Osteosynthesis of Common Acetabular Fractures Operated on Through a Single Posterior (Kocher-Langenbeck) Approach with or without Trochanteric Flip Osteotomy. A Case Series.

BACKGROUND: The Kocher-Langenbeck approach is recommended in the majority of common posterior acetabular injuries. Trochanteric osteotomy can be used to extend the exposure of the Kocher-Langenbeck approach superiorly and anteriorly. We evaluated the functional outcome of common acetabular fractures operated on through the Kocher-Langenbeck approach with or without trochanteric flip osteotomy. MATERIAL AND METHODS: This prospective study enrolled 42 patients with posterior wall, posterior column, transverse, posterior wall with posterior column, transverse with posterior wall and both column acetabular fractures. The Kocher-Langenbeck approach was used in 35 patients and trochanteric flip osteotomy was done in 7 patients. The radiological outcome was evaluated by Matta's criteria and the functional outcome was evaluated using modified Merle d'Aubigné and Postel criteria. RESULTS: D'Aubigne Postel scores at the final follow-up were excellent in 12 patients, good in 18, fair in 8 and poor in 4. Thirty-seven patients had congruent reduction (anatomical in 29, imperfect in 8) and 5 patients had non-congruent reduction on radiographs as per Matta's criteria. Radiographic congruity (88.09%, 37 out of 42 cases) correlated fairly well with the functional outcome (excellent or good functional outcome in 71.4%, 30 out of 42 cases). The complications included traumatic nerve palsy (3 cases), iatrogenic nerve palsy (2 cases), deep venous thrombosis (2 cases), wound infection (3 cases), non-congruent reduction (5 cases), 8 cases of osteoarthritis of hip, 2 cases of avascular necrosis of femoral head and 3 cases of heterotrophic ossification. CONCLUSIONS: 1. Surgical treatment of common acetabular fractures with major posterior involvement can be attempted via a single posterior approach (Kocher-Langen-beck with or without trochanteric flip osteo-tomy) and leads to good-to-excellent results in a majority of the cases. 2. It is superior to conservative management, which has been found to be accompanied by a much higher rate of complications. 3. A thorough study of the pre-opera-tive radiographs, Judet's views and 3D-reconstructed CT images helps in classifying the fracture and thereby assigning or not assigning it for the posterior approach.

Occurrence of Aflatoxin M1 in raw and processed milk and assessment of daily intake in Lahore, Multan cities of Pakistan.

In this survey aflatoxin, M1 was quantified in raw and processed milk from various areas of two big cities of Punjab province, i.e. Lahore and Multan. The results indicated that approximately 90% of the raw milk samples collected from Lahore city was contaminated with aflatoxin M1. Similarly, around 92% of the raw milk samples collected from Multan city was contaminated with aflatoxin M1. All samples of processed milk and tea whiteners were contaminated and 56% of the contaminated processed milk samples and 66% of the contaminated tea whitener samples were violating the maximum limits. The dietary exposure data of AFM1 among six different groups was calculated, which indicated that the male children population was the most vulnerable group to AFM1, up to 6.68 ng L-1 per day and the least affected one was the female group above 20 years of age with 1.13 ng L-1 per day.

Simultaneous Symmetrical Bilateral Bimalleolar Open Fracture with Ankle Dislocation by Indirect Injury - Case Study.

A rare case of symmetrical open bimalleolar fractures with bilateral dislocation of ankles is described. A 30-year-old man sustained indirect trauma working in squatting position with a heavy log of wood falling on his knees with ankles in inversion, and sustained symmetrical open III B bimalleolar fractures with dislocation of bilateral ankles with the distal fibula coming out of the skin. The patient underwent operative management on bilateral ankles and the post-operative course was uneventful. The patient had no complaints at 4 years' follow-up and had a full, pain-free function. The probable mechanism of the fracture is discussed.

Evaluation of Complications from Stainless-Steel Flexible Intramedullary Nailing in Children's Femoral Shaft Fractures and Recommendations for Continued Use.

