Pseudoarthrosis of medial tibial plateau fracture----role of alignment procedure.

Nonunion in tibial plateau fractures is very rare. Limited literature is available on Pubmed search on intraarticular tibial nonunion. Most of the cases reported have been following failed surgical treatment and none was neglected fractures. Three patients of isolated and neglected medial tibial plateau nonunion with almost similar demographic profile are reported in this paper. All the three patients were managed by minimally invasive compression fixation using lag screws supplemented with limb realignment procedure of high tibial osteotomy. We discussed the injury mechanism, management and rehabilitation in such cases and reviewed the available literature regarding such a presentation.

Improvisations in classic and modified techniques of flap surgery to improve the success rate for pressure ulcer healing in patients with spinal cord injury.

The recurrence of pressure ulcers (PrUs) and dehiscence of reconstructive flap have always been a problem. The present study aimed to evaluate the results of reconstructive flap surgeries in patients with spinal cord injury (SCI) having PrUs, using classic and modified flaps with improvisations to decrease wound dehiscence, flap necrosis and tension in flap. This is a prospective clinical study. The setting was a tertiary care centre in northern India. Thirty-five patients with SCI having 37 stage III and IV PrUs. PrUs were treated using classic and modified flaps with improvisations. The outcome was evaluated using criteria of wound dehiscence, flap necrosis and recurrence. The results of flap surgery were excellent in 32 (86·48%) patients, good in 4 (10·81%) patients and poor in 1 (2·7%) patient. Partial flap necrosis (2·7%), low incidence of PrU recurrence rate at flap site (5·4%) and overall PrU recurrence (11·4%) were the complications observed. Improvisation of classic and modified techniques of flap surgeries along with reinforcement of general care principles of paraplegia can be effective in minimising complications often associated with PrU reconstructive surgery thus improving the ultimate outcome.

Locked intramedullary femoral nailing without fracture table or image intensifier.

The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18-70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist-Hansen types I and II) diaphyseal fractures of the femur.

Simultaneous use of cannulated reamer and schanz screw for closed intramedullary femoral nailing.

Introduction. Closed reduction is a critical component of the intramedullary nailing and at times can be difficult and technically challenging resulting in increased operative time. Fluoroscopy is used extensively to achieve closed reduction which increases the intra-operative radiation exposure. Materials and Methods. Sixty patients with femoral diaphyseal fractures treated by locked intramedullary nailing were randomized in two groups. In group I, fracture reduction was performed under fluoroscopy with a cannulated reamer in the proximal fragment or with simultaneous use of a cannulated reamer in the proximal fragment and a Schanz screw in the distal fragment. Patients in group II had fracture reduction under fluoroscopy alone. Results. Closed reduction was achieved in 29 patients in group I and 25 patients in group II. The guide wire insertion time, time for nail insertion and its distal locking, total operative time, and total fluoroscopic time were 26.57, 27.93, 68.03, and 0.19 minutes in group I, compared with 30.87, 27.83, 69.93, and 0.24 minutes in group II, respectively. The average number of images taken to achieve guide wire insertion, for nail insertion and its locking and for the complete procedure in group I, respectively, was 12.33, 25.27, and 37.6 compared with 22.1, 26.17, and 48.27, respectively, in group II. Conclusion. The use of cannulated reamer in proximal fragment as intramedullary joystick and Schanz screw and in the distal fragment as percutaneous joystick facilitates closed reduction of the fracture during closed intramedullary femoral nailing with statistically significant reduction in guide wire insertion time and radiation exposure.

Functional outcome of modified Pauwels' intertrochanteric osteotomy and total hip arthroplasty in femoral neck fractures in elderly patients.

BACKGROUND: A high union rate (75%-100%) with a lower incidence of avascular necrosis (8%-9.3%) has been reported with intertrochanteric osteotomy in femoral neck fractures in elderly whereas arthroplasty eliminates the incidence of nonunion and avascular necrosis We present a series of femoral neck fracture in elderly treated with modified Pauwels' intertrochanteric osteotomy and total hip arthroplasty for their functional outcome. MATERIALS AND METHODS: 29 elderly patients of 60 years and above sustaining fresh subcapital femoral neck fracture underwent total hip arthroplasty (group I, n=14) and modified Pauwels' intertrochanteric osteotomy (group II, n=15). Functions were evaluated using modified Harris hip score, d'Aubigne and postel criteria and SF-36 score at 6, 12, 52 and 100 weeks. RESULTS: The fracture union in group II was achieved in 14 (93.3%) patients at the fracture site at an average of 15 weeks and osteotomy united in all patients. Avascular necrosis of the femoral head was observed in one patient (6.7%). Average operative time was 88.9 and 65.6 minutes in group I and II, respectively (P value = 0.00001). An average of 0.8 and 0.2 unit blood was transfused in patients in group I and II, respectively (P value = 0.001). Average time of full weight bearing was 6.1 weeks and 11.6 weeks in group I and group II, respectively. At 100 weeks 71.4% (n = 10) patients in group I and 80% (n = 12) patients in group II showed good to excellent results on the basis of modified Harris hip score. 71.4% (n = 10) patients in group I and 66.6% (n = 10) patients in group II showed good to excellent results on the basis of d'Aubigne criteria. Average SF-36 score was 17.2% in group I and 17.6% in group II. Revision osteotomy was performed in one patient in group II because of implant cut through. Another patient in group II underwent THR because of painful hip. One patient in group I presented with dislocation after 3 weeks of surgery. CONCLUSION: Functional results of total hip arthroplasty and intertrochanteric osteotomy are comparable and the valgus intertrochanteric osteotomy with osteosynthesis in subcapital femoral neck fractures in elderly patients of sixty years and above may be considered as an option.

Evaluation of surgical stabilization of metacarpal and phalangeal fractures of hand.

BACKGROUND: Optimized functional results are difficult to achieve following hand injuries. This prospective study was undertaken to evaluate the functional outcome after surgical stabilization of metacarpal and phalangeal fractures. MATERIALS AND METHODS: Forty-five fractures of digits of hand in 31 patients were managed by surgical stabilization. Five fractures were fixed with closed reduction and percutaneous Kirschner wire fixation; 10 with external fixator; 26 with open reduction and Kirschner wire fixation; and four with open reduction and plate and screw or screw fixation. RESULTS: Final evaluation of the patients was done at the end of three months. It was based on total active range of motion for digital functional assessment as suggested by the American Society for surgery of hand. Overall results were excellent to good in 87%. Better total active range of motion (excellent grade) was observed in metacarpal fractures (47%) versus phalanx fractures (31%); closed fractures (57%) versus open fractures (27%); and single digit involvement (55%) versus multiple digits (29%). Excellent total active range of motion was observed with all four plate and screw/ screw fixation technique (100%) and closed reduction and percutaneous kirschner wire fixation (60%). Twenty-two complications were observed in 10 patients with finger stiffness being the most common. CONCLUSION: Surgical stabilization of metacarpal and phalangeal fractures of hand seems to give good functional outcome. Closed fractures and fractures with single digit involvement have shown a better grade of total active range of motion.