunion can be managed with careful planning of surgical approaches and fixation techniques.

Cathepsin K Mutation-A Subtle Clinical Presentation.

Context: Pyknodysostosis is an uncommon inherited disorder associated with consanguinity, often presenting with sclerotic bone disease, short stature, dysmorphic features, and recurrent fragility fractures at an early age. Case: A 34-year-old woman was evaluated for the cause of recurrent fragility fractures. She was born of a third-degree consanguineous marriage and had a twin brother who was of short stature. The index patient had a height of 141 cm, dysmorphic features including frontoparietal bossing, blue sclera with short stubby fingers and toes. Radiological evaluation revealed diffuse osteosclerosis with acro-osteolysis exclusively in the toes, apart from mid-facial hypoplasia, lack of pneumatization of the paranasal sinuses, dental abnormalities, and scoliosis. Dual-energy x-ray absorptiometry revealed increased bone mineral density. Based on the clinical features, the patient was tested for cathepsin K gene variants using next-generation sequencing and was found to be positive for a novel homozygous c.224T>C, p.Met75Thr likely pathogenic missense variant. Discussion: This patient presented at a later age than expected with recurrent fragility fractures and the diagnosis was not suspected till adulthood, owing to the subtle clinical features. Confirmation with genetic testing helped in establishing the diagnosis. Conclusion: Pyknodysostosis, although uncommon, is one of the differential diagnoses for diffuse osteosclerosis presenting with recurrent fragility fractures. Next-generation sequencing in an appropriate setting may confirm the diagnosis.

The Role of the Ilizarov Ring External Fixator in the Management of Tibial Fractures with Impending/Incomplete Compartment Syndrome.

Objective The management of tibia fractures complicated by compartment syndrome affects the treatment and functional outcome of patients due to the complications associated with fasciotomy. The purpose of the present study is to differentiate impending/incomplete compartment syndrome (ICS) from established acute compartment syndrome (ACS) in tibial fractures, and to assess the outcome of the fixation of the Ilizarov apparatus in patients with these fractures presenting with ICS, who were not submitted to fasciotomy. Methods After the establishment of the inclusion and exclusion criteria, 19 patients were included in the study from January 2007 to December 2017. All patients were male, with an average age of 42.3 ± 11.38 years. All of these patients were managed with Ilizarov ring fixation as per the medical and surgical protocol established in the present study. Results The average follow-up obtained for our 18 patients was of 47 ± 41.5 months, with one patient being lost to follow-up. The average time for ring application was of 3.7 ± 1.7 days. In total, 3 (16.7%) of these patients had nonunion. There were no soft-tissue or neurovascular complications in the immediate postoperative period. All of the patients eventually united and were independently mobile without any sequelae of compartment syndrome. Conclusion The Ilizarov ring external fixator can be used in the management of tibial fractures with ICS, avoiding fasciotomy with its various complications of infection and nonunion, resulting in fewer surgeries and faster rehabilitation. Surgeons should carefully differentiate ACS and ICS in these patients, as the clinical and functional results vary significantly. Unnecessary fasciotomies should be avoided.

Use of an Angled Blade Plate for 31A3 Intertrochanteric Fractures.

