P. R. J. V. C. Boopalan

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.

Incidence and Radiologic Outcome of Intraoperative Lateral Wall Fractures in OTA 31A1 and A2 Fractures Treated With Cephalomedullary Nailing.

Objectives: To determine the incidence of intraoperative lateral wall fracture in OTA 31A1 and A2 fractures treated with a cephalomedullary nail and to determine whether this contributed to the failure of treatment. Design: Retrospective review. Setting: University hospital. Patients/Participants: A cohort of 291 patients (31.A1/A2-231, A3-60) was assessed with pre- and postoperative radiographs. Patients with intact lateral wall fractures were included in the study. One hundred sixty-five of 231 patients (77%) completed radiologic follow-up. They were divided into 2 groups. Group 1 (129 patients, 78%) consisted of patients with an intact lateral wall postoperatively. Group 2 (36 patients, 22%) consisted of patients who sustained lateral wall fracture intraoperatively (FLW). Intervention: Closed reduction and intramedullary nail insertion. Main Outcome Measurements: Rate of failure/reoperation and collapse were compared between the groups. Results: The incidence of intraoperative lateral wall fracture was 21% (48 of 165). Fracture collapse and failure rate were not statistically significant in either groups (group 1: 1%, group 2: 5%). Conclusions: The incidence of intraoperative lateral wall fracture in OTA 31A1 and A2 pertrochanteric fractures after cephalomedullary nailing is similar to sliding hip screws. The presence of lateral wall fracture did not adversely affect healing of pertrochanteric fractures. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Open infected Achilles tendon injury--reconstruction of tendon with fascia lata graft and soft tissue cover with a reverse flow sural flap.

We present a patient with an open, infected Achilles tendon injury with a soft tissue defect of 12 cm x 5 cm and a tendon defect of 10 cm. He underwent a two-stage procedure. A first stage debridement of tendon and soft tissue was followed by a second stage tendo Achilles reconstruction using fascia lata graft and soft tissue cover with a reverse flow sural flap. He had a good functional outcome with minimal donor site morbidity.

Tuberculosis of and around the Ankle

Osteoarticular tuberculosis of the ankle joint is rare, and diagnostic delays are common with this condition. The aim of our report is to highlight the varied clinical and radiologic presentation of this entity. We present a retrospective review of 16 patients with tuberculosis in and around the ankle joint who were surgically treated during a 6-year period. The incidence of ankle joint involvement in extraspinal osteoarticular tuberculosis was 15.7% in our unit. The most common presentation in our series was chronic septic arthritis, followed by periarticular osseous lytic lesion. Tuberculous synovitis, tenosynovits, and retrocalcaneal bursitis were also seen. Osteopenia, the hallmark of osteoarticular tuberculosis, might not be seen in all forms of tuberculosis affecting this joint. Chemotherapy remains the mainstay of treatment. Adjuvant surgery is often required to establish the diagnosis and in the treatment of patients with deformity and widespread destruction of articular cartilage owing to delayed presentation.

Indices affecting outcome of neglected femoral neck fractures after valgus intertrochanteric osteotomy.

Objectives: To evaluate preoperative neck resorption and postoperative valgus orientation as predictors of union and functional outcome after valgus intertrochanteric osteotomy for treatment of neglected femoral neck fractures and nonunions. Design: Retrospective cohort study. Setting: Tertiary care center. Patients/Participants: Forty consecutive patients with neglected femoral neck fracture and nonunions were treated with valgus intertrochanteric osteotomy, and follow-up was available in 32 patients (average age, 43 years; range, 14–60 years; average nonunion duration, 6 ± 7 months; range, 1–36 months). Intervention: Valgus intertrochanteric osteotomy. Main Outcome Measurements: Clinical outcome was assessed with Harris hip score. Plain radiographs were evaluated for union, avascular necrosis, preoperative bone deficiency (neck resorption ratio), and postoperative femoral head fragment alignment (head-shaft angle). Results: Follow-up at 5 ± 3 years (range, 2–12 years) after surgery showed union in 29 patients (91%), and Harris hip score was 82 ± 13 points (range, 63–100 points). The 3 patients with persistent nonunion at the neck of femur had neck resorption ratio <0.52. Increased postoperative head-shaft angle was associated with lower follow-up Harris hip score; postoperative valgus alignment >15 degrees compared with the contralateral side was associated with poor functional outcome. The presence of avascular necrosis did not affect the outcome. Conclusions: Valgus intertrochanteric osteotomy resulted in union and satisfactory functional outcome in most patients who had neglected femoral neck fractures and nonunions. Preoperative neck resorption ratio <0.5 was a risk factor for nonunion, and excessive valgus alignment was a risk factor for poor functional outcome after osteotomy. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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.

Managing Skin Necrosis and Prosthesis Subluxation After Total Knee Arthroplasty

Skin necrosis and prosthetic subluxation are dreaded complications after total knee arthroplasty. It can result in deep infection with subsequent failure of prosthesis. The incidence of infection in patients with rheumatoid arthritis who undergo knee arthroplasty is high when compared to patients with primary osteoarthritis. The gastrocnemius muscle flap has been described for cover of proximal tibia and tendon loss because of malignancy and has been used as a bridge graft in trauma patients with patellar tendon loss. We describe a patient with total knee arthroplasty with anterior knee skin necrosis and prosthesis subluxation because of attenuation and loss of continuity of patellar tendon. This was managed by using gastrocnemius bridge grafting. Here, the gastrocnemius bridge graft was used as a soft tissue cover as well as a dynamic anterior stabilizer for the prosthesis.

Valgus osteotomy for nonunion and neglected neck of femur fractures

Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics. The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomy-optimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure.

Reserve or Resident Progenitors in Cartilage? Comparative Analysis of Chondrocytes versus Chondroprogenitors and Their Role in Cartilage Repair

Introduction Articular cartilage is made up of hyaline tissue embodying chondrocytes, which arise from mesenchymal stromal cells (MSCs) and specialized extracellular matrix. Despite possessing resident progenitors in and around the joint primed for chondrogenesis, cartilage has limited intrinsic capacity of repair and cell turnover. Advances in isolation, culture, and characterization of these progenitors have raised the possibility for their use in cell-based cartilage repair. Chondroprogenitors (CPCs) have been classified as MSCs and have been postulated to play a vital role in injury response and are identified by their colony forming ability, proliferative potential, telomere dynamics, multipotency, and expression of stem cell markers. The combined presence of CPCs and chondrocytes within the same tissue compartments and the ability of chondrocytes to dedifferentiate and acquire stemness during culture expansion has obscured our ability to define and provide clear-cut differences between these 2 cell populations. Objective This review aims to evaluate and summarize the available literature on CPCs in terms of their origin, growth kinetics, molecular characteristics, and differential and therapeutic potential with emphasis on their difference from daughter chondrocytes. Design For this systematic review, a comprehensive electronic search was performed on PubMed and Google Scholar using relevant terms such as chondrocytes, chondroprogenitors, and surface marker expression. Results and Conclusion Our comparative analysis shows that there is an ill-defined distinction between CPCs and chondrocytes with respect to their cell surface expression (MSC markers and CPC-specific markers) and differentiation potential. Accumulating evidence indicates that the 2 subpopulations may be distinguished based on their growth kinetics and chondrogenic marker.