[b]Background.[/b] Flexible intramedullary nailing is currently considered the treatment of choice for femoral diaphyseal fractures in school-aged children. The purpose of our study was to critically evaluate and analyze the complications of stainless steel flexible intramedullary nailing in children's femoral shaft fractures. (mean age, 8.2 years) with a femoral shaft fracture treated with stainless steel flexible intramedullary nailing from January 1, 2009 to July 31, 2015 and evaluated for complications.[b]Results.[/b] All fractures united in a mean time of 9.2 weeks. Minor complications were noted in 19 patients, and major complications were noted in two patients. The Flynn score was excellent in 74 patients, satisfactory in 23 patients, and poor in three patients.[b]Conclusions.[/b] 1. Stainless steel flexible intramedullary nailing in children's femoral shaft fractures is associated with minimal complications. 2. These complications are not related to the alloy of the implant and are mostly due to the long nail end; these complications can be prevented easily. 3. Stainless steel flexible intramedullary nailing is also cost effective, and we recommend its use be enhanced for the treatment of femoral shaft fractures in children.

Management of capitellar fractures with open reduction and internal fixation using Herbert screws.

BACKGROUND: Capitellar fractures are rare elbow injuries and can cause severe limitation of function if not properly managed. Numerous treatments have evolved, from closed reduction and cast immobilization to open reduction and internal fixation (ORIF), so as to achieve a stable joint that allows early mobilization. We determined the functional outcomes of treating these fractures with ORIF using Herbert screws via an extensile lateral approach. METHODS: Fifteen patients with capitellar fractures were included in this retrospective study. A well taken lateral radiograph was important and stressed upon in all patients. All fractures were open reduced and internally fixed using Herbert screws via an extensile lateral approach over a period of 5 years. Clinical, radiographic, and Mayo Elbow Performance Index were evaluated at a mean followup of 3.6 years (range, 1.5-6 years). RESULTS: Nine type I and six type IV capitellar fractures were identified using Bryan and Morrey classification system. The average time to bone union was 12 weeks (range 8-16 weeks) with no case of nonunion. The mean range of flexion was 130° (range 125°-135°). The average extensor lag was 10° (range 0°-30°), with a functional range of motion of elbow achieved in all patients. On the final follow-up, one case of osteoarthritis was seen, but no evidence of avascular necrosis or heterotrophic ossification was seen. Two patients needed screw removal. The outcome was excellent in 10 patients and good in five patients. CONCLUSION: Herbert screw fixation provides stable fixation in capitellar fractures and good to excellent outcomes with excellent elbow motion, can be achieved following internal fixation of these complex fractures using the extended lateral exposure.

Use of external fixator versus flexible intramedullary nailing in closed pediatric femur fractures: comparing results using data from two cohort studies.

PURPOSE: Although external fixation and flexible intramedullary nailing have been extensively used in the management of pediatric femur fractures, there are very few studies, which have compared the results. The purpose of the study was to compare the results of external fixation and flexible intramedullary nailing in pediatric femur fractures. METHODS: Two groups of patients were treated by external fixator (EF) and flexible intramedullary nailing (FIN) over two different but successive time periods and results compared. The first group (EF) consisted of 45 patients, and the second group had 50 patients. RESULTS: The age in EF group ranged from 6 to 14 years (average 9.93 years), and the age in FIN group ranged from 6 to 11 years (average 7.66 years). In the EF group, fixator was removed at an average of 12.23 weeks. In the FIN group, radiographic union was evident at an average time of 10.06 weeks. Pin-site infection was common in EF group. One patient had a re-fracture in EF group, and one patient had to be re-operated in FIN group after he developed anterior angulation of more than 30°. CONCLUSION: We believe that it is the discretion of the surgeon to operate on the femur fracture using either of the treatment modalities. Further randomized studies need to be conducted between these two treatment modalities.

Deformity Correction about Knee with Ilizarov Technique: Accuracy of Correction and Effectiveness of Gradual Distraction after Conventional Straight Cut Osteotomy.

