Management of femoral neck fracture non union with modified Pauwels' osteotomy.

Modified Pauwels' intertrochanteric osteotomy is a promising procedure to heal a non union of the femoral neck fracture, with a success rate of 80-90%. Caxa vara correction and limb length equalization can be achieved simultaneously with this procedure. Two stage surgical procedure has the advantage of keeping blood loss and bone exposure to minimise the risk of infection. We herewith present some tips and tricks and the details of doing this osteotomy.

Clinicoradiologic Profile of Involvement and Healing in Tuberculosis of the Spine.

BACKGROUND: There is no much information about how tuberculous lesions of the spine progress/heal; what clinical and radiological features suggest progression/healing; what is the optimal duration of antitubercular treatment; and what clinical, laboratory, and radiological investigations and their frequency should be done to monitor the disease course. AIMS: The present study aimed to evaluate what specific clinicoradiologic features suggest involvement and healing in tuberculosis of the spine. SUBJECTS AND METHODS: Fifty spinal tuberculosis patients (30 males and 20 females) diagnosed clinicoradiologically were enrolled in the study. Patients were evaluated clinically, radiographically, and by magnetic resonance imaging (MRI) at regular intervals to monitor the disease course till 24 months of the initial presentation. RESULTS: Wedge/collapse (23/50 cases), soft tissue mass (29/50 cases), disc narrowing (45/54 discs), and endplate erosions (89/107 endplates) were the plain radiological findings of tubercular spinal involvement. Earliest sign of healing on plain radiography was decrease in fuzziness of endplate, ultimately leading to either sclerosis of endplate or fusion of adjacent vertebrae. Initial MRI findings included bone marrow edema (50/50 cases), discitis (53/62 discs), endplate erosions (105/123 endplates), pre- and para-vertebral collections (45/50 cases), epidural involvement (26/50 cases), epidural spread (77/109 vertebrae), and subligamentous spread (42/50 cases). Earliest feature of healing on magnetic resonance (MR) examination was decrease in inflammatory soft-tissue masses and reduction in marrow edema. CONCLUSIONS: Salient features of spinal involvement in tuberculosis on plain radiograph were paradiscal involvement, endplate destruction, and soft tissue masses. Marrow edema, paravertebral collections, subligamentous spread, extradural component, endplate erosion, and discitis suggested tubercular involvement of the spine on MRI. A decrease in these was observed to have prognostic value both in monitoring disease course and response to chemotherapy. Based on the clinicoradiologic findings of the present study, we propose decision-making algorithm, follow-up algorithm, and MR examination protocol for spinal tuberculosis. LEVEL OF EVIDENCE: This was a Level II study.

Check-Rein Technique for Management of Neglected Locked Posterior Shoulder Dislocations: Evaluation of Mid-term Outcome of a Novel Technique.

Introduction: Neglected locked posterior shoulder dislocations, although rare, are quiet perplexing to manage. Various treatment methods have been explained for their management, but a consensus is still lacking. Besides describing a novel technique for the management of these lesions, this study aims to evaluate the mid-term outcome of this technique. Method: This prospective study involved seven consecutive patients with locked posterior dislocation of the shoulder with humeral defect between 25% and 50%. All patients underwent open reduction of the locked posterior dislocation with the current technique. The final outcome was assessed at a mean follow up of 3.5 years (range 2-5 years) using the DASH score. Result: The mean age of the patients was 32 years (range 21-44) and all were men. The mean time to presentation from initial injury was 2.4 years (range 2-4 years). The patient related outcome as measured by DASH score improved from a preoperative mean of 59.1 to mean value of 8.6 at the time of final follow up. There were no cases of graft pull out, nonunion at the graft site or infection. Conclusion: This technique results in pain-free range of motion with a stable shoulder though a larger sample population with a longer follow up is required to further support our observations.

Hypertrophic nonunion humerus mimicking an enchondroma.

Introduction. Although fractures of humeral shaft show excellent results with conservative management, nonunion does occur. Case Report. We bring forth the case of a young male with a 1.5-year-old hypertrophic nonunion of the humerus mimicking an enchondroma. The initial X-ray images of the patient appeared to be an enchondroma, which only on further evaluation and histopathological analysis was diagnosed conclusively to be a hypertrophic nonunion. Discussion. Enchondromas are often incidentally diagnosed benign tumours. It is however not common to misdiagnose a hypertrophic nonunion to be an enchondroma. We present this case to highlight the unique diagnostic dilemma the treating team had to face.

Modified Pauwels' intertrochanteric osteotomy in the management of nonunion of a femoral neck fracture following failed osteosynthesis.

We report the outcome of 39 patients who underwent a modified Pauwels' intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels' classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d'Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels' intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed.

Functional outcome in athletes at five years of arthroscopic anterior cruciate ligament reconstruction.

