Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System.

Background: Bone defects remain challenging to manage. The wide array of treatment options is a testament no single strategy works in every patient. This is more complex if consideration is given to the status of the host and the soft tissues. The choice of treatment should be based on specific patient requirements after taking all variables into account. Materials and Methods: We present a comprehensive classification system and treatment algorithm to assist with decision-making in management. All potential treatment modalities including amputation are discussed with their relevant pearls and pitfalls. Conclusion: The proposed classification system may potentially assists with communication, enable patient stratification for assigning the most appropriate treatment modality and guide reporting of treatment outcomes. How to cite this article: Ferreira N, Tanwar YS. Systematic Approach to the Management of Post-traumatic Segmental Diaphyseal Long Bone Defects: Treatment Algorithm and Comprehensive Classification System. Strategies Trauma Limb Reconstr 2020;15(2):106-116.

Bioactive glass as dead space management following debridement of type 3 chronic osteomyelitis.

BACKGROUND: Chronic osteomyelitis is a challenging condition to treat and although no exact treatment guidelines exist, the surgical management strategy includes wide resection of necrotic and infected bone followed by dead space management. This study evaluates the use of bioactive glass as a single-stage procedure for dead space management following surgical debridement. METHODS: A consecutive series of 24 patients with Cierny-Mader type 3 osteomyelitis, treated between March 2016 and June 2018, were identified and evaluated retrospectively. Patients were managed with bioactive glass as dead space management following surgical debridement. RESULTS: Of the patients who completed more than 12 months follow-up, all fourteen (100%) showed complete resolution of symptoms. Of the remaining ten patients with less than 12 months follow-up, eight had complete resolution of symptoms. Therefore, a preliminary result of 22 out of 24 patients (91.65%) had resolution of symptoms following debridement and dead space management with bioactive glass. One patient experienced a complication related to the use of bioactive glass. This manifested as prolonged serous wound drainage that resolved with local wound care. CONCLUSION: The use of bioactive glass appears to be effective for dead space management following debridement of anatomical type 3 chronic osteomyelitis of the appendicular skeleton.

The role of bioactive glass in the management of chronic osteomyelitis: a systematic review of literature and current evidence.

Background: The increase of orthopaedic surgical interventions has given rise to an increased prevalence of chronic osteomyelitis. The principles of management of chronic osteomyelitis are well defined and include a thorough debridement, dead space management followed by an adequate period of appropriate antibiotics. Bioactive glass has garnered interest in recent years as a potential void filler following debridement. In the present systematic review, we explore the role of bioactive glass as a dead space management agent following debridement of chronic osteomyelitis.Methods: A search was made for all the articles pertaining to the role of bioactive glass in chronic osteomyelitis. The keywords used for search in PUBMED/MEDLINE were 'Bioactive glass' and 'chronic osteomyelitis'. A total of nine publications evaluating the outcome of 206 patients were included for evaluation.Results: The overall cure rate was 86% with 24 patients (11.6%) experiencing recurrence, while five patients were lost to follow-up. Out of the total 24 recurrences or persistent infections, 10 were associated with poor post-operative wound healing which progressed to recurrence.Conclusions: Bioactive glass appears to provide an attractive alternative for bone void filling after debridement of chronic osteomyelitis with good long-term outcomes. Potential advantages include a unique mechanism of anti-microbial action rendering it active against multi-drug resistant bacteria, use as a single stage procedure and gradual replacement by bone.

Mid-term results of impaction bone grafting in tibial bone defects in complex primary knee arthroplasty for severe varus deformity.

