Long-Term Outcome of Valgus Osteotomy and Fixation with Double Angled Dynamic Hip Screw for Nonunion Fracture of the Neck of the Femur in Young Adults.

Objective To evaluate the long-term results of valgus intertrochanteric osteotomy fixed with double angled dynamic hip screw for nonunion fracture of the neck of the femur in young adults. This implant allows more freedom of fixation in the sagittal plane. Very few studies have evaluated the long-term outcome for treatment of nonunion in fractures of the neck of the femur. Methods This is a prospective interventional study that included 20 patients with nonunion of the fracture of the neck of the femur aged < 60 years old without avascular necrosis of the head and significant resorption of the neck of the femur. A lateral closing wedge osteotomy was performed just above the lesser trochanter after inserting the Richard screw across the nonunion site, and it was fixed with a double-angle 120° barrel plate. The outcome was evaluated using union rate and the Harris Hip Score for functional outcome. Results The average postoperative decrease in the Pauwels angle was of 28.9°. A total of 80% of the cases progressed to union within a mean duration of 7.53 months. The mean Harris Hip Score at the final follow-up was 86.45. Conclusion Valgus intertrochanteric osteotomy and fixation with a double angled dynamic hip screw is a reliable and effective method for preservation of head and promoting union in an ununited fractured neck of the femur in young patients.

Long-Term Outcome of Valgus Osteotomy and Fixation with Double Angled Dynamic Hip Screw for Nonunion Fracture of the Neck of the Femur in Young Adults / Desfecho a longo prazo da osteotomia valgizante e fixação com parafuso dinâmico de quadril de ângulo duplo de fratura não consolidada do colo femoral em adultos jovens

Abstract Objective To evaluate the long-term results of valgus intertrochanteric osteotomy fixed with double angled dynamic hip screw for nonunion fracture of the neck of the femur in young adults. This implant allows more freedom of fixation in the sagittal plane. Very few studies have evaluated the long-term outcome for treatment of nonunion in fractures of the neck of the femur. Methods This is a prospective interventional study that included 20 patients with nonunion of the fracture of the neck of the femur aged < 60 years old without avascular necrosis of the head and significant resorption of the neck of the femur. A lateral closing wedge osteotomy was performed just above the lesser trochanter after inserting the Richard screw across the nonunion site, and it was fixed with a double-angle 120° barrel plate. The outcome was evaluated using union rate and the Harris Hip Score for functional outcome. Results The average postoperative decrease in the Pauwels angle was of 28.9°. A total of 80% of the cases progressed to union within a mean duration of 7.53 months. The mean Harris Hip Score at the final follow-up was 86.45. Conclusion Valgus intertrochanteric osteotomy and fixation with a double angled dynamic hip screw is a reliable and effective method for preservation of head and promoting union in an ununited fractured neck of the femur in young patients.

Resumo Objetivo Avaliar os resultados a longo prazo da osteotomia intertrocantérica valgizante, fixada com parafuso dinâmico de quadril (DHS, na sigla em inglês) de ângulo duplo, em fraturas não consolidadas do colo femoral em adultos jovens. Este implante permite uma liberdade maior de fixação no plano sagital. Muito poucos estudos avaliaram o desfecho do tratamento a longo prazo da fratura não consolidada do colo femoral. Métodos Trata-se de um estudo prospectivo de intervenção que incluiu 20 pacientes com fratura não consolidada do colo femoral com idade < 60 anos, sem necrose avascular da cabeça femoral e significativa reabsorção do colo femoral. Foi realizada uma osteotomia em cunha de fechamento lateral logo acima do trocânter menor após a inserção do parafuso tipo Richard no sítio do retardo da consolidação óssea, sendo fixada com uma placa cilíndrica de ângulo duplo de 120°. O resultado foi avaliado com o uso da taxa de consolidação e da escala Harris Hip Score quanto ao desfecho funcional. Resultados Foi obtida uma redução pós-operatória média de 28,9° do ângulo de Pauwels. Os casos que evoluíram para a consolidação alcançaram 80%, em um período médio de 7,53 meses. A média da escala Harris Hip Score foi de 86,45 no acompanhamento final. Conclusão A osteotomia intertrocantérica valgizante e a fixação com DHS de ângulo duplo é um método confiável e eficaz para a preservação da cabeça do fêmur, promovendo a consolidação de uma fratura não consolidada do colo femoral em pacientes jovens.

Role of triangular osteosynthesis in vertically unstable transforaminal sacrum fractures: clinical and radiological outcomes.