BACKGROUND: A subgroup of pertrochanteric fractures-namely, the AO/OTA 31A3 fracture-continues to be a difficult problem to treat, even with cephalomedullary nails. We present the results for 26 patients with a 31A3 fracture treated with the angled blade plate. METHODS: The records of 26 consecutive patients with a 31A3 fracture that was treated operatively with the angled blade plate device between 2007 and 2012 at our center were reviewed, and the patients were contacted for follow-up. The functional outcome (traumatic hip rating score) and radiographic outcome (the neck-shaft angle at the time of fixation and final follow-up) were obtained for 20 of the 26 patients at a minimum follow-up of 1 year. RESULTS: All 26 patients had primary surgery. At final review, 2 patients had died and 4 had been lost to follow-up. Of the 4 patients lost to follow-up, 2 had revision of the fixation with the angled blade plate. Of the 20 patients with follow-up, 1 had malreduction and implant failure but eventually had healing after revision of the fixation with the angled blade plate. The mean traumatic hip rating score at the time of follow-up was 50.0 with 4, 14, and 2 patients having excellent, good, and failed outcomes, respectively. The mean neck-shaft angle at the time of final union was 126.16°, which was an average of 4° less than that on the unaffected side. However, this did not correlate with functional outcome. There was no significant difference between the immediate postoperative and final neck-shaft angles. CONCLUSIONS: This study demonstrated that blade plate fixation for 31A3 fractures is associated with low rates of failure (15%), revision surgery (15%), and infection (15%), which are comparable with the results of nail fixation (range, 5% to 12%) and superior to those of sliding hip screw fixation. This large series demonstrates that the angled blade plate can be utilized for these complex fractures and should be part of the armamentarium for these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intravenous Mannitol reduces intracompartmental pressure following tibia fractures: A randomized controlled trial.

PURPOSE: Impending compartment syndrome is a common event following closed tibia fractures, which can progress to sinister compartment syndrome. Fasciotomy is the only definitive treatment available, though it has its own drawbacks and complications. Medical management at present consists of limb elevation and adequate hydration. This study aims at determining whether intravenous administration of Mannitol reduced the intracompartmental pressure in patients with closed tibial fractures. METHODS: This is a double blinded, randomized control trial done in a single tertiary care center in India. Forty-five patients were recruited between February 2012 and October 2012. Forty patients who presented to the emergency department with isolated, closed, high velocity, and proximal 2/3 tibia fractures were included in this study. Patients with contraindication to Mannitol were excluded. They were allocated into 2 groups by the investigator using computer generated randomization. The pressure in the anterior compartment of the leg was measured with a handheld Stryker pressure monitor. Then either 20% Mannitol or 0.9% normal saline as given intravenously in a blinded manner, based on the randomization. The intracompartmental pressure was measured at 0, 1 and 3 h after the infusion. The participant, investigator and statistician were masked to the group assessment. RESULTS: There was no difference in intracompartmental pressures at 1 or 3 h, between the groups. However, in patients with the baseline of compartmental pressures ≥30 mmHg, Mannitol showed a marked reduction in pressure of 8.5 mmHg at 1 h compared to almost no change in pressure in the saline group. There were no adverse events with the use of Mannitol. CONCLUSIONS: This preliminary study appears to show that Mannitol is useful in the management of the increased compartment pressure. The limitations of this study were that it only involved a small group of patients and the baseline pressures in both the groups were not comparable. More studies are required before the use of Mannitol as a standard of care in the management of compartment syndrome can be established.

Time to debridement in open high-grade lower limb fractures and its effect on union and infections: A prospective study in a tropical setting.

PURPOSE: To prospectively evaluate whether time to debridement has any correlation with union, infection, and quality of life in high-grade lower limb fractures in a tropical setting. METHODS: A prospective cohort study was conducted at a tertiary care center in South India. Two hundred fifty-four adult skeletally mature patients with 301 grade 3 fractures involving the femur, tibia, or fibula were recruited. The cohort was empirically divided into two groups (early and late) based on the time to debridement (less than or more than 12 h from injury). OUTCOME: The primary outcome was nonunion. Secondary outcomes were deep infection rates and patients' quality of life. Short form-36 (SF-36) and short musculoskeletal functional assessment (SMFA) questionnaires were also used. Patients were followed up for 9 months. RESULTS: The follow-up rate was 93%. The late group had a significantly higher risk of nonunion (odds ratio(OR): 6.5, 95% confidence interval (CI): 2.82-14.95) and infections (OR: 6.05, 95% CI: 2.85-12.82). There was a 4% increase in the infection risk for each hour of delay for the initial 50 h (p < 0.0001). SF-36 and SMFA scores were superior in the early group (p < 0.0001). CONCLUSION: The study contradicts findings reported in the literature from the West. Our study was in agreement with our hypothesis and proved that debridement within 12 h resulted in significantly lower rates of nonunion and infections and an overall improved quality of life in high-grade open lower limb fractures in a developing country. LEVEL OF EVIDENCE: Level II. TRIAL REGISTRATION: German Clinical Trials Register DRKS00015186.

