Sudhir Babhulkar

Osteonecrosis of femoral head: Treatment by core decompression and vascular pedicle grafting

Background: Femoral head-preserving core decompression and bone grafting have shown excellent result in preventing collapse. The use of vascularized grafts have shown better clinical results. The vascular pedicle bone graft is an easy to perform operation and does not require special equipment. We analyzed and report a series of patients of osteonecrosis of femoral head treated by core decompression and vascular pedicle grafting of part of iliac crest based on deep circumflex iliac vessels. Materials and Methods: The article comprises of the retrospective study of 31 patients of osteonecrosis of femoral head in stage II and III treated with core decompression and vascular pedicle grafting by using part of iliac crest with deep circumflex iliac vessels from January 1990 to December 2005. The young patients with a mean age 32 years (18–52 years) with a minimum follow-up of five years were included for analysis. Sixteen patients had osteonecrosis following alcohol abuse, 12 patients following corticosteroid consumption, 3 patients had idiopathic osteonecrosis. Nine patients were stage IIB, and 22 patients were stage IIIC according to ARCOs system. The core decompression and vascular pedicle grafting was performed by anterior approach by using part of iliac crest with deep circumflex iliac vessels. Results: Digital subtraction arteriography performed in 9 patients at the end of 12 weeks showed the patency of deep circumflex artery in all cases, and bone scan performed in 6 other patients showed high uptake in the grafted area of the femoral head proving the efficacy of the operative procedure. Out of 31 patients, only one patient progressed to collapse and total joint replacement was advised. At the final follow up period of 5–8 years, Harris Hip Score improved mean ± SD of 28.2 ± 6.4 (p < 0.05). Forty-eight percent of patients had an improvement in Harris Hip Score of more that 28 points. Conclusion: The core decompression and vascular pedicle grafting reduces the intraosseous tension to achieve early revascularization of ischemic femoral head. The high percentage of marrow and osteogenic cells survive within a vascularized pedicle graft, which helps in early vascularization and we have been able to achieve good outcome.

Role of gamma nail in management of pertrochanteric fractures of femur

Background: Pertrochanteric fractures which involve trochanteric fractures with varying fracture geometry pose a significant challenge to the treating orthopedic surgeon. The aim of this study is to evaluate the management of pertrochanteric fractures of the femur using gamma nail [Asia pacific (AP)]. Materials and Methods: Sixty patients of pertrochanteric fractures were treated by closed reduction internal fixation by gamma nail from 1 January 1993 to 31 December 2000. Four patients were lost to follow-up. The remaining 56 patients were followed for a mean period of 3.2 years (range 2-4 years).The results were evaluated by assessing the patients regarding their clinical and functional outcome at follow-up as per Kyles criteria. Results: Peroperative jamming of nail (n = 1), failed distal locking (n = 1), superior cut out of lag screw (n = 1) and postoperative varus malreduction (n = 1) were the complications observed. End results were excellent in 46.34%, good in 36.58%, fair in 14.64%, poor in 2.43%. Conclusion: Gamma nail in expert hands is a suitable implant for management of pertrochanteric fractures of the femur.

Controversies in the management of intra-articular fractures of distal humerus in adults

