Implant-associated Hoffa's Fracture in a Floating Knee: A Case Report and Review of Literature.

INTRODUCTION: Complex floating knee in the presence of a previous implant creates an unusual fracture pattern which is a rare entity and poses a unique challenge in management and subsequent rehabilitation. CASE REPORT: A 56-year-old psychiatric patient who jumped from height had a polytrauma and a floating knee injury. Following the primary care and damage control surgery with knee-spanning fixator at some other centers, he was shifted to us on ventilator care and was directly admitted to intensive care unit for further management. On presentation, it was a floating knee injury with gross comminution of both femur and tibia with associated Hoffa with bent implant in situ. It was managed by plating of both lower end femur and tibia and at the end of 6 months, showed a satisfactory outcome. CONCLUSION: Floating knee injuries further complicated by the presence of the previous implant in a polytrauma situation poses a unique challenge which requires meticulous surgical planning and prolonged rehabilitation to achieve satisfactory outcome.

Inhalational Ciclesonide found beneficial in prevention of fat embolism syndrome and improvement of hypoxia in isolated skeletal trauma victims.

BACKGROUND: Many studies have established intravenous corticosteroid as an effective prophylactic therapy in fat embolism syndrome (FES). However, its use is limited among surgeons because of systemic side effects. Inhalational steroids have least systemic effects and are widely used for several chest conditions (i.e., asthma), but their effectiveness in FES has not been established. QUESTION/PURPOSE: This study was sought to evaluate the (1) efficacy and (2) safety of inhalational Ciclesonide (CIC) in prevention of FES and treatment of hypoxemia in isolated skeletal trauma victims. METHODS: A nonrandomized prospective control trial was designed in which all patients between 18 and 40 years with isolated skeletal injury who presented within 8 h of injury were allocated to either Trial group or control group. Trial group patients received 640 mcg of inhalational CIC with a metered-dose inhaler at the time of admission, and at 24 h. Control group patients did not receive any prophylactic therapy. Both groups were evaluated for development of FES (Gurd's criteria) and hypoxemia (PaO2 <70 mmHg) for 72 h. The complications related to CIC administration were evaluated in trial group patients during their hospital stay. RESULTS: Of 35 patients in each group, two patients in Trial group and nine patients in control group developed FES (P = 0.022). Eight patients in Trial group had hypoxemia at the time of admission, six of them improved and one additional patient developed hypoxemia after inhalational CIC administration. In control group, ten patients had hypoxia at the time of admission, only one of them improved and remaining nine patients had persistent hypoxemia even after 72 h. Additionally, three patients developed hypoxemia. A significant improvement in hypoxemia and a significant decrease in the incidence of FES were observed in Trial group (P < 0.05) compared to control group. None of the patients presented with any complications or adverse effects of steroid in Trial group. CONCLUSION: Inhalational CIC is a safe and effective therapy for prevention of FES and also an effective drug for treatment of hypoxemia in orthopedic trauma victims. LEVEL OF EVIDENCE: Level III, therapeutic study.

Nonunions and malunions of the pelvis.

INTRODUCTION: Neglected pelvic fractures manifesting as pelvic nonunion or malunion are usually due to inadequate initial fixation or negligence of the injury because of increased attention towards other associated life-threatening conditions. The management of such injuries is complex. A systematic review was conducted to spot the clinical manifestations, evaluation, management and outcome of pelvic nonunion and malunion. MATERIALS AND METHODS: Two databases ("Pubmed" and "Google scholar") were searched to look for relevant literature on pelvic non-union and malunion.  The search was limited to 'English language' and 'Human being'. RESULTS: A total of 500 articles found, of which 10 articles were only reviewed which met the inclusion criteria. These articles discussed the clinical management and treatment of pelvic malunion and non-union following trauma without associated acetabular injury. CONCLUSION: The usual presentations of pelvic non-union and malunion are pain, deformity, gait abnormality or instability. A detailed preoperative evaluation is essential as a majority of them have associated hip and spine injury which may be the cause of symptoms. Radiographs and 3D CT scans have helped surgeons in deciding the best way of management. The surgeries are usually complex and may need multiple-staged procedures. Soft tissue release, multiple osteotomies to achieve anatomical or near-anatomical reduction, augmentation of healing process using bone graft and stabilizing the nonunion/ osteotomy site using plates/screws/rods is the basic principle of surgery. Per-operative use of somato-sensory evoked potential evaluation helps the surgeon in preventing iatrogenic nerve injury. Despite these precautions and surgeries, most of the patients do not regain their preinjury functional activity.

