Complications of Minimally Invasive Percutaneous Plating for Distal Tibial Fractures.

BACKGROUND: The management of distal tibia fractures continues to remain a source of controversy and debate. OBJECTIVES: The aim of this study was to evaluate the various complications of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a locking plate for closed fractures of distal tibia in a retrospective study. PATIENTS AND METHODS: Twenty-five patients with distal tibial fractures, treated by minimally invasive percutaneous plate osteosynthesis, were evaluated in a retrospective study. We studied the rate, probable etiological factors and preventive and corrective measures of various complications associated with minimally invasive plating of distal tibia. RESULTS: Mean age of the patients was 41.16 years (range 22 - 65). There were 13 male and 12 female patients. All fractures united at an average duration of 16.8 weeks. There were two cases of superficial and two cases of deep infection, and deep infections required removal of hardware for cure. There were four cases of ankle stiffness, most of them occurring in intra-articular fractures, three cases of palpable implant, three cases of malunion, one case of loss of reduction and one patient required reoperation. The average AO foot and ankle score was 83.6. CONCLUSIONS: We found MIPPO using locking plate to be a safe and effective method for the treatment of distal tibial fractures in properly selected patients yet can result in a variety of complications if proper precautions before, during and after surgery are not taken care of.

Functional results after osteosynthesis of distal humeral fractures with pre-contoured LCP system.

BACKGROUND: Evaluate the functional results and determine the complications after treating distal humerus fractures with an anatomically pre-contoured double plate system. MATERIAL AND METHODS: Twenty-five patients with distal humeral fractures were treated with a pre-contoured double plate system. There were 18 males (72%), 7 females (28%), with an average age of 39.68 years (22-70years). As per the AO classification, there were 4 type A fractures (16%) and 21 type C fractures (84%). In addition to clinical examination, functional results were evaluated using the Mayo elbow performance score (MEPS). RESULTS: Using the Mayo elbow performance score, the results obtained were graded as excellent or good results in 22 patients (88%), fair in 2 (8%) and poor in 1 (4%) of cases. Average time interval between admission and surgery was 3.8 days (average 1-9 days). All the fractures as well as the olecranon osteotomies united by 10-16 weeks (12.56 weeks). No patient had deep infection, implant failure, non-union of fracture site or olecranon osteotomy site. Superficial wound infection, which occurred in 4 (16%) patients, resolved with oral antibiotics. Transient ulnar nerve palsy developed in 1(4%) case. However, the patient recovered with conservative treatment. CONCLUSIONS: 1. An anatomically pre-shaped distal humerus locking plate system is useful in providing stable fixation of distal humerus fractures, thereby facilitating early postoperative rehabilitation. 2. In contrast to conventional plating, we did not observe any case of secondary fracture displacement, non-union or implant failure even in elderly patients with potentially reduced bone mass. 3. The multiple angular stable point fixation seems to be effective in the application of this system.

Operative management of displaced acetabular fractures: an institutional experience with a midterm follow-up.

BACKGROUND: Operative management is considered to be the treatment of choice in acetabular fractures as this is the unique way of achieving precise anatomical reduction, stable internal fixation, and early mobilization of joint. With this background in mind we undertook a prospective study with an aim to assess the outcome of surgery in displaced acetabular fractures at our general orthopedic centre as a first experience. MATERIAL AND METHODS: This study was conducted on 59 patients (45 Males, 14 Females ) with mean age of 38.35 years (range 18-60 years) with displaced acetabular fractures who were admitted consecutively at our centre from May 2008 through November 2011. Nine patients (7 Male, 2 Female) were lost during follow up. The average follow up was 3.5 years (range 2-5 years). Prophylaxis for deep venous thrombosis and heterotopic ossification was used routinely in all patients. RESULTS: Clinical evaluation was based on modified Merle-d'Aubigne and Postel scoring system. Radiological evaluation was done according to criteria developed by Matta. It was graded as excellent in 16% hips, good in 54% hips, fair in 20% hips and poor in 10% hips. Good to excellent results were achieved in 42 cases (70%). The complications included were implant backout, postoperative dislocation, iatrogenic nerve palsy, superficial wound infection, intraoperative bleeding and osteoarthritis. There is a positive relationship between quality of reduction and functional outcome. In our series, radiographic congruity (75%) correlated well with the function (70%). CONCLUSIONS: 1. We conclude that operative treatment is a safe and effective method of managing displaced acetabular fractures even in general orthopedic centres. 2. Time spent on a thorough study of the radiographs/CT scan for a proper preoperative plan is worthwhile and helps to outline an appropriate surgical approach and avoid complications.

