Lalit Maini

Delayed internal fixation of fractures of the neck of the femur in young adults A PROSPECTIVE, RANDOMISED STUDY COMPARING CLOSED AND OPEN REDUCTION

We have compared the results and complications after closed and open reduction with ternal fixation in young adults with displaced intracapsular fractures (Garden grades III and IV) of the neck of the femur. We also studied the risk factors which influenced nonunion and the development of avascular necrosis (AVN). A total of 102 patients aged between 15 and 50 years was randomised to receive either closed or open reduction. Both groups were compared for age, gender, time to surgery and posterior comminution as well as for union and complications. Using univariate and multivariate analysis the factors influencing nonunion and AVN were assessed. Of the 102 patients, 92 were available for review. There was no significant difference between the groups in terms of union (p = 0.93) and AVN at two years (p = 0.85). Posterior comminution, poor reduction and improper placement of the screws were the major factors contributing to nonunion. The overall incidence of AVN was 16.3% (15 of 92 patients) and it was not influenced by these factors. A delay of more than 48 hours before surgery did not influence the rate of union or the development of AVN when compared with operation within 48 hours of injury.

The Ilizarov method in infected nonunion of fractures.

Thirty patients with infected non-union of long bones were treated with radical resection of the necrotic bone and bone transport or compression/distraction osteosynthesis. Non-union, infection, deformity, bone gap and shortening were all addressed simultaneously using the Ilizarov principles. There were 15 cases with bone loss ranging from 4 to 12 cm (median bone gap of 7 cm), 10 cases of stiff non-union (six of which had an associated deformity) and five cases of mobile non-union. The median time in the Ilizarov frame was 150 days. Median follow up time after frame removal was 23.5 months. Bone grafting at the docking site was only required in three cases (10%). There were three cases of refracture (10%) and three cases of recurrence of infection (10%). The bone result was excellent in 21 patients (70%), good in three (10%), fair in none (0%) and poor in six (20%). The functional results were excellent in eight patients (26.7%), good in 12 (40.0%), fair in three (10%) and poor in seven (23.3%). It is difficult to precisely define the indications for preservation and reconstruction of severe injuries. The surgical team has to take into account the length, disability, complications and cost of treatment. Patients must be aware of the limitations of functional results and the possible difficulty of return to work despite the reconstructive attempt.

Spontaneous bilateral displaced femoral neck fractures in nutritional osteomalacia--a case report

A 24-year-old woman presented with sudden onset severe pain in both groins and inability to stand without support. She had had some groin discomfort for the past few weeks on walking. She had a sedentary lifestyle and took no strenuous exercise. She had no history of trauma or seizures. She was not on any medication and had no history

Management of idiopathic clubfoot in toddlers by Ponseti's method.

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10–15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.

Spinal epidural abscess - a report of six cases.

Abstract Six cases of spinal epidural abscess are presented. All patients were young with no predisposing conditions. All were treated with laminectomy and intravenous antibiotics. The patients with no neurological deficit recovered completely, while patients with pre-existing neurological deficit had a poorer outcome. Emphasis is given to early detection and surgical management to prevent irreversible damage to the spinal cord.Résumé 6 cas d’abces épiduraux sont présentés. Tous les patients étaient jeunes et sans facteur prédisposant. Tous les patients ont été traites par laminectomie et antibiotiques injectables. Les cas sans déficit neurologique ont guéri sans séquelle, alors que la récupération des cas avec déficit neurologique a été moins bonne. L’accent est mis sur la détection et le traitement chirurgical pour prévenir les lésions irréversibles de la moelle épinière.

Intrapelvic protrusion of guide wire during fixation of fracture neck of femur

Internal fixation is a common modality of treatment for fractures around the hip. In various kinds of osteosynthesis, guide wires are used for localizing the site of entry and to determine the final position of the screws or fixation devices. We report two instances of intrapelvic protrusion of a guide wire during internal fixation of a fractured neck of femur. Though there are several reports of post-operative k-wire migration around the hip [5] and shoulder girdle [2,3,6,7,10] (occurring as early as 7 days) [9] the aforesaid complication has not been reported in the literature, to our knowledge.

