Posterior cruciate ligament tibial insertion avulsion,management by open reduction and internal fixation using plate and screws through a direct posterior approach

PurposeThe purpose of our study was to evaluate the clinical and radiological outcomes after ORIF of PCL tibial insertion avulsion through the modified direct posterior approach using a small set plate and screws.MethodsBetween January 2017 to September 2019, 31 patients with isolated PCL tibial insertion bony avulsion were identified. Twenty-one (68%) patients presented within one week of the injury, 8 (26%) patients presented after injury by a mean 7.5 weeks (range 3:12), and two (6%) patients presented late at 7- and 9-months after injury.ResultsThe mean age was 28.3 ± 6.3 years, 26 (84%) males, and 5 (16%) females. The mean operative time was 39.8 ± 7.9 min. In all patients, a one-third tubular plate was used. Fracture union was achieved in all patients after a mean 8 ± 2.1 weeks. The mean knee flexion at last follow up was 120.7° ± 4.3 with full extension in all patients. The knee Lysholm scoring was excellent in 27 (87%) patients, good in 3 (10%) patients, and fair in one (3%); the mean score was 93.4 ± 3.9. The PDT was positive in 4 patients (13%), three grade I, and one grade II. No neurovascular bundle or hardware related complications were reported. Two (6.5%) patients had a superficial wound infection with no further intervention.ConclusionUsing small set plates and screws for ORIF of PCL tibial avulsion fractures through a direct posterior approach revealed good results in terms of surgical exposure, safety, radiological and clinical outcomes.     

A mid-term follow-up retrospective evaluation of tarsometatarsal joint fracture-dislocations treated by closed reduction and percutaneous K-wires fixation

IntroductionInjuries involving the tarsometatarsal (TMT) joint are relatively uncommon, and the surgical treatment is potentially characterized by a high complications rate. The purpose of this study is to evaluate the results of the treatment of Lisfranc fracture-dislocations treated with closed reduction and percutaneous fixation with K-wires, considering complications and re-intervantion rate.Materials and methodsA retrospective review was performed on all patients undergone closed reduction and percutaneous fixation with K-wires of a Lisfranc fracture-dislocation. Patients have been clinically evaluated at last follow up by American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Visual Analogue Scale (VAS), as well as by radiograph assessment.ResultsFollowing inclusion and exclusion criteria, 15 patients have been included, with a mean age of 48.2 ± 5.6 years. Average follow-up was 3.8 ± 1.8 years (range 1–6). 7 fractures analyzed were classified as type A, 7 as type B (3 were B1, 4 were B2) and 1 as type C1. No case of loss of reduction has been observed at radiographic 1-month follow-up. At last follow-up mean AOFAS midfoot score and VAS score were respectively 82.2 ± 10.4 and 1.5 ± 1.3. Registered complications showed one deep vein thrombosis and 2 cases of complex regional pain syndrome (CRPS). One patient subsequently underwent arthrodesis of the tarsometatarsal joint for post-traumatic arthritis.ConclusionsThe treatment of the fracture-dislocations of the Lisfranc joint by percutaneous reduction and fixation with K-wire can achieve good clinical outcomes with a low rate of complications and reoperations.Level of EvidenceLevel IV     

Hallux Valgus: A modified Kramer osteotomy

ObjectiveThe purpose of this study is to evaluate the outcomes for surgical treatment of Hallux Valgus deformity with the use of modified Kramer osteotomy.MethodsFrom January 2003 to January 2005, 101 (23 bilaterally) modified Kramer osteotomies were performed in 78 patients evaluated clinically (74 of 78) with a phone interview and radiographic assessment with a mean follow up of 23.3 ± 6.9 months.ResultsThe average grade of satisfaction score was 7.9 ± 2.0 (0–10). 82.4% of patients would come back to be operated by the same surgery if necessary, 6.7% needed special shoes, 21.6% needed insoles, 87.8% practiced sports activity. The postoperative radiographic assessments in metatarsophalangeal, intermetatarsal, distal metatarsal articular angle and sesamoid reduction showed a significant change (p < 0.001), compared with the preoperative values. Complications: 1.2% vein thrombosis, 1.2% deep infection, 6.7% recurrences and 17.8% hipercorrected distal metatarsal articular angle.ConclusionThe modified Kramer osteotomy enables a good correction in mild and moderate HV deformity with low rate of complications.     