INTRODUCTION: Bone defects are a challenging problem encountered occasionally during primary knee arthroplasty. These defects should be meticulously addressed so as to avoid malalignment and premature loosening and failure. Out of the many options available to deal with these defects, impaction bone grafting provides a more biological solution, which is especially important in case of primary knees. MATERIALS AND METHODS: A retrospective analysis was done and patients with severe varus deformity of more than 20 degrees who had undergone primary knee arthroplasty with impaction bone grafting of the tibial condyle defect were followed up. RESULTS: Between 2008 and 2014, out of the 1124 patients who underwent primary total knee arthroplasty, only 26 knees in 23 patients met the inclusion criteria. The amount of varus deformity ranged from 20 to 35 degrees. Follow-up ranged from 3 to 8 years with an average of 6 years. The average pre-operative Knee Society Score (KSS) and Western Ontario McMaster Universities (WOMAC) score were 24.2 and 78, respectively. There were significant improvements in the post-op scores, with the average KSS being 90.2 and the WOMAC being 38. CONCLUSION: Impaction bone grafting provides an invaluable option to the orthopedic surgeon for managing bone defects, especially in case of primary knee arthroplasty as it reconstitutes the bone stock.

Desmoplastic Fibroma of Bone: a Case Series and Review of Literature.

Desmoplastic fibroma is an uncommon locally aggressive benign tumor of the bone. Patients usually present with a long-standing history of pain and swelling. Radiologically and histologically, it can mimic a variety of tumors. This article presents a report on three cases of desmoplastic fibroma in the proximal humerus, distal femur, and neck femur region. The varied radiographic features and the management of the three cases are described in detail. All the three patients were treated by extended curettage. Follow-up ranged from 2 to 5 years. There were no local or systemic recurrence until the last follow-up. Tumor resection with adequate margins is the preferred treatment, although extended curettage can be an acceptable alternative treatment modality when resection is not possible or acceptable.

Extensive Re-ossification and Reformation of the Proximal Femur After External Beam Radiotherapy in Metastatic Carcinoma Breast.

Management of metastatic bone disease is still evolving and is dependent upon many factors including the primary tumour type, expected life expectancy, site and size of lesion, character of the lesion, lytic or blastic, and the number of lesions. Active orthopaedic surgical intervention is usually required at the time of pathological fracture either impending or actual. Management options are either in situ fixation or replacement/arthroplasty. The role of post-operative radiotherapy is still not clearly defined and its biological effect on healing of pathological fracture is unclear. In this report, we describe a case of breast carcinoma with a large metastatic lytic lesion in the proximal femur, which was treated by in situ fixation followed by hormonal therapy and external beam radiotherapy. In the post-operative period, rapid and dramatic ossification and reformation of the proximal femur was observed.

Percutaneous elevation of depressed lunate fossa: A surgical technique.

Die-punch fractures or impaction fractures of distal radius articular surface are difficult to treat and hard to achieve satisfactory reduction. We present a unique, percutaneous and minimally invasive technique to elevate the depressed lunate fossa and maintain the reduction of the elevated fragment with no need of grafting in such fractures. This technique is simple, reproducible and can be executed with simple instrumentations. We think it deserves a variety of implications in the treatment of distal radius fractures.

Retrospective analysis of open reduction and internal fixation of coronal plane fractures of the capitellum and trochlea using the anterolateral approach.

INTRODUCTION: Coronal plane distal humeral injuries are relatively rare. Numerous classification systems have been proposed as the complexity of these fractures has been realized. We in the present series of ten patients describe the surgical technique of Open Reduction and Internal Fixation of Coronal plane fractures of the distal humerus with headless compression screws performed using the anterolateral approach. MATERIAL AND METHOD: It was a retrospective study, the data collected from March 2010 to 2015 was analysed and the final outcome was assessed using the DASH score. Out of a total of 13 patients with distal humerus coronal plane fractures, 10 patients were available for follow up. The X-rays and CT scans were reviewed and the fractures were classified according to Dubberley and Bryan and Morrey classification. Radiographic were evaluated for presence of union or nonunion, avascular necrosis, joint line step-off (none/1-mm/>1-mm), hardware failure and instability. RESULTS: The average age was 41 years. The average DASH score in our study was around 24. The time to union ranged between 8-12 weeks with the average time being around 10 weeks. One patient had post traumatic Arthritis radiologically classified as Broberg and Morrey Type 2 and one patient had Heterotrophic ossification Brooker Grade 1. CONCLUSION: Open reduction and internal fixation of coronal shear fractures of capitellum and trochlea using headless screw compression via the antero-lateral approach is a reliable treatment modality and results in stable fixation with restoration of a functional arc of motion. LEVEL OF EVIDENCE: IV.

