Sound Union Research Articles

Correction of Leg-Length Discrepancies by Ilizarov Technique

The management of leg-length discrepancies is one of the most challenging problems that the surgeon confronts in his daily practice. We are presenting here the use of Ilizarov apparatus-external ring device in a series of 86 patients for the limb lengthening. 66 patients are male & 20 female; the patients are 17 post polio shortening; 25 post-traumatic shortening; 5 gun short shortening; 10 congenital pseudoathrotic shortening, 24 congenital idiopathic shortening, shortening due to osteomyelitis-5. Among the complications 9 pin track infections were observed from which all responded positively to local care. Among the 86 patients, 3 admitted with the gun shot injury with 13 cm shortening, 39 admitted with the shortening of 7 cm, 18 with 5 cm & 26 with 3.5 cm. Lengthening & sound union was achieved according to Ilizarov’s technique. The Ilizarov apparatus & technique represents a useful method for the successful lengthening of the limbs.

Early Results of a Posterolateral Polyaxial Angle-Stable Plate for Tibiotalocalcaneal Arthrodesis

Tibiotalocalcaneal arthrodesis is still considered the reference standard therapy for salvage of severe osteoarthritic deformities of the ankle and hindfoot. Because of the unique anatomy and biomechanics of the ankle, even minor injuries can progress to end-stage osteoarthritis over time. This can be debilitating to patients' general health and physiologic ambulation. Arthrodesis aims to correct the misalignment and should comply with Glissan's principles (i.e., maintenance of permanent stability and sound compression between the fused elements). Several different surgical techniques have been described in the international medical literature. Intramedullary nails can create and maintain a stable condition but lack the necessary compression. Screw fixation can generate compression but might not yield enough stability until sound union has been achieved. In the present study, we report the early results of an innovative posterolateral polyaxial angle-stable plate that combines the features that address all the principles of arthrodesis in 1 device.

English

BACKGROUND: Forearm represent a critical anatomic unit of the upper limb, permitting the effector organ of the upper limb, the hand, to perform multi axial daily activities of living conservative reduction of fracture BBFA results in a poor functional outcome, non-union, mal-union rotational deformity. Hence perfect reduction is essential in maintaining the rotation (supination and pronation). This is achieved by ORIF using LC-DCP. The term LC-DCP stands for a new approach to plate fixation, reduced trauma to bone, preservation of blood supply, avoidance of stress raisers produced at implant removal and improved healing. This study is undertaken to assess the results of diaphyseal fractures of BBFA using LCDCP to study the advantages and its complications. MATERIALS AND METHODS: Patients who are admitted tin Victoria and Bowring & Lady Curzon Hospitals (Bangalore Medical College) taken for study after obtaining their consent. This is prospective study from January 2004 to February 2006. RESULTS: This study consists of 20 cases of fracture BBFA. All cases were openly reduced and internally fixed with 3.5 mm LCDCP. Age distribution ranged from 18-65 years with fracture being most common in 2 nd and 3 rd decade (Average 34.6). Sex distribution out of 20 patients, 17 patients (85%) was male and 3 (15%) female. Side affected 13 (65%) left side and 7 patients (35%) right side. Mode of injury RTA 10 (50%), 8 (40%) with fall 2 (10%) assault. 18 (90%) patient s had sound union in less than 6 months, 2 (10%) patients had delayed union. Results were evaluated by Andersons scoring system. Using this scoring system we had 17 (85%) patients with excellent results. 2 (10%) patients with satisfactory results and 1 (5%) with unsatisfactory result (radioulnar synostosis). Superficial infection 2 (10%) posterior interosseous nerve injury 1 (5%) Radioulnar synostosis 1(5%). CONCLUSION: LC-DCP facilitates biological, rigid fixation and early bone union with excellent radiological and functional outcome in majority of the patients. Until newer implants are devised and extensively assessed as the versatile LC-DCP these should be used as the implant of choice for all closed displaced diaphyseal fractures of both bones.