Management of neglected acetabular fractures.

Management of neglected acetabular fractures is a difficult task. Osteosynthesis in such cases may not be an ideal solution because of the femoral head damage due to pressure by the fractured acetabular edge, avascular necrosis, difficulty in mobilizing the fragments due to callus formation, difficulty in indirect reduction of the fracture fragments and macerated acetabular fragments all contributing to inadequate fracture reduction. Majority of such fractures are now treated with total hip replacement. While treating such fractures with THR, problems associated with neglected acetabular fractures such as fracture non-union, hip dislocation, protrusio, cavitary bone defect or peripheral bone defect must be considered. 3D computed tomography scan provides a clear view about the acetabular and periacetabular bony anatomy. Impaction grafting and antiprotrusio cage or ring with a cemented acetabular cup can address most of the hip protrusio and cavitary bone defects. Segmental bone defect needs cortical strut-bone graft fixation and subsequent implantation of a cemented or uncemented acetabular cup implantation. Fracture non-union needs approximate reduction and fixation with plates followed by bone grafting and implantation of an acetabular cup. Despite these efforts, the outcome of THR in neglected acetabular fracture is considerable worse than after conventional hip replacement.

Predictors of postoperative outcome for acetabular fractures.

BACKGROUND: The outcomes of surgically treated acetabular fractures are dependent on many factors. The purpose of this retrospective study is to evaluate these factors in a group of patients operated on by a single surgeon in one institute. METHODS: One hundred and eighteen patients, treated surgically for their displaced acetabular fracture and who had completed two years follow-up, were evaluated clinically with Modified Postel Merle d'Aubigné score and radiologically with Matta's radiological outcome grading. The effect of age (≤ 55 or >55 years), gender, fracture displacement (≤ 20mm or >20mm), hip dislocation, delay in surgery (≤ 2 weeks or >2 weeks), associated injury and length of follow-up (≤ 5 years or >5 years) on the functional outcome was evaluated. RESULTS: There were 99 (83.9%) males and 19 (16.1%) females with mean age of 38.75 years (16 to 65 years). The mean duration of follow-up was 3.95 years (range 2 to 14 years). The mean Modified Postel Merle d'Aubigné score was 15.7 ± 2.2 (range, 8 to 18). The clinical outcome was excellent in 27 (22.9%), good in 52 (44.2%), fair in 20 (16.9%), and poor in 19 (16.1%, 10 patients who underwent THR for secondary arthritis were considered as poor outcome) patients. The Modified Postel Merle d'Aubigné score was significantly affected by quality of reduction (P=0.0001), presence of associated injuries (P=0.0001), initial fracture displacement of >20mm (P=0.018), joint dislocation (P=0.015) and delay in surgery (P=0.001). However, age, gender, fracture type and length of follow-up did not have any effects on the clinical outcome. CONCLUSION: Poor reduction, associated injuries, fracture displacement of >20mm, joint dislocation and late surgery definitely carry poor prognosis in predicting the outcome of surgically treated acetabular fractures.

Effect of liposomal celecoxib on proliferation of colon cancer cell and inhibition of DMBA-induced tumor in rat model.

