Manasseh Nithyananth

Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnabs criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.

Long-term outcome of high-energy open Lisfranc injuries: a retrospective study.

BACKGROUND The outcome of open Lisfranc injuries has been reported infrequently. Should these injuries be managed as closed injuries and is their outcome different? METHODS We undertook a retrospective study of high-energy, open Lisfranc injuries treated between 1999 and 2005. The types of dislocation, the associated injuries to the same foot, the radiologic and functional outcome, and the complications were studied. There were 22 patients. Five patients died. One had amputation. Of the remaining 16 patients, 13 men were followed up at a mean of 56 months (range, 29-88 months). The average age was 36 years (range, 7-55 years). RESULTS According to the modified Hardcastle classification, type B2 injury was the commonest. Ten patients had additional forefoot or midfoot injury. All patients were treated with debridement, open reduction, and multiple Kirschner (K) wire fixation. All injuries were Gustilo Anderson type IIIa or IIIb. Nine patients had split skin graft for soft tissue cover. Mean time taken for wound healing was 16 days (range, 10-30 days). Ten patients (77%) had fracture comminution. Eight patients had anatomic reduction, whereas five had nonanatomic reduction. Ten of 13 (77%) patients had at least one spontaneous tarsometatarsal joint fusion. The mean American Orthopaedic Foot and Ankle Society score was 82 (range, 59-100). Nonanatomic reduction, osteomyelitis, deformity of toes, planus foot, and mild discomfort on prolonged walking were the unfavorable outcomes present. CONCLUSION In open Lisfranc injuries, multiple K wire fixation should be considered especially in the presence of comminution and soft tissue loss. Although anatomic reduction is always not obtained, the treatment principles should include adequate debridement, maintaining alignment with multiple K wires, and obtaining early soft tissue cover. There is a high incidence of fusion across tarsometatarsal joints.

Open intramedullary nailing in neglected femoral diaphyseal fractures

INTRODUCTION Neglected femoral diaphyseal fractures are not uncommon in developing nations however there is a paucity of literature in this regard. Due to lack of effective traction, reduction or immobilisation these fractures are invariably associated with shortening and adjacent joint stiffness, presenting a challenging problem to the treating surgeon. The socioeconomic constraints in our society which result in patients seeking non-medical forms of treatment in the first place also warrant the need for an economically viable, simple effective form of treatment which can be carried out in a less advanced setup, gives reliable outcomes and allows early return to work. METHODS Eleven patients with neglected or late presenting femoral diaphyseal fractures were considered for the study. All patients underwent open intramedullary nailing, bone grafting and manipulation of the knee under anaesthesia. Iliac crest graft was harvested when local callus did not suffice. All patients received a supervised regimen of physiotherapy. Patients were followed up clinically and with plain radiographs at 6 weeks and 3 months to assess union and at monthly intervals thereafter. RESULTS The mean patient age was 28.8 years (15-48). The mean delay in presentation was 14 weeks (3-32 weeks). The mean shortening was 3.8 cm with four fractures showing signs of malunion. Five patients were given preoperative traction and bone resection was performed in only one patient. The mean hospital stay was 11 days (5-25 days). One patient was lost to follow up, of the remaining 10 patients all united at a mean of 11.9 weeks with 7 patients regaining full range of motion. The mean knee range of motion was 142.5 degrees . There were no wound related or neurological complications. One patient had a patellar tendon rupture which was repaired and another required dynamisation and bone marrow injection for delayed union. CONCLUSION We conclude that the treatment of neglected femoral diaphyseal fractures with open intramedullary nailing and bone grafting followed by manipulation of the knee with preoperative traction in selected cases is a satisfactory method of treatment showing reliable bony union however knee mobilisation should be undertaken with caution.

Reconstruction of open contaminated achilles tendon injuries with soft tissue loss.

