Saubhik Das

Retrospective analysis of proximal humeral fracture-dislocations managed with locked plates

BACKGROUND Fracture-dislocation is the extreme variant of injury to the proximal humerus that occurs more commonly in young adults as a result of high-velocity trauma. We evaluated the functional and radiologic outcome of fixation of proximal humeral fracture-dislocations with locked plates. METHODS This was a retrospective review of 33 proximal humeral fracture-dislocations in 29 patients with a mean age of 35 years (range, 19-60 years) treated by open reduction and internal fixation with locked plates between January 2009 and December 2013. The fracture-dislocation in 85% was the result of high-energy trauma resulting in 3- or 4-part fracture-dislocation. The fracture-dislocation was anterior in 27 and posterior in 6. RESULTS The average delay from injury to surgery was 7 days (range, 1-35 days), with a mean follow-up of 40 months (range, 24-66 months). All of the fractures united at an average of 15 weeks after surgery. At the final follow-up, the mean forward flexion was 129° (range, 100°-160°), and mean abduction was 128° (range, 100°-150°). The mean Constant score at the final follow-up was 78 points (range, 68-88 points). One case of complete osteonecrosis of the humeral head and 1 case of partial osteonecrosis of the humeral head were noted. Two cases of screw perforation of the humeral head were seen, with subsequent restricted range of motion improving after removal of the offending screws. CONCLUSIONS Most young patients with 3- and 4-part proximal humeral fracture-dislocations can achieve good functional outcome after fixation with locked plates.

Analysis of functional outcome of Hoffa fractures: A retrospective review of 32 patients

Purpose: Hoffa fractures are uncommon intra-articular fractures of femoral condyle in coronal plane. The purpose of our study is to assess radiologic and functional outcome in operatively treated Hoffa fractures. Methods: We retrospectively reviewed 32 patients of isolated Hoffa fracture from January 2010 to March 2015. All were treated with open reduction and internal fixation using lateral approach for lateral Hoffa and medial approach for medial Hoffa fracture. Cancellous screws in lag mode and/or antiglide plate were employed for fixation in accordance with fracture anatomy. All patients were subjected to aggressive physical therapy postoperatively. Knee Society Score (KSS), International Knee Documentation Committee Score (IKDC), and Knee range of motion (ROM) were documented at final follow-up for functional evaluation. Results: All fractures united by mean time of 11.56 ± 1.5 weeks. No evidence of subsequent displacement or fixation failure, arthritis, Avascular necrosis (AVN) of femoral condyle was elicited in any of the patients. Documented mean KSS and mean IKDC Score at final follow-up were 83.19 ± 8.43 and 81.62± 6.95, respectively. ROM at final follow-up was ranging from 0° to mean 116.41° ± 13.98°. Complications included stiffness of the involved knee in four patients, including one patient who developed infection and had to undergo implant removal after fracture union. Conclusion: Operative treatment of Hoffa fractures yields fairly good functional outcome. One must endeavor to achieve adequate intraoperative exposure and stable congruous articular reconstruction. Early aggressive physical therapy is a harbinger of optimal outcome.

Response to Chouhan DK, regarding: “Retrospective analysis of proximal humeral fracture-dislocations managed with locked plates”

In reply: We appreciate the effort of the authors in reading our article with interest and providing insightful comments to our article titled “Retrospective analysis of proximal humeral fracturedislocations managed with locked plates.” We would like to address the raised queries in the following manner. In our series, we did not encounter recurrent instability after osteosynthesis of fracture-dislocations of the proximal humerus. The presence of a bony Bankart lesion or anterior glenoid rim fracture was specifically looked for before embarking on surgery with computed tomography scans. Labral tears were ruled out intraoperatively in all cases having separate lesser tuberosity fractures. An attempt to look for the same was not made in fractures with intact lesser tuberosity fractures. Capsular tears were present, whereas significant labral tears were not found in our series. At the end of every fixation, intraoperative fluoroscopy was also used to rule out any residual instability. In our experience, unlike simple dislocations, fracturedislocations have different pathoanatomy. Given the lack of observation of labral tears in our series and absence or lack of mention of the same in other such series, it may be possible that fracture-dislocations do have much lower incidence of labral tears and much higher incidence of capsular tears compared with simple dislocations. Robinson et al in their series of 58 patients with a mean age of 66 years had 20 soft tissue Bankart lesions, 3 bony Bankart lesions, and 2 cases with partial inferior soft tissue labral attachment. However, their publication, of a different cohort, does not elaborate on any repair of these lesions and does not mention any complication related to instability. Lahav et al also mentioned 2 cases of fracture-dislocation with anterior glenoid rim fractures in which they fixed the glenoid rim along with performing an arthroplasty for proximal humerus fracture in their patients of old age. The use of an anterior approach to fix these fracturedislocations may cause fibrosis of the anterior structures, which may in turn prevent instability. In spite of early physiotherapy, some stiffness may persist that may also contribute to decreased chances of instability. Soliman and Koptan reported no case of redislocation after fixation in a series of 39 patients with 4-part fracture-dislocation of the proximal humerus in young adults. They remarked that this intriguing fact might be because all the patients in their study were on the stiff side. We feel that if labral tears are evident in such fractures, they should be fixed in the same setting to prevent any unnecessary future procedures. However, additional dissection just to look for the same should be avoided to preserve vascularity of fragments to a maximum, especially in cases in which osteosynthesis is contemplated, looking at the low possibility of instability after such procedures on the basis of both our experience and published literature. To the best of our knowledge, no such reports of recurrent dislocation of the shoulder after fixation have been mentioned in the literature, Hence, very little is known about the frequency of such a complication; neither any comprehensive pathoanatomy of soft tissue injury pattern of the capsulolabral complex nor any standard treatment rationale has been detailed. Going by the available evidence and the standard practice in patients of our tertiary care trauma center, we can speculate that labral injury might not be necessary to repair in this complex injury, and only open reduction– internal fixation might be sufficient to produce satisfactory results. We once again thank the authors for bringing the issue to the fore and letting us explain our point.

