Evaluation of Anterolateral Plating of Distal Third Tibial Fractures.

Background Distal one-third tibial fractures with or without articular involvement can be difficult to manage. Variety of treatment methods have been suggested for these injuries, including conservative treatment, external fixation with or without limited internal fixation, intramedullary nailing, plate fixation (medial or anterolateral) and more recently minimally invasive plate osteosynthesis (MIPO). All of these techniques have advantages and disadvantages. None of these techniques can be considered the "gold standard" for these injuries. Objective The objective of this prospective study was to evaluate the results of anterolateral plating of these fractures. Method Forty-five fractures of distal third of tibia were treated with open reduction and internal fixation with anterolateral tibial plate from December 2011 to December 2016. All the patients were followed up at least for nine months for the study. Radiological union was finally assessed in nine months. Result All the fractures united within nine months of plating without angulation in sagittal or coronal plane. One patient (2%) had limb length shortening of more than one cm. Full range of motion of ankle and knee joint was achieved compared to the normal side by nine months follow up. 17 (38%) patients developed marginal skin necrosis. Three (7%) patients developed superficial wound infection. These complications were seen more in patients in whom posterior below knee slab was used for pre-operative splintage (as compared to calcaneal traction). Conclusion Hence distal one-third tibial fractures with or without articular involvement can be treated with anterolateral tibial plate.

Open reduction and internal fixation of supracondylar fractures of the humerus: revival of the anterior approach.

INTRODUCTION: Supracondylar fractures of the humerus occur commonly in the paediatric age group. Gartland type III fractures are treated by closed manipulation and percutaneous pinning with K-wires. Open reduction is indicated in open fractures, failed closed reductions and in a dysvascular limb. There are various approaches that can be utilized to perform an open reduction. The approach of choice must be safe, surgeon and patient friendly and should provide a good access to the fracture and the important surrounding structures. The anterior approach has been described as the most versatile approach. The aim of the study was to review the advantages and drawbacks of the anterior approach and to assess the functional outcome of fractures treated via this approach. MATERIALS AND METHODS: Twenty five (15 male and 10 female) patients out of a hundred and twenty eight children with Gartland type III extension variety of supracondylar fractures of the humerus from underwent open reduction and internal fixation with K-wires via an anterior approach January 2007 to January 2011. The results were assessed at six months using Flynn's radiological and clinical criteria. RESULTS: Twenty five patients (19.53%) out of hundred and twenty eight patients underwent open reduction and internal fixation. According to Flynn's clinical and radiological criteria, 20 (80%) were found to have excellent and 5 (20%) good results. CONCLUSION: The anterior approach is safe, easy and provides direct exposure of the surrounding neurovascular structures with good to excellent results.

Functional outcome of operatively treated displaced intra-articular calcaneal fractures using two parallel contoured reconstruction plates.

INTRODUCTION: The treatment of displaced intra-articular calcaneal fracture is controversial. Conventionally, they were treated non-operatively. However, some surgeons are now operatively treating these fractures because of continuing dissatisfaction with the outcome of conservative treatment of these fractures and improvements that have occurred in surgical techniques and complication rates. OBJECTIVE: The aim of this study was to determine the functional outcome of operatively treated displaced intra-articular calcaneal fractures using two parallel contoured reconstruction plates. MATERIALS AND METHODS: 12 patients with 14 displaced intra-articular calcaneal fractures involving the subtalar joint were included in the study conducted between July 2005 and December 2008. The fracture site was exposed using extended lateral approach. Internal fixation was done by two nearly parallel 3.5mm reconstruction plates and screws contoured to form a gentle curve in all cases with the fi rst plate fixed just below the articular surface. At the end of follow up, the patients' foot function was assessed by Calcaneal Fracture Scoring System of Kerr et al. Patients were also inquired about their satisfaction with their treatment outcome. RESULTS: The patients were followed up for duration of 12 to 24 months (mean 15.64 months). The outcome score as measured by Calcaneal Fracture Scoring System ranged from 48 to 94 (mean 83.64). 11 of 12 patients (91.6 %) were satisfied with the treatment. CONCLUSION: Displaced intra-articular fractures treated by open reduction and internal fixation, using two nearly parallel, contoured reconstruction plates through an extensile lateral approach and following the principles of treatment of intraarticular fractures, have good functional results with high patient satisfaction rate.

Osteosynthesis of intercondylar humerus fracture using Bryan and Morrey approach.

BACKGROUND: The olecranon approach has been the gold standard for surgical approaches to fracture fixation of distal articular surface of humerus. Although it provides a good exposure, it also has disadvantages of delayed union, nonunion and implant related complications at the osteotomy site. OBJECTIVE: The aim of this study was to determine the functional outcome of displaced intra-articular distal humerus fracture fixation using an alternative approach: the Bryan and Morrey approach. MATERIALS AND METHODS: Twenty patients with twenty AO type C1 and C2 intercondylar fractures of the distal humerus had bicolumnar fixation of the distal humerus with two contoured reconstruction plates and screws on the dorsal surface or various combinations of a single reconstruction plate, screws and K-wires using a Bryan and Morrey approach. Twelve of the patients were male and eight were female. The average age of the patients was 44.8 years. Eleven patients had sustained the injury as result of fall and nine of the patients had sustained it in road traffic accidents. Right elbow was involved in fifteen patients and left in five. All patients were followed up for 12 months post operatively. RESULTS: All twenty fractures had united at 4 months follow-up. The mean fixed flexion deformity was 9.0º (range 0º-15º) and the mean arc of motion was 115.0 º (range 85 º- 130º). All patients had grade 4 triceps strength and stable elbows at the end of 12 months follow up. One patient had deep seated wound infection resulting in necrosis of the triceps tendon requiring a second operative procedure. CONCLUSIONS: Bryan and Morrey approach is a simpler, easier and better approach as compared to the other posterior approaches to the elbow joint, and therefore, can be used as the approach of choice for fixation of fractures of the distal articular surface of humerus.