Primary cemented hemiarthroplasty for unstable intertrochanteric fractures in elderly: an intermediate follow-up

BackgroundStandard methods of internal fixation for comminuted or osteoporotic unstable intertrochanteric fractures in the elderly have a relatively high complication rate. This is because of the poor bone quality and prolonged immobilization periods needed to protect the construct until sound union occurs.AimThe aim of the work was to evaluate the results of primary cemented hemiarthroplasty in elderly patients with unstable osteoporotic intertrochanteric fractures.Patients and methodsA total of 27 patients (all were above the age of 70 years) with unstable intertrochanteric fractures who were prospectively managed with primary cemented hip hemiarthroplasty were followed for an average of 4 years (range: 3.5-5.5). Harris hip score and patients' satisfaction were the evaluation criteria.ResultsAccording to the Harris hip score, 10 patients (37%) were graded as excellent, 12 patients (44.5%) as good, five patients as fair (18.5%), and no patients were graded as having poor end results. Total complications were 11 in number (0.4 complication/patient) with no major complications or operative mortality.ConclusionPrimary cemented hemiarthroplasty in elderly's unstable intertrochanteric fractures is a successful procedure regarding early mobilization, functional results, and complication rate.

English

INTRODUCTION: Conservative treatment of fracture humerus has resulted in malunion, nonunion, and ultimately poor functional outcome. Internal fixation of fracture shaft of humerus allows ready access for nursing care in patients with multiple injuries and associated co morbid conditions. And also restrictive bandages and splints are avoided, early mobilization of the patients and his limbs helps to prevent fracture disease. Hence the present study was undertaken to provide satisfactory functional outcome and to know the advantage and complications of the interlocking nail in treating humerus fracture. MATERIALS AND METHODS: A prospective study of 32 patients with closed diaphyseal fracture humerus aged above 18 years who were medically fit were included in study. They were managed surgically by using interlocking nail. Average follow up period was 38 weeks. Functions results were scored using. Naiman, PT Schein, A.J.et al criterion. RESULTS: Male preponderance (62.5%) was observed in the study with right humerus predominance (56.25%). Road traffic injury accounted for 87.5% of fractures. Majority were middle third fractures (62.5%) with type A3 being the most common (53.125%). 2 patients had radial nerve palsy and they were recovered post operatively. 26 patients had sound union in less than 4 months and 3 patients at 6 months, with 29 (90.625%) cases having excellent result according Naiman, PT Schein, A.J.et al criterion system. Post operative complications in the form of nonunion in 3 cases (9.375%) underwent reoperation and were united. and shoulder pain noted in 3 patients (9.375%). CONCLUSION: The interlocking nail properly applied, is an excellent method for internal fixation of fractures of the shaft of the humerus alternative to plating. Most of the fracture united within 4 months with minimal complication.

Thirty cases of distal humerus intra-articular fractures treated by open reduction and internal fixation: A 3-year review

Introduction: Fractures of the distal humerus involving articular surface remains one of the challenging situations for any orthopedic surgeon. Congruent articular reconstruction is mandatory for an acceptable functional recovery. Materials and Methods: This was a case series of 30 patients of distal humeral intraarticular fractures treated by open reduction and internal fixation and followed up at the end of 3 years.Fractures were classified according to AO [Arbeitsgemeinschaft fur Osteosynthesefragen] and the results were evaluated using Cassebaums rating system, and other parameters. Results: Majority of the patients had a favourable outcome.There was no neurovascular complications and majority had a sound union. One case developed postoperative infection. Two cases resulted in nonunion. Conclusion: Open reduction and internal fixation with congruent articular reconstruction in young patients resulted in acceptable and good functional recovery. This was achieved with the use of recent AO ASIF plates. [AO/ASIF - Arbeitsgemeinschaft fuer Osteosynthesefragen - Association for the Study of Internal Fixation].

