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   2008| October-December  | Volume 42 | Issue 4  
    Online since October 15, 2008

 
 
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REVIEW ARTICLES
Treatment principles in the management of open fractures
William W Cross III, Marc F Swiontkowski
October-December 2008, 42(4):377-386
DOI:10.4103/0019-5413.43373  PMID:19753224
The management of open fractures continues to provide challenges for the orthopedic surgeon. Despite the improvements in technology and surgical techniques, rates of infection and nonunion are still troublesome. Principles important in the treatment of open fractures are reviewed in this article. Early antibiotic administration is of paramount importance in these cases, and when coupled with early and meticulous irrigation and debridement, the rates of infection can be dramatically decreased. Initial surgical intervention should be conducted as soon as possible, but the classic 6 h rule does not seem to be supported in the literature. All open fractures should be addressed for the risk of contamination from Clostridium tetani . When possible, early closure of open fracture wounds, either by primary means or by flaps, can also decrease the rate of infection, especially from nosocomial organisms. Early skeletal stabilization is necessary, which can be accomplished easily with temporary external fixation. Adhering to these principles can help surgeons provide optimal care to their patients and assist them in an early return to function.
  24 13,659 1,365
ORIGINAL ARTICLES
Utilization of the less-invasive stabilization system internal fixator for open fractures of the proximal tibia: A multi-center evaluation
James P Stannard, Christopher G Finkemeier, Jackson Lee, Philip J Kregor
October-December 2008, 42(4):426-430
DOI:10.4103/0019-5413.43390  PMID:19753230
Background: Locked plating has become popular and has clear biomechanical advantages when compared with conventional plating. When combined with minimally invasive surgical techniques, locked plating may cause substantially less iatrogenic tissue damage when compared with conventional plating. These characteristics may make locked plating an attractive option for treating open fractures of the tibial plateau and proximal tibia for which coverage over the plate can be obtained. The purpose of this study was to evaluate the use of the Less-Invasive Stabilization System (LISS) for high-energy open fractures involving either the tibial plateau or proximal tibia. Materials and Methods: This study is a retrospective evaluation of a consecutive multicenter series of 52 consecutive patients operated by seven surgeons, who used LISS plating in open proximal tibia or tibial plateau fractures seen at one of four Level I Trauma Centers. All patients were treated using a locked plating system that was implanted using minimally invasive submuscular surgical techniques. The primary outcome measure was the incidence of deep and superficial infection. Results: Fifty-two patients with open fractures have been evaluated, with a mean follow-up of 16.8 (12-36) months. Three patients (5.8%) developed deep infections. Two patients (6.3%) with tibial plateau and one (4.3%) of patients with a tibial shaft fracture developed deep infections. Fifteen patients required flap coverage of their open wounds. The incidence of deep infection as per Gustilo and Anderson classification was Type I and II - 0 (0%); Type IIIA - 2 (7.7%); Type IIIB - 1 (7.1%); and Type IIIC - 0 (0%). Conclusions: Biomechanically, the LISS functions as an "internal-external fixator" rather than a plate. Traditional plate osteosynthesis has yielded rates of infection between 18% and 35%. Our data indicate that locked plating using minimally invasive techniques yield deep infections rates that are no worse than published series using intramedullary nails or external fixators. Technical difficulties that can be encountered with the LISS system revolve primarily around obtaining and maintaining reduction while performing a minimally invasive procedure. Additional difficulties can include "cold welding" of screws to the plate and malposition of the plate leading to failure in the diaphysis. High-energy open fractures involving the tibia shaft or plateau remain high-risk injuries, but LISS is an acceptable alternative for treatment of these fractures.