Introduction. The purpose of this study was to analyze the functional outcome in competitive level athletes at 5 years after ACL reconstruction with regard to return to sports and the factors or reasons in those who either stopped sports or showed a fall in their sporting levels. Methods. 48 competitive athletes who had undergone arthroscopic assisted ACL reconstruction with a minimum follow up of at least 5 years were successfully recalled and were analyzed. Results. 22 patients had returned to the preinjury levels of sports and 18 showed a decrease in their sporting levels. Of the 18 patients, 12 referred to fear of reinjuring the same or contra-lateral knee as the prime reason for the same while 6 patients reported persisting knee pain and instability as reasons for a fall in their sporting abilities. The difference in the scores of these groups was statistically significant. 8 patients out of the 48 had left sports completely due to reasons other than sports, even though they had good knee outcome scores. Conclusion. Fear of reinjury and psychosocial issues that are relevant to the social milieu of the athlete are very important and affect the overall results of the surgery with respect to return to sports.

Mini-incision dynamic condylar screw fixation for comminuted subtrochanteric hip fractures.

PURPOSE: To review the results of indirect reduction and mini-incision dynamic condylar screw (DCS) fixation for comminuted subtrochanteric femoral fractures. METHODS: 29 men and 14 women aged 25 to 65 (mean, 44) years with comminuted subtrochanteric femoral fractures underwent indirect reduction and mini-incision DCS fixation. Fractures were classified according to the AO classification (10 type 32B and 33 type 32C) and Seinsheimer classification (6 type III, 15 type IV, and 22 type V). Functional outcomes were assessed using the Harris hip score and Merle d'Aubigne score. RESULTS: The mean time to full weight bearing was 11 (range, 8-19) weeks. The mean time to union was 16 (range, 13-22) weeks. There were no cases of non-union or implant failure after a mean follow-up period of 25 (range, 18-30) months. Seven patients had a mean limb length discrepancy of 1.5 (range, 1-2) cm. Two patients had coxa vara and persistent limp. According to the Harris hip score, functional results were excellent in 12 and good in 31 patients. The mean Harris hip score was 88 (range, 80-99) and the mean Merle d'Aubigne score was 17 (range, 14-18). There was no deep infection or avascular necrosis of the femoral head. Restriction of knee flexion beyond 90 degrees was noted in 2 patients. CONCLUSION: Results of indirect reduction and mini-incision DCS fixation for comminuted subtrochanteric femoral fractures are favourable. Proper planning and execution of the technique is required to achieve good functional outcomes and avoid complications. Preservation of vascularity of the medial fragments leads to rapid callus formation and early union and hence avoids implant failure and secondary bone grafting.

Diagnostic significance of radiologic measurements in posterior heel pain.

BACKGROUND: Posterior heel pain is a common complaint in both athlete and non-athlete. For diagnosis of etiology certain angles, lines and soft tissue parameters have been developed in the literature to describe the calcaneal prominence and its relationship to Achilles tendon and its bursae. OBJECTIVES: A prospective study was undertaken to evaluate the diagnostic values of these angles, lines and soft tissue parameters in posterior heel pain. MATERIALS AND METHODS: Seventy-one painful heels in 58 patients (30 males and 28 females, mean+/-S.D. age; 41.4+/-10.82 years) were clinically and radiologically examined. This was compared with 50 heels in 25 control subjects. A lateral weight bearing film of the foot was taken to calculate different angles, lines and soft tissue parameters mentioned in the literature. RESULTS: There were 45 Pavlov's parallel pitch line positives and using test of Denis and Huber-Levernieux in only one posterior superior crest extended beyond vertical tangential. There was only one heel with Fowler & Philip angle >75 degrees. There were 10 heels with Steffensen & Evensen angle >65, 5 heels with total angle >90 degrees and 52 heels with Chauveaux-Liet angle >12 degrees. There were 73% true positive for Chauveaux-Liet angle and 63% true positive for parallel pitch line. Among soft tissue parameters ill defined retrocalcaneal recess was present in 61 symptomatic heels, plantar spur in 42 heels, posterior calcaneal step in 33 heels, Achilles tendon calcification in 29 heels, superficial tendo-Achilles bursitis in 58 heels, posterior calcaneal spur in 31 heels and antero posterior diameter of tendo-Achilles more than 9 mm in 68 symptomatic heels. CONCLUSION: Parallel pitch lines, Chauveaux-Liet angle, ill-defined retrocalcaneal recess, superficial tendo-Achilles bursa and anteroposterior diameter of Achilles tendon more than 9 mm about 2 cm above insertion are reliable objective diagnostic indicators of bony deformity of calcaneus and soft tissue affection in patients with posterior heel pain. It is the combination of these bony and soft tissue parameters, which enhance the diagnostic certitude.

Extraskeletal osteochondroma in the nape of the neck: a case report.