BACKGROUND Open achilles tendon injuries, present a complex problem to the treating surgeon especially if associated with tendon and soft tissue loss. We present eight such patients treated with tendon repair/reconstruction and reverse flow sural artery flap for soft tissue cover. PATIENTS Eight patients (age, 12-64 years) with a spectrum of open tendo-achilles injuries of acute and chronic (infected), including loss of tendon of up to 10 cm, tendon defects with no distal attachment and one with partial loss of the calcaneum were treated between November 2005 and July 2006. Two of them had significant medical comorbid factors. The skin defect measured after debridement ranged from 6 x 5 cm to 15 x 10 cm. The tendon injuries were sutured directly when possible or sutured to bone if avulsed from the calcaneum. They were otherwise reconstructed using the central part of the proximal segment. A reverse sural artery was used to provide soft tissue cover. RESULTS All flaps survived. All patients had a normal gait, were able to stand on tip toes, had active plantar flexion and had returned to their original occupation 4 months after reconstruction. They had full range of movement at the ankle. One diabetic patient had terminal necrosis of the flap that required a split skin graft. He developed a late infection which did not compromise the functional result. CONCLUSION In the management of complex tendo-achilles injuries with tendon and soft tissue loss, radical debridement, single stage tendon reconstruction, and reverse flow sural artery flap gives good functional outcome. This gives consistent results across a spectrum of open tendo-achilles injury.

Disseminated rhinosporidiosis destroying the talus: a case report

Rhinosporidiosis is a chronic granulomatous fungal disease caused by Rhinosporidiosis seeberi. It usually affects the mucocutaneous tissue of the nose; bone involvement is rare. We report the clinical features, diagnosis, and management of rhinosporidiosis involving the face, forehead, and right foot. As antimicrobial therapy was ineffective, a below-knee amputation was performed.

Non-vascularised fibular graft as an intramedullary strut for infected non-union of the humerus

Purpose. To review outcomes of 7 patients who underwent revision surgery for infected non-union of the humerus using a fibular graft as an intramedullary strut. Methods. Records of 7 men aged 29 to 59 (mean, 40) years with humeral diaphyseal infected nonunion who underwent fixation using a compression plate and a non-vascularised fibular graft as an intramedullary strut were reviewed. The mean number of previous surgeries was 2.7 (range, 2–4). Three of the patients had active draining sinuses previously. Their C-reactive protein levels were normal and tissue cultures negative. The remaining 4 patients had active draining sinuses. They first underwent implant removal and debridement. Tissue cultures confirmed infection in 3 of them. The mean duration between debridement and the index surgery was 5 (range, 3–10) months. Results. The mean length of the fibulae harvested was 13 (range, 12–15) cm. All 7 non-unions healed. The mean time to healing was 5.4 (range, 4–8) months. The mean follow-up period was 15 (range, 13–24) months. All patients had weakness of the extensor hallucis longus, which improved to near normal at month 3. There was no donor-site morbidity. Three patients with active infection at presentation underwent repeat surgery. Two of them had wound washouts, and their non-unions went on to heal successfully; one underwent implant removal after union due to an active sinus. Six of the patients returned to their pre-injury activity level, and one endured a brachial plexus injury. Conclusion. Fixation using a compression plate and a non-vascularised fibular graft as an intramedullary strut achieved good outcome for infected non-union of the humerus despite prior multiple failed surgeries.

Experience of using local flaps to cover open lower limb injuries at an Indian trauma center

Background: Optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, skeletal stabilization, and in providing appropriate soft tissue cover. Timely coordination between orthopedic and plastic surgeons, though ideal, is often difficult. In our center, orthopedic surgeons undertake comprehensive treatment of open fractures including soft tissue cover. We reviewed the results of the local flaps of lower limb, done by orthopedic surgeons. Materials and Methods: We retrospectively reviewed the results of the lower limb flaps done between January 2005 and December 2006. All flaps done at and below the level of knee were included. Results: There were 105 patients with 120 flaps during this period. Two patients with two flaps were lost to follow-up. The average age was 32 years. Sixty-four patients had Type IIIB Gustilo and Anderson injuries. Thirty-nine patients had isolated soft tissue injuries. The indications for flaps were exposed bone, tendon, and joint in 45, 11, and 12, respectively, or a combination in 35 patients. The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and seven foot flaps. The flap dimensions ranged from 2 × 2 to 30 × 15 cm. Ninety-three flaps (79%) healed primarily. Among 25 flaps (21%) with necrosis, 14 flaps required secondary split skin graft for healing, while the other nine flaps healed without further surgery. Conclusion: Appropriate soft tissue cover provided by orthopedic surgeons can help in providing independent, composite care of lower limb injuries.