Plate on plate technique of minimally invasive percutaneous plate osteosynthesis in distal tibial fractures, an easy and inexpensive method of fracture fixation.

BACKGROUND: Plate on plate technique can lessen operative time and patient morbidity. OBJECTIVES: This study aimed to evaluate the outcomes of minimally invasive percutaneous plate osteosynthesis (MIPPO) using plate on plate technique of locking plate fixation for closed fractures of distal tibia in a prospective study. PATIENTS AND METHODS: Twenty-five patients with distal tibial fractures were treated by MIPPO using locking plate by plate on plate technique. Preoperative variables including age of patient, mode of trauma, type of fracture and soft tissue status were recorded for each patient. Perioperative variables included surgical time and radiation exposure. Postoperative variables included wound status, time to union, return to activity and the American orthopaedic foot and ankle score (AOFAS). RESULTS: All the fractures had united at one year. The average time to union was 16.8 weeks. There were two cases of superficial infection and two cases of deep infection, which required removal of hardware after the fracture was united. The average AO foot and ankle score was 83.6 in our study population. CONCLUSIONS: MIPPO using locking plate by plate on plate technique was a safe, effective, inexpensive and easily reproducible method for the treatment of distal tibial fractures in properly selected patients, which minimized operative time and soft tissue morbidity.

Bilateral subtrochanteric stress fractures in a Dambali mystic dancer--a unique complication of a Sufi ritual. Case study.

Stress fractures are commonly seen among soldiers and athletes with the usual sites being the tibia, fibula or the metatarsals. Clinical examination may not be very helpful in such cases unless a high degree of suspicion is directed towards the pathology. We present a case of bilateral synchronous subtrochanteric stress fractures in a Sufi mystic dancer who presented with mild leg pain. The patient responded well to rest and conservative management.

Excision of radial head fractures with medially displaced fragments using 2 incisions: the nutcracker effect.

Marginal radial head fractures with displaced fragments are relatively common, especially when associated with a concomitant posterior elbow dislocation. The separated fragments are usually displaced forward and outward into the lateral part of the elbow or proximally in the elbow joint. Ulnar displacement of the separated fragments has been described in few cases, and in most of them treatment consisted of excision of the entire radial head.This article present a case series of 4 Mason type 3 radial head fractures with medially displaced fragments that had to be excised via a separate medial incision. Surgery was performed using 2 incisions, the standard Kocher and a medial incision; complete radial head excision was performed. Clinical and radiological assessment was done for all cases. Pain and range of motion at 2 years and any evidence of heterotrophic ossification were assessed. All patients had some degree of flexion deformity at final follow-up. One patient had some loss of rotation. No heterotrophic ossification existed in any patient. The authors postulate that the medial displacement may have been due to a nutcracker effect that caused the medial portion of the radial head to be compressed between the capitellum and the radial shaft and lateral part of the radial head. Such injuries are rare, and postoperative loss of flexion should be expected. Posterior elbow dislocation may not be present in all cases.

Isolated osteochondroma of the femoral neck presenting as hip and leg pain. A case study.

