Amite Pankaj

Dome osteotomy for posttraumatic cubitus varus: a surgical technique to avoid lateral condylar prominence.

The indication for surgery in most children with posttraumatic cubitus varus is the presence of an unsightly deformity. The function of the limb is generally not impaired. Lateral closing-wedge supracondylar osteotomy, although a widely used corrective procedure, tends to produce lateral condylar prominence, thus jeopardizing the cosmetic outcome. The authors used the dome supracondylar osteotomy, as described by Tien et al, as the corrective procedure for cubitus varus in 12 consecutive children. The average follow-up was 2.3 (range 1-4) years. The objective evaluation was done by one of the authors by measuring the pre- and postoperative lateral condylar prominence index, carrying angle, and the range of movement at the elbow. The patients and parents were also asked to self-assess the cosmetic outcome. There were seven excellent and five good results. None of the children showed a prominent lateral humeral condyle. Hypertrophic scar formation and ulnar neurapraxia were seen in one patient each. These results were comparable to the published results of lateral closing-wedge osteotomy in terms of correction of carrying angle and preservation of elbow motion and were superior to those of the lateral closing-wedge osteotomy in terms of the prominence of lateral humeral condyle, acceptability of the scar, and cosmesis. The authors offer independent verification of the observation that the technique of dome osteotomy as described by Tien et al for the correction of the posttraumatic cubitus varus is a simple, safe, and technically sound procedure that prevents the lateral condyle from becoming prominent and yields an excellent cosmetic outcome.

Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial

PurposeThere is no consensus about the best option of internal fixation for unstable intertrochanteric fractures. The aim of the present study was to compare proximal femoral nail (PFN) with contralateral reverse distal femoral locking compression plate (reverse-DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall.MethodIn a randomized controlled study, from November 2011 to October 2012, 40 patients with unstable intertrochanteric fractures with compromised lateral wall (AO 31A 2.2 to 3.3) had osteosynthesis by PFN (n = 20) or reverse-DFLCP (n = 20). Intra-operative variables compared were duration of surgery, blood loss during surgery, fluoroscopy time and surgeons perception of the surgery. Patients were followed up clinically for a minimum of one year. Functional outcome was assessed by Parker Palmer mobility score (PPMS), Harris hip score (HHS), and Short Form-12. Failure was defined as any condition which would necessitate revision surgery with change of implant.ResultsDuration of surgery (p = 0.022), blood loss during surgery (p = 0.008) and fluoroscopy time (p = 0.0001) were significantly less in the PFN group than in the reverse-DFLCP group. No significant difference was found in type of reduction, difficulty in reduction and surgeon’s perception of surgery. The PFN group had better functional outcome than the reverse-DFLCP group. HHS for the PFN group was 81.53 ± 13.21 and for the reverse-DFLCP group it was 68.43 ± 14.36 (p = 0.018). SF-12 physical (p = 0.002) and mental component (p = 0.007) scores in the PFN group was significantly better than in the reverse-DFLCP group. There was one failure in the PFN group as compared to six in the reverse-DFLCP group (p = 0.036).ConclusionDue to favourable intra-operative variables, better functional outcome and lower failure rates, we conclude that PFN is a better implant than reverse-DFLCP for intertrochanteric fractures with compromised lateral wall.

Displaced osteochondral fracture of the lateral femoral condyle associated with an acute anterior cruciate ligament avulsion fracture: a corollary of “the lateral femoral notch sign”

AbstractAnterior cruciate ligament (ACL) rupture is usually accompanied by bone contusions resulting from impact of tibia on femur. The injury sometimes becomes manifest as a depression on the lateral femoral condyle giving rise to “lateral femoral notch” sign. The authors describe a rare case of impaction of the tibia and femur resulting in an osteochondral fracture rather than the usual bone contusion, which frequently occurs with ACL rupture. Open reduction and internal fixation of both the ACL avulsion fracture and the osteochondral fracture from the lateral femoral condyle were done, and the patient had a good outcome at 1-year follow-up. Level of evidence V.

Arthroscopic management of popliteal cysts.

Background: Management of popliteal cyst is controversial. Owing to high failure rates in open procedures, recent trend is towards arthroscopic decompression and simultaneous management of intraarticular pathology. We retrospectively analysed clinical results of symptomatic popliteal cysts after arthroscopic management at 24 month followup. Materials and Methods: Retrospective analysis of hospital database for patients presenting with pathology suggestive of a popliteal cyst from June 2007 to December 2012 was done. Twelve cases of popliteal cyst not responding to NSAIDS and with Rauschning and Lindgren Grade 2 or 3 who consented for surgical intervention were included in the study. All patients underwent arthroscopic decompression using a posteromedial portal along with management of intraarticular pathologies as encountered. Furthermore, the unidirectional valvular effect was corrected to a bidirectional one by widening the cyst joint interface. The results were assessed as per the Rauschning and Lindgren criteria. Results: All patients were followed for a minimum of 24 months (range 24-36 months). It revealed that among the study group, six patients achieved Grade 0 status while five had a minimal limitation of range of motion accompanied by occasional pain (Grade 1). One patient had a failure of treatment with no change in the clinical grading. Conclusion: Arthroscopic approach gives easy access to decompression with the simultaneous management of articular pathologies.