BACKGROUND: The aim of the study was to retrospectively analyse the long term clinical outcome, accuracy of correction, and the complication rate in patients treated for deformities around the knee with gradual distraction with or without additional limb lengthening using Ilizarov technique. MATERIAL AND METHODS: The study presents a retrospective analysis of 26 patients treated for deformities about the knee by gradual distraction with Ilizarov technique with an average follow-up of 6.1 yrs (2-13 yrs). Preoperative and post-operative radiographs of all patients were assessed for the deformities. Deformity involved the tibia in 16 patients and the femur in 9 patients and one patient had both components. The deformity comprised of varus in 15 patients and valgus in 11 patients, and deformity in two planes (oblique plane) in 2 patients, while 8 patients had either deformity with associated average shortening of 4.75 cms (2-7 cm).The mean angle of deformity in the frontal plane was 30 degrees (15-60 degrees) and 48 deg on sagital plane. The CORA (centre of rotation of angulation) was located in the juxtaepiphyseal region in 15 patients, metaphysis in 6 patients and at the metadiaphyseal junction in 5 patients. RESULTS: All except two adult patients achieved exact correction with gradual distraction at an average correction of 30 degrees. Exact limb lengthening was achieved in all 8 patients with shortening. Complications involved mild procurvatum in three patients, mild mismatch of the mechanical and anatomical axes in two patients with tibial deformities, pin tract infection in two patients and one incidence of pin breakage, however, with no true complications. CONCLUSION: Gradual distraction after conventional corticotomy provides excellent results with deformities around the knee with or without additional limb lengthening.

External fixation of pediatric femoral shaft fractures: a consecutive study based on 45 fractures.

Forty-five displaced femur fractures in children were treated with unilateral external fixation as a standard treatment from March 2007 to March 2009 and the last follow-up was completed in May 2012. The average age of the children at presentation was 9.93 years. Patients were followed up till union, at 1 year, and at an average of 3.5 years after fixation. The fixator was removed at an average of 12.23 weeks. Twenty-one (47%) patients had a minor complication of pin-site infection. One patient had a major complication of refracture. Treatment of uncomplicated femur fractures using an external fixator in children yields satisfactory results. Our series had a longer duration of follow-up and fewer refractures compared with other series.

Bilateral simultaneous anterior obturator dislocation of the hip by an unusual mechanism - a case report.

A case of bilateral simultaneous anterior dislocation of the hip in a 30-year-old female is presented herein. The patient was managed conservatively. Follow-up at two years showed excellent results with no signs of avascular necrosis. The cause and mechanism of injury are discussed, which are different from those of previously reported cases.

Toilet seat injury of the Achilles tendon a series of twelve cases.

Lacerations of the Achilles tendon are caused by a number of mechanisms. The toilet seat as a cause of Achilles tendon injury is rare. We report on this rare mechanism of laceration of the tendo Achilles. The injury can be avoided with the use of western toilets and the additional devascularisation caused by extending the wound should be avoided while repairing the tendon in such situations.

The reciprocal ledge closing wedge osteotomy for post traumatic coxa vara.

To report a proximal femoral osteotomy with retention of bone ledges in a reciprocal position to increase bone contact and stability. The method was applied to 5 patients over a 3-year period. All patients had coxa vara. The average length gained was 1.5 cm, and the average neck shaft angle improvement was 30°. The Harris hip score improved from an average of 63 to 82. The reciprocal ledge osteotomy is technically less demanding and also allows conversion of normal shear forces around the upper femur to stabilizing forces. This method allows easier use of the DHS implant as potential rotation about the axis of the screw is negated by the ledges and the dynamic forces.

Contracture of the third toe as a delayed presentation of a foreign body in the foot.

Foreign body retention in the foot after a penetrating injury is an unusual occurrence with varied presentation. A degree of suspicion needs to be present in situations where there is an inexplicable swelling, sinus, abscess, or tenderness. The authors present a case with a contracture of the third toe that had been caused by plantar fascial fibrosis secondary to retention of a rubber foreign body in the foot. This case report highlights the fact that an ultrasound to rule out retention of the foreign body might be a judicious investigation if common causes of toe contracture are excluded. It may also have therapeutic implications.

Delayed fixation of the transcervical fracture of the neck of the femur in the pediatric population: results and complications.

PURPOSE: To determine the impact of a substantial delay in providing surgical treatment on the final outcome in transcervical femoral neck fractures in children. METHODS: Data on all pediatric patients with transcervical fractures of the femoral neck that were fixed by reduction and internal fixation after a delay of ≥7 days in our department between 2000 and 2008 were collected both retrospectively and prospectively. RESULTS: The medical records of 14 patients (15 fractures) were analyzed. The results after an average of 43 months of follow-up showed that the complication and avascular necrosis rates were higher in cases in which treatment had been delayed compared to those in comparable fractures that had been treated promptly after the event in other series. Nine of the 15 fractures had developed avascular necrosis at final follow-up. Overall, there were four excellent, three good, and eight poor results (based on the Ratliff criteria). CONCLUSIONS: Children whose transcervical fractures of the femoral neck were surgically treated after a delay of 1 week or longer had a high avascular necrosis rate and a relatively poor outcome. Reduction and internal fixation as the initial treatment should be implemented shortly after injury in order to enhance treatment outcome.