  15 4,053 537
Radiation exposure from fluoroscopy during fixation of hip fracture and fracture of ankle: Effect of surgical experience
Rajesh Botchu, Kassetti Ravikumar
October-December 2008, 42(4):471-473
DOI:10.4103/0019-5413.43398  PMID:19753238
Background: Over the years, there has been a tremendous increase in the use of fluoroscopy in orthopaedics. The risk of contracting cancer is significantly higher for an orthopedic surgeon. Hip and spine surgeries account for 99% of the total radiation dose. The amount of radiation to patients and operating surgeon depends on the position of the patient and the type of protection used during the surgery. A retrospective study to assess the influence of the radiation exposure of the operating surgeon during fluoroscopically assisted fixation of fractures of neck of femur (dynamic hip screw) and ankle (Weber B) was performed at a district general hospital in the United Kingdom. Materials and Methods: Sixty patients with undisplaced intertrochanteric fracture were included in the hip group, and 60 patients with isolated fracture of lateral malleolus without communition were included in the ankle group. The hip and ankle groups were further divided into subgroups of 20 patients each depending on the operative experience of the operating surgeon. All patients had fluoroscopically assisted fixation of fracture by the same approach and technique. The radiation dose and screening time of each group were recorded and analyzed. Results: The radiation dose and screening time during fluoroscopically assisted fixation of fracture neck of femur were significantly high with surgeons and trainees with less than 3 years of surgical experience in comparison with surgeons with more than 10 years of experience. The radiation dose and screening time during fluoroscopically assisted fixation of Weber B fracture of ankle were relatively independent of operating surgeon's surgical experience. Conclusion: The experience of operating surgeon is one of the important factors affecting screening time and radiation dose during fluoroscopically assisted fixation of fracture neck of femur. The use of snapshot pulsed fluoroscopy and involvement of senior surgeons could significantly reduce the radiation dose and screening time.
  15 4,556 293
Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit
Anupam Gupta, Abhishek Srivastava, Arun B Taly, Thyloth Murali
October-December 2008, 42(4):448-453
DOI:10.4103/0019-5413.43395  PMID:19753234
Background: To assess the effect of single-stage multilevel soft-tissue surgery (Single Event Multiple Level Resections, SEMLR) on deformities and locomotion in patients with cerebral palsy (CP) with static contracture(s) in lower limbs. Patients and Methods: Study included 34 patients (M:F, 23:11) with mean age of 9.53 3.92 years (4-16 years). Among them 22 had diplegia and four each had quadriplegia and right and left hemiplegia. Fourteen patients (41.2%) had their intelligence quotient (IQ) in the normal range (IQ ≥ 80), while others had mental retardation (MR) of varying severity: borderline MR (IQ = 70-79) in 12, mild MR (IQ = 50-69) in 5, and moderate MR (IQ = 35-49) in patients 3. All patients underwent surgery (total number of procedures 153, average 4.5 procedures/patient) over a period of 30 months (April 2005 to September 2007). Improvement in functional abilities and locomotion was assessed using Gross Motor Functional Classification Scale (GMFCS) scores and by physical examination. Results: Significant improvement in function was observed ( P = 0.000) after surgery when comparing the preoperative and postoperative GMFCS scores. All patients were maintaining ambulation at a mean follow-up duration of 13.12 6.07 months (3-24 months), with five patients using knee-ankle-foot orthoses (KAFO), 22 using ankle-foot orthoses (AFO), and six patients using knee gaiters. Sixteen patients were using walker, and two were using crutches as assistive devices. Conclusion: This study suggests that CP patients with good trunk control and static contractures at multiple joints in the lower limbs can be made ambulant with single-stage multilevel soft-tissue surgery. It has to be a team effort of the surgeon and the rehabilitation team in the postoperative period for the attainment of satisfactory goal.
  12 5,161 448
Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: A multivariate analysis of factors affecting deep infection and fracture healing
Kazuhiko Yokoyama, Moritoshi Itoman, Masataka Uchino, Kensuke Fukushima, Hiroshi Nitta, Yoshiaki Kojima
October-December 2008, 42(4):410-419
DOI:10.4103/0019-5413.43385  PMID:19753228
Background: The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis. Materials and Methods: We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (≤6 h or >6 h), method of soft-tissue management, skin closure time (≤1 week or >1 week), existence of polytrauma (ISS<18 or ISS≥18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection. Results: Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection ( P <0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA ( P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion ( P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r 2 = 0.263, P = 0.0001). Conclusion: Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.