Expanded Age Indication for Ponseti Method for Correction of Congenital Idiopathic Talipes Equinovarus: A Systematic Review

The deformity known as congenital idiopathic talipes equinovarus (CTEV) is probably the most common (1 to 2 in 1000 live births) congenital orthopedic condition requiring intensive treatment. With the perception that the treatment of idiopathic CTEV by extensive soft tissue release is often complicated by stiffness, recurrence, and the need for additional procedures, the minimally invasive Ponseti method has been accepted as the first line of treatment, which has achieved excellent results globally. The Ponseti method has achieved excellent results in children with idiopathic CTEV aged ≤2 years. However, the upper age limit for the Ponseti treatment has not yet been defined. We reviewed the published data to determine the efficacy of the Ponseti method in older children with neglected CTEV.

Midterm results of trochanteric flip osteotomy technique for management of fractures around the hip

Introduction: In this study, we aimed to investigate safety and efficacy of the trochanteric flip osteotomy with surgical hip dislocation technique in selected displaced acetabular and femoral head fractures with clinico-radiological outcome and potential complications. Materials and methods: We retrospectively reviewed 32 patients from January 2009 to June 2014. Selected displaced acetabular fractures with comminution and/or cranial extension of posterior wall, marginal impaction, intraarticular fragment, femoral head fractures and hip fracture-dislocations were operated by this modified approach of trochanteric flip osteotomy and surgical hip dislocation. Patients were evaluated for fracture reduction, femoral head viability, trochanteric union, abduction power, and functional evaluation was done by Merle d’Aubigné-Postel scoring system. Minimum follow-up was 24 months. Results: Reduction was judged to be anatomical in 84.38% of cases, and within 1-3 millimetres in 9.38% of cases. All osteotomies healed in an anatomical position. Heterotopic ossification was found in 2 patients limited to Brooker class I. Osteonecrosis developed in 1 patient. 2 patients developed arthritis of the hip as sequelae of poor reduction. Abduction power was MRC 5/5 in all except in 1 patient (4/5). Mean Merle d’Aubigné-Postel score was 16.18; overall good to excellent result was achieved in 87.5% of cases. Conclusions: Trochanteric flip osteotomy with surgical dislocation allows better intraarticular assessment, control of intraarticular fragments, assists accurate reduction and the fixation of complex acetabular and femoral head fractures, without compromising femoral head vascularity and abductor strength. This technique has provided excellent midterm results in the management of complex injuries around the hip.

Traumatic Pubic-type Anterior Dislocation of the Hip with an Ipsilateral Greater Trochanter Fracture: Case Report and Review of Literature

Due to the inherent stability of the hip joint, hip dislocations constitute a relatively small proportion of all the traumatic dislocations encountered in the emergency department. Among them, the anterior type of hip dislocation is less common than the posterior type of dislocation. Anterior dislocations are usually associated with an injury to other, nearby structures like the acetabulum and femoral head. An ipsilateral greater trochanter fracture with anterior hip dislocation is very sparsely reported in the literature. We report the case of a pubic type of anterior hip dislocation associated with a concomitant ipsilateral greater trochanter fracture. The joint was reduced promptly with traction-countertraction under sedation, and the associated fracture was subsequently fixed with two 6.5 mm partially threaded, cannulated, cancellous screws. The patient was symptom-free at the last follow-up of one year with a full range of hip joint motion, and without any evidence of osteonecrosis or osteoarthritis. The mechanism of greater trochanter fracture in such injuries and its management has been discussed.