Conservative treatment of nonarticular fractures of distal third tibia.

INTRODUCTION: Distal one third tibial fractures can be difficult to manage. Variety of treatment methods have been suggested for these injuries, including conservative treatment, external fixation, intramedullary nailing, and plate fixation. None of these techniques can be considered the "gold standard" for these injuries. The purpose of this prospective study is to evaluate the results of conservative treatment of these fractures. METHODS: Total 39 fractures of distal third of tibia were treated with closed reduction and long leg cast for six to eight weeks followed by PTB cast for six to eight weeks from January 2004 to October 2008. One year follow up was done with 32 patients, eight months follow up with three patients and four patients were lost to follow up. RESULTS: All the fractures united within six months of duration. Immediate post-reduction average angulation was 3.72 degree in sagital plane and 3.32 degree in coronal plane. Average final angulation was 5.04 degree in sagital plane and 4.32 degree in coronal plane. Average limb length shortening was 6.8 mm. Full range of motion of ankle and knee joint was achieved compared to the normal side by six months of follow up. Though there was displacement of fracture during conservative treatment final outcome was within acceptable limit. CONCLUSION: Hence distal one third tibial fractures can be treated conservatively with closed reduction and cast immobilization with numerous advantages over operative methods.

External and internal fixation for comminuted intra-articular fractures of distal radius.

BACKGROUND: Distal radius fractures are a common injury and without proper treatment leads to high functional impairment and frequent complications. OBJECTIVE: The aim of this study was to see the functional outcome in patients with comminuted distal radius fractures treated with combined external fixation and open reduction and volar plating. MATERIALS AND METHODS: All comminuted distal radius fractures classified as type C in AO/OTA classification were enrolled for the study from 2005 till 2008. The clinical scoring chart modified by Cooney was used to evaluate the functional outcome. RESULTS: There were twenty-two patients with the average age of 42.18 years (range 19-60) with 15 male and 7 females. The follow-up period was from 14 to 46 months. Accordingly, there were 11 (50%) excellent, 7 (31%) good, 2 (9%) fair and 2 (9%) poor results. There were very few complications in our series. In three patients additional K-wire supplementation was necessary along with external and open internal fixation. CONCLUSIONS: Comminuted intra-articular fractures of distal radius should be treated by open reduction and combined internal and external fixation to achieve a high rate of patient satisfaction and satisfactory functional outcome.

Sub-trochanteric fractures of the femur: results of ORIF at KMCTH.

Sub-trochanteric fractures of the femur are not commonly encountered as compared to trochanteric or neck of femur fractures. Relatively younger persons are injured more and a considerable violence is required for this fracture to occur. These fractures, treated conservatively by methods like traction, splints or casts, are often associated with complications like non-union, mal-union, shortening of the limb etc. Thus, we undertook this study of 10 consecutive cases of sub-trochanteric fractures of the femur treated by open reduction and internal fixation and bone grafting in Kathmandu Medical College Teaching Hospital, Sinamangal, from the year Nov. 2000 to April 2006. There were 4 females and 6 male patients. Their age on average was 46.8 years (range 15 to 86 years). Most of the patients were in Type II or III in Seinsheimer classification; Type II A, B, and C, one, two and one respectively, and in Type III A and B three patients each. Seven patients were treated with dynamic hip screw. Three patients with type III were managed with centro-medullary interlocking nail with one cerclage suture. They were followed for a period of minimum 6 months to 6 years (average 3.5 years). Union was achieved in all, on an average 4 months postoperatively. Results were excellent and complications like nonunion, malunion or breakage of the implants, were not encountered in any patient.

Percutaneous extensor tenotomy for chronic tennis elbow using an 18G needle.

INTRODUCTION: Tennis elbow is a common orthopaedic problem presenting in office orthopaedics, but its exact patho-aetiology has not been identified to date. It is treated operatively when conservative measures including multiple local steroid injections are not helpful to the patients. MATERIAL AND METHOD: This was a retrospective study to assess the outcome of tennis elbow patients on whom percutaneous release of the common extensor origin was performed using an 18 gauge hypodermic needle. 17 patients with 21 elbows were included in the study. Data was collected by going through the patients' medical records, and follow -up by questionnaire mailed to the patient's home, to assess the outcome and patient satisfaction with the procedure. RESULTS: 14 of the 21 (66.7%) elbows became completely pain free. The time taken to achieve a completely pain free elbow ranged from 1 day to 3 months (average 60.3 days). Those that did not achieve a pain free elbow had a residual pain of 1.5 to 8.5 on the VAS (average 2.64). 9 elbows (42.9%) had an excellent outcome, 7(33.3%) had good, 4(19%) had satisfactory and 1(4.8%) had poor outcomes. CONCLUSION: Tennis elbow probably results from degenerative tear of common extensor origin and a percutaneous tenotomy using an 18 gauge hypodermic needle is a simple, safe, patient friendly, effective and easily reproducible method of treating it in those who require surgery and can be done as an office procedure.