The Results of Nonoperative Treatment of Craniovertebral Junction Tuberculosis: A Review of Twenty-six Cases

BACKGROUND There is scarce information on craniovertebral junction tuberculosis even in developing countries. The pendulum of treatment in craniovertebral junction tuberculosis has periodically vacillated between nonoperative management and radical surgery. METHODS We performed a retrospective review of prospectively collected clinical and radiographic data on twenty-six consecutive patients with craniovertebral junction tuberculosis who were treated nonoperatively in our institution. The patients who had weakness of the limbs, pyramidal signs, or evidence of atlantoaxial dislocation and/or basilar invagination were immediately managed with immobilization with Crutchfield tongs traction (Group A), followed by halo-vest application. Patients without a neurological deficit, pyramidal signs, or atlantoaxial dislocation or basilar invagination were treated with cervical immobilization with early application of a halo vest (Group B). RESULTS The common presenting features were neck pain, restriction of neck movement, and spastic weakness of limbs. A retropharyngeal purulent fluid collection and osseous involvement of the dens and lateral mass of the atlas were the common radiographic findings. Twelve patients were partially or completely dependent on others for activities of daily living, and marked ligamentous and bone destruction with displacement at the atlantoaxial level was seen in eight patients at the time of presentation. The twenty patients in group A had cervical traction for a mean of 5.9 weeks, and a halo vest was applied for a mean of 6.9 months with antitubercular therapy for eighteen months. The mean follow-up period was 25.2 months (range, eighteen to forty-two months). All of the patients were independent in activities of daily living at the time of the last follow-up. CONCLUSIONS In the Indian subcontinent, the disease process of craniovertebral junction tuberculosis is usually quite advanced at the time of presentation. On the basis of our study, patients with craniovertebral junction tuberculosis can be managed successfully with nonoperative treatment even with advanced involvement of bone or soft tissues at this spinal level. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Fracture of distal end clavicle: A review

Management of fracture distal end clavicle has always puzzled the orthopaedic surgeons. Now-a-days with a relatively active lifestyle, patients want better results both cosmetically and functionally. Despite so much literature available for the management of this common fracture, there is no consensus regarding the gold standard treatment for this fracture. In this article, we reviewed the literature on various techniques of management for this fracture, both conservative as well as surgical, and their merits and demerits.

Isolated involvement of the posterior elements in spinal tuberculosis: a review of twenty-four cases.

BACKGROUND The literature on tuberculosis of the posterior spinal elements without involvement of the vertebral body is scarce. In this study we report our experience with twenty-four cases of neural arch tuberculosis that were treated at our center. METHODS We performed a retrospective review of the clinical and radiographic data of twenty-four consecutive patients who had tuberculosis of the posterior spinal elements with total sparing of the vertebral bodies and intervertebral disc space. We categorized the patients into two groups on the basis of the clinical and radiographic evaluation. The patients who had rapid onset weakness of the lower limbs or pyramidal signs or who showed evidence of epidural abscess underwent emergency decompressive laminectomy (Group A). Patients who had pyomyositis of the posterior spinal muscles without any neurological deficit, pyramidal signs, or epidural abscess were managed with antitubercular therapy alone (Group B). RESULTS The common presenting features were spastic limb weakness and back pain. The majority of the patients had involvement of the thoracic spine. Epidural abscess, erosion of lamina, and pyomyositis of posterior spinal muscles were common imaging findings. Group A consisted of nineteen patients and Group B consisted of five patients. The mean period of follow-up was 16.9 months (range, nine to sixty months). Patients in Group A had a poorer outcome than those in Group B. Thirteen of the nineteen patients in Group A improved to become independent in the activities of daily living, with complete neurological recovery in eight patients and partial recovery in five patients. Six of the nineteen patients continued to have spastic paraplegia and were wheelchair-dependent. All of the patients in Group B remained neurologically intact during the follow-up period. None of the patients had recurrence of the disease or developed anterior element involvement or kyphotic deformity during the follow-up period. CONCLUSIONS Neural arch tuberculosis is often missed at the time of initial presentation. In association with epidural abscess, it leads to rapid neurological deterioration. This atypical picture of spinal tuberculosis showed a high rate of neurological deficit at the time of initial presentation for medical care.

A new method of removing a fractured interlocked nail

After removing all the locking screws the proximal part of the nail is removed. The ball tip of a guide wire is then passed through the nail’s entry point to beyond its distal tip without opening the fracture site (Fig. 2). A plain guide wire of smaller diameter is then passed beyond the distal tip (Fig. 3). Finally, both the wires are pulled out simultaneously (Fig. 4), thus accomplishing the removal of the fractured nail (Fig. 5).