Glenoid neck length in a healthy population and its association with scapular notching

BackgroundScapular notching is a radiographic finding associated with the use of a reverse shoulder prosthesis. The morphological characteristics of the glenoid neck have been scarcely explored as a relevant factor in relation to scapular notching. The objective of this study is to measure the length of the glenoid neck in a three-dimensional CT reconstruction of a healthy population and to simulate the scapular notching free range of motion for the “long neck” and for the “short neck” groups.MethodsCT scans of 214 shoulders were reviewed, excluding incomplete, poor quality, or altered studies. 100 CT scans were finally processed. The mean age was 51.7 years (SD 19.4; range, 15–84 years), with 49 female and 51 male patients. For each of the scapulae, four morphometric measurements were obtained: anterior glenoid neck (AGN), middle glenoid neck (MGN), posterior glenoid neck (PGN) and alternative posterior glenoid neck (aPGN). Using 3D software, we simulated a reverse shoulder prosthesis, and the scapular notching free range of motion was registered. Differences between measurements were evaluated with an unpaired t-test using StataIC16®. P-values < 0.05 were considered significant. The intraobserver and interobserver correlation was evaluated with the intraclass correlation coefficient.ResultsThe AGN measured 7.43 ± 2.52 mm (range, 1.72–13.3 mm); MGN measured 8.05 mm ± 1.93 (range, 2.92–13.2 mm); PGN measured 7.26 ± 2.6 mm (range, 2–13.4 mm); and aPGN measured 8.97 ± 2.3 mm (range, 4.08–15.4 mm). The scapular notching free range of motion for the “long neck” group was 74.98° ± 7.35 (range, 55–83°) and for the “short neck” group, it was 62.93° ± 6.84 (range, 45–70°) (p = 0.0004).ConclusionsMeasurement of posterior glenoid neck length exhibits excellent reliability and reproducibility, as well as being associated to the scapular notching free range of motion.Study designBasic, retrospective, CT images research.     

The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using minimal invasive deltoid-splitting approach

BackgroundThe purpose of this study was to evaluate the incidence and risk factors for axillary nerve injury after plate fixation of humeral fractures using minimal invasive deltoid-splitting approach. We hypothesized that the use of medial support screw (MSS) would be associated with the outcome of axillary nerve injury.MethodsThis study retrospectively evaluated consecutive 32 patients who underwent surgical treatments for proximal or midshaft humeral fractures. Of them, we included 26 patients who were examined by electromyography/nerve conduction (EMG/NCV) study at 3–4 weeks postoperatively. We excluded 6 patients because two of them were not compliant to EMG/NCV and the remaining two died due to unrelated medical illness. Outcome assessments included pain, functional scores, range of motion, and radiographic results.ResultsThere were 8 male and 18 female patients with mean age of 67 ± 15 years. Mean duration of follow-up period was 31 ± 11 months. The mean time to EMG/NCS after surgery was 3.5 ± 0.6 weeks. EMG/NCS examinations revealed incomplete axillary nerve injury in 8 patients (31%) without complete nerve injury. Active forward elevation at 3 months postoperatively was significantly lower in patients with axillary nerve injury than in those without it (99° ± 12 and 123° ± 37, respectively, p = 0.047), although final clinical outcomes were not different. At surgery, MSS was used in 17 patients (65%), and 8 of them were associated with nerve injury. The use of MSS was only correlated with the outcome of axillary nerve injury, because the axillary nerve injury developed only in MSS group (p = 0.047). The MMT grade 4 in abduction strength was more common in patients with axillary nerve injury than in those without (p = 0.037).ConclusionsAxillary nerve injury was a concern after plate fixation of proximal humeral fracture using minimal invasive deltoid-splitting approach. The use of medial support screw to improve the stability could increase a risk of axillary nerve injury when used with this approach.     

Presence and magnitude of anterior physeal separation in slipped upper femoral epiphysis helps identifying those at high risk for avascular necrosis