  10 4,507 548
REVIEW ARTICLES
The utility of scores in the decision to salvage or amputation in severely injured limbs
Shanmuganathan Rajasekaran
October-December 2008, 42(4):368-376
DOI:10.4103/0019-5413.43371  PMID:19753223
The decision to amputate or salvage a severely injured limb can be very challenging to the trauma surgeon. A misjudgment will result in either an unnecessary amputation of a valuable limb or a secondary amputation after failed salvage. Numerous scores have been proposed to provide guidelines to the treating surgeon, the notable of which are Mangled extremity severity score (MESS); the predictive salvage index (PSI); the Limb Salvage Index (LSI); the Nerve Injury, Ischemia, Soft tissue injury, Skeletal injury, Shock and Age of patient (NISSSA) score; and the Hannover fracture scale-97 (HFS-97). These scores have all been designed to evaluate limbs with combined orthopaedic and vascular injuries and have a poor sensitivity and specificity in evaluating IIIB injuries. Recently the Ganga Hospital Score (GHS) has been proposed which is specifically designed to evaluate a IIIB injury. Another notable feature of GHS is that it offers guidelines in the choice of the appropriate reconstruction protocol.The basis of the commonly used scores with their utility have been discussed in this paper.
  10 4,902 749
ORIGINAL ARTICLES
Taylor spatial frame in the treatment of open tibial shaft fractures
Mohammed J Al-Sayyad
October-December 2008, 42(4):431-438
DOI:10.4103/0019-5413.43393  PMID:19753231
Background: The Taylor spatial frame (TSF) is a modern multiplanar external fixator that combines the ease of application and computer accuracy in the reduction of fractures. A retrospective review of our prospective TSF database for the use of this device for treating open tibial fractures in pediatric, adolescent, and adult patients was carried out to determine the effectiveness and complications of TSF in the treatment of these fractures. Materials and Methods: Nineteen male patients with open tibial fractures were included. Of these fractures, 10 were Gustilo Type II, five were Gustilo Type IIIA (two had delayed primary closure and three had split thickness skin grafting), and four were Gustilo Type IIIB (all had rotational flaps). Twelve of our patients presented immediately to the emergency room, and the remaining seven cases presented at a mean of 3 months (range, 2.2-4.5 months) after the initial injury. The fractures were located in proximal third (n=1), proximal/middle junction (n=2), middle third (n=3), middle/distal junction (n=8), distal third (n=3), and segmental fractures (n=2). Patients were of an average age of 26 years (range, 6-45years). Mean duration of follow-up was 3.5 years. Results: All fractures healed over a mean of 25 weeks (range, 9-46 weeks). All were able to participate in the activities of daily living without any difficulty and most were involved in sports during the last follow-up. Postoperative complications included pin tract infection in 12 patients. Conclusion: The TSF is an effective definitive method of open tibial fracture care with the advantage of early mobilization, ease of soft tissue management through gradual fracture reduction, and the ability to postoperatively manipulate the fracture into excellent alignment.
  6 5,666 354
Lateral closed wedge osteotomy for cubitus varus deformity
Amit K Srivastava, DC Srivastava, SC Gaur
October-December 2008, 42(4):466-470
DOI:10.4103/0019-5413.43397  PMID:19753237
Background: Lateral closed wedge (LCW) osteotomy is a commonly accepted method for the correction of the cubitus varus deformity. The fixation of osteotomy is required to prevent loss of correction achieved. The fixation of the osteotomy by the two screw and figure of eight wire is not stable enough to maintain the correction achieved during surgery. In this prospective study we supplemented the fixation by Kirschner's (K-) wires for stable fixation and evaluated the results. Materials and Methods: Twenty-one cases of the cubitus varus deformity following supracondylar fractures of the humerus were operated by LCW osteotomy during February 2001 to June 2006. The mean age of the patients at the time of corrective surgery was 8.5 years (range 6.6-14 years). The osteotomy was fixed by two screws with figure of eight tension band wire between them and the fixation was supplemented by passing two to three K-wires from the lateral condyle engaging the proximal medial cortex through the osteotomy site. Result: The mean follow-up period was 2.5 years (range seven months to 3.4 years). The results were assessed as per Morrey criteria. Eighteen cases showed excellent results and three cases showed good results. Two cases had superficial pin tract infection. Conclusion: The additional fixation by K wires controls rotational forces effectively besides angulation and translation forces and maintains the correction achieved peroperatively.
