Amitabh Jitendra Dwyer

Floating knee injuries: long-term results of four treatment methods.

One hundred twenty-four consecutive patients with true floating knee injury presented between 1987 and 2001. They were treated with non-operative, operative (external fixation and intramedullary nailing) and combined modalities. Sixty patients were followed up, at an average of 7.2 years, for age, gender, type of trauma and fracture; time to fracture union and time to mobilisation. Complications that were encountered and return to normal activities were recorded. Better and comparable union rates of fractures, earlier return to activities and higher excellent and good long-term functional results were observed among combined and operative (intramedullary nail) groups. Using combined modalities of treatment is an affordable, practicable and effective approach, especially for a resource-poor environment. External fixation of the fractured femur resulted in a decreased range of movement at the knee due to quadriceps muscle fixation. Fractured tibia, treated by any of the method, did not interfere with patient’s joint mobilisation whereas associated injuries did.RésuméCent vingt-quatre malades consécutifs ont présenté un genou flottant traumatique entre 1987 et 2001. Ils ont été traités avec une méthode non—opératoire, une méthode opératoire (fixation externe et enclouage centromédullaire) et une méthode à modalités combinées. Soixante malades ont été suivis pendant une moyenne de 7,2 années en notant l’âge, le genre, le type de trauma et de fracture, la durée de consolidation osseuse, le délai de début de mobilisation, les complications rencontrées et le retour aux activités normales. Parmi les groupes combinés et opératoires (enclouage centromédullaire) ont été observés une meilleure vitesse de consolidation des fractures , une reprise d’activité plus rapide et plus de bons ou très bons résultats fonctionnels. La modalité combinée est une approche accessible et efficace pour un environnement aux ressources limitées. La fixation externe du fémur fracturé a entrainé une diminution de la mobilité du genou à cause de la fixation du quadriceps. La fracture du tibia, quelque soit son traitement, n’interfère pas avec la mobilisation articulaire à la différence des lésions associées

Complications after posterior dislocation of the hip

Thirty-five consecutive patients with unilateral posterior dislocation of the hip were studied for complications at an average follow-up of 4.6 years (range 2–10 years). Thompson–Epstein type IV dislocation was most frequent (10/35), reflecting an increase in high-speed motor vehicles in the developing countries. It is also a severe injury that leads to a maximum number of complications, which include avascular necrosis, osteoarthosis, sciatic nerve injury and heterotrophic ossification. Avascular necrosis and osteoarthritis of the hip were observed maximally in type IV patients, even when reduction was achieved in less than twelve hours and may reflect the severity of initial injury. Heterotrophic ossification was observed in five of the ten patients with type IV dislocation and was associated with multiple attempts at reduction. Sciatic nerve injury did not recover completely in all cases, especially when reduction was delayed over twelve hours. Observing that the greatest numbers of complications were seen among patients with type IV dislocations, it may be prudent to warn such individuals about the likely prognosis at the outset, especially in today’s world when the demands and expectations are high.Résumé35 patients consécutifs présentant une luxation postérieure de la hanche ont été étudiés avec un recul moyen de 4,6 ans (2 à 10 ans). Les luxations de type 4 de Thompson–Epstein sont les plus fréquentes (10/35) et sont le reflet de l’augmentation de la vitesse des véhicules à moteur dans les pays développés. Il s’agit également de traumatismes sévères qui ont conduit la plupart du temps à des complications de nécroses avasculaires, de lésions dégénératives, de lésions du nerf sciatique et d’ossification hétérotopique. Ce sont les traumatismes sévères qui ont été à l’origine du maximum de complications. Les nécroses avasculaires et les arthroses de hanche sont surtout observées chez les patients de type IV, même si la réduction a été réalisée avant 12 heures. Les ossifications hétérotopique sont été observées chez 5 patients sur 10, notamment dans les luxations de type 4, les lésions du nerf sciatique n’ont jamais récupéré complètement surtout lorsque la réduction a été retardée après 12 heures. Il faut remarquer que le plus grand nombre de complications ont été observées chez les patients dont la luxation était de type IV. Il est plus prudent dans ce cas là de faire part du pronostic réservé à ces patients, d’autant plus que la demande et l’attente d’un résultat parfait est très importante dans le monde d’aujourd’hui.