AimsWe sought to determine if the magnitude of anterior physeal separation (APS) in slipped upper femoral epiphysis was a predictor for the subsequent development of avascular necrosis (AVN). Anterior Physeal Separation (APS) is defined as the distance between the anterior lip of the bony capital epiphysis and the lateral corresponding point of the adjacent bony metaphysis on the Lauenstein radiographic view. It represents hinging of the posterior aspect of the metaphysis with the anterior epiphysis lifting away from its adjacent metaphysis, indicating instability and potential vulnerability of the vessels.Patients and MethodsA retrospective review of all patients treated regionally for slipped upper femoral epiphysis over a 9 year period (2010–2018 inclusive) were identified. Data regarding demographics, radiological parameters and outcomes was recorded. APS was measured on a Launestein radiograph view, with the patient supine, the hip and knee are flexed to 40°, and the hip externally rotated 45°, with film-focus distance of 100 cm. Analysis of the APS was performed to validate a threshold above which AVN occurs.ResultsWe identified 147 hips in 142 patients, of which 5 had bilateral slips at the time of presentation. Average anterior physeal separation was 3.8 ± 1.8 mm, with higher grade slips having significantly greater APS values. Increased APS values were seen with Loder “unstable” slips. Seven hips (4.8%) developed AVN, and in these cases the APS was significantly larger than those who did not (8.5 ± 1.4 Vs 3.9 ± 1.7; p < 0.001). Receiver operator curve analysis demonstrated a critical value of 7.5 mm was associated with a 100% sensitivity and 98.6% specificity for AVN. We identified some grade II/moderate slips with high APS values had similar outcomes to grade III/severe slips, and therefore suggest that APS may serve to alert the surgeon on counselling patients on the risk of developing AVN and to consider strategies to minimise the risk of AVN.ConclusionsAPS is sensitive, specific, accurate and reliable for the association with AVN in SUFE. Its values closely reflect the high AVN rates seen in acute and unstable SUFE. This risk is greatest if the magnitude of APS exceeds the critical value of 7.5 mm.     

Long-term outcome of primary total hip arthroplasty with cementless bioactive glass ceramic bottom-coated implants and highly cross-linked polyethylene: A minimum 10-year analysis

BackgroundCementless glass ceramics containing apatite and wollastonite (AW-GC) bottom-coated titanium hip implants were developed; early excellent clinical and radiographic results have been reported previously. This study aimed to investigate the long-term clinical and radiographic outcomes in detail, and the wear rate of HXLPE.MethodsWe retrospectively evaluated 99 patients (117 hips) between November 2001 and December 2007. The survival rate was estimated using the Kaplan–Meier method. Hip joint function was evaluated using the Japanese Orthopaedic Association (JOA) score. The extent of radiographic signs was determined from the radiographs performed at the last follow-up. Polyethylene wear was measured using Martell's Hip Analysis Suite. We assessed the possible factors affecting the steady-state linear wear rate.ResultsThe mean follow-up period was 14.8 ± 2.1 (10–18.6) years. The mean JOA score improved to 88.7 ± 9.4 (59–100) at the final follow-up from 47.8 ± 12.5 (17–76) before surgery. The overall survival rate with the end point of all-cause revision and wear-related revision was 99% and 100% respectively. There was no osteolysis or loosening of either the acetabular or femoral component. All hips were classified as having bone ingrowth fixation. The mean steady-state wear rate was 0.008 ± 0.025 mm/year. We found no significant correlation between the wear rate and age, body weight, body mass index, cup inclination and femoral head size.ConclusionThe combination of AW-GC bottom-coated implants and HXLPE showed excellent implant survival and wear resistance for 15 years.     

Classification of femur trochanteric fracture: Evaluating the reliability of Tang classification

IntroductionGiven the drawbacks of a femoral intertrochanteric fracture classification based on 2-dimensional radiographic imaging, an artificial intelligence-based classification system— the Tang classification system—which uses 3-dimensional image analysis, has previously been developed. This study explored the reliability of the Tang classification by comparing the consistency of this classification with the conventional 2-dimensional femoral intertrochanteric fracture classification systems.MethodsX-ray and computed tomography (CT) data of 258 patients with femoral intertrochanteric fractures were classified by 6 orthopedic surgeons using the Evans, Jensen, AO/OTA, and Tang classification systems on 2 separate occasions, 1 month apart. Kappa statistics were used to evaluate the inter- and intraobserver differences in classifications.ResultsWhen the interobserver reliability was based on X-ray image analysis, the Kappa values for the Evans, Jensen, AO/OTA, and Tang classifications were 0.54 ± 0.03 (moderate agreement), 0.53 ± 0.02 (moderate agreement), 0.46 ± 0.02 (moderate agreement), and 0.63 ± 0.02 (substantial agreement), respectively. When the interobserver reliability was based on CT images, the Kappa values of the Evans, Jensen, AO/OTA, and Tang classifications were 0.49 ± 0.03 (moderate agreement), 0.49 ± 0.03 (moderate agreement), 0.44 ± 0.03 (moderate agreement), 0.64 ± 0.02 (substantial agreement), respectively. For X-ray images, the intraobserver Kappa values for the Evans, Jensen, AO/OTA, and Tang classification were 0.53 ± 0.02 (moderate agreement), 0.54 ± 0.03 (moderate agreement), 0.45 ± 0.03 (moderate agreement), and 0.65 ± 0.03 (substantial agreement), respectively. When intraobserver reliability was based on CT images, the Kappa values for the Evans, Jensen, AO/OTA, and Tang classification were 0.52 ± 0.03 (moderate agreement), 0.52 ± 0.02 (moderate agreement), 0.41 ± 0.02 (moderate agreement), and 0.63 ± 0.03(substantial agreement), respectively.ConclusionsThe current study suggests that the Tang classification system is more reliable than the Evans, Jensen, and AO/OTA classification systems for measuring intertrochanteric fractures of the proximal femur.     