Fusion of Double-layered Patella Using a Single Small Fragment Partially Threaded Screw

The double-layered patella (DLP) was first described by Büttner in 1925 and is now considered pathognomonic for multiple epiphyseal dysplasia. In this study, we describe the case of an 11-year-old girl with multiple epiphyseal dysplasia and right-sided DLP. The patient presented with intermittent unilateral anterior knee pain and swelling. There was a reproducible high-pitched click with every step. Imaging showed a DLP in good alignment. Surgical management comprised open debridement and fixation of the 2 patellar layers using one 3.5 mm (removed-) partially threaded AO small fragment screw. Standard radiographs of the right knee, 3 years postoperatively, showed sound union of the 2 patellae. The patient now plays sports, and recent examination showed a full range of movement with no instability, effusion, or tenderness. We conclude that surgical fusion of the patellar fragments in DLP using a single small fragment partially threaded screw provides excellent outcome at 3 years follow-up. This case report shows a comparatively simple and economical surgical solution to the problem of DLP.

Fixed intramedullary nailing and percutaneous autologous concentrated bone-marrow grafting can promote bone healing in humeral-shaft fractures with delayed union

Treatment of humeral diaphyseal nonunion can be difficult and usually requires an extensive approach to the humerus with bone grafting, a procedure that could result in a lengthy operation with significant morbidity for the patient. The purpose of the present study is to describe a novel minimally invasive technique for the treatment of humeral-shaft fractures that do not demonstrate union progress within 16–24 weeks of injury. Fixed intramedullary nailing with percutaneously harvested and introduced autologous concentrated bone-marrow cells (mixed with demineralised bone matrix putty) was successfully used to treat five patients who had delayed union of a humeral-shaft fracture. The procedure was minimally invasive with no complications and resulted in sound union of all cases within 20 weeks.

Treatment of benign pathological femoral neck or trochanteric lesions by using dynamic condylar screw or hip joint spanning external fixator

Objective To investigate treatment method for existing and impending benign pathological femoral neck and trochanteric lesions.Methods A retrospective study wad done on 25 patients with benign proximal femur lesions treated between 2002 and 2004.All patients were treated with lesion curettage,cauterization,autografting and/or allografting.Then,dynamic condylar screw (DCS) or hip joint-span external fixator were selected according to the involved area of the lesion of the proximal femur.The duration of follow-up was mean 2.3 years (2-4 years).Results Sound bony union was seen on the radiographs of all patients by 3-6 months after surgery.There found no local recurrence or avascular necrosis of the femoral head,or complications like necrosis,infections or fractures.Function of the patients in the current series was graded excellent,assessed by the validated outcome measures MSTS-87,MSTS-93 and TESS lower extremity.Conclusion DCS or hip joint-span external fixator may be better alternative treatment of benign pathological femoral neck and trochanteric lesions,compared with conventional surgical methods such as simple bone grafting,traction and hip spica cast. Key words: Fractures,pathological; Femoral fractures; Femoral neck fractures; External fixators; Dynamic condylar screw

Reconstruction of tibia defects by ipsilateral vascularized fibula transposition

Segmental defects of the tibia after open fractures, sepsis and tumor surgery present a challenging problem. Similarly, tumor surgery often involves radical resections and multiple procedures and is frequently accompanied by irradiation or chemotherapy creating an avascular bed. The aim of this study is to report the results and discuss the role of the ipsilateral pedicle vascularized fibula (IPVF) a technique used for reconstruction of tibia defects. Reconstruction of large tibia defects 6-22 cm due to tumor resection were performed in 5 patients by ipsilateral vascularized fibula transposition. The mean age of the patients was 35.4 years (19-42) SD 9.31. The mean follow-up was 59.6 months (24-96) SD 29.2. The mean length of the bone defect was 14.6 cm (6-22) SD 6.066 and the mean time for union was 8 months (6-12) SD 2.82. Arteriography was used preoperatively in all patients to evaluate the lower limb vasculature and to select the optimal surgical approach. The osteosynthesis was stabilized by a plate. There was sound union in all cases. There were only two minor complications one partial paresis of peroneal nerve and one superficial infection. The mean follow-up was 59.6 months (24-96) SD 29.2. No patient presented with any complaints with the procedure and all had good functional results. The procedure was technically simple compared to free vascularized fibula and could be performed in hospital with low resources. There are several advantages: (a) achievement of bone defect reconstruction retaining periosteal and endosteal circulation, (b) preservation of a major vessel of the lower leg, (c) avoidance of difficulty and risk of microvascular technique and (d) no donor-morbidity. We routinely recommend preoperative angiography and intraoperatively meticulous dissection to prevent damage to the vascular pedicle.