Decision making in the management of malunion and nonunion of intertrochanteric fractures of the hip.

AIM: Intertrochanteric fractures account for almost 50% of hip fractures.Nonunion and malunion of these fractures are relatively uncommon. This study reviews the outcome of 31 cases of intertrochanteric fracture failures. An algorithm for the management of these injuries is also proposed. METHODS: 19 patients with intertrochanteric malunion and 12 patients with non-union were included in this study. Treatment of these injuries was initiated according to the algorithm proposed in this study. Treatment outcomes were evaluated by assessing union, pre and postoperative shortening and HSA (head-shaft angle). Functional outcomes were assessed by the Parker mobility scale and presence or absence of pain. RESULTS: All the patients with intertrochanteric malunion with follow-up had united. The postoperative shortening in all patients were ⩽2.5 cms. Patients having intertrochanteric nonunion with follow-up, who underwent internal fixation had united with an acceptable Parker mobility scale score, except in 1 patient who sustained an ipsilateral distal femur fracture. The average HSA correction obtained was 21° (range 3-60°). CONCLUSION: The algorithm proposed in this study helps streamline the treatment according to each case scenario.It helps in planning and managing patients with intertrochanteric fracture failures.

Management of Chronic Infected Intra-Articular Fractures of the Proximal Tibia with Ilizarov Ring Fixation.

Infected nonunion and malunion of tibial plateau are rare injuries with no standardized protocols for treatment. This study assessed the outcome of chronic infected intra-articular proximal tibial fractures with and without metaphyseal bone loss managed with the Ilizarov ring fixator. A series of six patients of intra-articular infected nonunion of the tibial plateau and two patients with malunited plateau with metaphyseal nonunion were treated in a tertiary care hospital. Three of these eight patients had a metaphyseal bone loss or bone gap after debridement and underwent internal transport with distal corticotomy to obtain the bone length. The remaining five patients underwent static ring fixation after correction of the articular deformity. Clinical evaluation was done by Knee Society Score, Rasmussen radiological and Association for the Study and Application of Methods of Ilizarov scores. All patients but one achieved union with the ring fixator. The average follow-up was 33 months (range, 12-120 months). Average time to achieve union was 11.5 months (range, 3-30). The scores were good in four patients and poor in the rest four, out of which three had undergone internal transport. Proximal tibia intra-articular infected nonunion and malunion with or without metaphyseal bone loss can be treated successfully with the Ilizarov fixator. Malunion of the tibial plateau has to be addressed in cases with varus alignment of the limb or articular step-off of ≥ 5mm between the two tibial surfaces. Patients with associated metaphyseal bone loss tend to have complications and take a longer duration to heal. Single-stage treatment avoids intra-articular malunion and loss of limb alignment.

Early outcome of culture-negative infection in open fractures of the lower limb: A prospective study.

Background: Culture-negative infections in open long bone fractures are frequently encountered in clinical practice. We aimed to identify the rate and outcome of culture-negative infections in open long bone fractures of lower limb. Methodology: A prospective cohort study was conducted from November 2015 to May 2017 on Gustilo and Anderson Grade III open long bone fractures of the lower limb. Demographic data, injury details, time from injury to receiving antibiotics and index surgical procedure were noted. Length of hospital stay, number of additional surgeries and occurrence of complications were also noted. Patients with infected open fractures were grouped as culture positive or culture negative depending on the isolation of infecting microorganisms in deep intraoperative specimen. The clinical outcome of these two groups was statistically analysed. Results: A total of 231 patients with 275 open fractures involving the femur, tibia or fibula were studied. There was clinical signs of infection in 84 patients (36.4%) with 99 fractures (36%). Forty-three patients (51.2%) had positive cultures and remaining 41 patients had negative cultures (48.8%). The rate of culture-negative infection in open type III long bone fractures in our study was 17.7%. There was no statistical difference in the clinical outcome between culture-negative and culture-positive infections. Conclusion: Failure to identify an infective microorganism in the presence of clinical signs of infection is routinely seen in open fractures and needs to be treated aggressively.

