Evaluation of Clinical Outcomes of Negative-Pressure Wound Therapy in Gustilo-Anderson Type IIIA/IIIB Open Fractures of Extremities.

Background Open fractures are common and serious injuries that primarily affect young males. Fracture management has improved in the last decade. However, infections with their complications are still a concern, especially in open fractures for primary closure of the injured area. A newer technique called vacuum-assisted therapy has become a therapy of choice for many orthopedic surgeons. This study aimed to determine whether vacuum-assisted closure reduces the duration of wound healing and the frequency of infections after fixation of Gustilo-Anderson Type IIIA/IIIB fractures of the extremities. Methodology An observational analytical study was conducted among 34 patients with Gustilo-Anderson Type IIIA/IIIB fractures of the limbs who presented to the Department of Orthopaedics, R. L. Jalappa Hospital, Kolar, from December 2019 to July 2021. Negative-pressure wound therapy was employed for wound closure after fixation of fractures. Patients were followed up for one month. Results The mean age of the patients was 37.06 ± 10.340 years. The prevalence of infection before vacuum-assisted closure dressing was 80.6%, and the prevalence of infection after vacuum-assisted closure dressing was 19.4%. The difference in proportion before versus after the intervention was statistically significant (p < 0.001) according to the McNemar Test. Hence, vacuum-assisted closure dressing decreased the rate of infection. The mean dimension of the wound before vacuum-assisted closure therapy was 66.05 cm2 and the mean dimension of the wound after vacuum-assisted closure therapy was 27.97 cm2. The difference in the mean before and after the intervention was statistically significant according to the paired t-test (p < 0.001). Hence, vacuum-assisted closure dressing helped decrease the wound size which was proven statistically. Conclusions Vacuum-assisted closure is a viable and beneficial treatment option for complicated fractures with large soft-tissue abnormalities.

Basilar Invagination With Chiari Type I Malformation and Atlanto-Axial Instability: A Rare Case Report.

Basilar invagination (BI) and Chiari malformation type I (CM-I) are important anomalies involving the craniovertebral junction (CVJ) involving the skull base and occipitocervical region. The incidence of BI is rare involving < 1% of the general population worldwide. They present with varied and complex clinical-radiological features. We present a 36-year-old male who displayed complaints of persistent reeling sensation at our center. Clinical examination revealed bilateral cerebellar signs along with nystagmus and restricted neck movements. Imaging revealed evidence of BI with cerebellar tonsil herniation of ~14.7 mm. Atlantodens interval of 6 mm was noted. The unexpected findings of C1-C2 fusion and instability were also noted. We describe a rare case of BI with C1 prolapse into the foramen magnum along with CM-1 malformation and congenital fusion of C1-C2. We conclude that the treatment algorithm for these rare cases is not very well established and is individually dependent.

Comparison of Clinical, Magnetic Resonance Imaging (MRI) and Arthroscopic Findings in Assessment of Cartilage Defects and Internal Derangement of Knee.

BACKGROUND: The knee is the most commonly injured joint because of its anatomical structure, its exposure to external forces, and its functional demands. Orthopaedic surgeons previously relied on clinical evaluation for diagnosing any internal derangement of the knee joint. With the advent of new clinical methods for diagnosing ligament injuries and cartilage defects, there are very less studies comparing the accuracy of all three methods, clinical examination, magnetic resonance imaging (MRI) and arthroscopy to reach a definitive diagnosis. OBJECTIVE: This study aims to compare the sensitivity, specificity, accuracy and predictive values of clinical examination and MRI with that of arthroscopy which is the ideal investigation of choice for cartilage defects and internal derangements of the knee. MATERIAL AND METHODS: A prospective, observational and hospital-based study was done on patients with internal derangement of knee and cartilage defects. Clinical examination (based on the clinical tests for each ligament), MRI (1.5 T) and arthroscopy were done on all patients, the findings of which were compared using the Chi-square test. The following parameters were assessed while using arthroscopy as the gold standard of reference: accuracy, specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Anterior cruciate ligament (ACL) was the most common ligament to be injured followed by the medial meniscus. The overall accuracy of clinical evaluation and MRI to diagnose meniscal injuries was found to be 94% and 91% respectively. The clinical examination had sensitivity and specificity of 96% and 82% in diagnosing ACL tears, respectively, whereas MRI had sensitivity and specificity of 88% and 76% respectively. For the medial meniscus, the clinical examination had sensitivity and specificity of 93% and 96% respectively whereas MRI had a sensitivity of 100% and specificity of 89%. We observed that the accuracy of MRI for grading ACL and meniscal tears was similar i.e. 79% and 78% respectively, but was slightly low (70%) for grading of chondromalacia patellae. CONCLUSION: This study supports the use of MRI and clinical assessment in the diagnosis of chondral defects and internal knee derangement. Clinical tests are reliable and have high sensitivity in diagnosing ACL tears and chondral defects when compared to MRI. Not all lesions should routinely undergo MRI for diagnostic purposes; only a few circumstances warrant its usage. MRI is less reliable in grading ACL tears, meniscal tears and chondral injuries.