Preoperative embolisation in benign bone tumour excision

Purpose. To assess the role of preoperative embolisation in benign bone tumour excision. Methods. 3 men and 3 women aged 19 to 35 (mean 23) years with either a giant cell tumour or an aneurysmal bone cyst in limb girdle sites underwent preoperative embolisation a day prior to wide local excision by the same surgeon. Tumour size, blood loss, wound healing, infection, and tumour recurrence were assessed. Results. The mean total blood loss was 391 (range, 100–980) ml. No blood transfusion was needed. No patient had any surgery- or embolisation-associated complication. No tumour recurred within a minimum 5-year follow-up. All patients had satisfactory limb function. Conclusion. Preoperative embolisation is useful in the management of vascular and aggressive bone tumours located at limb girdle sites where a tourniquet cannot be used.

Incidence and predictors of radial nerve palsy with the anterolateral brachialis splitting approach to the humeral shaft

Purpose Fractures of the humeral shaft are common and account for 3%–5% of all orthopedic injuries. This study aims to estimate the incidence of radial nerve palsy and its outcome when the anterior approach is employed and to analyze the predictive factors. Methods The study was performed in the department of orthopaedics unit of a tertiary care trauma referral center. Patients who underwent surgery for acute fractures and nonunions of humerus shaft through an anterior approach from January 2007 to December 2012 were included. We retrospectively analyzed medical records, including radiographs and discharge summaries, demographic data, surgical procedures prior to our index surgery, AO fracture type and level of fracture or nonunion, experience of the operating surgeon, time of the day when surgery was performed, and radial nerve palsy with its recovery condition. The level of humerus shaft fracture or nonunion was divided into upper third, middle third and lower third. Irrespective of prior surgeries done elsewhere, the first surgery done in our institute through an anterior approach was considered as the index surgery and subsequent surgical exposures were considered as secondary procedures. Results Of 85 patients included, 19 had preoperative radial nerve palsy. Eleven (16%) patients developed radial nerve palsy after our index procedure. Surgeons who have two or less than two years of surgical experience were 9.2 times more likely to induce radial nerve palsy (p = 0.002). Patients who had surgery between 8 p.m. and 8 a.m. were about 8 times more likely to have palsy (p = 0.004). The rest risk factor is AO type A fractures, whose incidence of radial nerve palsy was 1.3 times as compared with type B fractures (p = 0.338). For all the 11 patients, one was lost to follow-up and the others recovered within 6 months. Conclusion Contrary to our expectations, secondary procedures and prior multiple surgeries with failed implants and poor soft tissue were not predictive factors of postoperative deficit. From our study, we also conclude that radial nerve recovery can be reasonably expected in all patients with a postoperative palsy following the anterolateral approach.

Time required for effective action of phenol against giant cell tumour cells.

Purpose. To evaluate the time required for effective action of phenol against the giant cell tumour (GCT) cells. Methods. Fresh GCT cells were harvested from 9 patients with primary GCT of the distal femur (n=4), proximal tibia (n=4), and proximal humerus (n=1), with the Campanacci tumour grades 3 (n=6), 2 (n=2), and 1 (n=1). Specimens were immersed in 80 % phenol for one, 3, 6, and 10 minutes, and were assessed by a single pathologist for irreversible cell death and the depth of phenol penetration. Results. Phenol caused consistent GCT cell death in 6 of the 9 specimens after 3 minutes and in all 9 specimens after 6 minutes, compared to none in controls (p<0.0001). The mean depths of phenol penetration were 15 (range, 11–20) and 19 (range, 15–25) cell thickness after 6 and 10 minutes, respectively (p<0.0001). Conclusion. GCT cells immersed in 80% phenol for 6 minutes resulted in consistent cell death.