Osteochondromas, or exostoses, are overwhelmingly found as isolated lesions although they can be present within the context of multiple hereditary exostosis. Increased exostotic load associated with multiple hereditary exostosis can lead to limb-length discrepancy, increased femoral anteversion, valgus angulation, and acetabular dysplasia. Solitary osteochondromas have been linked with bursal inflammation and pain, compression on neurovascular structures, and malignant degeneration, groin and lower extremity pain. Isolated exostosis involving the femoral neck is a rare entity which is often diagnosed late when the patient is being investigated for other problems. We present a young female with a history of hip pain for 3 years with restriction of movements around the hip joint and radicular pain which turned out to be a solitary osteochondroma of the femoral neck. Surgical excision relieved the symptoms.

Neuritis ossificans of the radial nerve.

Neuritis ossificans is a rare reactive process affecting the peripheral nerves that is challenging to diagnose and treat. The usual presentation is mononeuropathy, pain, variable weakness, and a palpable mass along the nerve distribution. A paucity of literature exists on this disorder. It is often confused with myositis ossificans; many cases in the literature have reported myositic masses that have caused neuropathies. Diagnosing neuritis ossificans requires a high degree of clinical suspicion and excellent radiological and histopathological evaluation. The exact etiology of neuritis ossificans is unclear, but repeated localized trauma may be a factor. Treatment is mostly surgical, although conservative management with drugs has been reported to give good relief. The chance of iatrogenic nerve damage during microsurgical excision is high.This article describes a case of neuritis ossificans of the radial nerve, which was treated by surgical excision of the lesion without nerve resection. No iatrogenic neurodeficit occurred, and the patient made a full recovery.Neuritis ossificans should be considered in the differential diagnosis of painful mononeuropathies, particularly at atypical sites for compression neuropathy. Surgical resection of the mass may relieve pain and improve strength if the nerve can be sufficiently spared. Enucleation of this rare lesion is possible without neural compromise and should be considered as a treatment option for neuritis ossificans.

The chopstick-noodle twist: an easy technique of percutaneous patellar fixation in minimally displaced patellar fractures.

We report six cases of minimally displaced two-part patellar fractures with skin injury over the patella that were treated with percutaneous K wire fixation and compression applied using stainless steel (SS) wire. This technique makes it possible to perform early operative treatment in cases where unhealthy skin is not amenable to conventional tension band wiring. The technique employs two K wires inserted through the two fracture fragments under local or regional anaesthesia. They are then compressed using simple SS wire knots at the two ends - making it look like noodles at the end of two chopsticks. The fixation is subsequently augmented with a cylindrical plaster-of-Paris cast. The technique is simple, cheap and does not cause soft tissue injury.

Callus patterns in femoral lengthening over an intramedullary nail.

Our objectives were to evaluate callus patterns seen in femoral lengthening over an intramedullary nail by Li classification regarding shape and type and to predict the result while using the nail to reduce the external fixation period and its complications. Eight hundred digital radiographs of 15 patients with 15 segments of femur shortening who underwent femoral lengthening with a monolateral external fixator over an intramedullary nail were analyzed retrospectively by four observers. Each radiograph was studied for callus shape, feature type, and callus density using pixel values. The classification was tested for concurrence and reproducibility by interobserver studies and callus patterns were compared with treatment indices to evaluate how they correlated with the outcome. Mean length gained was 4.5 cm (range: 2-8 cm). External fixator index (EFI) was 21.68 days/cm. Average distraction consolidation index (DCI) was 48.49 days/cm. Fusiform callus was seen in three cases, cylindrical in seven, and lateral in five. The homogenous pathway had higher DCI (43.7) than the heterogeneous pathway (32.9), and mixed pathways making up the rest had a DCI of 50.1. Pixel value of callus showed gradual increase in density until 20-24 weeks, then density gradually fell for 8 weeks, again increased after 32 weeks, again gradually fell, and was comparable to adjacent normal bone by 44-48 weeks. Our results suggest that the Li classification can be satisfactorily applied to lengthening procedures over intramedullary nails. The radiologic pattern and pixel value of regenerate can be correlated with the clinical outcome and can be an aid of prognostic value for the surgeon.

A case study in bilateral radial head fractures in apparently trivial trauma: a subtle diagnosis.