Delayed manifestations of the "Nail-Slipper injury".

Penetrating injuries of the foot are a common presenting complaint in the emergency department. The residents of the underdeveloped world are especially prone to suffer such injuries as barefoot walking is still common. However, a relatively common injury that occurs in the shod feet is the "Nail-Slipper injury". A metal nail penetrates through the rubber sole of the footwear introducing the rubber piece into the soft tissue of the foot. As the nail is removed the piece remains behind often leading to delayed manifestations. This article describes the various delayed manifestations of this injury. A leading question for the antecedent injury of this kind should be asked from all patients with such presentations, especially in the urban setting.

Draining infected non union of the distal third of the tibia. The use of invaginating docking over short distances in older patients.

BACKGROUND: The distal third of the tibia is unique in the sense that it has a minimal muscle cover and consequently the blood supply is easily compromised after a fracture in this area. Infected non union in this area provides a challenge to the orthopaedic surgeon. These difficulties are especially profound in the geriatric age group. MATERIAL AND METHODS: 12 cases with an infected non union of the distal third of the tibia were managed with acute docking over a distance of up to 2.5 cms. The age of these patients was more than 55 years. RESULTS: The average shortening at final follow up was 1.8 cms. The bone results were assessed according to the protocol laid down by the association for the study and application of the method of Ilizarov. Accordingly we had 3 excellent, 8 good and 1 fair result. The functional result was calculated as per the Ilizarov criteria [1]. On this basis we had 7 excellent, 4 good and 1 fair result. CONCLUSION: The acute docking modality is applicable to the distal tibia in such situations even in the geriatric population with predictable results.

A reciprocating ledge technique in closing wedge osteotomy for genu valgum in adolescents.

PURPOSE: To describe a technique that preserves anterior and posterior alternate ledges in a closing wedge osteotomy. METHODS: Five patients aged 14 to 19 years underwent a closing wedge osteotomy for genu valgum in 8 limbs using a reciprocating ledge technique. A unicortical wedge of bone was removed, with the anterior and posterior cortices spared. The anterior cortex at the proximal level and the posterior cortex at the distal level were cut through. With a wobbling action, the osteotomy site was rotated, and the distal fragment externally rotated. Manual force was applied to close the osteotomy site ensuring overlapping of the reciprocal ledges. The distal fragment was translated laterally to prevent club deformity. The osteotomy site was held with one or 2 staples. Stability was tested by flexion and extension of knee. RESULTS: All 8 limbs attained bone union within 12 weeks, and full range of motion within a mean of 13 (range, 12-15) weeks. The mean correction of the tibiofemoral angle was 13 degrees. At a mean follow-up of 12 months, all patients were pain-free and none developed club deformity. CONCLUSION: Sparing reciprocal ledges in a closing wedge osteotomy for genu valgum may increase stability in the flexion-extension axis, enable early range-of-motion exercises, and facilitate early bone union.

Open reduction and internal fixation in a case with transscaphoid perilunate dislocation 8 months after the injury: a patient with a 5-year follow-up.

The management of perilunate dislocations diagnosed later than three months continue to elicit debate with literature being scarce. We report a 22-year-old male with transscaphoid perilunate dislocation who reported to our hospital 8 months after sustaining the injury. Open reduction was done along with bone grafting. Five years after the surgery the patient is symptom-free with an excellent range of motion.

Pattern of orthopaedic injuries in bear attacks: report from a tertiary care centre in Kashmir.

Interaction between humans and wild animals has increased in recent times, because of overlap of habitats. A proportion of this interaction is violent. Most of the literature describing the injuries sustained by humans in such contact pertains to the involvement of soft tissues. Trauma to bones and joints is only witnessed when larger animals attack humans. We studied the pattern of orthopaedic injuries over a period of 2 years in a series of 32 cases presenting to our hospital with a history of being attacked by the Asian black bear (Ursus thibetanus). This paper also documents the complications and challenges involved in managing these injuries. We suggest that orthopaedic traumatologists need to be prepared to deal with such cases in areas where interaction between humans and large wild animals is manifest.