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.

Does Tranexamic Acid Reduce Perioperative Bleeding in Short Segment Pedicle Screw Fixation in Thoracolumbar Spine Fractures?

INTRODUCTION: Blood loss with spinal surgery is common potential cause of morbidity and often requires blood transfusion. Tranexamic acid (TXA), is effective in reducing bleeding in patients undergoing knee arthroplasty. TXA used in spine surgery studies have included different cases leading to inconsistence of surgical procedures. Purpose of this prospective observational study was to examine effect of TXA decreasing bleeding in short segment pedicle screw fixation for thoracolumbar fractures. METHODS: 38 patients' undergoing short segment pedicle screw for thoracolumbar fractures were enrolled in study from July 2011 to August 2013. There were 28 male and 10 female patients, with an average age of 36.5 years. Patients received 10 mg/kg of TXA or a control 30 minutes intravenously before skin incision and 3 hours post-operative and oral medication for three days. Intraoperative bleeding was estimated by weighing surgical sponges, blood collected by suction container and by subtracting all irrigation fluid. Postoperative bleeding was measured from volume in vacuum drainage bag. RESULTS: Twenty (20) patients were in control group and eighteen(18) to TXA group. There were no statistical differences between groups in terms of age, gender, co-morbidities, and operating time, preoperative Hemoglobin, PT and INR. Intra-operative bleeding in TXA group was significant than in control group. Post-operative drainage and Hemoglobin in first 48 h was reduced compared with placebo in TXA group. Need for post-operative transfusion was nil in TXA group. CONCLUSIONS: Administration of TXA before surgery significantly reduces perioperative bleeding in patients undergoing short segment pedicle screw fixation for thoracolumbar spine fractures.

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.

Ultrasound: an extension of clinical examination.

AIMS AND OBJECTIVES: To study the impact the use of portable ultrasound can have for the benefit of the patients when used by doctors other than radiologist, in this case surgeons. METHODS: Ultrasound performed by surgeons in the pre-operative, operative and post-operative period was studied. Patients presenting to the Hospital with acute abdomen was subjected to ultrasound. They were either pre-operative or post-operative patients. Five patients were scanned intraoperatively. The impact of these scans to the patients as well as the clinicians was studied. RESULTS: This is an ongoing study and preliminary results of the scans show two pre-operative diagnosis of acute appendicular collection and one acute hydronephrosis. In the operation room, ultrasound was done on 5 cases. On three occasions, it was to locate renal stones so that it could be extracted with ease. On two of the case, it was t to confirm the adequacy of common bile duct exploration thereby allowing primary closure of the common bile duct. Post-operatively, it was used in four cases of which in two cases post-operative hemorrhage were detected timely within hours. In the other two cases, the surgical team was assured that the patient's complaint was not surgically related. CONCLUSION: Ultrasound should be an extension of the clinical examination when indicated and all clinicians should be proficient in its use in their respective fields.

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.

Reduction of acute anterior shoulder dislocations: comparing intraarticular lignocaine with intravenous anesthesia.

Anterior shoulder dislocation is the most common dislocation in the body. Various methods of anesthesia are available for reduction. The objective of this study was to compare the application of intra-articular anesthesia with intravenous anesthesia for reduction of acute anterior shoulder dislocation. This study was conducted at Kathmandu Medical College Teaching Hospital (KMCTH) and Kathmandu Hospital and comprised of patients coming with anterior dislocation of shoulder from July 2001 to June 2005. Forty-five patients aged 17-55 years with no associated fractures of adjoining bones were included in the study. In twenty-three patients, reduction was done using intra-articular anesthesia and in 22 patients intravenous anesthesia was given. In five patients (three in intra-articular group and two in intravenous group) the reduction technique had to be changed to the Hippocratic method. In these three patients intravenous anesthesia had to be given after intra-articular anesthesia failed to relieve pain and spasm. In the intravenous group two patients had to be admitted overnight while in the intra-articular group none had to be admitted to the hospital. However, in the intra-articular group the average time taken from injection to reduction was significantly longer (<.001). The use of intra-articular lignocaine for reduction of shoulder dislocation is safe and effective especially when patients present early. In patients presenting late (more than 5 hours) intravenous anesthesia should be primarily considered as the method for shoulder reduction.

