This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the “constant fragment” in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures?
Infected nonunion of long bones may require intravenous antibiotics over a lengthy period which may result in a high rate of complications. This study aims to assess the efficacy of local antibiotics used as a replacement to prolonged intravenous therapy. Thirteen patients with infected nonunion of long bones who failed at least one previous surgery were included. The infection was treated through extensive debridement, application of antibiotic-impregnated calcium sulphate pellets and the bone stabilized with external fixation. These patients were monitored for union and infection by clinical signs, laboratory values, and radiographs over a period of 24 months. The results support an eradication of infection and union in all patients with no antibiotic-associated complications. Local antibiotic delivery using calcium sulphate pellets provides an effective method for treatment of nonunion in long bones and is free of the complications from the intravenous route.
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Persico F, Vargas O, Fletscher G, Zuluaga M. Treatment of extraarticular knee extension contracture secondary to prolonged external fixation by a modified Judet quadricepsplasty technique. 2018; 13 (1):19-24.
The goal of this study is to evaluate the functional results of the modified Judet quadricepsplasty for a knee extension contracture secondary to prolonged external fixation. This is a retrospective study of 31 patients with the diagnosis of an extraarticular knee extension contracture who had prolonged external fixation of the femur. Functional assessment was conducted after a minimum follow-up of 1 year. After performing the functional assessment, according to the Judet scale, 51% of the 31 patients had good results and 19.35% (6 cases) showed excellent results. The improvement in mobility from pre-operative to post-operative range of motion was significant. The performance of the technique, following the authors’ described steps and making the subsequent modifications, allowed for partial knee mobility restoration, which significantly improved the patients’ functional status.
Level of evidence: IV. Series of cases.
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Elsoe R, Larsen P, Petruskevicius J, Kold S. Complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported QOL: a prospective observational study of 46 complex tibial fractures treated with a ring fixator. 2018; 13 (1):25-33.
The long-term outcomes following complex fractures of the tibia are reported to carry a risk of knee pain, malalignment, articular injury and post-traumatic osteoarthritis. The main objective of this study was to account for the patient-reported quality of life (QOL) 12 months after ring fixator removal in patients with a complex tibial fracture. Secondary objectives included a review of the socio-economic characteristics of the patient group and the rate of return to work in the study period. A prospective follow-up study was conducted of 60 patients with complex fractures of the tibia treated with ring external fixation. Patient-reported outcomes, radiological outcomes and socio-economic status including employment status of the patients were obtained 12 months after frame removal. Forty-six patients completed the assessment 12 months after frame removal (77%). The mean age of the patient at the time of fracture was 54.6 years (range 31–86). There were 19 males and 27 females. At 12 months after frame removal, the mean EQ5D-5L index was 0.66 (CI 0.60–0.72). The mean EQ5D-5L VAS was 69 (CI 61–76). When this was compared to the established reference population from Denmark, the study population showed a significantly worse EQ5D-5L index. The majority of patients (87%) were in the lower social classes suggesting a higher degree of social deprivation in the study population. Twenty-seven per cent of patients who were employed prior to injury had returned to employment at approximately 19 months following fracture. The onset of post-traumatic osteoarthritis was present in the knee joint in 29% of patients following a proximal intra-articular fracture, whereas osteoarthritis was present at the ankle joint in 35% of patients following a distal intra-articular fracture 12 months after frame removal. This study indicates that at 12 months after frame removal there are poorer patient-reported QOL as when compared to reference populations. Furthermore, this study suggests that complex tibial fractures are associated with lower social classes and that only 27% of patients in this sample, who prior to injury were employed, had returned to employment at approximately 19 months after the injury.
Jagandeep Singh Virk,
Fasciotomy incisions lead to large, unsightly, chronic wounds after surgical intervention. Classic management was to use split-thickness skin grafts, but this leads to insensate skin with reports that as many as 23% of patients are dissatisfied by the appearance of the wound. Since no skin loss has occurred with the fasciotomy incision, utilizing the dermal properties of creep, stress relaxation and load cycling, closure can be achieved in a better way. We describe using dermotaxis for skin edge approximation that is done using inexpensive equipment available readily in any standard operating room. Twenty-five patients had fasciotomy wounds closed either by dermotaxis or a loop suture technique with the inclusion criteria being closed fractures, no concomitant skin loss, fracture-related compartment syndrome and fasciotomy performed within 36 h. The fasciotomy incision was closed in a single stage by loop suture technique or gradually by dermotaxis once the oedema had settled between 3 and 5 days. Results were graded as excellent if approximation could be achieved, good if sutures had to be applied for protective care and poor if wounds needed to be skin-grafted. In the dermotaxis group, results were excellent in 15, good in 8 and poor in 2 cases. In the loop suture technique group, results were excellent in 20, good in 4 and poor in 1 case. Dermal apposition using inexpensive, readily available equipment is an alternative method for closure of fasciotomy wounds. If limb oedema has settled sufficiently, closure using a loop suture can be done in a single stage. If the limb remains oedematous, gradual closure can be done using dermotaxis.