  6 6,277 632
REVIEW ARTICLES
Pearls and tips in coverage of the tibia after a high energy trauma
Antonio Rios-Luna, Homid Fahandezh-Saddi, Manuel Villanueva-Martinez, Antonio Garcia Lopez
October-December 2008, 42(4):387-394
DOI:10.4103/0019-5413.43376  PMID:19753225
Coverage of soft-tissue defects in the lower limbs, especially open tibial fractures, is currently a frequently done procedure because of the high incidence of high-energy trauma, which affects this location. The skilled orthopedic surgeon should be able to carry out an integral treatment of these lesions, which include not only the open reduction and internal fixation of the fracture fragments but also the management of complications such as local wound problems that may arise. There is a wide variety of muscular or pedicled flaps available for reconstruction of lower limb soft-tissue defects. These techniques are not commonly used by orthopedic surgeons because of the lack of familiarity with them and the potential for flap failure and problems derived from morbidity of the donor site. We present a coverage management update for orthopedic surgeons for complications after an open tibial fracture. We choose and describe the most adequate flap depending on the region injured and the reliable surgical procedure. For proximal third of the tibia, we use gastrocnemius muscle flap. Middle third of the tibia could be covered by soleus muscle flap. Distal third of the tibia could be reconstructed by sural flaps, lateral supramalleolar skin flap, and posterior tibial perforator flap. Free flaps can be used in all regions. We describe the advantages and disadvantages, pearls, and tips of every flap. The coverage of the tibia after a major injury constitutes a reliable and versatile technique that should form part of the therapeutic arsenal of all the orthopedic surgeons, facilitating the integral treatment of complex lower limb injuries with exposed defects.
  6 5,003 576
CASE REPORTS
Intervertebral disc calcification in a child
Athar M Ahemad, Bibhas Dasgupta, Jairam Jagiasi
October-December 2008, 42(4):480-481
DOI:10.4103/0019-5413.43401  PMID:19753241
Disc calcification in children is a rare condition of which only approximately 200 cases have been reported worldwide and one from India and we report one such case. A five year-old boy presented with neck pain, torticollis and limitations of cervical motions following a fall while playing 3 months back. He had low grade fever cervical lymphadenopthy, paraspinal muscle spasm. His blood counts and ESR was raised. Fine needle aspiration cytology of lymph node revealed reactive lymphadenitis. His cervical radiograph slowed calcification of C 6-7. MRI scan showed hypointense signals in C6-C7 and D5-D6 disc on both T1 and T2 W images. Cerebrospinal fluid examination was normal. He improved on analgesics, bed rest and cervical traction.
  5 2,725 181
Pseudoachondroplasia: A rare cause of rhizomelic dwarfism
Anupama Tandon, Satish K Bhargava, Sandeep Goel, Shuchi Bhatt
October-December 2008, 42(4):477-479
DOI:10.4103/0019-5413.43400  PMID:19753240
Pseudoachondroplasia is a rare rhizomelic short-limbed skeletal dysplasia. Its inheritance is varied; autosomal dominant pattern and germline or somatic mutations can occur. Children at 2-3 years of age present with short height, gait disturbances, or limb deformities. Characteristic skeletal changes include shortening of long bones, predominantly of femur and humerus with irregular, flared metaphysis and fragmented epiphysis. Platyspondyly is also present, but the interpedicular distance is normal. The diagnosis is essentially based on imaging, and thus, it is important to be aware of the radiological features. Here, we report a case of two brothers where the elder sibling had classical radiological features of pseudoachondroplasia, whereas the younger one had early changes of this disorder.
  4 3,767 234
Robinow syndrome
SS Suresh
October-December 2008, 42(4):474-476
DOI:10.4103/0019-5413.43399  PMID:19753239
Robinow syndrome is a rare autosomal recessive mesomelic dwarfism with just more than 100 cases reported in the literature so far. The lower extremity is spared with skeletal deformity usually confined to the forearm, hand, and the dorsal spine. Diagnosis is made easily in the early childhood by the typical "fetal facies" appearance, which disappears to a certain extent as the patient grows. The author reports two cases of this entity with vertebral segmentation defects, rib fusion, and typical severe brachymelia and facial features.