Extraskeletal osteochondroma in the nape of the neck is rare and its pathological diagnosis is based on radiological and histopathological examination. It is vital that such a diagnosis be considered when a discrete, ossified mass is localised in soft tissues, even at atypical sites. Differential diagnoses include myositis ossificans, a lipomatous lesion, a pseudomalignant osseous tumour, an ossifying fibromyxoid tumour, an extraskeletal chondroma with endochondral ossification, synovial (osteo) chondromatosis, tumoural calcinosis, a synovial sarcoma, and an extraskeletal osteosarcoma. Clinical awareness of this benign entity is important as no malignant transformation or metastasis has been reported. Marginal excision with histopathological identification is the treatment of choice.

Treatment of pathologic femoral neck fractures with modified Pauwels' osteotomy.

UNLABELLED: Treatment of pathologic femoral neck fractures secondary to extensive lesions of fibrous dysplasia and simple bone cysts has been controversial. We think that modified Pauwels' intertrochanteric osteotomy and osteosynthesis can result in sound healing of the lesion and of the fracture, with no recurrence, low complication rates, and good functional results. Seven patients were treated with a uniform approach consisting of biopsy (Stage I) and osteotomy with osteosynthesis (Stage II). Curettage of the lesion and bone grafting were not done. The average followup was 79.28 months (range, 32-142 months). All of the fractures and osteotomy sites healed in means of 14 weeks (range, 12-16 weeks) and 9.1 weeks (range, 8-10 weeks), respectively. All fibrous dysplasia lesions healed radiologically. Grade IV radiographic healing was seen in both patients with simple bone cysts after 35 and 92 months. Using the Musculoskeletal Tumor Society functional evaluation and Toronto Extremity Salvage Score, all the patients had good to excellent results. Complications such as infection, local recurrence, refracture, femoral neck deformity, osteonecrosis of the femoral head, and growth arrest of capital femoral physis were not seen. In addition to biomechanical advantages, the procedure seems to have had a biologic role in healing of the fracture and of the lesion by initiating osteogenesis to replace the defect with new bone. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Wheat thresher agricultural injuries: a by-product of mechanised farming.

Farm mechanization has resulted in extensive use of wheat threshers on Indian farms. It has also increased agricultural injuries. A prospective study was undertaken for analysis of wheat thresher agricultural injuries and their remedial measures. Fifty two patients presenting with thresher injuries during the wheat harvesting season of March to June, 2003 were studied. A study-specific 14-point proforma was prepared to gather all possible information from site of injury to hospital records. Injuries were mostly of the upper limb and amputations accounted for most of these. Poor light arrangements, unskilled workers, drug / alcohol abuse, fatigue, poor designing and lack of orientation to work on these machines were the contributory factors to such injuries. The analysis emphasizes that the need of the hour is to decrease wheat thresher injuries through specific preventive approaches like improved designing, education, legislation, compensation and surveillance programmes.

Osteosynthesis and primary valgus intertrochanteric osteotomy in displaced intracapsular fracture neck of femur with osteoporosis in adults.

Fifty-three adults sustaining intracapsular femoral neck fractures (subcapital 38 and transcervical 15) with osteoporosis were treated primarily by osteosynthesis with valgus intertrochanteric osteotomy. Final evaluation was done in 50 patients (1 patient died and 2 lost to follow up, were not considered). Union was achieved in 47 (94%) patients in an average period of 12.2 weeks (range 10-18 weeks) with 100% union at osteotomy site. An axial collapse between 2 and 14 mm was observed in 74% of patients at the fracture site. Average neck shaft angle achieved was 141 degrees . Retroversion of the femoral head was seen in 28% of patients postoperatively, but none demonstrated a further posterior tilt of proximal femoral fragment, thus preventing implant cut through. One of the four patients with avascular necrosis of the femoral head exhibited late segmental collapse between 98 and 171 weeks. Final results were excellent to good in 76% of patients (average hip score 92), fair in 18% (average Harris hip score 73) and poor in 6% (average Harris hip score 30). Deep infection in 2%, superficial infection in 4%, implant penetration into the joint in 4%, limb length discrepancy in 6% and external rotation in 68% were other complications. Primary osteosynthesis with valgus intertrochanteric osteotomy is a dependable procedure to provide stable fixation in fresh fractures of the neck of femur with osteoporosis. The potential benefit of retaining a viable biologic joint justifies the usefulness of this procedure.

Digital soft tissue Ewing's sarcoma of foot--a case report.

A 22-year-old female presented with rapidly increasing, fungating and painful growth of right foot of 4 months duration. The growth had superadded infection. Radiography revealed soft issue mass between 2nd and 3rd toes without any bony involvement. Histopathologically it was confirmed to be a case of extraskeletal Ewing's sarcoma. Amputation above the ankle was done. She was advised for chemotherapy. She is still alive after 2 years. Here in this case the tumour arose in the subcutaneous tissue between 2nd and 3rd toes and diagnosed as a case of Ewing's sarcoma of the foot.