Manish Raj

Evaluation of Vacuum Assisted Closure Therapy for Soft Tissue Injury in Open Musculoskeletal Trauma

INTRODUCTION The application of controlled levels of negative or sub atmospheric pressure for a prolonged period of time on a wound had shown to accelerate removal of excess fluid and promote hyperaemia, which eventually promote wound healing. AIM The study was conducted with the aim to evaluate the effectiveness of Vacuum Assisted Closure (VAC) therapy for soft tissue injury in open musculoskeletal trauma. MATERIALS AND METHODS Twenty cases of complex musculoskeletal wound involving different parts of body were included in this progressive randomized study. In patients, aggressive debridement was done before the application of VAC therapy. Controlled negative pressure was uniformly applied to the wound. Dressings were changed after every 4 to 5 days. The evaluation of results included healing rate of the wound, eradication of infection, complication rate, and number of secondary procedures. RESULTS VAC therapy over the wound was administered for an average of 20.4 days ±6.72 days (range 14 to 42 days). There was decrease in wound size attained by VAC therapy ranged from 2.6 to 24.4cm(2), with an average reduction of 10.55 cm(2). Three wounds were infected at the start of VAC therapy. However, all patients were cleared of bacterial infection by the end of VAC therapy. CONCLUSION VAC therapy using negative pressure promote Wound healing by increasing local capillary perfusion and increased rate of granulation tissue formation, decreases the duration of wound healing and requires fewer painful dressing change.

Early Conversion of External Fixation to Interlocked Nailing in Open Fractures of Both Bone Leg Assisted with Vacuum Closure (VAC) - Final Outcome

INTRODUCTION Management of compound grade III fractures of both bone leg includes external stabilization for long period, followed by various soft tissue coverage procedures. Primary interlocking of tibia had been also done with variable results. External fixation for long time without any bone loss often leads to infected nonunion, loss of reduction, pin tract infection and failure of fixation, primary interlocking in compound grade III fractures had shown high medullary infection rate. We managed all cases of compound grade III A/B fractures with primary external fixation, simultaneous wound management using vacuum assisted closure (VAC) followed by early conversion to interlocking within 2 weeks of fixator application. AIM To determine the effectiveness of vacuum assisted closure (VAC) for the early conversion of external fixator to definitive interlocking in open fractures of the both bone leg. MATERIALS AND METHODS In current study we selected 84 cases of compound grade IIIA/B diaphyseal fractures of both bone leg during period of May 2010 to September 2013. We managed these cases by immediate debridement and application of external fixation followed by repeated debridement, application of vacuum assisted closure (VAC) and conversion to interlocking within two weeks. RESULTS Out of 84 cases union was achieved in 80(95%) of cases with definitive tibial interlocking. Excellent to good result were obtained in 77(91.8%) of cases and fair to poor result seen in rest of 7(8.2%) of cases according to modified Ketenjians criteria. 5 out of these 7 poor result group cases were from Compound Grade III B group to start with. Deep infection rate in our series were 7% i.e. total 6 cases and 4 out of these were from compound Grade III B group to start with. CONCLUSION Vacuum assisted closure (VAC) give a good help for rapid closure of the wound and help in early conversion to definitive intramedullary nailing. Reamed nail could well be used in compound grade IIIA/B fractures without increasing the risk of infection. It gives better stability to fracture site and lessen the risk of implant failure.

Dynamic hip screw with locked plate VRS Proximal Femoral Nail for the management of intertrochanteric fracture: A comparative study

Dynamic hip screw has long been a standard implant for intertrochanteric hip fractures. The inception of intramedullary nails has further revolutionized their management. With a constant evolution in the designs of both these implants, there has always been a conflict concerning the superiority of one over the other. In this randomized prospective cohort study, 80 patients with intertrochanteric fracture femur were segregated into two groups based on internal fixation with DHS with locking side plate (DHS) (n=40) or Proximal femoral Nail (PFN) (n=40). Clinical and radiological parameters were studied and functional evaluation was done with Harris hip score. The intraoperative parameters were in favor of PFN with significantly less duration of surgery, length of incision and blood loss but more fluoroscopy time. Postoperatively also, PFN group patients excelled with significantly less postoperative pain, less incidence of deep infection , better range of motion, less mean limb length discrepancy and more patients regaining their pre injury walking capability and also fewer complications. Average union time was comparable between the groups. Functionally, PFN emerged to be superior to DHS in unstable intertrochanteric fractures while in stable fractures, results were same. We deduce that surgical planning and expertise with rigorous regard to the personality of the fracture are pivotal for outstanding results.