PURPOSE: We aim to report clinical and radiological results of triangular osteosynthesis for a homogenous group of vertically unstable transforaminal sacral fractures. METHODS: Between 2013 and 2018, 22 consecutive patients with unstable sacral fractures were treated with triangular osteosynthesis consisting of iliosacral screw augmented by spinopelvic fixation. Patients were followed up prospectively as a single cohort. Bone union, complications, clinical and radiological outcomes were investigated. RESULTS: Mean follow-up was 3.1 years (12-76 months). There was one bilateral fracture. Two patients underwent anterior plating for pubic symphyseal disruption. Based on Majeed and Iowa pelvic scores, 13 patients had excellent, seven had good and two had fair clinical outcome. All the patients could perform squatting, sitting cross-legged and kneeling without any restrictions. There were no additional neurological injuries. One patient had non-union of sacral fracture, one patient had deep infection, one patient had marginal wound necrosis and two patients complained of pain related to implant prominence. Two patients had connecting rod backout. All but one patient attained pre-operative work status. CONCLUSION: Triangular osteosynthesis is a reliable procedure in treating unstable transforaminal sacral fractures. It permits early weight-bearing and facilitates faster functional recovery. Careful attention to details such as sacral dysmorphism, soft tissue injury, implant placement and anterior pelvic injury helps in keeping complications to an acceptable rate.

The presence of high-grade pivot shift test preoperatively is associated with inferior functional outcomes.

BACKGROUND: The effect of high-grade preoperative pivot shift test on outcomes of anterior cruciate ligament (ACL) reconstruction surgery is not very well established. The present study was conducted to study the factors associated with high-grade pivot shift test and effect of high-grade preoperative pivot shift test on functional outcomes after ACL reconstruction surgery. METHODS: Three hundred and sixty-two patients who underwent primary ACL reconstruction surgery were enrolled in the study. The pivot shift test was performed preoperatively under anesthesia in all patients. Side of the meniscal tear, if present at the time of ACL reconstruction, was documented. Patients were divided into two groups depending upon the grade of pivot shift test: group H, high-grade pivot shift (n = 84/362; 23%); and group L, low-grade pivot shift (n = 278/362; 77%). Patients were further divided into two groups depending upon the duration of injury: acute (<6 months) and chronic (>6 months). The functional assessment was done using Lysholm score and Tegner activity scale. RESULTS: The presence of lateral meniscus tear (27/84 vs. 53/278) or both menisci tear (29/84 vs. 60/278) was associated with high-grade pivot shift (p < 0.05). Chronic ACL tears were also observed to be associated with high-grade pivot shift (p = 0.03). The mean Lysholm score in group H and group L patients was 93.8 ± 5.1 and 95.2 ± 5.3, respectively (p = 0.04). The mean post-op Tegner activity scale in group H was 6.8 and in group L was 7.3 (p = 0.0001). Also, 181/253 (71.5%) patients returned to same or higher level of sports activity in group L as compared to 33/72 (46%) patients in group H. The incidence of graft failure in groups H and L was 6.5% (5/77) and 1.6% (4/257; p = 0.03), respectively. CONCLUSIONS: The high-grade pivot shift is associated with chronic ACL tear (>6 months) and concomitant lateral meniscus tear. The presence of high-grade pivot shift preoperatively is associated with inferior clinical outcomes and lower rate of return to sports. LEVEL OF EVIDENCE: Level IV, case-control study.

Peroneal Nerve Dysfunction in Patients with Clubfoot Deformity: Evaluation of Clinical Presentation and Treatment.

BACKGROUD: Complete peroneal nerve dysfunction associated with congenital clubfoot is uncommonly reported. Our retrospective study highlights the recognition of clinical presentation and mid-term outcomes of treatment in these patients. METHODS: Eight out of 658 patients undergoing treatment for clubfoot were identified with unilateral complete peroneal nerve dysfunction associated with congenital clubfoot. Three patients presented primarily to our center; 5 were treated elsewhere initially. All patients were treated with Ponseti casts, Achilles tenotomy, and subsequent foot abduction bracing. Diagnosis of complete peroneal nerve dysfunction was confirmed using nerve conduction velocity studies in all patients. After full-time bracing, an insole polythene molded ankle foot orthosis was given. Three patients underwent tibialis posterior transfer to improve foot dorsiflexor power. RESULTS: The mean age at presentation was 1.3 years (range, 1 week-5 years). All patients had prominence of lateral 3 metatarsal heads and dimpling of intermetatarsal spaces. At a mean follow-up of 5.1 years, mean shortening of 1.2 cm in tibia (range, 1-2.5 cm) and mean calf wasting of 4.4 cm were observed. There was no relapse of any clubfoot deformity till the final follow-up. CONCLUSIONS: Prominence of lateral metatarsal heads and dimpling of intermetatarsal spaces should raise early suspicion of peroneal nerve dysfunction. Standard Ponseti protocol is useful in treatment of these patients. Tibialis posterior transfer to dorsum partially restores the ankle dorsiflexion.