Background: The surgical approach, type of olecranon osteotomy, method of stabilization of osteotomy, type of fracture stabilization, orthogonal vs parallel plate fixation, need for transposition of ulnar nerve, place for primary total elbow replacement, and type of rehabilitation schedule after surgical fracture treatment are the controversial issues in the treatment of complex intra-articular distal humerus fractures (C2 and C3) in adults. Severe comminution, bone loss, and osteoporosis at the site of distal articular fractures of humerus often lead to unsatisfactory results due to inadequate fixation. We hereby report the outcome of a series of intracondylar fractures of the humerus treated by open reduction and internal fixation and discuss the controversies in light of published literature. Materials and Methods: One hundred and eighty-four patients of intra-articular fractures of distal humerus (C2 and C3) were operated by posterior transolecranon approach between January 1980 and December 2008. Initially, in the first part Chevron intra-articular osteotomy (n=108) was performed out of which 94 have been published in another publication. In later second part (1993 onward), extra-articular olecranon osteotomy (n=76) was routinely performed. Both columns were stably fixed by orthogonal methods; (n=174) however, during the last 2 years, in 10 patients with severe comminution with bone loss, stabilization was achieved by parallel plating. The osteotomy was routinely stabilized by tension band wiring with two parallel K-wires introduced up to the anterior ulnar cortex. The results were evaluated by the staging system of Caja et al. at a minimum follow-up of 2 years. Results: In the first part of the study (n=94), there was delayed union in 4% (n=4), with the fracture taking more than 20 weeks for union. There was delayed union of ulnar osteotomy (n=3) and failure of one tension band wiring, requiring revision. Some loss of motion was seen in 20% of cases and these patients did not achieve full flexion and extension. However, all these patients had useful range of function, with 20°–110° of flexion and full pronation-supination. As per the staging system of Caja et al., the results were in the range of excellent to good in 72% cases (n=67), fair in 19% (n=18), and poor in 9% patients (n=9). In the second part of study (n=90) dual plate fixation of both columns by orthogonal methods (n=80) and parallel plate fixation in 10 patients was performed. The results were excellent to good in 78 patients (86%). Conclusions: The high rate of union can be achieved in complex intra-articular fractures of distal humerus if the proper principles of stable fracture fixation are followed, i.e., a posterior transolecranon approach and dual fixation of both columns and restoration of the continuity of articular surface. The stability achieved by this technique permits institution of early intensive physiotherapy to restore elbow function.

Recalcitrant aseptic atrophic non-union of the shaft of the humerus after failure of surgical treatment: management by excision of non-union, bone grafting and stabilization by LCP in different modes

Non-union of the humeral shaft is infrequently noticed after surgical fixation. Sixty eight patients whose osteosynthesis of humeral shaft had failed leading to non-union were identified over a duration of 10 years from (January 2006 to December 2015). Clinical and radiographical follow-up was available for 64 patients (4 patients were lost for follow-up), with a mean age of 58 years (range 25-78 years). All patients had aseptic atrophic non-union of either: proximal shaft (n=12), mid shaft (n=38), and lower shaft (n=14). All these patients had failure of primary fixation, with a minimum duration from 36 to 110 weeks. Non-unions were operated by excision of non-union, autogenous bone grafting and osteosynthesis by locking compression plating. Adequate fixation of non-union with bone grafting was achieved in all patients. All non-unions healed well at an average of 16 weeks (range 6-36 weeks). The mean length of follow-up was 120 weeks (range 60-250 weeks). The mean range of movements following healing of non-union was forward flexion of 140°, external rotation and internal rotation of 30° at shoulder and average fixed flexion deformity of 10° and flexion of 130° at elbow. Two patients had postoperative radial nerve palsy because of neuropraxia, which recovered in eight weeks. Three patient developed superficial infections at the iliac crest, which settled with antibiotics, dressings in 3 weeks time and two patients had some discomfort over the fibular graft harvest site. In all patients complete clinical and radiological union was achieved with satisfactory outcome in terms of relief of symptoms and functional improvement in the range of movements. The main points in surgical treatment were complete excision of non-union, correction of deformity, use of plenty of corticocancellous graft, furthermore the use of intramedullary fibula and osteosynthesis by long locking compression plating in different modes of fixation provided good to excellent results and clinical outcome.

Gamma nail in treatment of ipsilateral fracture of shaft and neck of the femur

Background: Ipsilateral fractures of shaft and neck of femur pose a problem of missed diagnosis and management. Method: Forty eight patients of ipsilateral femoral shaft and neck fractures were treated by closed reduction and fixation by Gamma nail. Patients were followed for average period of 48 months. Results: Six femoral shafts and two femoral necks had isolated non unions while one patient had nonunion at both sites. Varus malunion with resultant shortening was seen in six patients. Conclusion: Gamma nail is a good implant to treat ipsilateral fractures of shaft and neck of femur.