Radial head and neck fractures are common in young to middle age adults and are seen in nearly 20 % of acute elbow injuries in this age group. These are usually associated with high energy traumas like falls from height, road traffic accidents and sports injuries. Unilateral radial head fractures are relatively common and may be associated with other concomitant injuries. Bilateral radial head fractures are rare and are mostly seen in situations when the patient has a fall on outstretched, supinated hands or a direct fall on the elbow. These injuries can be easily missed by the attending physician if the symptoms are more severe on one side, thus neglecting the other. The treatment of these fractures may be conservative or operative, depending upon the degree of head comminution, the percentage of articular surface involved, presence of loose intra-articular fragments and angulation between the radial neck and proximal shaft. We present a case series of three patients with bilateral type 1 radial head fractures (one case having type 3 on one side) managed with brief immobilization followed by active physiotherapy and full, uneventful recovery. The emphasis in these cases is the need for a high index of suspicion in the diagnosis of multiple injuries, no matter how `trivial` the mechanism of injury and, unless the history of the mode of trauma is highly suggestive, such injuries can be missed easily and cause long term problems for the patient.

Meyer's dysplasia : delayed ossification of the femoral head as a differential diagnosis in perthes' disease.

Meyer's dysplasia strongly mimics Legg-Calve-Perthes' disease despite differing markedly in eventual outcome. This study presents the clinicoradiologi-cal features which differentiate it from Perthes' disease in a group of 178 children with a preliminary diagnosis of Perthes' disease, of whom nine were subsequently diagnosed with Meyer's dysplasia. All had a near normal development of the femoral head; mild flattening was seen in two cases. Clinical initial presentation often resembles Perthes' disease. However, the presence of a granular aspect of the femoral head, often bilateral, in a male child with a preliminary diagnosis of Perthes' disease should alert the clinician to the possibility of Meyer's dysplasia. Restitution of normal capital architecture is usual; there may however be a mild residual hypoplasia.

Changes of Sagittal Spinopelvic Parameters in Normal Koreans with Age over 50.

STUDY DESIGN: A prospective comparative study. PURPOSE: To describe the changes in the spinopelvic parameters on normal Koreans more than 50 years of age. OVERVIEW OF LITERATURE: There are differing opinions regarding the changes in the thoracic kyphosis, lumbar lordosis, C7 plumb with age in the elderly population. METHODS: Sagittal standing radiographs of the whole spine including the pelvis in 132 Korean adult male volunteers more than 50 years of age were evaluated prospectively. Volunteers with a history of spine operation, spinal disease, pain in their back or legs, scoliosis, spondylolisthesis, monosegment disc space narrowing, or compression fracture in radiographs were excluded. The following parameters were included: thoracic kyphosis (T5 upper end plate [UEP]-T12 lower end plate [LEP]), thoracolumbar kyphosis (T10 UEP-L2 LEP), lumbar lordosis (T12 LEP-S1 UEP), lower lumbar lordosis (L4 UEP-S1 UEP), sacral slope, pelvic incidence, and the distances from the C7 plumb to the posterosuperior endplate of S1. These parameters in the 6th, 7th and 8th decade groups were compared and the changes in these parameters according to age were examined. RESULTS: The thoracic kyphosis demonstrated significant differences in the in the three age groups (p = 0.019), and increased with age (r = 0.239, p < 0.006). The other parameters did not show any significant difference or correlation. CONCLUSIONS: Similar global sagittal balances and spinopelvic parameters may be observed in Korean males older than 50 years, with a trend towards increasing thoracic kyphosis with age.

Spontaneous regression of curve in immature idiopathic scoliosis - does spinal column play a role to balance? An observation with literature review.