Conversion of failed hemiarthroplasty to total hip arthroplasty: A short to mid-term follow-up study

Background: The conversion of hemiarthroplasty (unipolar or bipolar) of the hip to total hip replacement has been reported to be associated with very high rates of intra- and postoperative complications. We present a prospective analysis of the outcome of conversion surgery in patients with failed hemiarthroplasty. Materials and Methods: Forty-four cases, 30 women and 14 men, average age 62 years (range 42-75 years) of failed hemiarthroplasty were converted to total hip replacement between January 1998 and December 2004. Groin pain was the main presenting complaint in the majority of the patients (24 out of 44). Six patients had infection and were operated with staged procedure. All acetabular and the majority (86.5%) of femoral components used in our series were uncemented. Results: After an average follow-up of 6.4 years (range, two to nine years) Harris hip scores improved from 38 (range 15-62) preoperatively to 86 (range 38 to 100) and 22 (50%) patients were community ambulators without support while 17 (38%) needed minimal support of cane. Fifteen out of 18 (83%) patients who had isolated groin pain preoperatively experienced no pain postoperatively while three patients (17%) reported only partial improvement. Intraoperative and postoperative complications included iatrogenic fracture of the femur in two, femoral perforation in two, partial trochanteric avulsion in two, fracture of the acetabular floor in three hips, and postoperative dislocation in one. None of these complications resulted in a poor long-term outcome. The rate of loosening in our series was 2.3% (one out of 44) after a mean follow-up of 6.4 years with a mean survival of 97.4% at 72 months. Conclusion: Conversion of symptomatic hemiarthroplasty to total hip arthroplasty is a safe option that gives good functional results, with marginally higher rates of intra-operative complications. The patients should be warned of the possibility of incomplete relief of groin pain postoperatively.

Hip dislocation associated with ipsilateral femoral neck and shaft fractures: an unusual combination and dilemma regarding head preservation

Traumatic posterior hip dislocation associated with a fracture of the femoral neck is a rare injury. The combination of posterior dislocation of the femoral head with ipsilateral femoral neck and shaft fractures is even rarer, with only one such case reported in literature. We present the case of a 50-year-old man, with traumatic posterior dislocation of the hip, and fractures of the femoral neck and shaft, in addition to an undisplaced superior pubic ramus fracture of the acetabulum. Osteosynthesis of the femoral shaft fracture followed by open reduction of the femoral head and fixation of the neck was undertaken, while taking care not to damage the intact retinaculum on the posterosuperior aspect of the femoral neck. The radiographs revealed union of all fractures without evidence of avascular necrosis of the femoral head at final follow-up of two years. This case is of particular interest as it highlights some of the important factors in deciding between head preservation versus arthroplasty for this complex fracture-dislocation.

Concomitant ipsilateral proximal tibia and femoral Hoffa fractures

OBJECTIVE The aim of this study was to report our experience on concomitant ipsilateral proximal tibia and femoral Hoffa fractures. METHODS Nine patients (8 male, 1 female; mean age: 30.9; range: 19-49 years) presented to our emergency room with an ipsilateral proximal tibia and femoral Hoffa fracture, following road traffic accident. Six patients had open fracture. Two patients had ipsilateral femoral shaft fracture, two patients had fracture of intercondylar part of distal femur, one had fracture of patella and one had fracture of both bones of the leg. Out of nine Hoffas fracture eight involved lateral and one involved medial femoral condyle. There were five type II, two type VI, one type I and one type IV proximal tibial fracture according to Schatzker classification. RESULTS Mean duration of follow-up was 13 months (range: 9-21 months). At final follow-up, all fractures united. Mean knee society score was 163 (range: 127-182). Mean ROM at knee joint was 97.4 degrees (75°-115°). CONCLUSION Our results suggest that in this combination of intraarticular fractures anatomic reduction and rigid fixation followed by early mobilization reveal satisfactory results.

