Pramod Saini

Biological fixation of comminuted subtrochanteric fractures with proximal femur locking compression plate

INTRODUCTION Subtrochanteric fractures are difficult fractures associated with high incidence of complications and various implants, both intramedullary and extramedullary, are available for their fixation. Traditional extramedullary implants are associated with higher rate of implant failure and varus collapse while the biomechanically better intramedullary nails are technically demanding and are associated with higher re-operation rates. This study was done to evaluate the outcome following biological (indirect) fixation of unstable comminuted subtrochanteric fractures with proximal femur-locking compression plate (PF-LCP). METHODS Thirty-five consecutive patients with comminuted subtrochanteric fractures were operated upon with PF-LCP by using an indirect reduction technique. Seinsheimer types 3-5 fractures were included in the study. Operating time, blood loss and any technical difficulty with the implant were recorded. Patients were followed clinically and radiologically for union at fracture site and implant-related complications. The Harris Hip Score was used to document hip function at final follow-up. RESULTS Thirty-two patients with average age of 44.7 years were available for final evaluation. The mean operating time was 79.5min and total blood loss averaged 233.13ml. Union was achieved in all cases with an average time of 15.62 weeks. Complications included two cases of delayed union and two cases of infection. Two cases had a shortening of 1cm and one case had malunion with external rotation. No instances of implant failure or nonunion were recorded. CONCLUSION Biological fixation of comminuted subtrochanteric fractures with PF-LCP provides stable fixation with high union rate and fewer complications.

Bilateral anterior shoulder dislocation

Shoulder dislocations are the most common major joint dislocations encountered in the emergency departments. Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations. Bilateral anterior shoulder dislocation is very rare. We present a case of 24-year-old male who sustained bilateral anterior shoulder dislocation following minor trauma, with associated greater tuberosity fracture on one side. Prompt closed reduction followed by immobilization in arm sling and subsequent rehabilitation ensured a good outcome.

Elbow dislocation with ipsilateral distal radius fracture.

Elbow dislocation associated with ipsilateral distal radius fracture is a rare pattern of injury, although it is common for elbow dislocation and forearm fractures to occur separately. We report a rare case of a 20-year-old male who had a posterior elbow dislocation and ipsilateral distal radius fracture. Elbow dislocation was first reduced in extension and distal radius fracture was then reduced in flexion. Both the injuries were conservatively managed. At 6 months follow-up, the patient had no pain in his elbow and minimal pain in his wrist on heavy lifting and had resumed his work as a laborer.

Spontaneous migration of bullet from arm to forearm and its ultrasound guided removal

Spontaneous migration of a retained bullet is rare. We are presenting here a case of a 24-year-old male with spontaneous migration of bullet from arm to forearm. At the time of initial injury, bullet was left inside the arm as it was deep and patient had no complaints. Three months after injury, he started complaining of pain over forearm and tingling sensations in the forearm and hand over median nerve distribution. Radiographs showed bullet in the proximal forearm. The bullet was than precisely localized and removed under ultrasound guidance. This case report emphasizes the fact that spontaneous migration of bullet in extremities may occur and have the potential to cause neurovascular damage. Removal under ultrasound guidance is a viable option in such locations.SommarioLa migrazione spontanea di un proiettile trattenuto è rara. Presentiamo il caso di un paziente maschio, di 24 anni di età, con migrazione spontanea di una pallottola dal braccio all’avambraccio. Al momento iniziale, il proiettile era stato lasciato all’interno del braccio perchè in sede profonda in paziente con scarsa resistenza al dolore. Tre mesi dopo, questi ha iniziato a lamentare dolore al l’avambraccio e sensazioni di formicolio a braccio e mano, nelle aree innervate del nervo mediano. Le radiografie hanno mostrato il proiettile nell’avambraccio prossimale. Il proiettile veniva localizzato con più precisione e rimosso sotto guida ecografica. Questo caso sottolinea il fatto che la migrazione spontanea di un proiettile nelle estremità può verificarsi ed è potenzialmente causa di danni neurovascolari. In tale situazione la rimozione sotto guida ecografica è una valida opzione.