BACKGROUND: Child with mild scoliosis is always a subject of interest for most orthopaedic surgeons regarding progression. Literature described Hueter-Volkmann theory regarding disc and vertebral wedging, and muscular imbalance for the progression of adolescent idiopathic scoliosis. However, many authors reported spontaneous resolution of curves also without any reason for that and the rate of resolution reported is almost 25%. Purpose of this study was to question the role of paraspinal muscle tuning/balancing mechanism, especially in patients with idiopathic scoliosis with early mild curve, for spontaneous regression or progression as well as changing pattern of curves. METHODS: An observational study of serial radiograms in 169 idiopathic scoliosis children (with minimum follow-up one year) was carried. All children with Cobb angle < 25° and who were diagnosed for the first time were selected. As a sign of immaturity at the time of diagnosis, all children had Risser sign 0. No treatment was given to entire study group. Children were divided in three groups at final follow-up: Group A, B and C as children with regression, no change and progression of their curves, respectively. Additionally changes in the pattern of curve were also noted. RESULTS: Average age was 9.2 years at first visit and 10.11 years at final follow-up with an average follow-up of 21 months. 32.5% (55/169), 41.4% (70/169) and 26% (44/169) children exhibited regression, no change and progression in their curves, respectively. 46.1% of children (78/169) showed changing pattern of their curves during the follow-up visits before it settled down to final curve. Comparing final fate of curve with side of curve and number of curves it did not show any relationship (p > 0.05) in our study population. CONCLUSION: Possible reason for changing patterns could be better explained by the tuning/balancing mechanism of spinal column that makes an effort to balance the spine and result into spontaneous regression or prevent further progression of curve. If this which we called as "tuning/balancing mechanism" fails, curve will ultimately progress.

A novel technique of rotator cuff repair using spinal needle and suture loop.

BACKGROUND: We present a simple technique of arthroscopic rotator cuff repair using a spinal needle and suture loop. METHODS: With the arthroscope laterally, a spinal needle looped with PDS is inserted percutaneously into the shoulder posteriorly and penetrated through the healthy posterior cuff tear margin. Anteriorly, another spinal needle loaded with PDS is inserted percutaneously to engage the healthy tissue at the anterior tear margin. The suture in the anterior needle is then delivered into the suture loop of the posterior needle using a suture retriever. The posterior needle and loop are then pulled out carrying the anterior suture with it. The two limbs of this suture are then retrieved through a cannula for knotting. The same procedure is then repeated for additional suturing. Suture anchors placed over the greater tuberosity are used to complete the repair. CONCLUSION: This is an easy method of rotator cuff repair using simple instruments and lesser time, hence can be employed at centers with less equipment and at reduced cost to the patient.

Separation of the tip of a coblation wand within the knee joint: a complication of arthroscopic adhesiolysis.

Coblation devices are now widely used in arthroscopic surgery and they show a very low incidence of intraoperative complications. We experienced a case where the tip of the wand separated and migrated into the posterior knee compartment in an arthrofibrotic knee. The free wand tip was identified and then extricated from the popliteal hiatus of the knee with using C-arm fluoroscopic control. To the best of our knowledge, this is the first report of its kind involving coblation wands. We describe this complication to show that the use of coblation devices can lead to unexpected problems and it is imperative to inspect all instruments before and after each surgical use.

A novel technique for arthroscopic reduction and repair of a bucket-handle meniscal tear.

We present a new technique designed for the reduction and repair of bucket-handle meniscal tears. After assessing the rotation of the displaced tear fragment of the meniscus, the centrally displaced portion of the tear is vertically pierced with a suture hook enabling passage of a No. 0 PDS suture, both limbs of which are retrieved out of the joint. Next, using a spinal needle and a shuttle relay system, both ends of the No. 0 PDS on the femoral and tibial surfaces of the meniscus are extricated outside the joint capsule. In the final step, reduction of the displaced fragment is achieved by pulling on the PDS suture and the same suture is used for repair too, after which additional sutures are applied. This is a useful technique, which affords the benefit of rotational reduction of a bucket-handle meniscal tear using a single suture, as well as improved maneuverability for freshening of the tear margins prior to repair and additional suturing, and finally for repair as a full-thickness vertical suture.