Celecoxib, a selective cyclooxygenase-2 inhibitor, has shown potential anticancerous activity against majority of solid tumors especially on patients with colon cancer. However, associations of serious side effects limit the usage of celecoxib in colon cancer treatment. To address this issue and provide an alternative strategy to increase the efficacy of celecoxib, liposomal formulation of celecoxib was prepared and characterized. Anticancer activity of liposomal celecoxib on colon cancer cell HCT 15 was evaluated in vitro. Furthermore, tumor inhibition efficiency by liposomal celecoxib was studied on 7,12-dimethyl benz(a)anthracene (DMBA)-induced tumor in rat model. In order to elucidate the antioxidant activity of celecoxib-loaded liposomes, antioxidant superoxide dismutase (SOD) generation and lipid peroxide (LPx) formation in both liver and kidney tissues were examined. Characterization of the formed unilamellar liposomes revealed the formation of homogeneous suspension of neutral (empty) or anionic (celecoxib-loaded) liposomes with a well-defined spherical shape which have a mean size of 103.5 nm (empty liposome) and 169 nm (liposomal celecoxib). High-performance liquid chromatography (HPLC) analysis and hemolytic assay demonstrated 46% of celecoxib entrapment efficiency and significantly low hemolysis, respectively. Liposomal celecoxib exhibited dose-dependent cytotoxicity and apoptotic activity against HCT 15 cells which are comparable to free celecoxib. In vivo study demonstrated inhibition of tumor growth. Biochemical analysis of the liposomal celecoxib-treated group significantly inhibited the LPx formation (oxygen-free radicals) and increased the activity of SOD. Our results present the potential of inhibiting colon cancer in vitro and DMBA-induced tumor in rat model in vivo by liposomal celecoxib.

MDCT arteriographic spectrum in acute blunt peripheral trauma--a pictorial review.

Unrecognized arterial injuries in patients with blunt peripheral trauma can cause significant morbidity. Rapid diagnosis and localization of arterial injury is required for choosing the optimal surgical strategy in patients with extremity trauma. Multidetector computed tomography (MDCT) arteriography provides an accurate, rapid, and noninvasive means for diagnosis of arterial injuries. We discuss and depict the spectrum of findings on MDCT arteriography in acute blunt peripheral trauma.

Comminuted refracture of the distal femur and condyles in patients with an intramedullary nail: a report of 5 cases.

Patients with in situ intramedullary nails sustaining a second distal femoral fracture following high-velocity trauma are infrequently reported in the literature. We report 5 such patients who sustained a second injury after 6 to 24 months, resulting in another fracture at the nail-tip level. These second fractures severely comminuted the femoral condyles. These patients required removal of the intramedullary nail, reconstruction of the comminuted femoral condyles, and stabilisation using an angled or buttress plate. Four of the 5 patients were followed up for a mean period of 36 months and were evaluated for knee status and outcome using Judet's criteria. Postoperative knee stiffness was common, and further interventions such as manipulation, hardware removal, arthrolysis, and quadricepsplasty were needed. One patient was lost to follow-up. The final results of the knees were good, with more than 100 degrees range of movement. It is important to adhere to established internal fixation protocols in the treatment of these complex nail tip fractures.

Bilateral simultaneous iliac dislocation of the hip.

Traumatic anterior dislocation of the hip is an uncommon injury and bilateral anterior dislocation of the hip is still rare. A case is described of hitherto unreported simultaneous bilateral anterior iliac hip dislocation, complicated by fracture of the femoral head on one side. The extreme rarity of this fracture and the peculiar mechanism of injury (the treatment planning and the post reduction protocol) make this case worth reporting. (Hip International 2004; 14: 196-8).

Fracture epiphyseal separation of the distal humerus.

Seven patients seen with fracture separation of the distal humerus epiphysis have been analysed for the problems linked with the radiological diagnosis of this injury. Peculiar male predominance, exclusive left-side involvement, consistent postero-medial displacement of the epiphyseal fragment and ability to achieve near anatomic reduction by closed manipulation in fresh cases have been some of the other features observed. The literature has been briefly reviewed for this infrequent and usually misdiagnosed injury.

Patellar angle in Osgood-Schlatter disease.

A new patellar angle is described in lateral radiographs of the knee joint. One line is drawn along the articular surface of the patella and another from the end of the inferior articular cartilage to the patellar apex. The angle formed by these two lines averaged 33 degrees in 68 knees joints afflicted with Osgood-Schlatter disease and 47 degrees in 71 age-matched controls and 198 adult controls. The small angle in Osgood-Schlatter disease is proposed to be an important factor in the pathogenesis of the traction apophysitis.