Comparison of Reverse Sural Artery Flap Healing for Traumatic Injuries Above and Below the Ankle Joint.

The reverse sural artery (RSA) flap is popular among trauma surgeons to cover the distal third of the leg to the foot. However, flaps that inset in the foot seem to have a high necrosis rate. This study compared the healing of RSA flaps performed for defects proximal to the ankle versus defects distal to the ankle. Patient data were collected retrospectively between January 2005 and December 2009. Eighty-five patients with the lower leg, ankle, and traumatic foot injuries were divided into 2 groups. Group 1 (49 patients) had RSA flap cover for soft tissue and bony defect proximal and up to the ankle joint line, and group 2 (36 patients) had RSA flap cover distal to the ankle joint line. The time to healing and type of healing were compared between the groups. The demographics between the 2 groups were similar. The successful RSA flap healing rate was 65% in group 1 (32 of 49) and 42% in group 2 (15 of 36). The average time to flap healing between the groups was similar (p = .16). Group 1 had predominantly primary healing compared with group 2 (p = .03). Group 2 had a higher reoperation rate for wound necrosis, which was significant (p = .001). The success of the RSA flap is higher when used for proximal to ankle joint line defects. Surgeons should be aware of the chances of flap necrosis when undertaking RSA flap cover distal to the ankle joint line.

Outcome of screw post fixation of neglected posterior cruciate ligament bony avulsions.

BACKGROUND: Contrary to acute posterior cruciate ligament (PCL) bony tibial avulsions, surgical management of chronic injuries is technically challenging and appears to be controversial. We sought to assess the outcome of a novel screw post augmentation technique in neglected cases. METHODS: 16 patients were followed up in a tertiary single-center retrospective study. The bony fragment was fixed using a lag screw with a spiked washer and an additional screw post through an open posterior approach. The pre- and postoperative knee range of movement (ROM), laxity, and modified Tegner-Lysholm (TL) scores were compared. RESULTS: The median time from injury to surgery was 10 weeks (range, 3-260). The mean clinical follow-up time was 24.25 ± 9.21 months. At the final follow-up, the mean knee ROM flexion was 130° ± 11.55° with no extension lag. 3 patients had grade 1 laxity. The TL grade was predominantly excellent, and the overall median score improved from 76 preoperatively to 95 postoperatively (p < 0.0004). Bony union was achieved in all cases. CONCLUSION: The described screw post fixation technique results in an excellent outcome for these rare injuries. LEVEL OF EVIDENCE: Level IV, case series.

Alternate Method of Arthroscopically Confirming Femoral Button Deployment for Knee Anterior Cruciate Ligament Graft Suspensory Cortical Fixation.

Accurate deployment of the femoral button on the lateral aspect of the lateral femoral condyle when using a suspensory fixation device for anterior cruciate ligament reconstruction is ideal. Direct visualization would be the most appropriate method of visualization in the lateral gutter. A previously described technique is performed with the knee in flexion. In this position, maneuverability of the arthroscope in the lateral gutter may be difficult in small knees because of tight lateral structures. We describe a simple technique in which visualization is performed with the knee in extension, which is especially useful in small knees.

Head salvage of an infected neck of femur fracture in an adult: a case report.

Head preservation of an infected neck of femur fracture appears to be extremely rare with no described cases in literature till date. We present the outcome of head salvage in a young adult with an infected neck of femur nonunion who in addition had chronic osteomyelitic sequelae of his entire femur with reactivation of latent infection in the distal femoral diaphysis. Osteosynthesis was performed by means of cancellous screw fixation augmented with bone substitute following a failed attempt at salvage with a valgus intertrochanteric osteotomy. The patient had an excellent functional outcome with near normal hip range of movements at a follow-up of 5 years after union.