Ipsilateral hip and knee dislocation: Case report and review of literature

Hip and knee dislocations are not uncommon but simultaneous ipsilateral dislocation of the hip and knee joint is rare; consequently, there is an inadequate amount of literature on the subject. We identified only 11 such cases reported in English literature. In the present report, we describe the case of a 23-year-old male patient who presented with ipsilateral hip and knee dislocation on the right side after being involved in a road traffic accident. The hip dislocation was associated with a posterior wall acetabular fracture. The hip as well as the knee joints was reduced in the emergency bay. The patient underwent an urgent fixation of the posterior wall acetabular fracture with delayed ligament reconstruction for the knee dislocation. At one-year follow-up, he had no pain in the hip or knee. There was grade 1 posterior sag but no symptoms of knee instability. Radiographs revealed no evidence of avascular necrosis or arthritis of the femoral head. The normal treatment protocol for individual injury is affected by the simultaneous occurrence of hip and knee dislocation.

Authors response: the lateral femoral wall

Dear Editor, We would like to thank the authors [1] for showing keen interest in our article [2] comparing two different implants for fixation of intertrochanteric fractures with a compromised lateral femoral wall. We have emphasised in our article that in spite of the general consensus about the importance of the lateral femoral wall in the management of intertrochanteric fractures, the literature is not clear about the exact area of the proximal femur which constituents the lateral femoral wall. Gotfried [3] defined it loosely as the proximal extension of the femoral shaft, but did not define its exact proximal or distal extent. Similarly, Palm et al. [4] defined it as the lateral femoral cortex distal to the vastus ridge without qualifying the distal extent. To clarify this confusion, we have defined both the proximal as well as the distal extent of the lateral femoral wall: (1) the proximal extent is the point on the lateral femoral cortex where the line drawn as a tangent to the superior femoral neck meets it (point b in Fig. 4. of the original paper [2]) and (2) the distal extent is the point on the lateral femoral cortex where the line drawn as a tangent to the inferior femoral neckmeets it (point d in Fig. 4. of the original paper [2]). The proximal extent defined by us, as rightly observed by the authors, is slightly above the vastus laterals ridge. This ensures two things: (1) all isolated fractures above it can be safely labelled as avulsion fractures of the greater trochanter and (2) all low intertrochanteric fractures, which exit lateral to the greater trochanter, near the vastus ridge and have a vulnerable lateral femoral wall, can be included. Similarly, taking the distal extent as defined by us ensures that (1) any fracture below it can be safely labelled as subtrochanteric fracture and (2) all reverse oblique (AO 31A 3.1–3.3) intertrochanteric fractures can be included (Fig. 1). If we were to define the lateral femoral wall as drawn by the authors [1], two large groups of intertrochanteric fractures, namely (1) low intertrochanteric fractures, which exit lateral to the greater trochanter near the vastus ridge, with a vulnerable lateral femoral wall, and (2) AO 31A 3.1–3.3 fractures with a preoperatively broken lateral femoral wall, would be excluded. We need to understand that a lateral femoral wall fracture which is seen on immediate postoperative intertrochanteric fracture radiographs fixed with DHS can be due to two reasons: (1) either the lateral femoral wall is broken pre-operatively, as is the case in AO 31A 3.1–3.3 fractures, or (2) the lateral femoral wall is vulnerable pre-operatively and breaks intra-operatively during the large diameter drilling for the sliding hip screw [3–6]. This is usually the case in AO 31A 2.2 and 31A 2.3

Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures.

To the Editor: We read with interest the article by Ostrum et al, ‘‘Penetration of the distal femoral anterior cortex during intramedullary nailing for subtrochanteric fractures: A report of three cases’’ (J Orthop Trauma. 2005;19:656–660). We congratulate the authors for bringing to the readers’ notice this potentially disastrous complication of intramedullary nailing for subtrochanteric fractures of the femur. The authors have described 3 cases of penetration of distal femoral anterior cortex with the use of 3 different designs of nails and different starting points of insertion, stressing that this complication can occur with any technique or implant. We agree with the reason given for this complication by the authors that straighter femoral nails cannot conform to the bowed femoral canal because the isthmus is intact in subtrochanteric fractures, whereas in femoral shaft fractures, some angulation at the fracture site prevents anterior cortex impingement. In addition, they have also cited an anterior entry point and external rotation of the nail as being responsible for anterior impingement. The authors conclude that if the final nail seating is not effortless, a lateral fluoroscopic view should be obtained to examine the distal nail placement in the femoral canal. We would like to draw the authors’ attention to the concept of blocking/Poller screws that can be utilized to avoid anterior cortex impingement, should this complication be encountered or anticipated. Blocking screws are transmedullary screws, described by Krettek et al in 1999, used to facilitate alignment in association with interlocking nailing of the tibial fractures with either proximal or distal fragments. Their use has also been described in distal femoral fractures. These screws help redirect the nail in the spacious metaphyseal portions of the medullary canal of long bones. We wish to highlight that an anteriorly placed blocking screw can be utilized to avoid anterior impingement of the nail.