Thilak S. Jepegnanam

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.

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.

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.

Lateral gastrocnemius flap cover for distal thigh soft tissue loss.

BACKGROUND The gastrocnemius muscle flap has been used extensively for cover around the knee. However, the use of the lateral gastrocnemius for cover of the distal thigh has not been well described. METHODS The lateral gastrocnemius flap was used in eight patients from October 2004 to February 2009 for cover of the distal thigh proximal to the knee joint. We included patients who had soft tissue loss secondary to trauma and infection and who required soft tissue cover in the distal lateral thigh (>8 cm proximal to the joint line). The average age of the patients was 40 years (21-64 years). Four patients had soft tissue loss secondary to trauma, two had loss secondary to chronic infection, and two patients had soft tissue loss after surgical infection. RESULTS All patients had resolution of infection at final follow-up. The average area of soft tissue cover achieved was 14 × 9 cm. The maximal proximal extent reached with lateral gastrocnemius flap from the joint line was 17 cm (8-17 cm) measured in full knee extension. There were two complications. One patient developed a common peroneal palsy and infection, which recovered after re-exploration. Another patient developed a sinus, which resolved after removal of a loose screw. CONCLUSION The lateral gastrocnemius muscle flap is effective in the cover of the lateral distal thigh.

Reconstruction of traumatic medial malleolus loss: A case report

We describe the reconstruction of the medial malleolus in a severe open ankle injury with iliac crest bone graft and sural artery flap in a young adult. At two years follow-up he had a good outcome with a painless, stable ankle with nearly full plantarflexion but restricted dorsiflexion.

Isolated, Traumatic Anterior Dislocation of the Radial Head In An Adult

Isolated radial head dislocation in adults is extremely rare and has been predominantly posterior. A case of isolated, acute anterior dislocation of the radial head an adult is reported.A 26-year-old male sustained an isolated radial head dislocation following a fall on the outstretched hand. The dislocation was treated by closed reduction and transcapitellar Kirschner wire fixation.At final follow-up the patient had recovered full range of motion of the elbow. Radiographs of the forearm including elbow and wrist were normal. A management algorithm for this injury is proposed, based on a review of the literature.

Claw Toe Deformity of the Foot due to Foreign Body Granuloma

We present a case of dynamic claw deformity of the right third toe due to a foreign body granuloma adhering to the flexor digitorum longus (FDL) tendon at the level of the body of the metacarpal bone. The deformity was completely corrected after removal of the granuloma and lengthening of the FDL tendon. A 25-year-old woman presented with pain and claw deformity of the right third toe, which corrected with ankle plantar flexion. Ultrasound and magnetic resonance imaging suggested the presence of foreign body granuloma of the right FDL tendon at the level of body of third metacarpal bone. On removal of the granuloma and Z plasty of the FDL tendon, there was complete correction of the claw. In the reported literature, claw deformity is seen with compartment syndrome or ankle fractures due to fixed length phenomenon or checkrein deformity of the flexor tendons usually at the level of medial part of the ankle. Here, we present a case of checkrein claw deformity of the FDL tendon due to a foreign body granuloma. Levels of Evidence: Therapeutic, Level IV: Case study