Primary plate osteosynthesis in compound fractures of proximal and distal tibia by locked anatomical plate using minimally invasive technique: Our experience of 94 cases

Introduction: Juxta-articular or intra-articular compound proximal tibia fractures presents a great therapeutic challenge to an orthopaedic surgeon. The treatment of this kind of fractures is often complicated either by the patients compromised general conditions, or by soft tissue damage. The development of biological techniques in plate fixation and the design of implants which cause the least possible interference with the periosteal blood supply have enhanced the use of plates and screws for stabilisation of open proximal tibia fractures. The primary aim of this study is to assess the role of biological plate fixation in compound proximal and distal tibia fractures. Material and Method: We selected 94 patients of compound proximal and distal tibia fractures including Gustilo and Anderson type 1,2 and 3A. Our protocol included debridement, irrigation, and splint casting in emergency room with definitive stabilization with the biological plate through minimally invasive surgical techniques if the soft tissue injury and wound allowed. Patients were followed up for at least two years. Outcome were measured using knee society clinical rating score for proximal tibia fracture cases and Modified American Orthopaedic Foot and Ankle Society score (AOFAS) for distal tibia fracture cases. Results: Further, final outcome of these patients was assessed after 2 years of follow-up using Knee society score. Excellent results were seen in 35(73%) cases and good result in 10 (20.8%) cases. Three cases show fair to poor score and all these cases were from compound Grade III group. one case required early plate removal and external fixation and showed poor result. Functional outcome of distal tibia fracture cases was assessed with the modified AOFAS ankle-hind foot score at final follow-up. Out of the 40 cases, 20(50%) shown excellent result. Out of the 40 cases, 14 (35%) shown good result. Overall good to excellent result was seen in 34 (85%) cases. Two cases showed fair result and poor result was seen in 4 (10%) cases. Discussion: The biological plate presents another good option in the treatment of open fractures in open proximal and distal tibial fractures. The combination of minimal soft tissue dissection, small surgical approaches, and plates that do not compress the bone, yield an implant that would be expected to yield a lower rate of infection than other alternative methods in treatment of open proximal tibial fracture.

Long term outcomes of neglected intracapsular fracture neck in young adults managed by modified double angle barrel plate (DABP) with intertrochanteric valgusosteotomy

Introduction: Fracture neck of femur in young adult have relatively higher incidence of complications such as nonunion, avascular necrosis (AVN) of femoral head, loss of fixation, screw cut-out, and delayed secondary osteoarthritis. Delayed presentation of these cases in developing countries such as India further compromises the outcome of these fractures. Situations like this in young adult lead to difficulty in fixation by simple cancellous screw because of lack of compression surface area. Replacement surgeries in these cases are a difficult choice in these patients; it is difficult to restrict squatting for lifelong due to social culture and lack of toilets. Now, days also preferences are given to head sparing surgeries and osteosynthesis. Materials and Methods: Cases were selected from the patients attending orthopedics outpatient department and emergency trauma center from August 2006 to August 2012. During this period, total 56 cases of neglected fracture neck femur came to our department. Of these 56 cases, 36 cases qualify for inclusion into this study. Of 36 cases, 22 were female and 14 were male with an age range from 22 years to 48 years and average age of 42 years. Average duration from injury to operative procedure was 4.9 weeks (34 days) and range from 2 weeks to 18 weeks. These cases were operated by modified double angle barrel plate (DABP) with intertrochanteric valgus osteotomy with one cannulated cancellous screw (CCS). Results: Total 36 cases were operated using DABP and trochanteric osteotomy. Final outcomes were evaluated using modified Askin and Bryan criteria. Of these 36 cases, 32 (88.8%) cases gave good to excellent results and completed their full follow-up. Rest four cases were unable to continue with same implant fixation. These were kept in failure group. These four cases showed failure due to loss of reduction, screw cut-out, and secondary collapse of femoral head after AVN. These cases further managed by replacement surgeries. Discussion: Neglected fracture neck femurs are not rare presentation in developing countries. Various modalities of treatment are fibular graft, iliac bone graft, multiple screws with fibular graft, muscle pedicle graft. In our case series, we had done combination of DABP with trochanteric osteotomy with CCS and achieved excellent to good results and this method can be used a primary method for management of neglected femoral neck fracture.