The reorienting subtalar arthrodesis

The subtalar joint is part of what may be called the "lower ankle joint" and can be considered as the weight-bearing part of it. In the case of articular problems such as post-traumatic malunions or congenital abnormalities, a joint fusion limited to the subtalar joint can be indicated. Resection of the joint surfaces for accommodating the bones to achieve sound union results in a loss of height which must be considered and avoided. Fractures of the os calcis also often cause a loss of height of the hindfoot, together with a maloriented heel which is incompatible with functional and stable gait. The technique of fusion in those cases implements full liberation of the calcaneus from the talus for complete tridimensional reorientation which most often results in an equivalent empty space. It is then necessary to stabilize the reorientation achieved, most efficiently by an autologous tricortical bone block taken from the posterior iliac crest at the sacroiliac joint level. The optimal surgical approach is from posterolateral as described by Gallie.

The deep inguinal ring, development, function and repair.

Abstract The deep inguinal ring opening, due to the outgrowth of the processus vaginalis around the gubernaculum, appears at the end of the 2nd month of foetal life. Around this opening the U-shaped ring of transversalis fascia begins to develop about the 5th month. The U-shaped ring is well formed and its valvular design established at the 7th month. Descent of the testis usually takes place during the 7th or 8th month of intra-uterine life, but the processus vaginalis, which should normally close before or soon after birth, may remain open throughout life. The pressure valve of the deep inguinal ring, with its active closure mechanism, is capable of protecting an open processus vaginalis, often for months or years, against the onset of a hernia. The need to join together cut or raw edges to give sound union is emphasized and the indications for ring repair in oblique hernia and major repair in direct hernia are outlined.

Giant cell tumors of lower end of the radius : Problems and solutions

Background: Giant cell tumors of bone are aggressive, potentially malignant lesions. Juxtaarticular giant cell tumours of lower end radius are common and present a special problem of reconstruction after tumor excision. Out of the various reconstructive procedures described, use of nonvascularised fibular autograft has been widely used with satisfactory functional results. Methods: Sixteen patients with a mean age of 20.2 years, with either Campanacci grade II or III histologically proven giant cell tumours of lower end radius were treated with wide excision and reconstruction with ipsilateral nonvascularised proximal fibular autograft. Host graft junction was fixed with intramedullary nail in 12 cases and DCP in last 4 cases. Wrist ligament reconstruction and fixation of the head of fibula with carpal bones using K-wires and primary cancellous iliac crest grafting at graft host junction with DCP was done in last 2 cases. Results: The follow up ranges from 2 - 5 years (mean 3.5 years). At last follow up, the average combined range of motion was 110° with range varying from 60-125°. The average grip strength was 39% in comparison to the contralateral side (range 21-88%). The average union time was 8 months (range 4-12 months). Sound union occurred in 5 months, where DCPs were used. There were 5 nonunions, one resorption of graft, 10 wrist subluxations (2 painful), one recurrence, 3 superficial infections, one wound dehiscence and one amputation. There was no case of graft fracture, metastasis, death or significant donor site morbidity. A total of 10 secondary procedures were required. Conclusions: Enbloc resection of giant cell tumours of lower end radius is a widely accepted method. Reconstruction with nonvascularised fibular graft, internal fixation with DCP with primary corticocancellous bone grafting with transfixation of the fibular head and wrist ligament reconstruction minimizes the problem and gives satisfactory functional results.