An early experience of the use of dual mobility cup uncemented total hip arhroplasty in young patients with avascular necrosis of the femoral head

IntroductionTHA (Total hip arthroplasty) in advanced grade (grade 4) avascular necrosis (AVN) is a challenge to the treating surgeon as it affects young patients who have high functional demands and increased dislocation risk. The aim of the study was to evaluate the efficacy, survivorship, and dislocation rate of uncemented dual mobility cups (DMC) in advanced grade IV AVN young patients.MethodsRetrospective cohort study involving 204 DMC THA for advanced grade IV AVN from January 2013 to December 2015. The sample size of the study was estimated to be 188 hips with an α error of 0.05 and β error of 0.2. Inclusion criterion was patients less than 55 years of age with advanced grade IV AVN. Patients >55 years of age, patients diagnosed with primary osteoarthritis of the hip and hip fracture were excluded from the study. 172 patients (32 with bilateral & 140 with unilateral affection) with 204 DMC THA were evaluated clinically by Harris Hip Score (HHS) and radiologically at a follow up of 60 months. P value < 0.05 was considered significant.ResultsMean age of the patients was 42.5 ± 5.3. Preoperative HHS was 50.6 ± 10.5. Postoperative HHS at 5 years follow up was 96.4 ± 2.6. None of the operated patient had any dislocation episode or had undergone hip revision surgery (statistically significant against historical control of 2%, p value = 0.042). The radiological evaluation at 5 years showed no signs of radiolucent lines, periprosthetic osteolysis, polyethylene wear and signs of displacement or migration of the DMC. Cumulative survivorship rate at 5 years follow up was 100% without any revision/dislocation.ConclusionUse of DMC THA in young, advanced grade IV AVN patients was found to be a reliable option showing excellent early functional results with no dislocation. Ongoing follow up of this cohort is required to confirm the maintenance of these excellent functional results at follow up in the long term.     

Acute high-grade acromioclavicular dislocations treated with triple button device (MINAR): Preliminary results

ObjectiveDescribe the clinical and radiological results of triple button device in the treatment of high-grade AC dislocations (Rockwood, type V) and assess whether improves vertical and horizontal stability compared to the techniques previously described.Material and methodsThis retrospective study included 39 patients with type V acromioclavicular dislocations treated with Twin Tail TightRope™ system (triple button device). Of the 39 patients, 33 (26 men and 7 women) were able to participate in clinical and radiographic follow up. At the time of surgery, the mean age was 25 years ± 7 (range, 17–49). All patients underwent bilateral-weighted Zanca (CC distance) and Alexander view (AC distance) as well as the Constant Score (CS) and Acromioclavicular Joint Instability Scoring System (ACJI). Radiological and clinical outcome was assessed during routine follow-up examinations preoperatively, postoperatively, 1, 3, 6 months and every year after the surgery. The presence of calcification, degenerative changes, mobilization of implants and bone resorption were also assessed.ResultsAfter a mean follow up of 25 ± 4 months (range 14–38), the results of the Constant (CS) were 94.1 ± 5,5 (range 76–100) and test ACJI 87.3 ± 9,8 (range 65–100), showing no significant differences with the uninjured shoulder (CS 95.8 ± 2.5, range 83–100; ACJI 94.1 ± 3.7, range 80–100). At final review, we observed that preoperative coracoclavicular distance (Zanca View) improved from 21,75 ± 1.97 mm to 8,73 mm ± 0.75 and the acromioclavicular distance (Alexander View) from 12,65 mm ± 1.99 to 0,35 ± 0.3 mm. Compared with healthy shoulder, these differences were not significant. There was no loss of reduction with this system in the vertical plane. 4 patients (12.12%) revealed signs of posterior instability with worse clinical test results. The presence of degenerative joint changes (6,06%), calcifications (27,2%) or mobilization of the implant (18,18%) was not associated with worse clinical outcomes.ConclusionTwin Tail device using minimally invasive technique improves stability in the vertical and, specially in the horizontal plane relative to the previously described techniques without increasing number of complications.     