Evaluation of rehabilitated bilateral lower limb amputees – an Indian study

Objective: This study assessed activities of daily living (ADL) and ambulation of rehabilitated bilateral lower limb amputees with relation to their level of amputation in an Indian setting. Subjects and Methods: This retrospective study of 25 subjects comprised 12 bilateral Trans-femoral (TF) amputees, 8 bilateral Trans-tibial (TT) amputees and 5 a combination of ipsilateral Trans-femoral and contralateral Trans-tibial amputation. All subjects were contacted by post/telephone, were physically examined and assessed at the Orthopaedic clinic at a mean follow-up of 6.6 years. Physical rehabilitation was evaluated using ADL score and by grading the level of ambulation. Results: ADL scores showed no significant difference according to level of amputation (p > 0.05), but the scores of prosthetic users were significantly higher than non-prosthetic users (p = 0.002). Only 11/25 amputees became prosthetic ambulators and most (50%, 6/12) were TF amputees. All prosthetically rehabilitated subjects were mobilising with their prostheses at follow-up and graded as unlimited or limited community ambulators. Conclusion: Though it is well documented that the potential for successful rehabilitation is best for bilateral TT amputees, given the subjects’ economic constraints, higher prosthesis rehabilitation among bilateral TF amputees indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation. Implications for Rehabilitation Rehabilitation of a bilateral lower limb amputee requires a team effort and constitutes a very difficult challenge for the subject. Low prosthesis ownership is largely due to subjects’ inability to afford a pair of prostheses in a developing country like India. Activities of daily living improve significantly with use of prostheses. Though it is well documented that the potential for successful rehabilitation is best for a bilateral TT amputee, higher prosthesis rehabilitation among bilateral TF subjects in this study indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

Remodeling of Tibial Fractures in Children Younger Than 12 Years

Forty-eight children with an average age of 7.2 years (range: 3-12 years) were examined clinically and radiographically at an average 4-year follow-up (range: 2-10 years), between 1989 and 2000 to analyze correction of deformities following tibial shaft fractures. An inconsistent alteration in the length of the fractured tibia was observed. Anterior angular deformity realigned maximally (52.7%) followed by varus (40.9%) and valgus (23.9%) deformities. Posterior deformity corrected the least (18.5%). In the sagittal plane, acceptable critical anterior and posterior angular deformities that corrected completely were 12 degrees and 6 degrees respectively. In the coronal plane, acceptable critical angular deformities were 10 degrees varus and 8 degrees valgus.

Nutritional status and wound healing in open fractures of the lower limb.

Forty-three patients averaging 28.2 (range 16–74) years with open fractures of the lower limbs were studied prospectively for 40 weeks using anthropometrical, biochemical and haematological parameters to ascertain their relationship to wound healing following injury. Nearly half (21/43) of the patients were malnourished at admission and the number increased to 22 a week after injury. Dietary advice and better food intake improved nutritional status with only 13 patients remaining malnourished at the 40th week. Wound healing was earlier when creatinine-height index was normal throughout the course of treatment and was delayed when serum albumin level was low.RésuméNous avons suivi prospectivement, pendant quarante semaines, 43 malades avec des fractures combinées du membre inférieur en utilisant des paramètres anthropométrique, biochimique et hématologique pour étudier leur relation avec la cicatrisation des parties molles après l’accident. Prés de la moitié des patients (21/43) étaient considérés comme malnutris à leur admission. Les conseils diététiques et une meilleure prise de la nourriture ont amélioré le statut nutritionnel avec seulement treize malades dans le groupe malnutris à la quarantième semaine. La guérison des blessures était plus précoce quand l’index de créatinine était normal durant le cours du traitement et a été retardée quand le niveau de sérum albumine était bas.

Relation of nutritional status to healing of compound fractures of long bones of the lower limbs.

This article attempts to determine the correlation of nutritional status and union of open fractures of the lower limbs using autropometric, biochemical, and hematological parameters.

Amputations through the hind foot: a report of three cases using a modified Dwyer and Paul procedure.

Salvage of limb length following oblique proximal foot amputations is presented. The technique, results, and follow-up of this procedure are described and compared with other standard procedures. A prospective study was done on 3 adolescents who presented consecutively during years 1999 and 2000. The salvage procedure described was performed on all 3 patients, and they were followed up for an average 3.5 years (range 3-4 years). All patients ambulated soon after surgery using crutches. Union of the graft between the distal tibia and calcaneus was achieved at 6 months, and all patients could walk bare foot as well as using their prosthesis both indoors and outdoors. We conclude that salvage of leg length and preservation of the sole of the foot in its normal plantigrade position by this procedure offers a viable and acceptable option to the surgeon and young patients.