Valgus osteotomy for nonunion and neglected neck of femur fractures.

Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics. The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomy-optimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure.

Claw Toe Deformity of the Foot due to Foreign Body Granuloma.

UNLABELLED: We present a case of dynamic claw deformity of the right third toe due to a foreign body granuloma adhering to the flexor digitorum longus (FDL) tendon at the level of the body of the metacarpal bone. The deformity was completely corrected after removal of the granuloma and lengthening of the FDL tendon. A 25-year-old woman presented with pain and claw deformity of the right third toe, which corrected with ankle plantar flexion. Ultrasound and magnetic resonance imaging suggested the presence of foreign body granuloma of the right FDL tendon at the level of body of third metacarpal bone. On removal of the granuloma and Z plasty of the FDL tendon, there was complete correction of the claw. In the reported literature, claw deformity is seen with compartment syndrome or ankle fractures due to fixed length phenomenon or checkrein deformity of the flexor tendons usually at the level of medial part of the ankle. Here, we present a case of checkrein claw deformity of the FDL tendon due to a foreign body granuloma. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case study.

Indices affecting outcome of neglected femoral neck fractures after valgus intertrochanteric osteotomy.

OBJECTIVES: To evaluate preoperative neck resorption and postoperative valgus orientation as predictors of union and functional outcome after valgus intertrochanteric osteotomy for treatment of neglected femoral neck fractures and nonunions. DESIGN: Retrospective cohort study. SETTING: Tertiary care center. PATIENTS/PARTICIPANTS: Forty consecutive patients with neglected femoral neck fracture and nonunions were treated with valgus intertrochanteric osteotomy, and follow-up was available in 32 patients (average age, 43 years; range, 14-60 years; average nonunion duration, 6 ± 7 months; range, 1-36 months). INTERVENTION: Valgus intertrochanteric osteotomy. MAIN OUTCOME MEASUREMENTS: Clinical outcome was assessed with Harris hip score. Plain radiographs were evaluated for union, avascular necrosis, preoperative bone deficiency (neck resorption ratio), and postoperative femoral head fragment alignment (head-shaft angle). RESULTS: Follow-up at 5 ± 3 years (range, 2-12 years) after surgery showed union in 29 patients (91%), and Harris hip score was 82 ± 13 points (range, 63-100 points). The 3 patients with persistent nonunion at the neck of femur had neck resorption ratio <0.52. Increased postoperative head-shaft angle was associated with lower follow-up Harris hip score; postoperative valgus alignment >15 degrees compared with the contralateral side was associated with poor functional outcome. The presence of avascular necrosis did not affect the outcome. CONCLUSIONS: Valgus intertrochanteric osteotomy resulted in union and satisfactory functional outcome in most patients who had neglected femoral neck fractures and nonunions. Preoperative neck resorption ratio <0.5 was a risk factor for nonunion, and excessive valgus alignment was a risk factor for poor functional outcome after osteotomy. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The efficacy of single-stage open intramedullary nailing of neglected femur fractures.

BACKGROUND: Neglected femur fractures are not rare in the developing world. Treatment options include single-stage open reduction and intramedullary nailing, or open release, skeletal traction, and then second-stage open intramedullary nailing, with bone grafting. Single-stage procedures have the potential advantage of avoiding neurovascular complications secondary to acute lengthening, but they require a second operation, with potentially increased resource use and infection risk. QUESTIONS/PURPOSES: We sought to determine the (1) likelihood of union, (2) complications and reoperations, and (3) functional results with single-stage open intramedullary nailing without bone grafting in patients with neglected femur fractures. METHODS: Between January 2003 and December 2007, 17 consecutive patients presented to our practice with neglected femoral shaft fractures. All were treated with single-stage nailing without bone grafting. There were 15 men and two women with a median age of 27 years. The average time from fracture to treatment was 13 weeks (range, 4-44 weeks). Eleven patients underwent open nailing with interlocked nails and six were treated with cloverleaf Kuntscher nails. Patients were followed for a minimum of 6 months (mean, 33 months; range, 6-72 months). The mean preoperative ROM of the knee was 28° (range, 10°-150°) and femoral length discrepancy was 3.1 cm (range, 1-5 cm). RESULTS: All fractures united and the mean time to union was 16 weeks (range, 7-32 weeks). There were no neurologic complications secondary to acute lengthening. The mean postoperative ROM of the knee was 130° (range, 60°-150°). All patients were able to return to preinjury work. Sixteen patients regained their original femoral length. CONCLUSIONS: One-stage open intramedullary nailing of neglected femoral diaphyseal fractures without bone grafting was safe and effective, and obviated the need for a two-stage approach. Although the findings need to be replicated in larger numbers of patients, we believe this technique may be useful in treating patients with this injury, and may offer advantages in resource-constrained environments.