Pre-operative assessment of K-nail length in fracture shaft of femur.

INTRODUCTION: Internal fixation of diaphyseal fracture of shaft of femur in an adult by Kuntscher nail is the most common operative method of treatment in Nepal where operative facilities for the same exist. Since the complete range of K-nail sizes and length are not available in most operation theatres in Nepal, most orthopaedic surgeons assess the size and length of the K-nail pre-operatively by various methods and keep one size above and below the assessed length for the planned surgery. MATERIALS AND METHODS: The following measurements were taken in five hundred people involved in the study: Measurement No. 1: Tip of the greater trochanter to lateral knee joint line minus 2 cm. Measurement No. 2: Tip of the olecranon process to the tip of little finger, and Measurement No. 3: Tip of the greater trochanter to the upper pole of patella. An average of all three lengths were analysed to see if there were any differences in their mean lengths. RESULTS: Analysis showed that there were significant differences between the mean lengths measured by the three different methods. The average length of measurement no: 2 was 3 cm longer than the average length of measurement no: 1, which is the reference pre-operative length of K.nail. CONCLUSION: However, in practice since measurement no:2 is more convenient to perform and can also be used when the patient has sustained bilateral fractures of femur, an accurate pre-operative K-nail length assessment can be done by subtracting 3 cm from measurement no:2, i.e. the tip of the olecranon process to the tip of the little finger.

Isokinetic external rotation strength of shoulder : correlation with age and muscle size.

The purpose of this study was to determine the correlation between quantitative (cross sectional areas) evaluation of the posterior cuff muscles and mechanical strength in asymptomatic shoulders with special reference to aging. The cross-sectional area of the combined infraspinatus and teres minor muscles were measured, in the sagittal oblique magnetic resonance images, in eighty-one patients with a mean age of 44.06 years (range 19 - 74). These areas were correlated with the measured isokinetic strength in external rotation at angular velocities of 60 deg/s and 180 deg/s using Cybex 770 NORM. The results show that there was a gradual decrease in size of the muscles as the age of the individual increases. A strong correlation was found between aging and combined cross-sectional area and peak torque as well. The correlation between combined cross-sectional area and peak torques at both angular velocities were less strong. Further, the correlation between the peak torque/cross-sectional area ratio with aging was also less significant, which may imply that the decrease in the muscle strength was greater than the change in muscle area. Our results suggest that there may be other qualitative and biochemical factors that may determine the true strength of the muscles in the aged population.

Results of autogenous trephine biopsy needle bone grafting in fractures of radius and ulna.

Cortico-Cancellous bone graft harvested from the anterior iliac crest by the conventional open method is associated with more morbidity and is more time consuming as compared to the percutaneous method using trephine biopsy needle. The aim of the study was to determine whether cancellous bone graft harvested from anterior iliac crest using trephine biopsy needle consistently achieved bone union in comminuted fractures and fractures of more than 3 weeks duration of radius and ulna and also to determine the morbidity at the donor site. Autogenous cancellous bone graft was harvested percutaneously from 28 iliac crests in 16 patients and applied at fracture sites of 30 forearm bones using a 4mm trephine biopsy needle after the fractures had been fixed with plate and screws. The patients were followed up regularly upto 6 to 9 months post - operatively in the OPD to determine the union status of the fractured bones and the morbidity at the donor site. 29 of the 30 fractures of the forearm bones united without any problems. The shaft of a trephine got bent during the harvesting procedure at the beginning of the study due to improper technique. Cancellous bone graft harvested from the anterior iliac crest results in predictable good union results in comminuted fractures of forearm bones and also fractures presenting after 3 weeks of injury. It is also an easier and quicker way of harvesting bone graft and is associated with lesser morbidity and earlier recovery as compared to conventional open method.

Acute sacrococcygeal dislocation (anterior type): a case report.

Sacrococcygeal dislocation is a rare injury. A twenty nine year old male presented to us with pain over the lowest part of spine of 5 days duration. He fell down on stairs with his buttock landing directly over the edge of the stairs. On examination, a step was felt in the continuity of sacrum and coccyx. The tip of the coccyx was not palpable. Per rectal examination revealed a small bump on running the finger along the sacrococcygeal curvature. On plain radiographs of sacro coccygeal region, lateral view revealed anterior dislocation of the coccyx over the sacrum. On antero posterior view, the injury could not be identified. Under general anaesthesia, an attempt to reduce the dislocation per rectally was tried, but failed. The patient was treated conservatively with analgesics. He refused surgery, as he was relieved of pain with analgesics.

