Rajesh Kumar Kanojia

Surgical management for late presentation of supracondylar humeral fracture in children

Purpose. To report the results of surgical management for late-presenting displaced supracondylar fractures of the humerus in children. Methods. Between February 2002 and June 2003, 40 children (mean age, 7 years) with late presentation (range, 2–12 days) of displaced supracondylar humeral fractures were prospectively recruited. Gentle closed manipulation under image intensification was attempted in all patients, except one with a compound open fracture. Manipulation was successful in 25 patients and percutaneous skeletal stabilisation with Kirschner wires was performed. The remaining 15 patients were treated with open reduction and Kirschner wire fixation, using a mediolateral approach. Results. The mean delay in presentation was approximately 4 days. No patients presenting more than 7 days after injury had the fracture reduced by closed manipulation. The mean hospital stay was 41 hours. At the final follow-up (mean, 18 months), 88% of the patients had a satisfactory result, according to Flynns criteria. Conclusion. Operative treatment for late presentation of supracondylar humeral fractures in children is effective. It minimises the risk of complications and the need for continuous traction or corrective osteotomy.

Preliminary soft tissue distraction using external fixator in radial club hand.

Preliminary soft tissue distraction using an external fixator before centralisation and tendon transfer of the flexor and extensor carpi ulnaris to the little finger metacarpal was used to treat Bayne’s type III and IV deformities in 18 hands of 14 patients with radial club hands. Treatment with external fixator was started at a mean age of 8 (range 3–30) months. In 16 of 18 hands, the surgical treatment was completed before 10 months of age. Adequate soft tissue stretching was achieved before centralisation using fractional distraction with the external fixator in the majority of hands. After an average follow-up period of 31 months, there were seven good, eight satisfactory and one unsatisfactory result.

One-stage osteotomy and fixation using a long proximal femoral nail and fibular graft to correct a severe shepherd's crook deformity in a patient with fibrous dysplasia: a case report

We report a case where a one-stage osteotomy and fixation, using a long proximal femoral nail and fibular graft, was performed to correct a severe shepherds crook deformity (70° varus and 50° retroversion) of the femoral neck with a pathological stress fracture in a patient with fibrous dysplasia. The neck shaft angle was corrected to 125°. At the 57-month follow-up, the patient was free of pain and had no limp or evidence of recurrence.

Acquired radial club hand with humero-ulnar dislocation: a rare sequel to infantile compartment syndrome following venous cannulation: a case report

Acquired radial club hand caused by infection has been reported occasionally. We report a rare case of acquired radial club hand with an associated septic dislocation of the elbow, primarily caused by compartment syndrome following venous cannulation. The deformity and instability were treated with distraction using an external fixator followed by a centralisation procedure. At the 2-year follow-up the appearance and functions of the left forearm had improved considerably and the wrist was stable. There was no deterioration in ulnar growth.

Comparative study of complete subtalar release and Joshi's external stabilization system in the management of neglected and resistant idiopathic clubfoot.

BACKGROUND Various procedures have been used for the management of neglected and resistant clubfoot. The aim of our study was to assess the clinical and radiological correction by Joshis external stabilization system (JESS fixator) and Simons subtalar release in resistant and neglected idiopathic congenital talipes equinovarus in children between the ages of 1 and 2 years. METHODS A total of 50 resistant and neglected clubfeet were randomly divided into two equal groups of 25 feet each. Group I was treated with JESS fixator and group II was treated with complete subtalar release as described by Simons. Assessment of correction achieved was done both clinically and radiologically. Functional outcome was assessed with Ponseti scale. RESULTS The change in clinical deformity and radiological correction of deformity were statistically significant within each group, but not significant when compared to each other. In group I excellent results were obtained in 17 (68%) and good in 8 (32%) of the feet. In group II, excellent results were found in 16 (64%) and good in 9 (36%) feet out of the 25 feet. Pin-site infections were seen in two cases in group I and serious skin problems occurred in two feet in group II. CONCLUSION We conclude that there were no statistical significant differences between the outcomes of the two techniques in this short-term follow-up of 2.4 years. Thus, functional distraction using JESS can be utilized as an alternative method in cases of neglected and resistant clubfoot.

Medial patellofemoral ligament reconstruction – A novel technique ☆

Patellofemoral instability is initially treated conservatively and surgical treatment is reserved for resistant cases. Reconstruction of medial patellofemoral ligament has gained popularity these days as it attempts at restoring soft tissue anatomy and biomechanics of medial patellar restraint back to normal. Here we describe our novel transverse patella single tunnel and femoral interference screw technique to reconstruct the medial patellofemoral ligament using free autologous gracilis and semitendinosus grafts.