Compound posterior cruciate ligament and popliteal artery injury due to dog bite: A case report.

Injuries due to dog bites are a common occurrence and are mostly trivial. Severe dog bite injuries requiring hospitalization and complex reconstructive procedures are more common in children. We present the case of a five year old child with popliteal artery thrombosis and compound Posterior Cruciate ligament injury due to a dog bite. The child was managed by immediate thrombectomy, meticulous debridement and knee spanning external fixation followed by Skin Grafting. At one year post surgery range of motion was 10-110°, with no distal neurovascular deficit and no sign of instability.

Retrospective analysis of extra-articular distal humerus shaft fractures treated with the use of pre-contoured lateral column metaphyseal LCP by triceps-sparing posterolateral approach.

Management of extra-articular distal humerus fractures presents a challenge to the treating surgeon due to the complex anatomy of the distal part of the humerus and complicated fracture morphology. Although surgical treatment has shown to provide a more stable reduction and alignment and predictable return to function, it has been associated with complications like iatrogenic radial nerve palsy, infection, non-union and Implant failure. We in the present series retrospectively analysed 20 patients with extra-articular distal humerus shaft fractures surgically treated using the extra-articular distal humeral locking plate approached by the triceps-sparing posterolateral approach. The outcome was assessed using the DASH score, range of motion at the elbow and the time to union. The mean time to radiographic fracture union was 12 weeks.

Rupture of the triceps tendon - A case series.

Triceps rupture is the least common among all tendon injuries. The usual mechanism of injury is a fall on an outstretched hand, although direct contact injuries have also been reported to cause this injury. The diagnosis of acute triceps tendon rupture may be missed, which can result in prolonged disability and delayed operative management. We presented three cases of acute triceps tendon rupture each at different site showing the spectrum of injury to the muscle and mechanism of injury and management were also discussed.

A Closed Lateral Subtalar Dislocation With Checkrein Deformity of Great Toe due to Entrapment of Flexor Hallucis Longus: A Case Report.

UNLABELLED: Closed lateral subtalar dislocation is a very rare injury. We report a case of closed lateral subtalar dislocation with entrapment of flexor hallucis longus tendon producing a checkrein deformity. The patient was managed immediately with closed reduction under regional anesthesia and fixated with percutaneous Kirschner wires. Early mobilization and weightbearing was started and there were no complications till the last follow-up visit. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case study.

Total knee replacement in triple deformity with posterior subluxation of the knee joint.

Dislocation or subluxation following total knee arthroplasty has been extensively reported, but vice versa that is total knee replacement for subluxed or dislocated knee has not been published. Triple deformity of knee that is flexion, external rotation, valgus at knee associated with posterior subluxation of tibia occurs in rheumatoid arthritis, advanced tubercular arthritis and neglected posttraumatic residual dislocated knee. A 50 year old female with seropositive rheumatoid arthritis had the above disabling deformity in left lower limb and varus with medial tibial thrust in the other. Bilateral total knee arthroplasty was planned. Conservative method of reduction of left knee posterior subluxation preoperatively by 90-90 skeletal traction failed; hence patient was subjected to a staged bilateral total knee replacement using an innovative technique. The most difficult and determining initial surgical step of knee replacement in such dislocated/subluxed knee is reduction of posterior subluxation and gaining flexion at knee, as only after gaining flexion and reducing dislocated tibia, will we be able to do knee arthroplasty in triple deformity of knee. These knees are grossly unstable as most of the capsule-ligamentous structures are attritioned/non-existent. So, a fine balance of bone cuts and soft-tissue release needs to be done in a sequential manner to fine tune valgus and posterior subluxation correction without jeoparadising neurovascular structures. After 3 years of knee arthroplasty the patient has painless, stable knee with good range of motion and is able to do all her activities, of living in a hilly terrain.

Triple modified French osteotomy: a possible answer to cubitus varus deformity. A technical note.