Functional outcome of biological condylar blade plating of subtrochanteric fractures.

BACKGROUND: The aim of this study was to review high-energy subtrochanteric fractures treated biologically with the 95° angled blade plate, to assess the time to union and return to work, and to perform a functional evaluation using the traumatic hip rating scale. PATIENTS AND METHODS: This study is a retrospective review of 22 patients with 23 fractures. Twenty-one patients (96%) with 22 fractures were available for analysis. The average age was 33 years (range 18-47). There were seventeen males and four females. The right side was involved in fifteen patients, the left in five patients, and one patient had bilateral fractures. Motor vehicle accident was the predominant mode of injury in eleven patients. Seven patients had other associated injuries. 32B2.1 (40%) was the commonest fracture pattern according to the OTA classification. RESULTS: The average follow-up period was 29 months (range 12-49). The mean time to fracture healing was 16 weeks (range 12-32). All patients returned to their pre-fracture occupation (100%). Eighteen patients (86%) healed without any additional surgery. The outcome according to the hip rating scale was excellent in ten patients and good in eleven patients. Two patients (9%) required additional surgery. CONCLUSIONS: Biological fixation of subtrochanteric fractures using 95° CBP results in a high union rate with low morbidity and good functional outcome.

Rapid resorption of calcium sulfate and hardware failure following corrective radius osteotomy: 2 case reports.

Bone substitutes are being increasingly used and may avert the need for autogenous bone graft in orthopedic surgery. Thus it is important to note complications that occur with them to better understand the limitations. We report on early mechanical failure of injectable calcium sulfate leading to implant failure in 2 elderly patients who had corrective osteotomies for malunited distal radius fractures. We hypothesize that these occurred because there was inadequate new bone formation to replace the resorbing bone substitute. We advise caution when using bone substitutes in patients with expected delayed fracture healing.

Experience of using local flaps to cover open lower limb injuries at an Indian trauma center.

BACKGROUND: Optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, skeletal stabilization, and in providing appropriate soft tissue cover. Timely coordination between orthopedic and plastic surgeons, though ideal, is often difficult. In our center, orthopedic surgeons undertake comprehensive treatment of open fractures including soft tissue cover. We reviewed the results of the local flaps of lower limb, done by orthopedic surgeons. MATERIALS AND METHODS: We retrospectively reviewed the results of the lower limb flaps done between January 2005 and December 2006. All flaps done at and below the level of knee were included. RESULTS: There were 105 patients with 120 flaps during this period. Two patients with two flaps were lost to follow-up. The average age was 32 years. Sixty-four patients had Type IIIB Gustilo and Anderson injuries. Thirty-nine patients had isolated soft tissue injuries. The indications for flaps were exposed bone, tendon, and joint in 45, 11, and 12, respectively, or a combination in 35 patients. The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and seven foot flaps. The flap dimensions ranged from 2 × 2 to 30 × 15 cm. Ninety-three flaps (79%) healed primarily. Among 25 flaps (21%) with necrosis, 14 flaps required secondary split skin graft for healing, while the other nine flaps healed without further surgery. CONCLUSION: Appropriate soft tissue cover provided by orthopedic surgeons can help in providing independent, composite care of lower limb injuries.