Closed Reduction, Osteotomy, and Fibular Graft Are Effective in Treating Pediatric Femoral Neck Pseudarthrosis After Infection

Background When treatment of acute septic arthritis of the hip is delayed, severe sequelae can occur. This may take the form of coxa breva, vara, or valga. Pseudoarthrosis of the femoral neck is a rare complication with only a few studies to guide treatment. Question/purposes In a small series of patients with pseudarthrosis of the femoral neck after acute septic arthritis, we wanted to determine (1) whether femoral neck union can be achieved using a variety of surgical approaches; (2) whether these patients satisfied criteria outlined by Hunka and Choi, defined as a stable hip, a flexion arc ≥ 70° and no fixed adduction or abduction contractures, fixed flexion deformity not more than 20°, pain relief, and restoration of activities of daily living after surgery; and (3) any treatment-related complications if observed. Methods We reviewed the charts of patients who had presented to the orthopaedics outpatient department at Lady Hardinge Medical College and Associated Hospitals with the diagnosis sequelae of septic arthritis of the hip. Between 2003 and 2014, a total of 54 pediatric patients (61 hips) with sequelae of a septic hip had undergone various hip reconstructive procedures. Of these, 16 patients (30%) were diagnosed with pseudarthrosis of the femoral neck and were included in this study. All patients with this diagnosis were treated surgically. In this group, the median age at first contact with our treating team was 48 months (range, 18-96 months). The age of onset of the initial infection was 0.3 months to 84 months (median, 8 months). These 16 patients underwent a total of 24 surgical procedures to achieve union at the pseudoarthrosis site. We performed close reduction, fibula graft, and valgus osteotomy in most of the patients. Wagner’s double intertrochantric osteotomy with a fibula graft was done in patients in whom there was a short femoral neck along with pseudoarthrosis. In all patients, the pseudarthrosis site was not exposed. Median followup was 6 years (range, 3-12 years). No patient was lost to followup before 3 years. Union was defined when there was complete radiologic healing at the pseudoarthrosis site. All the patients were clinically evaluated as per Choi’s criteria. Parents were also asked about daily activities and pain. Other related complications were also recorded. Results Fifteen of 16 patients achieved union at the pseudarthrosis site within 6 to 24 months (median, 9 months). Ten patients underwent a single procedure to achieve union, whereas four patients underwent two surgical procedures and two patients underwent three procedures. Fifteen patients achieved Choi’s criteria and one patient could not achieve this. While attempting this reconstruction, complications occurred in the form of deep infection and avascular necrosis. Conclusions Surgical reconstruction of pseudarthrosis of the femoral neck after pyarthrosis of the hip is difficult, but a successful result may be possible in many patients. Every effort should be made to achieve pseudarthrosis repair while the femoral head remains viable on radiographs. Once union is achieved, clinical function and hip stability improve. At early followup, many patients have adequate ROM with minimal pain, an acceptable limp, and are able to do indoor and outdoor activities without support. Long-term results are unknown, and we caution that treating the sequelae of childhood hip disease is challenging. Level of Evidence Level IV, therapeutic study.

Transient osteoporosis of the hip in a non-pregnant woman

Transient osteoporosis of the hip is a rare, self-limiting condition, occurring most commonly in middle-aged men, but also sometimes in women, usually in late pregnancy. It is characterised by gradual onset of hip pain aggravated by weight bearing without any associated history of trauma and systemic illness. It is usually of unknown aetiology, but pregnancy is a recognised risk factor for women. Other conditions that can mimic transient osteoporosis of the hip on MRI are osteonecrosis, osteomyelitis and neoplasms. We present a case of a 38-year-old non-pregnant woman with transient osteoporosis of the hip, managed conservatively, leading to a full recovery. Treatment is conservative, including protected weight bearing, physical therapy and non-steroidal analgesics. The patient was completely painless and symptom free at 2-year follow-up.

Genochondromatosis type I: A clinicoradiological study of four family members

Genochondromatosis is an extremely rare autosomal dominant disorder, which manifests during childhood and tends to regress in adult life. The bony lesions are symmetrically distributed with characteristic localization at the metaphysis of proximal humerus and distal femur. Two types have been described based on the involvement of clavicle. Usually asymptomatic, sometimes patients may present with pathological fractures. In this communication, we describe four members of a family with Genochondromatosis type I, with some additional clinical and radiological findings not reported previously.

Comparative study of posteromedial release and complete subtalar release in resistant/recurrent congenital talipes equinovarus foot: A 5-year follow-up study

Background:We compared the surgical outcomes of two commonly used soft-tissue surgical procedures (posteromedial release and complete subtalar release) in the treatment of congenital talipes equinovarus foot. Methods:A total of 44 congenital talipes equinovarus feet in 27 children were included in our study. The mean age of the patients was 14.20 months. We divided an equal number of feet into two groups. In group 1, 22 feet underwent a posteromedial release, and in group 2 an equal number of feet underwent complete subtalar release. We used new scoring system (modification of Magone’s scoring system) that included clinical, radiographic, and functional parameters to assess surgical outcomes. The average follow-up period in our study was 64 months. Results:No differences were noted between these two surgical techniques. Conclusions:We concluded that soft-tissue release is a good procedure in young children who do not respond to conservative treatment. We were able to achieve more than 80% excellent and good results using either technique.