Mohammad Farooq Butt

Delayed fixation of displaced femoral neck fractures in younger adults

We report the results of 52 patients aged 20-55 years with displaced femoral neck fractures, in whom delayed closed reduction and internal fixation was performed. Seven patients developed avascular necrosis (AVN) and non-union was seen in five patients. Whereas most patients with non-union were subjected to repeat procedures, none of the patients with AVN required surgery. The follow-up averaged 40 months (range 22-64 months). Three patients were lost to follow-up. Functional outcome was defined by Judets system. Good to excellent functional outcome was achieved in 45 cases. The study demonstrated that delayed closed reduction and internal fixation of displaced fractures in young adults which, we believe, is the prevalent form of treatment of these injuries in the developing world results in high rate of fracture union and good functional outcome. The rate of AVN, however, may be a concern if the patients are followed for a longer period.

Lateral invaginating peg (LIP) osteotomy for the correction of post-traumatic cubitus varus deformity.

Closing wedge osteotomies are the gold standard for the management of post-traumatic cubitus varus deformity. However, most of these osteotomies are fraught with complications such as lateral condylar prominence, instability, and difficulty in correcting internal rotation. We describe a new technique that provides a means for the management of all these problems simultaneously.

The posterior to anterior controlled technique of percutaneous Achilles tenotomy in the correction of idiopathic clubfoot: a technical report.

Percutaneous tenotomy of the Achilles tendon is an integral part of the Ponseti technique of clubfoot correction. Although originally described by Ponseti as an office procedure that was performed under local anaesthesia, serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation have been reported. We describe a new tenotomy technique, the posterior to anterior controlled technique, that may decrease the possibility of neurovascular damage, does not require exposure of the Achilles tendon and can be performed as an office procedure under local anaesthesia.

Outcome of treatment of the mismanaged pediatric elbow trauma: a series of 73 cases.

Purpose. To analyze the outcome of the management of pediatric elbow trauma referred to our hospital after initial intervention by traditional bone setters. Method. Retrospective study of 73 patients, presenting to the hospital with a complication attributable to the initial mismanagement of their injuries. Results. The mode of presentation was directly related to the type of initial intervention on the basis of which we were able to quantify bone setters into two groups. The first group using a rather rough method of trauma treatment involving the application of tight local bandages, massage and manipulation and a second group having a relatively less rough approach, applying splints to the injured extremity without tight bandages and manipulation. The result of treatment of these injuries was determined by the delay in presentation and the type of injury. Conclusion. This study highlights the importance of dealing with the unchecked and unsupervised practice of bone setting in the developing world. We believe that training these people on the pattern of traditional birth attendants can at the very least lower the occurrence, if not entirely eliminate the problem of mismanaged trauma in this part of the world.

Comment on Cheng et al.: Comparison study of two surgical options for distal tibia fracture—minimally invasive plate osteosynthesis vs. open reduction and internal fixation

Dear Editor, We read with great interest the article by Cheng et al. on ‘Comparison study of two surgical options for distal tibia fracture—minimally invasive plate osteosynthesis vs. open reduction and internal fixation’ [1] in the online issue of International Orthopaedics. The authors have concluded in their study that the minimally invasive plate osteosynthesis (MIPO) technique is not distinctively superior to open reduction and internal fixation (ORIF) in the treatment of distal tibial fractures. However, there are several intriguing points that we think need to be discussed further and elaborated upon. To have a meaningful comparative analysis, the comparison groups should be matched for as many important variables as possible except for the variable to be measured, which in this case happens to be the surgical technique. However, the authors have used only three variables, viz. age, gender and fracture pattern. Several other factors that influence fracture healing and have not been compared include nutritional status, pre-injury activity status, smoking status, osteoporosis and the presence of systemic diseases. Also, the authors have not mentioned whether the quality of reduction and fixation was assessed and if so, whether it was comparable across the paired groups. The fracture patterns included in the study are quite variable, ranging from simple patterns (AO type A), wedge patterns (AO type B) and comminuted patterns (AO type C). We believe that it is unrealistic to club all three categories together for a comparative analysis. Some interesting facts emerge from subgroup analysis of the comminuted (AO type C) fracture patterns. Although the number of cases is small, one can still appreciate the fact that three of four comminuted (AO type C) fractures (patients 7, 8, 9 and 10) united faster with the use of the MIPO technique. One case of four (25%) AO type C fractures developed osteomyelitis, whereas this complication was not seen in any case in the MIPO group. The authors performed fibular fixation only for fractures involving the syndesmosis. However, many authors have reported that fibular fixation is a must for comminuted tibial fracture patterns. By restoring the lateral column, indirect reduction can be achieved and this also prevents fracture collapse [2, 3]. To conclude, we believe it would be wrong to jump to the assumption that the MIPO technique is not superior to ORIF for all distal tibial fractures. Distal tibial fractures are a diverse group, ranging from simple fracture patterns to complex patterns. MIPO, when used with the principles of bridge plating, apparently seems to be the superior of the two techniques for the subgroup of comminuted (AO/OTA type C) fracture patterns. Large, multi-centre randomised controlled trials are needed to confirm or refute this observation. Regards, Siddhartha Sharma Mohammad Farooq Butt

Complications of paediatric elbow trauma treatment by traditional bonesetters.

This is a retrospective review of paediatric elbow trauma, which was initially treated by bonesetters and subsequently reported to the hospital for management. This paper describes the pattern of trauma and the complications of unscientific management. The report also recommends a basic training program for the bonesetters so as to make them aware of the potential complications involved in managing paediatric elbow trauma.