  3 3,860 304
ORIGINAL ARTICLES
Paraplegia of late onset in adolescents with healed childhood caries of dorsal spine: A cause of pressure on the cord and treatment
Rangachari Paravastu
October-December 2008, 42(4):454-459
DOI:10.4103/0019-5413.41871  PMID:19753235
Background: Paraplegia of late onset in adolescents with caries of dorsal spine is considered to be due to the reactivation of infection. Internal salient at the level of acute kyphotic deformity of the dorsal spine is formed by posterior cartilaginous remains of grossly destroyed vertebral bodies. The author presents a study of eight adolescent patients with paraplegia of late onset associated with severe kyphotic deformity of dorsal spine with observations on the cause of paraplegia, the final neurological outcome following anterior decompression and its prevention. Materials and Methods: Eight adolescent patients mean age 14.4 yrs 6 males and 2 females with healed childhood caries of dorsal spine, having a mean kyphotic angle of 80 (range 60-140) presented with paraplegia of late onset. Of these patients, two had medical research council grade 0 muscle power; four had grade 2 muscle power, and two others had grade 3 muscle power in the lower limbs and were unable to walk unaided. One patient with 140 kyphoscoliotic deformity with grade 3 muscle power had post-polio residual paralysis (PPRP) in addition. All patients were subjected to thorough anterior spinal decompression through transthoracic, transpleural thoracotomy from the left side. Results: In six of the eight patients, the spine at the site of deformity being very rigid, the deformity could not be corrected and the intervertebral gap was bridged with appropriate autogenous tricortical cortico cancelluous bone graft. In one patient (case 4), the kyphotic deformity could be corrected by 50%. In one patient with 140 kyphosis and PPRP, the gap after the decompression of cord, could not be bridged with bone graft and was given a custom made, well molded plastic black shell to wear while walking and, in particular, while traveling in a vehicle. In all seven patients, bone grafts took six months for bridging the intervertebral gaps. All patients recovered to grade 4 muscle power 6-12 months after surgery. Conclusion: In adolescents with healed caries of dorsal spine with acute kyphosis and paraplegia, the treatment of choice is anterior surgical decompression of the cord and bridging the gap thus created with bone graft.
  3 3,653 241
Cross-leg flap: Its role in limb salvage
Pawan Agarwal, HKT Raza
October-December 2008, 42(4):439-443
DOI:10.4103/0019-5413.43394  PMID:19753232
Background: Pedicled cross-extremity flaps for lower limb wound coverage have been replaced by free tissue transfer in the last two decades. However, there are certain difficult situations where the free flap cannot be employed and alternative methods are needed. We describe our experience with cross-leg flap in 18 patients for the reconstruction of difficult leg defects in which no suitable recipient vessels were available for microvascular anastomosis in the vicinity of the defect. Materials and Methods: 18 patients (17 men and 1 woman) with mean range 31.5 yrs(range 18-70 yrs) grade III B tibial fractures were included in the study. fasciocuteneous cross leg flap was employed and extremities were immobilized by external Fixator. Results: Fifteen flaps were completely available with two had marginal necrosis and one supsficial epidermal necrosis.No complications were related to the donor site, flap, or by immobilization are noted. Each patient resumed essentially normal gait and activity without any stiffness of joints related with the flap or external fixator. Conclusion: The addition of external fixator stabilization aids greatly in wound care, as well as for general ease of the patient mobility and positioning. Cross-leg flap offers the possibility of salvaging limbs that are otherwise nonreconstructable.