Outcomes of modified chevron osteotomy for hallux valgus

PurposeThis study aimed to detect the effect of a modified chevron osteotomy on hallux valgus (HV) deformity at five-year follow up.MethodsTwenty patients with symptomatic HV who underwent modified chevron osteotomy between June 2014 and January 2016 were included in the present study. The minimum follow-up duration was five years. Each patient was evaluated preoperatively, six weeks postoperatively and five years postoperatively using the visual analog scale (VAS) pain score, the American Orthopedic Foot & Ankle Society (AOFAS) score and cosmetic and radiological outcomes.ResultsThe AOFAS score improved from 54.40 ( ± 4.58) preoperatively to 94.30 ( ± 2.15) six weeks postoperatively (p < 0.001) and 96.95 ( ± 1.54) five years postoperatively (p < 0.001). The VAS scores decreased from 6.30 ( ± 1.17) preoperatively to 0.15 ( ± 0.37) five years postoperatively (p < 0.001). The mean intermetatarsal angle improved from 16.00° ( ± 2.20°) preoperatively to 4.15° ( ± 1.22°) six weeks postoperatively (p < 0.001) and 4.40° ( ± 1.39°) five years postoperatively (p < 0.001). The mean HV angle also improved, from 32.70° ( ± 5.34°) preoperatively to 4.80° ( ± 1.40°) six weeks postoperatively (p < 0.001) and 5.20° ( ± 1.32°) five years postoperatively (p < 0.001). The cosmetic results were either excellent or good in 19 patients (95%). There was no recurrence in this study during the five postoperative years.ConclusionA modified chevron osteotomy can achieve successful correction of moderate-to-severe HV, with excellent outcomes at five-year follow up.     

Medial meniscus posterior root repair prevents the progression of subchondral insufficiency fracture of the knee

BackgroundMedial meniscus posterior root tear (MMPRT) causes medial meniscus extrusion (MME) and leads to subchondral insufficiency fracture of the knee (SIFK). However, the progression of SIFK after MMPRT pullout repair remains unknown. This study aimed to investigate the progression of SIFK and compare clinical outcomes in patients with SIFK to those without SIFK after MMPRT pullout repair. We hypothesized that the progression of SIFK would be prevented by MMPRT pullout repair, and clinical outcomes would improve in all patients.MethodsThe SIFK grade (1–4) was evaluated using T2-fat suppression magnetic resonance imaging. Thirty-eight patients without SIFK (n = 22) and with low-grade SIFK (1 and 2; n = 16) who underwent MMPRT pullout repair were included. Preoperative factors, such as the duration from injury to the time of magnetic resonance imaging/surgery (weeks), femorotibial angle (degree), MME (mm), and clinical outcomes were evaluated, as well as the progression of SIFK.ResultsSIFK was identified in only 9 patients (grade 1) postoperatively. Significantly improved clinical outcomes were observed in all patients. Preoperative femorotibial angle, MME, and duration from injury to the time of magnetic resonance imaging/surgery were 177.1 ± 1.5°, 3.2 ± 1.6 mm, and 6.4 ± 7.0/10.1 ± 7.5 weeks, respectively. No significant difference in preoperative factors and clinical outcomes was observed between patients with SIFK and those without SIFK.ConclusionsMMPRT pullout repair prevented the progression of low-grade SIFK and improved clinical outcomes in all patients, although bone contusions (grade 1 SIFK) were not completely healed within 1 year. MMPRT pullout repair could be a good treatment option for optimizing clinical outcomes in patients with low-grade SIFK.     