BACKGROUND: Cubitus varus is the most common delayed complication of pediatric supracondylar humerus fractures. We developed a new technique, the triple modified French osteotomy, that we believe may be the answer to this common but yet unsolved deformity. MATERIALS AND METHODS: Ten patients aged between 6 and 12 years with post-traumatic cubitus varus deformity were operated on with the triple modified French technique. A varus angle of more than 10° measured on the radiograph was an indication for surgery. RESULTS: The radiologic union at the osteotomy site took place in a mean period of 5.5 weeks (range, 4.5-7 weeks). The average correction achieved by the osteotomy was 27°. There were no cases with complications of radial or ulnar nerve palsy or joint stiffness. CONCLUSION: The triple modified lateral closing wedge French osteotomy is a simple and cosmetically effective method of treating cubitus varus deformity in children. It may obviate the need for more complex procedures; at the same time, it also addresses the potential drawbacks of a simple closing wedge osteotomy.

Scapulothoracic and scapholunate dissociation in the ipsilateral upper limb of a trauma victim.

Scapulothoracic dissociation is a rare and complex injury pattern with varied presentation. Here we describe a case of a 32-year-old male who presented with scapulothoracic dissociation associated with brachial plexus injury, along with scapholunate dissociation. We also propose an injury mechanism that might link the two injury patterns, suggesting that the association might be more than by chance. The patient was managed according to established trauma care and resuscitation protocols followed by open reduction and internal fixation of the clavicle fracture, and fixation of scapholunate dissociation and had a successful outcome at follow-up.

Triple plating of tibia in a complex bicondylar tibial plateau fracture.

High-energy tibial plateau fracture poses a significant challenge and difficulty for orthopaedic surgeons. Fracture of tibial plateau involves major weight bearing joint and may alter knee kinematics. Anatomic reconstruction of the proximal tibial articular surfaces, restoration of the limb axis (limb alignment) and stable fixation permitting early joint motion are the goals of the treatment. In cases of complex bicondylar tibial plateau fractures, isolated lateral plating is frequently associated with varus malalignment and better results have been obtained with bilateral plating through dual incisions. However sometimes a complex type of bicondylar tibial plateau fractures is encountered in which medial plateau has a biplaner fracture in posterior coronal plane as well as sagittal plane. In such fractures it is imperative to fix the medial plateau with buttressing in both planes. One such fracture pattern of the proximal tibia managed by triple plating through dual posteromedial and anterolateral incisions is discussed in this case report with emphasis on mechanisms of this type of injury, surgical approach and management.

Ipsilateral intertrochantric and femoral head fracture without dislocation of the hip. Potentially misleading radiograph: a case report and review of literature.

BACKGROUND: Traumatic femoral head fracture without dislocation with ipsilateral intertrochanteric fracture is an extremely rare injury and has not been reported in the literature. CASE REPORT: We reported a case of simultaneous ipsilateral femoral head and intertrochantric fracture without dislocation of the hip in a 74-year-old woman. The patient presented with a history of road traffic accident. Radiographs and computerised tomography scans revealed a right intertrochantric fracture and femoral head fracture without dislocation of the hip. CONCLUSIONS: The case was managed by uncemented modular bipolar arthroplasty using LINK reconstruction prosthesis. In the case report we described this unusual pattern, mechanism of injury, and management of such cases.

Osteomyelitis in Kawasaki disease.

A child who was having all symptoms of Kawasaki disease (KD) was diagnosed with osteomyelitis. Very quick response was appreciated with intravenous immunoglobulin (IVIG) infusion for all the symptoms except osteomyelitis. Long term antibiotics were required to treat it. This kind of overlap between KD and pyogenic osteomyelits due to S. aureus, further supports relationship between these two.

Acute pediatric septic arthritis: a systematic review of literature and current controversies.

We present a review of the current literature and the author's opinion regarding Septic arthritis in the pediatric age group. The etiopathogenesis, clinical features, the laboratory parameters for diagnosis and monitoring of treatment, radiological features, are discussed along-with the debatable issues pertaining to the choice of antibiotics, their duration, and the need and mode of surgical drainage and mobilization of the joint.