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Teramoto T, Harada S, Takaki M, Asahara T, Kato N, Takenaka N, Matsushita T, Makino Y, Tasiro K, Kazutaka O, Nishi Y, Kinugsa K. The Teramoto distal tibial oblique osteotomy (DTOO): surgical technique and applicability for ankle osteoarthritis with varus deformity. 2018; 13 (1):43-49.
We have devised a medial peri-articular osteotomy, the distal tibial oblique osteotomy (DTOO), and have used this technique since 1994 for ankle osteoarthritis of advanced and late stages associated with varus inclination. This report describes the surgical technique and its applicability. DTOO can be used for cases of varus ankle osteoarthritis with a range of the ankle joint movement of at least 10° or more. The osteotomy is obliquely directed cut across the distal tibia from proximal-medial to distal lateral and is of an opening-wedge type with the centre of rotation coincident with the centre of the tibiofibular joint. A laminar spreader instrument is inserted in the osteotomy to open the wedge until the lateral surface of the talar body is seen on X-ray to be in contact and congruent with medial articular surface of the lateral malleolus. Common obstacles which may prevent this contact and congruency are bony spurs present on the anterior side of fibula or on the lateral side of the tibia; these require removal. The opening-wedge osteotomy is held in position by an Ilizarov external fixator or internally fixed with a plate. Bone graft is taken from the iliac crest and inserted into the open wedge. If, after completion of the osteotomy, the dorsiflexion angle of the ankle joint does not exceed 0°, a Z-lengthening is performed of the Achilles tendon. In the DTOO for ankle osteoarthritis, the contact area of the ankle joint increases and decreases the load pressure per unit area. Furthermore, as the width of the ankle mortice is restored through the realignment of the body of the talus, instability at the ankle joint decreases. There is additional improvement with restoration of the inclination of the distal tibial articular surface as this directs the hindfoot valgus and corrects the alignment of the foot, with consequent improvement of ankle pain.
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Elnahal WA, Fahmy M, Acharya M. Open complete anterior dislocation of the sacro-iliac joint in a 4-year-old boy: a case report of a rare injury with 5-year follow-up. 2018; 13 (1):51-55.
Pelvic fractures are uncommon in children and account for between 0.3 and 7.5% of all pediatric injuries. Open pelvic fractures only account for up to 12.9% of all pediatric pelvic fractures. An unusual case of open complete anterior sacro-iliac joint dislocation in a 4-year-old boy is presented with a long-term follow-up. The multidisciplinary approach is reported with review of the current literature. A 4-year-old male presented to our institution in January 2012 after having been run over by a tractor. He presented with gross hemodynamical instability, MISS of 25, and an unstable lateral compression type III pelvic fracture with complete anterior dislocation of the left hemipelvis and a groin wound extending into the left thigh. The patient was managed in accordance with the ATLS and open fracture guidelines. Reduction in the dislocated SI joint was achieved via a posterior approach to the SI joint, followed by fixation with 2K wires in S1 and S2 sacral segments, with an anterior external fixator. Pelvic asymmetry post-reduction was 0.9 cm, compared to 16 cm post-injury, and asymmetry persisted till final follow-up at 5 years. At 5 years, patient regained full function, including recreational sport activities. Patients scored a 96/96 on the Majeed score (after excluding 4 points for sexual function). We believe that posterior reduction in an anteriorly dislocated SI joint in the pediatric population is a viable option. A coordinated, multidisciplinary approach and restoration of pelvic ring stability can lead to optimal outcome.
Andrew James Hotchen,
Lynne V. Barr,
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Hotchen AJ, Barr LV, Krkovic M. Bridging hard callus at 48 days in an open femoral shaft fracture with segmental defect treated with a first-stage Masquelet technique: I wasn\'t expecting that. 2018; 13 (1):57-60.
The Masquelet technique is a strategy for management of segmental bone defects. It is a two-stage procedure that involves inducing a synovial-like membrane that can be used for a bone graft. Segmental bone defects can occur following trauma and can accompany traumatic brain injury. There is a well-documented, albeit debated, association between traumatic brain injury and increased rate of new bone formation. Here, we present a case of unexpected callus formation in a segmental femoral fracture. The patient had a traumatic brain injury and was treated with the first stage of the Masquelet technique. Owing to the amount of large callus, a second stage of the Masquelet was not required. The patient recovered well from the injury and at 16-week follow-up was able to partially weight bear. A case similar to this has not previously been reported within the literature.