Ostéotomie d’horizontalisation de la glène radiale dans les pseudarthroses du scaphoïde carpien

Purpose of the study We propose a different management scheme for painful post-traumatic osteoarthritis of the wrist resulting from pseudarthrosis of the carpal scaphoid bone. We report a prospective series with a maximum follow-up of 16 years. Material and methods From 1973 to 1990, we performed 100 first-intention wedge osteotomies of the distal radius in patients with painful pseudarthrosis of the carpal scaphoid bone. Inclusion criteria were painful wrists with established pseudarthrosis. The operation consisted in the removal of a small lateral wedge (base ≤ 0.5 cm) without affecting the length of the radius nor the function of the distal radio-ulnar joint. Twenty patients were lost to follow-up and follow-up was less than two years for two. The present series corresponds to 77 patients (all male manual laborers) followed for at least two years. Mean follow-up was 4 years (range 216 years). To evaluate outcome, we developed a devoted scoring system, the Scaphoid Pseudarthosis Hand Score, (SPHS, max 60 points) with items for pain, range of motion, grasping strength, work capacity, wrist function and post-traumatic arthritis. Results At last follow-up, the SPHS was 45.66 points versus 19.98 before surgery. The pain score was 8.51 versus 3.19: 67 patients (86%) were pain free or experienced mild pain for heavy work. Bone fusion or fibrous union was observed in 49 patients (64%) who were free of post-traumatic osteoarthritis; some improvement of which was observed in 11 other patients (14%) with less sclerotic bone. All patients but two resumed their occupational activities. Discussion Wedge osteotomy relieves pain and improves hand function by reducing the pressure applied to the radial and scaphoid joint surfaces. It acts positively in the event of post-traumatic arthritis, altering the dynamics of the wrist and producing the beneficial effects of styloidectomy. Although it was not the target, sound union of the pseudarthrosis observed in 25 patients at last follow-up was attributed to the applied treatment.

Factors Affecting Implant Failure in Fracture of the Shaft of Femur

17 cases of implant failure of fracture of shaft of femur were studied. All cases were young adults less than40 years of age. 15 were males. 16 of 17 cases sustained their initial injury in road - traffic accidents. Platefailures were detected earlier than those of nails as nails kept on providing splintage to an otherwise ununitedfracture. 10 of 17 cases were treated by interlocking nailing during the resurgery. Cortico-cancellous bonegrafting was done in 9 of 17 cases as per merit of each case. Follow-up ranged from 6 months to 2 years. 15of 17 cases went on to sound union after the second operation.The wrong choice of implant, implants improperly applied and bone grafting not done as recommended(i.e. technical errors) is the major cause of implant failure. Nails with diameter more than 10 mm should beused as far as possible. Early detection and resurgery for K-nail failure should be done to prevent greateramount of shortening. Wherever plating is done, instead of attempting anatomic reduction and devascularisingthe bone, biological method of fixation should be used.Key Words: Implant Failure, Shaft of Femur, Fracture.

Ilizarov technique in management of nonunited fracture of both bones of the forearm

Nonunited fracture of the forearm, although not a common problem, is associated with marked disability. Nonunion can due to infection secondary to open fracture or can be a complication of surgical open reduction and internal fixation. Nonunion can also result from improper management or technique that is not suitable for the type of injury. This study reviews 11 patients with nonunited fractures of the shafts of the radius and ulna. Average duration of nonunion was 18 months. Nine patients presented with active infection or a history of infection in the form of open discharging wound with or without exposed bone, while two had no history of infection. Patients were managed by surgical debridment, removal of dead bone and hard wear, if any, and application of Ilizarov external fixation frame followed by acute shortening by compressing the fracture site. Three weeks later, gradual lengthening started to regain the normal length. Eradication of infection and sound union was achieved in all cases, with good hand, wrist, and elbow function on final follow-up. Limitation in pronation and supination ranges of movement were found in all cases. This could be due to multiple surgeries, long duration of management, the external fixation wires that crossed the distal and proximal radio-ulnar joints, or loss of the normal radial and ulnar bowing during lengthening. Ilizarov technique and external fixation represent an option in the management of resistant nonunion of diaphysial fractures in the forearm.