Manipulation under anesthesia for post traumatic stiff knee-pearls, pitfalls and risk factors for failure

BACKGROUND Stiffness is common following fractures around knee. Manipulation under anesthesia (MUA) is the initial noninvasive procedure usually performed for such patients. Though MUA has been extensively evaluated for knee arthroplasty, there is paucity of literature regarding its benefits in trauma cases. The purpose of this study was to define the role of manipulation in post traumatic stiff knees. METHODS Hospital inpatient and outpatient records from January 2010 to June 2014 were retrospectively reviewed to identify patients undergoing MUA at our institution. Patients with more than one year follow up and adequate data were included. Clinical and radiographic parameters were analyzed to assess outcomes, complications, effect of timing on flexion gain as well as identify risk factors associated with failure. RESULTS Out of 45 patients undergoing manipulation, 41 patients with 48 knees (34 unilateral and 7 bilateral) met inclusion criteria. Thirty six manipulations were successful while 3 were abandoned due to tight tissues and 9 developed complications.Successful MUA resulted in immediate gain of 62.36° of flexion which decreased to 49.86° at 1year. There was statistically significant loss of flexion of 12.5° over a year (p value 0.0013). Arc of motion improved from 48.5° to 106.1° at 1year (p value <0.0001). Significant improvement was also seen in extension and fixed flexion deformity (p value <0.0001). No significant difference could be detected between early (<3 months) and late (>3 months) groups with respect to outcomes (p value 0.883)or complications (p value 0.3193). Failed group had significantly lower pre MUA flexion and pre MUA range of motion (p value 0.003). Univariate analysis showed that extensor mechanism ruptures during injury (p value <0.0001) and knees with Flexion <40° (p value 0.0022) or ROM<30° (p value 0.0002) were significantly associated with failures. CONCLUSION MUA is a suitable non invasive treatment option for post traumatic stiffness. There is no effect of timing on outcome and late manipulation also results in good outcome. Extensor mechanism rupture and pre manipulation ROM<30° or flexion <40° are associated with failure and such cases should be considered for alternative options for better outcome.

Well-leg compartment syndrome after fracture fixation in hemilithotomy position: case report of a preventable condition.

Objective: To report a case of subtrochanteric femur fracture that led to intraoperative compartment syndrome in the well leg. Clinical Presentation and Intervention: A 28-year-old obese male who presented with a comminuted subtrochanteric fracture underwent a prolonged open reduction and internal fixation using dynamic condylar screw. In the postoperative period, after the effect of epidural analgesia had worn off, the patient complained of severe pain and swelling of the well leg. A diagnosis of well-leg compartment syndrome was made and urgent two-incision fasciotomy was performed. Conclusion: Obesity and prolonged surgery could have caused the acute compartment syndrome of the well leg in this patient.

Single versus double blade technique for skin incision and deep dissection in surgery for closed fracture: a prospective randomised control study

Purpose. To compare blade cultures in surgery for closed fracture using a single or double blade technique to determine whether the current practice of double blade technique is justified. Methods. 155 men and 29 women aged 20 to 60 (mean, 35) years who underwent surgery for closed fracture with healthy skin at the incision site were included. Patients were block randomised to the single (n=92) or double (n=92) blade technique. Blades were sent for bacteriological analysis. Outcome measures were early surgical site infection (SSI) within 30 days and cultures from the blades. Results. The 2 groups were comparable in baseline characteristics. In the single blade group, 6 surgical blades and 2 control blades showed positive cultures; 4 patients developed SSI, but only one had a positive culture from the surgical blade (with different organism isolated from the wound culture). In the double blade group, 6 skin blades, 7 deep blades, and 0 control blade showed positive culture; only 2 patients had the same bacteria grown from both skin and deep blade. Five patients developed SSI, but only one patient had a positive culture from the deep blade (with different organism isolated from the wound culture). The difference in incidence of culture-positive blade or SSI between the 2 groups was not significant. The relative risk of SSI in the single blade group was 0.8. Positive blade culture was not associated with SSI in the single or double blade group. Conclusion. The practice of changing blade following skin incision has no effect on reducing early SSI in surgery for closed fracture in healthy patients with healthy skin.

Ochronotic black meniscus during knee arthroscopy

Ochronotic arthropathy is a rare condition found in patients with alkaptonuria, which is a hereditary metabolic disease associated with deposition the of homogentisic acid derivatives in various connective tissues of the body. We present the case of a 30-year-old woman in whom arthroscopic examination of the left knee prior to meniscectomy for bucket handle tear of medial meniscus revealed brown-black discoloration of the articular cartilage and menisci leading to the diagnosis of alkaptonuria by further laboratory evaluation. After medical and surgical treatment, patients complaints were alleviated and no further complaints were registered, during the next follow-up.