Nitesh Gahlot

Cephalomedullary fixation for femoral neck/intertrochanteric and ipsilateral shaft fractures: surgical tips and pitfalls

Objective: Surgical management options for femoral shaft fracture and ipsilateral proximal femur fracture vary from single‐implant to double‐implant fixation. Cephalomedullary fixation in such fractures has relative advantages over other techniques especially because of less soft tissue dissection and immediate postoperative weight bearing with accelerated rehabilitation. However, the surgery is technically demanding and there is a paucity of literature describing the surgical techniques for this fixation. The aim of the study was to describe the surgical technique of cephalomedullary fixation for femoral shaft fracture and ipsilateral proximal femur fracture. Methods: Sixteen cases (10 males and 6 females with a mean age of 41.8 years) of ipsilateral proximal femur and shaft fractures were treated by single‐stage cephalomedullary fixation at tertiary level trauma center in northern India. The fractures were classified according to AO classification. An intraoperative record of duration of surgery as well as technical challenges unique to each fracture pattern was kept for all the patients. Results: The most common proximal femoral pattern was AO B2.1 observed in 9 of our patients. The AO B2.3 fractures were seen in 4 patients while the AO A1.2 fractures in 3 patients. Four of the AO B2.1 and 2 of the AO B2.3 fractures required open reduction with Watson‐Jones approach. The mean operative time was around 78 minutes, which tended to decrease as the surgical experience increased. There was only one case of malreduction, which required revision surgery. Conclusion: Combination of ipsilateral femoral shaft fracture and neck/intertrochanteric fracture is a difficult fracture pattern for trauma surgeons. Cephalomedullary nail is an excellent implant for such fractures but it requires careful insertion to avoid complications. Surgery is technically demanding with a definite learning curve. Nevertheless, a majority of these fractures can be surgically managed by singleimplant cephalomedullary fixation by following basic surgical principles that have been summarized in this article.

True congenital dislocation of shoulder: A case report and review of the literature.

The dislocation of a shoulder joint in infancy is extremely rare and is usually the result of traumatic birth injuries, a sequel to brachial plexus injury, or a true congenital dislocation of shoulder. With more advanced obstetric care, the incidence of first two types has drastically decreased. We report a case of true congenital dislocation of shoulder, second of its kind, in a child who was delivered by cesarean section thereby negating any influence of trauma. We report the case because of its rarity, and review the available literature on this topic. We also discuss the management options when encountered with such a rare case scenario.

Open reduction and internal fixation compared with ORIF and primary subtalar arthrodesis for treatment of sanders type IV calcaneal fractures: a randomized multicenter trial.