  3 4,627 450
Therapeutic ultrasound in fracture healing: The mechanism of osteoinduction
PS John, CS Poulose, Benjamin George
October-December 2008, 42(4):444-447
DOI:10.4103/0019-5413.42804  PMID:19753233
Background: Ultrasound has been used therapeutically for accelerating fracture healing since many years. However, the controversy on the exact mechanism of osteoinduction still continues. In this study, we try to bring out the exact biomolecular mechanism by which ultrasound induces fracture healing. Materials and Methods: The study was conducted in two phases: animal experiments and clinical study. In the first phase, we induced fractures on the left tibia of Wistar strain rats under anaesthesia. They were divided into two groups. One of the groups was given low-intensity, pulsed ultrasound (30 MW/cm 2 ) 20 min a day for 10 days. Tissue samples and radiographs were taken weekly for 3 weeks from both the groups. In the second phase of our study, ten patients with fractures of the distal end of the radius (ten fractures) were included. Five of these were treated as cases, and five were treated as controls. Ultrasound was given 30 MW/cm 2 for 20 min every day for 2 weeks. The patients were assessed radiologically and sonologically before and after ultrasound therapy. Tissue samples were studied with thymidine incorporation test with and without adding various neurotransmitter combinations. Results: Radiological findings revealed that there was an increased callus formation in the ultrasound group. At the cellular level, there was an increased thymidine incorporation in the ultrasound group. When various neurotransmitters were added to the cells, there was an increased thymidine incorporation in the ultrasound group. In the second phase of the study, radiological and sonological assessments showed that there was an increased callus formation in the ultrasound group. In cytological study, thymidine incorporation was found to be increased in the ultrasound group. Conclusions: The results of animal and clinical studies demonstrated an early and increased callus formation in the ultrasound group. Cytological studies revealed increased thymidine incorporation, suggesting increased osteoblastic activity.
  3 4,054 396
Appraisal of the role of external skeletal fixation in the management of sequelae of open tibial fractures
Mahmoud A El-Rosasy
October-December 2008, 42(4):420-425
DOI:10.4103/0019-5413.43388  PMID:19753229
Background: Severe open tibial fractures are more apt to be followed by complications even with the universally accepted lines of treatment. The present study investigated the role of external skeletal fixation, based on Ilizarov techniques, in the management of the sequelae of open tibial fractures with modifications to meet the requirements of each case. Materials and Methods: We reviewed the results of treatment of 148 cases of late presentation with complicated open tibial fractures. Their ages ranged from 12 to 74 years (average, 34 years). Active infection was present in 40 cases. We performed acute shortening and relengthening in 60 cases; excision of nonunion, acute deformity correction, and lengthening for nonunion with deformity in 30 cases; segmental excision and bone transport in 20 cases; gradual deformity correction after osteotomy in 15 cases; and distraction and gradual deformity correction for hypertrophic nonunion with deformity in 23 cases. Ilizarov external fixator was used in 96 (65%) cases, and monolateral fixator was used in 52 (35%) cases. The mean follow-up was 35 months (range 24 to 118 months). Results: Fracture union was achieved in all cases (100%). Evaluation of results were based on both objective (clinical and radiological) and subjective criteria and patients' satisfaction. The results were satisfactory in 139 cases (94%) and unsatisfactory in nine (6%) cases because of residual leg length discrepancy, joint stiffness, and persistent pain. Conclusions: The use of external fixation, based on Ilizarov techniques, is invaluable in the management of difficult open tibia fractures. However, the technique should be tailored to the requirements of each case. The functional outcome is predetermined by the soft tissue status before treatment.
  3 2,720 335
EDITORIAL
Open fractures
Sudhir Babhulkar, HKT Raza
October-December 2008, 42(4):365-367
DOI:10.4103/0019-5413.43370  PMID:19753222
  2 3,820 600
ORIGINAL ARTICLES
Management of open fractures of the tibial shaft in multiple trauma
Boltuc Witold Stanislaw, Golec Edward Boguslaw
October-December 2008, 42(4):395-400
DOI:10.4103/0019-5413.43378  PMID:19753226
Background: The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients. Materials and Methods: The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8-10 days after the trauma. Results: The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation. Conclusion: Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8-10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture.