Transfibular ankle arthrodesis with use of sagitally split fibula as a biological plate leads to excellent outcome: A retrospective analysis

BackgroundWe studied ankle arthrodesis with a transfibular approach using sagitally spilitted fibula as a biological plate (onlay grafting) as well as other half of fibula as morcellised local interpositional graft (inlay grafting) to achieve bony union.Material and methodsRetrospective clinico-radiological evaluation of 36 operated cases was done at 3, 6, 12 and 30 months follow-ups. Clinically union was considered once ankle became pain free on full weight bearing. Pain assessment was done by using VAS (visual analogue scale) score and functional evaluation was done by AOFAS (American Orthopaedic Foot & Ankle Society) hind foot score preoperatively and at different follow ups. Radiologically, sagittal plane ankle alignment and fusion status was determined at each follow up.ResultsMean age of patients was 40.36 ± 10.56 years (range 18–55), who were evaluated for mean duration of 33.32 ± 11.25 months (range 24–65). Thirty-three (91.7%) ankles were fused adequately and mean duration to achieve bony union was 5.09 ± 1.3 months (range 4–9 months). Mean post-operative AOFAS score at final follow up was 76.65 ± 4.87 in comparison to 45.76 ± 3.38, preoperatively. VAS score improved significantly from 7.8 (pre-operative) to 2.3 (final follow-up). Non-union in three patients (8.3%) and ankle malalignment in one patient was observed.ConclusionTransfibular ankle arthrodesis achieves excellent bony unions and functional outcomes in severe ankle arthritis. Biologically incompetent fibula that to be judged individually by the operating surgeon to use it as a graft. Patients having inflammatory arthritis have more dissatisfaction than other aetiologies.     

Ankle conFUSION: The quality and readability of information on the internet relating to ankle arthrodesis

BackgroundThe internet is an important source of information for patients undergoing surgery. Multiple studies have identified inappropriately high reading levels of patient information online. The average reading level in the United States is 7–8th grade. Multiple organisations have recommended that patient information not exceed 6th grade level. This study aims to evaluate the reading levels and quality of information regarding ankle fusion surgery online.MethodsGoogle, Bing and Yahoo were searched (MeSH “ankle fusion”, “ankle arthrodesis”) and the top 30 URLs analysed. Readability was assessed using an online readability calculator to produce 3 scores (Gunning FOG, Flesch Kincaid Grade and Flesch Reading Ease). Quality was assessed using a HONcode detection web-extension and the JAMA benchmark criteria.ResultsNinety-eight webpages were identified. The mean Flesch Kincaid Grade level was 9.24 ± 2.33 (95% CI 8.78–9.71). The mean Gunning FOG grade was 10.88 ± 3.1 (95% CI 10.26–11.5). The mean Flesch Reading Ease score was 49.88 ± 14.46 (95% CI 46.98–52.78). 7 webpages were at or below the 6th grade reading level. The mean JAMA score was 1.34 ± 1.32 out of 4 (95% CI 1.07–1.6). 14 websites were HONcode accredited.ConclusionThe overall readability of medical information online is too high for the average patient. Given the important role that health literacy provides in patient reported outcomes, improving the readability and quality of these materials is imperative. Awareness by the general public is essential for them to critically appraise the information they receive online.     

Outcomes of topical phenytoin in the management of traumatic wounds

IntroductionRegular dressing of traumatic wounds is of paramount importance for healing. Phenytoin, an anticonvulsant, is thought to promote wound healing through multiple mechanisms, including fibroblast proliferation, granulation tissue formation, antibacterial activity, and pain alleviation.AimTo assess the effect of topical phenytoin on traumatic wound healing in terms of granulation tissue formation, pain alleviation, and time taken for wound healing.MethodologyFifty patients with traumatic wounds were divided into equal and comparable groups. After cleaning the wound, phenytoin dressing was done in the study group and saline dressing in the control group. Thereafter, regular dressings of the wounds were done, and healing was assessed on day 14 and day 21.ResultsOn day 14, the wound surface area, percentage of granulation tissue, VAS score amongst cases was 39.4 ± 29.75 cm², 82.12 ± 9.71%, 4.52 ± 1.08, and that of controls was and 51.28 ± 25.33 cm², 62.72 ± 9.01%, 6.52 ± 1.22, respectively. On day 21, the wound surface area, percentage of granulation tissue, VAS score amongst cases were 29.4 ± 29.88 cm², 92 ± 4.46%, 2.8 ± 0.94, and that of controls were 38.92 ± 23.24 cm², 78.56 ± 8.19%, and 4.88 ± 1.17, respectively. The time taken for wound healing was 21.76 ± 5.28 days amongst cases and 31.64 ± 8.31 days amongst controls. Staphylococcus aureus was the commonest organism isolated in both the groups. On day 14,18(72%), wounds in the study group showed negative culture, whereas, in the control group, it was negative in 12 (48%) patients. The rate of granulation tissue formation was higher in cases when compared to controls amongst smokers and diabetics. The difference in all these parameters between the groups was statistically significant (P-value <0.05).Discussion and conclusionWe observed a considerable increase in granulation tissue formation, pain alleviation, and reduction in time taken for wound healing. Topical phenytoin is a safe, effective, readily available, and frugal agent that can accelerate wound healing through its multimodal action, thus reducing patient morbidity and economic burden.MeSH termsPhenytoin, Wound healing, Topical, Ulcer, Anticonvulsant, Granulation Tissue, Saline dressing.     