To the Editor: We read with great interest the article titled “Open Reduction and Internal Fixation Compared With ORIF and Primary Subtalar Arthrodesis for Treatment of Sanders Type IV Calcaneal Fractures: A Randomized Multicenter Trial” by Buckley et al. The authors have performed a commendable job addressing a topic that is causing much controversy in the orthopaedic community. Nevertheless, we have certain reservations regarding some points and interpretation of the results of this study. The authors clearly state in the Introduction that a previous Canadian study had highlighted 2 facts: one that only “20 of the available 81 patients with Sanders type IV injury required fusion within 2 years of presentation” and second “47% of the late fusion group had Sanders type IV fractures.” Furthermore, patients with late subtalar fusion did well and patient satisfaction was high, regardless of whether or not they had received operative management. This raises a few points for debate. Should we even advocate primary fusion in these complex calcaneal fractures, a difficult operation even in experienced hands, when only 25% of these have been shown to need it subsequently? Additionally, less than half of the cases that were eventually fused were Sanders type IV, and this does not go in favor of advocating a complex procedure for the economic benefits alone. Some discrepancies in the presented data are worth mentioning. In the protocol and randomization paragraph, the authors clearly state that only “isolated Sanders IV Displaced Intraarticular Calcaneal fractures” were considered. In the subsequent paragraph they state, “bilateral calcaneal fractures were randomized by the patient and not the fracture.” Bilaterality is perceived by us to be a factor that could potentially contribute to poor outcome scores, and these cases should have perhaps been excluded. How many bilateral cases were evaluated in this study is also not clarified, as the Results section and Table 3 describes only 17 patients with open reduction and internal fixation (ORIF) and 14 with ORIF + primary subtalar arthrodesis (PSTA),” leaving the reader somewhat confused about the issue of bilaterality and how to interpret this. A few other points that need clarification are numerically listed below. 1. How do the authors justify a 10-week partial weight-bearing period for the ORIF group and a 6-week period for the ORIF + PSTA group, when actually the fractures in both groups are the same? The PSTA group has an extra surface to unite, the subtalar joint fusion, and would this be a factor in initiating weight bearing? 2. In Table 1, the authors have excluded “extremely comminuted intraarticular fractures of calcaneus, deemed impossible to reconstruct by the treating surgeon”; as this was a surgeon’s decision, it has the potential to cause a bias. Although this may seem like a practical clinical decision, we believe that this factor has the potential to introduce selection bias when interpreting the results of the study. Also it may become difficult for readers to replicate the results, as patient selection may subsequently vary. It may be better if the authors clearly mention the number of severely comminuted fractures that were excluded from the study. 3. The mean Visual Analogue Scale score for the ORIF + PSTA group mentioned in the article under the heading “Outcome Analysis” is different from that in Table 4 and needs to be clarified. 4. Going by Table 4 values, VAS scores are bad for both the groups in this study (36.8 vs. 36, P = 0.82) after 2 years, which means that even doing primary fusion did not relieve the patients of pain. Additionally, as secondary fusion has been shown in previous studies to give good functional result, it may be a better proposition to wait and do fusion secondarily, as many cases may avoid an unnecessary operation. 5. Taking the above point further, the results of this study clearly show that pain persisted along with poor functional scores in the primary fusion group (mean VAS scores = 36). What do the authors suggest should be performed next to relieve the symptoms in these cases, as subtalar joint has already been fused? Is it correct to thus assume that in a large percentage of cases, the pain generator is not the subtalar joint, and an unnecessary operation may have primarily been performed? We thus advise that the results of this study should be viewed with caution, especially with the authors own admission in the “Power and Sample Size Calculation” section that they were unable to collect even half the number of patients required per group to give a meaningful end result. Additionally, we believe that it would have been more meaningful and practically applicable if the functional outcomes of primary fusion and secondary fusion of subtalar joint had been considered, and economic factors were not made the sole criteria. As exact financial costs are not clarified in the 2 groups here, would it be worthwhile calculating how much is saved in that large subgroup that is routinely not fused primarily? And what would be the added costs to the patients who continue to have poor outcomes after primary fusion? Again, we thank the authors for publishing an article that stimulates so much debate, opening up avenues for more clarity in the management of this particularly complex fracture.

Prosthetic joint infection following total hip replacement: results of one-stage versus two-stage exchange

To the Editor, We read with great enthusiasm the manuscript titled “Prosthetic joint infection following total hip replacement: results of one-stage versus two-stage exchange” by Wolf et al. [1] published in the July issue of International Orthopaedics. We appreciate the authors’ attempt to address a controversial issue, suggesting simple criteria for managing periprosthetic joint infections, but we feel some important aspects were left unanswered:

Traumatic Anterior Dislocation of the Knee Without Any Neurovascular Complication-Case Report

We are reporting a case of traumatic anterior dislocation of the left knee without any neurovascular complication. To our knowledge, such complete dislocation without involvement of popliteal artery and/or peroneal nerve has not been reported before however similar cases are reported after total knee replacement with and without neurovascular compromise. This injury was recognized and treated promptly with rehabilitation commencing early, resulting in a good functional outcome. We discuss the possible injury mechanism and management of this unusual case.

Diaphyseal tuberculosis - a rare manifestation

A 2 year old child presented with low-grade fever, progressive pain and swelling of right leg for the past 3 months. There was no history of injury, chronic cough, respiratory symptoms, weight loss or arthritis. Child’s father had been treated for pulmonary tuberculosis 1 year back. On examination, there was a firm, diffuse, tender swelling over the medial aspect of middle one-third of right tibia and matted inguinal lymphadenopathy. Rest of the systemic examination was not contributory. A clinical diagnosis of diaphyseal bone tumour or chronic infective osteomyelitis was considered. Investigations showed erythrocyte sedimentation rate 46 mm in first hour, haemoglobin 96 g/L and 20 mm induration after Mantoux test and normal chest radiograph. Radiograph of the …

Results of open reduction and internal fixation in neglected PCL avulsion fracture with MCL insufficient knee – a case report and review of literature

We report a case of neglected posterior cruciate ligament (PCL) avulsion fracture with medial collateral ligament (MCL) injury and our experience with delayed (2 year post injury) open reduction and internal fixation of this fracture in combination with MCL reconstruction stabilization. After open reduction and rigid screw fixation, combined with a posteromedial stabilization using a hamstring tendon autograft, the patient returned to full activity in daily life. We recommend that if PCL substance is sufficient, delayed fixation of an old PCL avulsion fracture seems to be a viable alternative to PCL reconstruction.