Anil Kumar Joshi

Traumatic loss of talus: A rare injury

BACKGROUND Traumatic loss of talus during a compound injury of ankle is an unusual injury. OBJECTIVE We report a 55 years old woman who sustained an open ankle injury with complete extrusion of talus and loss at the injury site. METHOD A tricortical bone graft was obtained from iliac crest and talar dimensions carved with 5 cm length and 3 cm height given by buttressing fibular graft between them. These grafts are made in the shape of talus by fixing them together with cortical screw and binding them together with Ethibond No. 5. By anterior approach ankle was opened and talar graft was placed in between the raw surfaces of tibia and calcaneus to facilitate ankle arthrodesis. RESULT Patient had solid fusion at the ankle joint after 4 months with no pain on walking. CONCLUSION The definitive treatment of this serious lower extremity injury remains controversial we have attempted this novel way of treatment as the patient was unable to afford talar prosthesis and facilities of allogenic bone grafts were not there.

Road traffic accidents in hilly regions of northern India: what has to be done?

BACKGROUND Road traffic accidents (RTA) are responsible for 1.2 million deaths worldwide each year. RTA will become the 3(rd) largest contributor to the global burden of diseases after ischemic heart diseases (IHD) and depression. We conducted a retrospective study on RTA in a tertiary center in the hilly district of Uttarakhand in India. METHODS The number of RTA, pattern of RTA, the number of patients killed and injured, the pattern of injury causing death and disability, the severity of accidents, and the type of disability were noted from December 2009 to November 2011. The accident severity was calculated as the number of patients killed per 100 accidents. The methods for reducing the incidence of RTA were observed, and the role of policy makers was studied. RESULTS The majority of deaths and disabilities in Uttarakhand were due to road traffic accidents in the hilly districts of the states. The most common cause of RTA was driving fault followed by defective roads. CONCLUSION Proper designing of roads and minimizing the fault of drivers are essential to prevent road traffic accidents in hilly regions.

Wooden stick penetration from the perineal region up to the thorax.

BACKGROUND Penetrating injuries of the perineum are rare but very dangerous. Since the genitourinary and colorectal organs may be injured, how to evaluate surgical management of the injury is very important. METHODS The present report presents a case of penetrating injury of the perineum by a wooden stick when the patient fell on the upright wooden stick from a tree. The three feet long stick entered the perineal region just left lateral to the anal opening. Upon reaching the thoracic cavity, it broke and only a foot stick was left in the subcutaneous plane. These injuries are potentially serious with risk of damage to multiple organs. Exploratory laprotomy was done, and bladder injury was repaired. The entry wound and the track of stick was thoroughly washed and allowed for secondary intention healing. RESULTS The post operative period was uneventful and the patient recovered fully. CONCLUSION Meticulous evaluation and surgical management of perineal injuries are the key to prevent devastating complications.

Comment on Xue et al.: Alendronate treatment improves bone–pedicle screw interface fixation in posterior lateral spine fusion: an experimental study in a porcine model

We read the article entitled “Alendronate treatment improves bone–pedicle screw interface fixation in posterior lateral spine fusion: an experimental study in a porcine model” by Qingyun Xue et al. with great interest [1]. The purpose of the research was to investigate whether alendronate treatment improves bone–pedicle screw interface fixation in posterior lateral spine fusion. We would like to thank the authors for their innovative and encouraging paper, but we have some concerns about the safety profile of alendronate. The authors advocated wider use of alendronate based on the properties of bisphosphonates for reduction of bone remodelling by inhibition of osteoclastic activity. Normal bone remodelling is linked to new bone formation by the so-called coupling phenomenon. The most effective approach to prevent implant loosening would be to have a positive balance between bone formation and resorption in the active bone-remodelling time period. Alendronate treatment could protect the bone structure from extra resorption while maintaining the bone volume around the screw surface. In fact, prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of femur [2]. The fracture rate is higher in long-term use than during the first year of therapy, suggesting possible adverse effects on bone [3]. Alendronate inhibits bone resorption by suppressing activity of osteoclasts, and inducing them to undergo apoptosis. While this leads to an increase in bone mineral density (BMD) of patients with osteoporosis, treatment with alendronate has been shown to reduce bone turnover. In humans prolonged administration of bisphosphonates can lead to development of osteopetrosis or marble bone disease [4]. Keeping the above-mentioned facts in mind, authors must warn the orthopaedic community about liberal use of alendronate.

Management of floating knee

Dear Editor, We have read with great pleasure the article entitled “Ipsilateral fractures of tibia and femur or floating knee” [1]. We would like to congratulate the authors for evaluating the issue very well. They have definitely made a great contribution to the relevant literature on intramedullary (IM) nailing. IM nailing has become the gold standard to stabilise these fractures in immediate or delayed settings [2]. We would like to say that it is an era of “limb damage control orthopaedics,” which must be considered when dealing with polytrauma patients. During the 1990s it was advocated that the adverse outcome of fracture surgery, especially IM nailing, had systemic physiological effects known as “second-hit phenomena.” A major concern being to decrease second-hit phenomena, a more selective approach to fracture fixation was used; however, early fixation was still performed in most cases. This phenomenon, which particularly increases with reamed IM nailing in polytrauma patients, results in increased chances of pulmonary complications [3, 4]. We would like to draw the authors’ attention to the fact that they have not mentioned the approach for IM nailing. We suggest use of a single longitudinal incision over the knee for retrograde nailing of femur and antegrade nailing tibia in a single session with the advantage of decreasing the operative time and morbidity while obtaining equally good results [5].

Outcome of application of primary versus secondary Illizarov's fixator in open tibial shaft fractures.

BACKGROUND The present study aimed to compare outcome of primary and secondary Illizarovs fixator application as a treatment method for type III open tibial fractures in terms of non-union and wound infection. METHODS This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarovs apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarovs application, primary (n=28) and secondary (n=20). RESULTS In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were significantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group. CONCLUSION Primary wound closure and Illizarovs fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarovs fixation, mostly due to a significantly less number of patients with a bone defect in the primary group.

Comment on An et al.: Plating osteosynthesis of mid-distal humeral shaft fractures: minimally invasive versus conventional open reduction technique

Dear Editor, We commend the excellent paper entitled “Plating osteosynthesis of mid-distal humeral shaft fractures: minimally invasive versus conventional open reduction technique” [1]. This innovation will definitely revolutionise our understanding of fracture care. In our experience minimally invasive plate osteosynthesis (MIPO) for mid-distal humeral shaft fractures, however, could be a surgically dangerous procedure because of the risk of radial nerve injury [2]. The humeral shaft fractures by the MIPO method approached anteriorly is a safer approach in our experience. Moreover, to reduce the risk of radial nerve injury, the forearm must be kept in full supination during plate insertion, and excessive force should be avoided during retraction of the lateral half of the brachialis muscle together with the radial nerve in the distal incision. The principle of biological fracture fixation and implementation of locking plates in traumatology is suitable for long bones such as femur and tibia. Moreover, in polytrauma patients the risk of fat embolism is minimised. The ultrasonographic study in MIPO done in humerus fractures postoperatively revealed that the implant is quite close to the radial nerve and make it vulnerable to traction injury [3]. The MIPO technique is not applicable to every fracture so absolute indications should be defined [4]. We would like to note that this technique requires experience, as there are variable danger zones for the musculocutaneous and radial nerves which should be determined as a percentage of the humeral length [5].