Nonunion of the isolated capitate waist fracture

AbstractWe report a patient with nonunion of an isolated fracture of the capitate. A male 17-year-old high school student directly hit the dorsal aspect of the carpal with the wrist in flexion position against another player’s shoulder during a rugby football game. Radiographs did not show a fracture of the capitate on the day after the injury, but nonunion was distinct across the waist at the middle one-third of the capitate 4 months later. The fixation using two cannulated Herbert-Whipple screws with iliac cancellous bone graft led to sound union of the capitate and the patient’s ability to return to sporting activities. Although the initial plain radiographs do not show a fracture of the capitate, we should consider the capitate fracture and check the patient by repeated physical examinations and radiographs if the patient suffers from persistent localized pain and tenderness over the capitate.

スプラウトピンによる上腕骨近位端骨折の治療経験

We performed osteosynthesis for proximal humeral fractures using Sprout pins. The cases consisted of eight females, with an average age of 79.2 years. Under general anesthesia, the fractures were reduced, and alignment of the fracture was checked using an image intensifier. Sprout pin was inserted from the deltoid tubercle to the humeral head, along a medial portion of the humeral neck under image intensifier control. This operative procedure provided less surgical stress and sufficient stability for fractures. Pendulum exercise was started two days after operation. Active assisted exercise was started three days later. These patients were assessed using the Japanese Orthopaedic Association Shoulder Scoring System (JOA score).Eight patients had sound union of fractures and satisfactory results. The average JOA score was 89.6 points at discharge from the hospital, except for one case of inferior subluxation. We confirmed that osteosynthesis for proximal humeral fractures using Sprout pin is very useful.

Proximal scaphoid nonunion-osteosynthesis.

Proximal pole fractures of the scaphoid have a high incidence of nonunion and avascular necrosis. Because of their poor prognosis, the treatment of these fractures remains controversial. 102 patients with symptomatic nonunion of the proximal pole were treated by simple osteosynthesis, using retrograde screw fixation through a direct dorsal approach to the scaphoid. Fracture preparation and bone grafting were kept to a minimum, in order to preserve as much bone stock as possible, and to avoid damage to the already compromised vascularity of the proximal fragment. No postoperative splinting was used and most patients were able to return to their normal work within a few weeks of surgery. 69 patients were followed-up at an average of 34 months. 59 (85%) were asymptomatic, and had regained excellent wrist function, in spite of the fact that sound radiological union was present in only 50% of these. Union was often slow (3 to 36 months) and appeared to be related to the vascularity of the bone fragments. However, even when bone union was incomplete, the fracture remained stable, with no loss of fixation. The ten patients with unsatisfactory results had all developed late avascular necrosis of the proximal pole, requiring salvage surgery. Stable internal fixation of proximal pole nonunion leads to rapid symptomatic improvement in the majority of cases and sets the scene for revascularisation and healing. Even when union is incomplete the scaphoid remains intact, thus preserving excellent wrist function and, at the same time, offering the best possible long term prognosis.

Intramedullary Nailing of Forearm Fractures in Children

Forearm fractures are very common in children. They are usually treated orthopedically. For the last few years, Métaizeau's elastic stable nailing has been used in the authors' hospital. This study is based on 80 children with forearm fractures treated with intramedullary nailing: 64 boys and 16 girls, aged 6 to 16 (23 right sides, 58 left sides: 81 fractures). Nailing was performed 67 times for a displaced fracture, 3 times for a recurrent fracture, 3 times after a secondary displacement, and 7 times in patients with multiple injuries. Sound union was normally achieved in 78 patients, and normal motion in 79. Ten children experienced complications, but only complications involving the skin and sepsis were due to the technique. The seven skin complications (three in the ulnar fractures, and four in the radial fractures) consisted of three major local infections, one radial osteomyelitis, and three minor local nonunion of skin. One patient had limited thumb extension, and two patients fell a second time. One advantage of the method described here is that plaster casts are avoided, allowing children to go back to school early. Sound union is achieved as quickly as with orthopedic treatment, and recovery is excellent.