Lateral column lengthening (LCL) using a rectangular shape graft for managing symptomatic flexible flatfoot showed acceptable early functional and radiological outcomes

Purpose: We aimed to report the results of performing lateral column lengthening (LCL) using a rectangular-shaped graft to correct the flat foot deformity. Methods: A total of 28 feet of 19 patients (10 males, 9 females) having an average age of 10 ± 3.2 years who were unresponsive to conservative management underwent flat foot deformity correction through LCL procedure supplemented with rectangular-shaped graft harvested from the fibula. Functional assessment was performed according to the American Orthopedic Foot and Ankle Society (AOFAS) scale. The radiographic assessment consisted of four parameters, Meary’s angle in both anteroposterior (AP) and lateral (Lat.) views, calcaneal inclination angle (CIA), and calcaneocuboid angle (CCA). Results: After an average of 30.2 ± 8.1 months, the AOFAS improved significantly from 46.7 ± 10.2 preoperatively to 86.7 ± 9.5 at the last follow up (P < 0.05). All the osteotomies showed healing at an average of 10.3 ± 2.7 weeks. All the radiological parameters showed significant improvement at the last follow up compared to the preoperative measurements, CIA from 6.3 ± 2.8–19.3 ± 3.5, Lat. Meary's angle from 19.3 ± 4.9–5.8 ± 2.5, AP Meary’s Angle from 19.3 ± 5.8–6.1 ± 3.1, and CCA from 23.9 ± 8.2–6.8 ± 4.5, (P < 0.05). No pain at the site of the fibular osteotomy was reported in any of the patients. Conclusion: Lateral column lengthening using a rectangular graft effectively restores bony alignment with good radiological and clinical results, high patient satisfaction, and acceptable complications.     

Percutaneous bridge plating of extra-articular distal fibular fracture for the management of distal tibia type III open fracture

PurposeThe aim of this study is to conduct clinical and radiographic evaluations of the use of percutaneous bridge plating for distal fibular fractures combined with distal tibia type III open fractures.MethodsThirty-four patients with acute distal third fibular shaft fractures (4F2A_(c) and 4F2B_(c) according to the AO/OTA classification) combined with distal tibia type III open fractures were enrolled. Concurrent fibular fractures were fixed with the percutaneous bridge plating simultaneously, while distal tibia open fractures were temporally stabilized with a spanning external fixator. Clinical and radiographic outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the proportional length difference of the fibula, the talocrural angle, the union rate of the fibula and tibia, the operation time, and complications at the final follow-up.ResultsAll fibular fractures healed with an average bone healing time of 20.7 ± 6.3 weeks (range, 16–35). The mean proportional length difference was 0.492 ± 0.732% compared with that in the uninjured fibula. The functional assessment result according to the LEFS was 74.0 ± 3.70 points (range, 57–80). No cases of fibula fracture infection developed throughout the follow-up period in any of the patients. Iatrogenic postoperative superficial peroneal nerve injury was not found in any of the patients.ConclusionWith the perspective of minimizing soft tissue problems due to high-energy trauma, the application of percutaneous bridge plating for the treatment of distal fibular fractures can be an alternative to conventional treatment methods.     

