Hitesh Lal

Conjoint bicondylar Hoffa fracture in a child: a rare variant treated by minimally invasive approach

A case of conjoint Hoffa-type fracture in a child is presented. Hoffa fracture, i.e., coronal slice fracture of the condyles of the femur, is rare in adults and even rarer in the pediatric population. To date, no case of conjoint bicondylar Hoffa fracture has been reported in the literature. The presented case was successfully treated by arthroscopically assisted internal fixation.

Recurrent shoulder dislocations secondary to coracoid process fracture: a case report

Coracoid process fracture is easily missed in recurrent anterior shoulder dislocation. We report one such case in a 48-year-old man. Radiology revealed the Bankart lesion and the Hill-Sachs lesion only; the coracoid process fracture was discovered intra-operatively. The anatomy of the shoulder was restored by fixing the fragment to its scapular remnant with a 4-mm cannulated cancellous screw. The tip and the proximal fragment were reamed before inserting the screw. This fragment was routed with attached short head of biceps and coracobrachialis through the lower one third of the subscapularis, before homing it and fixing it to the proximal coracoid fragment. This extra-articular repair resulted in less stiffness than any intra-articular procedure. At the 2-year follow-up, the patient had had no further shoulder dislocation.

Two stage procedure for neglected transscaphoid perilunate dislocation.

We report a two-staged surgical procedure for neglected 3 month old volar transscaphoid, transcapitate perilunate fracture dislocation wrist in an 18 year old right handed male student. The lunate with proximal scaphoid and proximal capitate maintained its articulation with distal end radius while the rest of carpal bones had dislocated volarly. In the first stage, bilateral uniplanar wrist distractor was applied with the aim of stretching soft tissue. In the next stage open reduction and internal fixation was done by a combined volar and dorsal approach augmented by pronator quadratus flap. At 3 years followup the patient was pain free and had a full range of supination pronation of the forearms and radial and ulnar deviation of wrist with 10° dorsiflexion deficit.

Total knee replacement in triple deformity with posterior subluxation of the knee joint

Dislocation or subluxation following total knee arthroplasty has been extensively reported, but vice versa that is total knee replacement for subluxed or dislocated knee has not been published. Triple deformity of knee that is flexion, external rotation, valgus at knee associated with posterior subluxation of tibia occurs in rheumatoid arthritis, advanced tubercular arthritis and neglected posttraumatic residual dislocated knee. A 50 year old female with seropositive rheumatoid arthritis had the above disabling deformity in left lower limb and varus with medial tibial thrust in the other. Bilateral total knee arthroplasty was planned. Conservative method of reduction of left knee posterior subluxation preoperatively by 90-90 skeletal traction failed; hence patient was subjected to a staged bilateral total knee replacement using an innovative technique. The most difficult and determining initial surgical step of knee replacement in such dislocated/subluxed knee is reduction of posterior subluxation and gaining flexion at knee, as only after gaining flexion and reducing dislocated tibia, will we be able to do knee arthroplasty in triple deformity of knee. These knees are grossly unstable as most of the capsule-ligamentous structures are attritioned/non-existent. So, a fine balance of bone cuts and soft-tissue release needs to be done in a sequential manner to fine tune valgus and posterior subluxation correction without jeoparadising neurovascular structures. After 3 years of knee arthroplasty the patient has painless, stable knee with good range of motion and is able to do all her activities, of living in a hilly terrain.