Functional outcome of extra-articular distal humerus fracture fixation using a single locking plate: A retrospective study:

Purpose: The optimal method for fixation of extra-articular distal humerus factures poses a management dilemma. Although various plate configurations have been proposed, anatomic shaped extra-articular distal humerus locking plates have emerged as a viable solution for these complex injuries. We assessed clinico-radiologic outcome in our retrospective case series of extra-articular distal humerus fractures managed with these plates. Methods: Forty-five patients of extra-articular distal humerus fractures, who were operated at our level 1 trauma centre between January, 2012 and December, 2016, were identified. After exclusion, 36 patients were available for the final assessment. All patients were operated with the triceps-reflecting modified posterior approach. Regular clinico-radiologic follow-up was done evaluating elbow functionality, fracture union, secondary displacement, non-union, implant failure and any complications; Mayo Elbow Performance score (MEPS) was used for the final functional assessment. Results: Twenty-four (66.7%) male and 12 (33.3%) female patients constituted the study group, who had an average follow-up of 15 months. Preoperatively three patients and post-operatively one patient had radial nerve palsy; all had neurapraxia and recovered completely. Overall, 34 (94.4%) patients were adjudged to have complete radiological union within 3 months; 2 (5.5%) patients developed non-union. Mean flexion achieved was 122.9° ± 23°, and mean extension was −4.03° ± 6.5°; 1 patient with head injury developed flexion deformity of 45°. Average MEPS at the final follow-up was 90.8° ± 9.9°. Conclusion: Stable reconstruction and early initiation of physiotherapy are utilitarian to envision optimal outcome; the use of precontoured extra-articular distal humerus locking plates has yielded satisfactory results with minimal complications in our hands.

Proximal humerus fracture dislocation leading to axillary artery injury in an young adult: Case report of an unusual presentation

Proximal humerus fractures constitute five percent of all fracture cases. Though rare, severely comminuted proximal humerus fractures can cause injury to neurovascular structure. Majority of these injuries reported in literature were in elderly age group from low velocity injury owing to loss of elasticity of vessel wall. We report a case of proximal humerus fracture dislocation associated with axillary artery injury in a young male due to fall of heavy iron object. Timely exploration and removal of impinging bone fragment restored the blood supply. The purpose of this report is to heighten the clinical suspicion of the vascular injury in patients with proximal humerus fracture dislocations in all age groups.

CT based management of high energy tibial plateau fractures: A retrospective review of 53 cases

Objectives The management of high energy tibial plateau fractures is a surgical challenge. Recently described Luos classification is based on CT scans and is more objective with a better inter-observer agreement as compare to Schatzker and AO/OTA classifications. We describe the functional results of a series of 53 cases classified and managed according to the Luos column concept. Methods A retrospective review of 53 high energy tibial plateau fractures, operated between January 2012 and March 2015 at a Level I trauma center, was performed. CT scans were used to classify these injuries based on the number of columns involved. Plating configuration and surgical approach were chosen based on the number of independent articular fragments on axial sections at the level of fibular head. Results 1 one-column, 51 two-column and 1 three-column fractures were studied. Triple plating was done in 5 patients. Mean follow-up was 2.7 years and mean Insall Knee score was 95.42. Four patients had varus malalignment and 1 had joint depression in the post-operative period. These were due to imperfect reduction during the surgery itself, and no case of late collapse was detected. Conclusion Utilizing Luos classification for treating these complex injuries will assist in better understanding of fracture pattern and hence help in achieving a better functional outcome. Each fractured column needs to be independently addressed.

Unusual association of elbow dislocation with humeral biepicondylar fracture in a child: A case report and review of literature

Humeral biepicondylar fracture with elbow dislocation is an unusual pattern of injury encountered in paediatric population. We reported a case of humeral biepicondylar fracture-dislocation of elbow in a 11-year-old boy, who presented with tender, swollen, and deformed left elbow following fall on his outstretched hand. Roentgenographic and CT evaluation confirmed the diagnosis, and also showed incarcerated medial epicondylar fragment. Closed reduction was unsuccessful; open reduction and internal fixation was performed with headless screws. Avulsed medial collateral ligament was repaired with suture anchor. Following 4 weeks of immobilization, physiotherapy was started. The child regained satisfactory range-of-motion of the elbow with complete bony union within 3 months. Two years following operation, the child is asymptomatic, with pain free stable elbow. High index of suspicion and astute clinical and radiological assessment is utilitarian for timely diagnosis and appropriate management. Open reduction and internal fixation is believed to be pivotal to restore elbow stability and functionality.