  1 3,949 489
Three-level anterior cervical discectomy and fusion in elderly patients with wedge shaped tricortical autologous graft: A consecutive prospective series
Suk Ha Lee, Kwang Jun Oh, Kwang Su Yoon, Sung Tae Lee, Dilbans S Pandher
October-December 2008, 42(4):460-465
DOI:10.4103/0019-5413.43396  PMID:19753236
Background: Treatment of multilevel cervical spondylotic myelopathy/radiculopathy is a matter of debate, more so in elderly patients due to compromised physiology. We evaluated the clinical and radiological results of cervical fusion, using wedge-shaped tricortical autologous iliac graft and Orion plate for three-level anterior cervical discectomy in elderly patients. Materials and Methods: Twelve elderly patients with mean age of 69.7 years (65-76 years) were treated between April 2000 and March 2005, for three-level anterior cervical discectomy and fusion, using wedge-shaped tricortical autologous iliac graft and Orion plate. Outcome was recorded clinically according to Odom's criteria and radiologically in terms of correction of lordosis angle and intervertebral disc height span at the time of bony union. The mean follow-up was 29.8 months (12-58 months). Results: All the patients had a complete recovery of clinical symptoms after surgery. Postoperative score according to Odom's criteria was excellent in six patients and good in remaining six. Bony union was achieved in all the patients with average union time of 12 weeks (8-20 weeks). The mean of sum of three segment graft height collapse was 2.50 mm (SD = 2.47). The average angle of lordosis was corrected from 18.2 (SD = 2.59) preoperatively to 24.9 (SD = 4.54) at the final follow-up. This improvement in the radiological findings is statistically significant (P < 0.05). Conclusion: Cervical fusion with wedge-shaped tricortical autologous iliac graft and Orion plate for three-level anterior cervical discectomy is an acceptable technique in elderly patients. It gives satisfactory results in terms of clinical outcome, predictable early solid bony union, and maintenance of disc space height along with restoration of cervical lordosis.
  1 5,076 240
LETTERS TO EDITOR
Prosthetic replacement in femoral neck fracture in the elderly
Ashish Anand
October-December 2008, 42(4):482-482
DOI:10.4103/0019-5413.43402  PMID:19753243
  - 1,878 186
Authors' reply
Sanjiv Kumar Singh Marya, Rajiv Thukral, Chandeep Singh
October-December 2008, 42(4):482-483
DOI:10.4103/0019-5413.43403  PMID:19753242
  - 1,830 121
Teaching-learning and patient care
Amit Agrawal
October-December 2008, 42(4):483-483
DOI:10.4103/0019-5413.43404  PMID:19753244
  - 1,416 91
OBITUARIES
Obituary- Prof T K Shanmugasundaram (1929 - 2008)
S Rajasekaran
October-December 2008, 42(4):484-485
  - 1,788 170
TKS-The gentle molder
Surendar Mohan Tuli
October-December 2008, 42(4):485-485
  - 1,707 84
Obituary- Dr. Mahendra T. Mehta 1929-2008
Pravin Kanabar
October-December 2008, 42(4):486-486
  - 1,267 96
ORIGINAL ARTICLES
Incidence of infection after early intramedullary nailing of open tibial shaft fractures stabilized with pinless external fixators
Vikas Kulshrestha
October-December 2008, 42(4):401-409
DOI:10.4103/0019-5413.43382  PMID:19753227
Background: A major drawback of conventional fixator system is the penetration of fixator pins into the medullary canal. The pins create a direct link between the medullary cavity and outer environment, leading to higher infection rates on conversion to intramedullary nailing. This disadvantage is overcome by the AO pinless fixator, in which the trocar points are clamped onto the outer cortex without penetrating it. This study was designed to evaluate the role of AO pinless fixators in primary stabilization of open diaphyseal tibial fractures that received staged treatment because of delayed presentation or poor general condition. We also analyzed the rate of infection on early conversion to intramedullary nail. Materials and Methods: This study is a retrospective review of 30 open diaphyseal fractures of tibia, which were managed with primary stabilization with pinless fixator and early exchange nailing. Outcome was evaluated in terms of fracture union and rate of residual infection. The data were compared with that available in the literature. Results: All the cases were followed up for a period of 2 years. The study includes Gustilo type 1 (n=10), 14 Gustilo type 2 (n=14), and type3 (n=6) cases. 6 cases (20%) had clamp site infection, 2 cases (6.7%) had deep infection, and in 28 cases (93%) the fracture healed and consolidated well. Conclusion: This study has highlighted the valuable role of pinless external fixator in the management of open tibial fractures in terms of safety and ease of application as well as the advantage of early conversion to intramedullary implant without the risk of deep infection.
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PRESIDENTIAL ADDRESS
Past, present and future of IOA from my eyes and mind
HKT Raza
October-December 2008, 42(4):487-489
DOI:10.4103/0019-5413.43408  PMID:19753245
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