Letter to the Editor Surgical Technique: Hemilaminectomy and Unilateral Lateral Mass Fixation for Cervical Ossification of the Posterior Longitudinal Ligament

To the editor, We read the article by Liu et al. [2] with great interest. Liu and colleagues studied a new surgical technique for multilevel continuous/mixed cervical ossification of posterior longitudinal ligament (OPLL) without fixed kyphosis by multilevel hemilaminectomy with unilateral lateral mass fixation with good results. However, we have some concerns. As described by the authors, there are various options for cervical OPLL depending on its type, associated deformity, and number of vertebrae involved. A posterior approach is based on the concept of indirect decompression by increasing space available for the spinal cord through laminectomy or various type of laminoplasty without directly addressing the ossified lesion. Liu and colleagues stated that the occupying rates were a significant factor for poor results. Occupying rate is defined as the thickness of OPLL divided by the AP diameter of bony spinal canal on the axial CT image. Hemilaminectomy alone will not decompress enough to provide good results [1]. Lateral mass screw fixation is based on the biomechanical principle of “neutralization.” It provides stress shielding, and minimizes torsional bending, shearing, and axial loading [3]. Unilateral mass fixation will result in unequal axial loading, and it will not prevent torsional bending and shearing forces. Unilateral mass fixation will lead to implant failure and deformity of the spine.

Intrapelvic migration of hip lag screw of proximal femoral nail-sequele to a paradoxical reverse Z effect and their critical analysis

A 40-year-male treated with hip screw for unstable inter trochanteric fracture femur, had an implant failure after an aggressive therapy session .The Dynamic Condylar Screw was removed and fracture was fixed with Proximal Femoral Nail. The nail also failed to achieve its goal of fracture union, as a result of a unique type of reverse Z effect, in contradiction to expected Z effect resulting in intrapelvic migration of proximal hip lag screw of the proximal femoral nail.

A neglected case of rare palsy of the descending branch of the posterior interosseous nerve due to penetrating injury

Abstract Traumatic palsy of the descending branch of the posterior interosseous nerve (PIN) is rare. Traumatic palsy usually involves the entire PIN around the elbow, leading to finger drop with loss of extension of all fingers and thumb. In the literature, to the best of our knowledge, only one case of traumatic palsy of the descending branch of the PIN due to penetrating injury is reported [1]. We report a neglected, rare case with complete loss of thumb extension and weakness in index finger extension following penetrating injury to the forearm. Our report shows that to diagnose the lesion site in partial PIN palsy, detailed knowledge of the PIN branching pattern is necessary.

Tardy Palsy of Descending Branch of Posterior Interosseous Nerve: Sequela to Plate Osteosynthesis of Forearm Bones

We report a case of tardy paralysis of the descending branch of the posterior interosseous nerve as a consequence of plate osteosynthesis for fracture of both bone forearms. The patient had been operated on 23 years earlier and palsy occurred after a gap of 19 years. The most probable antecedent cause of the palsy was the use of a high-profile implant. The patient was treated by removal of the plate and tendon transfer.

A Method of Open Reduction of an Irreducible Hawkins Type III Fracture of the Talar Neck

Hawkins type III fracture talar neck may sometimes be a nightmare for surgeons to reduce, even intraoperatively. It is difficult to reduce as the talar body is locked into its dislocated posteromedial position out of both the ankle and subtalar joint. Maneuvers of reduction have been described both in dorsiflexion and plantarflexion of ankle, but these are complicated and not tissue friendly. Further, various methods of grasping and pushing the dislocated talar body by use of joysticks and distractors have been advocated. To accomplish this intraoperatively, we present a convenient and utilitarian method using only 2 smooth 1.5-mm Kirschner wires and a JESS distractor clamp. Two key concepts to keep in mind while reducing such fracture dislocations are also highlighted. This was done in a 22-year-old male with 7-day-old Hawkins type III fracture of the left talar neck and a right Pilon fracture with good results at 2 year follow-up.

Quiz December 2013.

A) Compared to general surgery orthopedic surgery is associated with a higher risk of venous thromboembolism. B) Incidence of venographically documented DVT is approximately twice as high with general anesthesia as with subarachnoid blockade. C) The peak incidence of clinical DVT appears to occur 5e10 days after THA or TKA. D) Therecently updated ACCP guidelines recommend extending thromboprophylaxis to up to 28e35 days following THA or hip fracture surgery. E) Fatal pulmonary embolism is more common after THA than hip fracture surgery.