Iatrogenic median nerve injury as a result of venous cut down procedure: A rare case report.

INTRODUCTION: Venous cut down is an emergency procedure done to get vascular access in trauma patients where peripheral cannulation/central venous catheter is challenging or causes delays. PRESENTATION OF CASE: We present a rare case of iatrogenic injury of right median nerve which occurred during basilic vein cut down. The injury came to notice when the patient presented with complaints of paraesthesia and weakness in his right hand for the past 6 weeks. On examination, tests for median nerve function were indicative of median nerve injury. Median nerve palsy was subsequently confirmed on electrodiagnostic studies. Upon exploration, it was noted that the median nerve was tightly tied circumferentially with a suture forming a constriction band which was released and neurolysis done. At 4 months follow up, patient showed complete recovery in terms of motor and sensory function of median nerve. DISCUSSION: The anatomical variations in the pattern of cubital veins have been reported in literature. These anatomical variations and close proximity of nerves should be kept in mind and anticipated for while performing venesection. Moreover, these procedures are done by junior doctors in emergency settings, under stressful circumstances and suboptimal conditions, especially in developing countries, which increase the risk of an iatrogenic injury. CONCLUSION: With good anatomical knowledge and high caution during the procedure, such complication could have been avoided.

Angular deformities of lower limb in children: Correction for whom, when and how?

Angular deformities are common presentations in childhood and adolescent age group. It is important to differentiate a true deformity from a physiological deformity, this requires measurement of the intercondylar and intermalleolar distance. Once a true deformity is diagnosed, the apex of the deformity requires to be established. Lower limb frontal plane deformities are evaluated with a true AP standing radiographs of the entire lower limb from hip to ankle. Mechanical or anatomical axis calculation gives the apex (CORA) as well as the magnitude of deformity. Frontal plane deformities require surgical intervention. In younger children, growth modulation surgery allows correction of the deformity with minimal morbidity and without the need for osteotomy. Older children, adolescents and adults require corrective osteotomy. The corrective osteotomy can be closed wedge, open wedge, or a dome osteotomy. The osteotomy may be stabilized with internal fixation with plate and screws or an intramedullary implant as is dictated by the level of osteotomy and the local bony anatomy. External fixators allow gradual and precise correction of the deformity.

An Initial Study into the Role of Teriparatide in Absent or Delayed Regenerate Formation during Distraction Osteogenesis: A Case Series.

Purpose: Distraction osteogenesis has been used for post-traumatic segmental bone defects. Absent or delayed callus formation in the distraction gap can lead to significant morbidity and affect the clinical outcome. Experimental evidence in animal models has demonstrated that teriparatide enhances the consolidation of regenerate and also strengthens it. This study aimed to report our experience with recombinant teriparatide therapy for patients with regenerate insufficiency. Materials and methods: Nine out of 43 patients undergoing limb lengthening using the limb reconstruction system (LRS) fixator were diagnosed with regenerate insufficiency. With informed consent, these patients received a therapeutic regime of 20 µg of teriparatide administered subcutaneously once daily for a period of 3 months. Results: The mean age in the sample was 40.22 years (SD 17.87). Regenerate insufficiency was diagnosed at a mean of 4.94 months (range 2.5-9 months) from surgery. Teriparatide injections were started at a mean of 6.94 months (range 4.5-11 months) from surgery. The sites of regenerate insufficiency were tibia (n = 5) and femur (n = 4). Favourable radiographic progress in visibility of callus was seen at a mean duration of 9.4 weeks (range 8-12 weeks) from the initiation of teriparatide therapy. No systemic complications were encountered. Conclusion: The initiation of teriparatide treatment as described in this study may be successful in triggering the osteogenic potential within poor regenerate and help in consolidation and avoid more invasive surgical procedures. How to cite this article: Patil B, Kansay R, Gupta S, et al. An Initial Study into the Role of Teriparatide in Absent or Delayed Regenerate Formation during Distraction Osteogenesis: A Case Series. Strategies Trauma Limb Reconstr 2020;15(2):117-120.