Reduction of acute anterior shoulder dislocations under local anaesthesia--a prospective study.

OBJECTIVE: To evaluate the application of local anaesthesia for reduction of acute anterior shoulder dislocation DESIGN: A prospective study of patients coming with anterior dislocation of shoulder to KMCTH from July 2002 to Sep 2003. SUBJECTS: Patients of aged 15-55 years with no associated fractures of adjoining bones. RESULTS: A total of fifteen patients with anterior inferior shoulder dislocation were studied and all were reduced safely under local anaesthesia. CONCLUSION: Use of intra-articular lignocaine for reduction of shoulder dislocation is safe and effective and is beneficial for countries like Nepal where health facilities are minimum in rural and suburban areas.

Effect of arm elevation and rotation on the strain in the repaired rotator cuff tendon. A cadaveric study.

In 14 cadaveric shoulders, a rotator cuff tear (2 cm wide and 1.5 cm long) was created and repaired under a 3-kg tensile force with the arm in adduction. Strain on the repaired tendon was measured at 0 degrees, 15 degrees, 30 degrees, and 45 degrees of elevation in the sagittal, scapular, and coronal planes and from 60 degrees of internal rotation to 60 degrees of external rotation. The strain in all of the planes decreased significantly with the arm elevated more than 30 degrees. With 30 degrees of elevation in the scapular and coronal planes, the strain increased in internal rotation and decreased in external rotation. In all of the positions measured, the strain in the sagittal plane was significantly greater than in the other planes. We concluded that more than 30 degrees of elevation in the coronal or scapular plane and rotation ranging from 0 degrees to 60 degrees of external rotation compose the safe range of motion after repair of the rotator cuff.

Function of the 3 portions of the inferior glenohumeral ligament: a cadaveric study.

The stabilizing function of the inferior glenohumeral ligament of the anterior band and posterior band has been investigated, but little is known about the function of the axillary pouch. The strain of the 3 portions of the inferior glenohumeral ligament in 17 fresh-frozen cadaveric shoulders was measured with use of linear transducers. The measurements were performed under the following conditions: 0 degrees, 30 degrees, 45 degrees, and 60 degrees of glenohumeral elevation in the coronal, scapular, and sagittal planes and internal to external rotations in 10 degrees increments. The anterior band and axillary pouch showed significant strain increases when the arm was elevated and externally rotated in the coronal and scapular planes but no increase in the sagittal plane. The posterior band showed no strain in the coronal and scapular planes, but a significant strain increase with the arm elevated and internally rotated in the sagittal plane. We conclude that the anterior band and axillary pouch, which showed the greatest strain in abduction and external rotation, are anterior stabilizers, whereas the posterior band, which showed the greatest strain in flexion and internal rotation, is a posterior stabilizer. We recommend that the 6 o'clock position be firmly repaired during the Bankart procedure.

Effect of superior capsule and coracohumeral ligament release on strain in the repaired rotator cuff tendon. A cadaveric study.

Twelve cadaveric shoulders were used to determine the effects of release of the superior capsule and the coracohumeral ligament on the strain in the repaired rotator cuff tendon. A rotator cuff tear (2 cm wide and 1.5 cm long) was created and repaired under a 3-kg tensile force. The strain in the repaired tendon was measured with use of linear transducers with the arm in 50 different positions. Release of either the superior capsule or the coracohumeral ligament diminished the tension of the repaired rotator cuff by an average of 25% with the arm in adduction. Release of both of these structures further reduced the tension by an average of 44% in adduction and 43% to 60% with the arm in 15 degrees of elevation. The maximum reduction of tension in the repaired rotator cuff occurred when both the superior capsule and coracohumeral ligament were divided and when the arm was positioned in adduction and in 60 degrees of external rotation. Release of the coracohumeral ligament is equally as efficient as releasing the superior capsule in reducing the strain of the repaired rotator cuff. Releasing both structures seems to be desirable when releasing one structure or the other is not sufficient.