Combined plate and nail fixation of bicondylar tibial plateau fractures

IntroductionBicondylar tibial plateau fractures with meta-diaphyseal comminution commonly have a compromised soft tissue envelope. Combined plate-nail fixation is an emerging technique that utilizes a limited anterolateral approach for plate application and percutaneous incisions for placement of an intramedullary nail. This technique alleviates the need for a separate medial approach to the proximal tibia. We report a series of patients treated with this approach and outline the steps for implementation.MethodsWe performed a retrospective review of 18 consecutive patients treated with combination lateral locked plating and intramedullary nailing at a single academic institution from 2016 to 2019. Of these, 16 patients met inclusion criteria and were included in this study. All patients had AO/OTA type 41C2/C3 fractures. Primary outcomes included coronal plane and sagittal plane alignment at latest follow up, rate of articular subsidence at latest follow up, and rate of postoperative infection.ResultsOf the 16 patients included, average followup was 8.2 months (range 0.1-29.7 months). At latest follow-up, average coronal alignment ranged from 0.8±1.2 degrees of varus (maximum 4.0 degrees) to 1.4±1.7 degrees of valgus (maximum 4.0 degrees). Average sagittal alignment ranged from 0.8±1.1 degrees of procurvatum (maximum 3.0 degrees) to 0.6±1.2 degrees of recurvatum (maximum 4.0 degrees). There was no radiographic evidence of articular subsidence at latest follow up for any patient. One patient (5.9%) presented at 141 days postoperatively with a draining wound and infection.ConclusionsCombination plate-nail fixation is a viable option for treating patients with select bicondylar tibial plateau fractures with meta-diaphyseal comminution. This case series with short-term followup demonstrates acceptable radiographic and clinical outcomes, as well as rates of postoperative infection and implant removal similar to those currently reported in the literature for other techniques used to treat these fractures.     

Single-position prone transpsoas fusion for the treatment of lumbar adjacent segment disease: early experience of twenty-four cases across three tertiary medical centers

Purpose

Prone transpsoas fusion (PTP) is a minimally invasive technique that maximizes the benefit of lateral access interbody surgery and the prone positioning for surgically significant adjacent segment disease. The authors describe the feasibility, reproducibility and radiographic efficacy of PTP when performed for cases of lumbar ASD.

Methods

Adult patients undergoing PTP for treatment of lumbar ASD at three institutions were retrospectively enrolled. Demographic information was recorded, as was operative data such as adjacent segment levels, operative time, blood loss, laterality of approach, open versus percutaneous pedicle screw instrumentation and need for primary decompression. Radiographic measurements including segmental and global lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope and sagittal vertical axis were recorded both pre- and immediately post-operatively.

Results

Twenty-four patients met criteria for inclusion. Average age was 60.4 ± 10.4 years and average BMI was 31.6 ± 5.0 kg/m². Total operative time was 204.7 ± 83.3 min with blood loss of 187.9 ± 211 mL. Twenty-one patients had pedicle screw instrumentation exchanged percutaneously and 3 patients had open pedicle screw exchange. Two patients suffered pulmonary embolism that was treated medically with no long-term sequelae. One patient had transient lumbar radicular pain and all patients were discharged home with an average length of stay of 3.0 days (range 1–6). Radiographically, global lumbar lordosis improved by an average of 10.3 ± 9.0 degrees, segmental lordosis by 10.1 ± 13.3 degrees and sagittal vertical axis by 3.2 ± 3.2 cm.

Conclusion

Single-position prone transpsoas lumbar interbody fusion is a clinically reproducible minimally invasive technique that can effectively treat lumbar adjacent segment disease.

     

A review of plain radiographic methods for measuring femoral version after total hip arthroplasty and validation of modified Budin’s method in Indian population

BackgroundMultiple plain radiographic methods; cross table radiographic method, modified Budin method, projected neck-shaft angle method, and trans lateral decubitus view method using Ogata-Goldsand formula, have been described in literature for measurement of femoral stem version (FSV) after total hip arthroplasty (THA).PurposeTo review these multiple radiographic methods and also determine validity and accuracy of modified Budin method in Indian population.Patients and methodsA literature search for different methods described for FSV measurement was performed and these methods were reviewed. In addition, for validation of modified Budin method in Indian population, data was collected for 36 THAs prospectively. A posteroanterior radiograph with patient sitting in 90° hip flexion and 30° abduction was taken 3 weeks and 6 weeks after surgery for calculating the FSV using modified Budin method. At 3 weeks, a CT scan was also done for version measurement. Intra and interobserver reliability, and reproducibility of radiographic FSV measurement, and the correlation between CT scan and radiographic FSV measurement were statistically calculated.ResultsAll the reviewed studies demonstrated that their method is comparable to CT method for FSV measurement, except FSV measured on cross table radiographic view. However, there were only one or at most two studies of every method described except for modified Budin technique. The mean FSV in our prospective case series using ‘modified Budin’ method was 11.6° which was comparable to the mean of CT scan version measurement (12.3°). The mean difference was 0.7° which was not statistically significant (p value > 0.05). In addition, there was high intra-class correlation coefficient in radiographic FSV for both intra- and inter-observer reliability.ConclusionMultiple methods have been described and validated in literature, however, the ‘modified Budin’ view have proved multiple times to have excellent reliability and validity for easy measurement of FSV.