Functional Outcome of Pediatric Subtrochanteric Fractures Treated With a Titanium Elastic Nailing System (TENS) Versus Plating.

Introduction Uncertainty exists regarding the ideal course of therapy for subtrochanteric fractures in children of intermediate age. These fractures are challenging to treat, with scarce literature-based evidence to support a definitive implant. The ideal course of treatment should consider the patient's weight, age, femoral canal size, associated injuries, fracture stability, and surgeon's experience. A subtrochanteric femoral fracture in a child between the age of 5-12 is difficult to treat. For these patients, there is debate concerning the optimal internal fixation, hence this study was conducted to try and determine the superior mode of treatment for these fractures. The objective of this study is to compare functional outcomes of subtrochanteric fractures in the paediatric age group operated on with titanium elastic nail and plate fixation and the complications associated with both treatment modalities. Materials and methods This is a retrospective observational study of 40 cases that were admitted and operated on in the hospital of the current study from May 2007 to November 2021. Twenty patients underwent titanium elastic nailing system (TENS) nailing and the other 20 patients underwent plating for subtrochanteric fractures. The surgeries were conducted at our institute and patients were followed up at one-, three-, and six-month intervals. The final functional results were calculated with the help of the Flynn scoring system.  Results Out of 40 patients involved in the present study, 17 were female while 23 were male. Twenty patients received treatment with titanium elastic nails, and the remaining twenty received plating. The majority of the patients were males around 9.6 years of age on average in the plating group and 8.9 years in the nailing group. In comparison to 75% of participants in the plating group, 40% of patients who received nailing showed excellent results. Results were satisfactory for five patients who received titanium elastic nails and one who received plating. The only poor outcomes were noticed in six people (30%) in TENS and three people (15%) in the plating group who went through unplanned surgery for complications. In comparison to the plating group, the overall rate of complication was much greater in the TENS group. Conclusion We would like to conclude our study that, in accordance with Flynn's score, both elastic nailing and plating stabilization can produce positive functional outcomes. Both groups have a similar percentage of excellent and good results. We also conclude that the overall complication rate is slightly higher for patients treated with TENS when compared to plating for subtrochanteric fractures.

Effect of Smoking on the Healing of Tibial Shaft Fractures in a Rural Indian Population.

Background Tibial shaft fractures account for 17% of all lower limb fractures. Nonunion and infection rates are estimated to be between 2% and 10%. Bone healing is a complex process that is influenced by biological, mechanical, and systemic factors. Adverse smoking effects on cardiovascular and respiratory systems have been well documented. An increasing interest in the effect of smoking on fracture healing following trauma has been noted in recent years. The biological consequence of smoking is relevant, especially in trauma surgery where no way of preventing presurgical smoking has been noted, hence increasing the patient's risk of nonunion. Cigarette smoking has been shown to impair fracture union and wound healing and lead to an increased risk of fracture site infection. Smoking and high-energy trauma are considered important risk factors for the delayed union of tibial shaft fractures. Objectives This study aims to assess the adverse effects of smoking in patients with tibial shaft fractures following trauma and fracture fixation. Materials and methods A retrospective cohort study was done on 110 (55 smokers and 55 nonsmokers) patients treated with intramedullary nailing or plating for tibial shaft fractures between July 2017 and January 2021 in the hospital of the current study. Fracture healing was assessed at the end of months 1, 3, and 6 and year 1. Results The mean time of healing in smokers was >48 weeks, whereas the average time to union was 24 weeks in nonsmokers. The majority (54.6%) of smokers took >48 weeks to heal, whereas 81.8% of patients in the nonsmoking group took 24-28 weeks to heal. Conclusion Similar to the results obtained in previous studies, our study showed that smoking hinders fracture healing after surgical fixation, and smokers have a higher chance of developing surgical site infection and osteomyelitis. Smokers take a longer time for radiological union and also have a high chance of delayed union and nonunion when compared with nonsmokers, which was shown in our study and is consistent with the results obtained in previous studies. Postoperative smoking cessation is as important as preoperative smoking cessation, and patients should be strictly counseled regarding the same.